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Self‐Study Answers
1. A natal tooth is present at birth, whereas a neonatal tooth erupts within a month of delivery
2. There are few complications associated with
the early loss of a primary incisor soon after birth.
There is always a theoretical risk that a natal or
neonatal tooth may be aspirated or swallowed.
Invariably, the permanent tooth erupts normally
and space loss does not present a problem
because the intercanine width is preserved. If the
hard tissue of a natal tooth is removed, leaving
some of the pulpal remnants behind, then a root
may form from the dental papilla. If such a tooth
is extracted, it is important to remove (curette) all
associated tissue
3.
It is essential that the airway is protected when
performing any invasive procedure on an infant.
Place a piece of gauze behind the teeth at the back
of the mouth to avoid accidental swallowing or
aspiration of the tooth. It is usually convenient to
use the knee to knee position with the child’s head in
the operator’s lap. Young babies are best managed
by wrapping them with a blanket to keep them
secure, which also minimizes movement. Local
anesthesia is usually not required because the tooth
is only indicated for extraction in cases where there
is extreme mobility. Very often during extraction
only, the hard tissue of the crown is removed,
leaving the dental papilla (pulp) behind. This tissue
must be removed with a curette to ensure that there
is no subsequent formation of hard tissue. Bleeding
is controlled with local measures and feeding can
start immediately
4. It is an ulceration affecting the ventral surface
of the tongue in infants, caused by continual protrusive and retrusive movement of the tongue over
the mandibular incisors or natal/neonatal teeth.
Treatment options include monitoring the ulcer
only, smoothing of the incisal edge of the offending
tooth, or extraction
Bibliography andAdditional Reading
Chiang ML, Huang WH. 2004. Odontogenic keratocyst clini-
cally mimicking an eruption cyst: report of a case. J Oral
Pathol Med 33:373–5.
Chung NY, Batra R, Itzkevitch M etal. 2010. Severe methemo-
globinemia linked to gel‐type topical benzocaine use: a case
report. J Emerg Med 38:601–6.
de Olveira AJ, Silveira MLG, Duarte DA, Diniz MB. 2018. Eruption
cyst in the neonate. Int J Clin Pediatr Dent 11(1):58–60.
Leung AK, Robson WL. 2006. Natal teeth: a review. J Natl Med
Assoc 98:226–8.
Padmanabhan MY, Pandey RK, Aparna R, Radhakrishnan V.
2010. Neonatal sublingual traumatic ulceration–case report
and review of the literature. Dent Traumatol 26:490–5.
Stamfelj I, Jan J, Cvetko E, Gaspersic D. 2010. Size, ultrastruc-
ture, and microhardness of natal teeth with agenesis of permanent successors. Ann Anat 192:220–6.
Sen‐Tunç, Açikel H, Sönmez IS et al. 2017. Eruption cyst: a
series of 66 cases with clinical features. Med Oral Patol Oral
Cir Bucal 22(2):e228–e232.
Vucicevic Boras V, Mohamad Zaini Z, Savage NW. 2007.
Supernumerary tooth with associated dentigerous cyst in
an infant. A case report and review of differential diagnosis.
Aust Dent J 52:150–3.
Ziai MN, Bock DJ, Da Silveira A, Daw JL. 2005. Natal teeth: a
potential impediment to nasoalveolar molding in infants
with cleft lip and palate. J Craniofac Surg 16:262–6.
188 Clinical Cases inPediatric Dentistry
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ORAL MEDICINE ANDOROFACIAL PATHOLOGY
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Case 2
Primary Herpetic Gingivostomatitis
Child has been seen by his general medical practi-
•
tioner who has prescribed antibiotics and referred to
the dentist
FUNDAMENTAL POINT 1
Obtaining aHistory forOral Inammation
andFever
Questions toAsk aChild’s Caretaker
• How long has it been since the child was initially
• Are there any other unwell children in the family
• When was the last time the child had something
• When was the last time the child urinated?
• Is the child able to sleep at night?
• Does anything relieve the pain or discomfort?
unwell?
or has the child come into contact with any
other children, relatives, or caregivers who are
also unwell or have similar lesions?
to eat or drink?
Figure 5.2.1 Facial photograph showing facial inflammation
and ulcerations.
A. Presenting Patient
• Twenty‐month‐old Arabic male (Figure5.2.1)
• New patient presenting as an emergency
B. Chief Complaint
• Child has been ill for two days with a very high fever
• Child is unable to eat or drink because his mouth is
extremely inflamed (see Fundamental Point 1)
C.
Social History
• Youngest of two children, older sister is four years of
age and attends preschool
• Cared for by his grandmother during the day
• Low socioeconomic status
D. Medical History
• Review of medical history showed no significant
findings, no known food or drug allergies, no medications, vaccinations are up to date
E. Medical Consult
• Consultation with general pediatrics regarding fluid
balance: the child has not had any fluid intake for
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Clinical Cases inPediatric Dentistry 189
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more than 12 hours and hence admission to the
hospital may be required to manage dehydration
F. Dental History
• No dental home
• First visit to the dentist
• Cariogenic diet
• Brushes teeth with fluoridated toothpaste infrequently with some adult supervision
• Lives in an optimally fluoridated area
• No history of trauma
G. Extraoral Exam
• A thorough examination is extremely difficult due to
the state of the child’s health
• The child is generally unwell, lethargic, and irritable,
with a temperature of 39 °C (102.2 °F)
• There is no extraoral swelling, but there is marked
inflammation and ulceration of the lips and the
lateral commissures. Numerous ulcers and open
lesions around the lips and face are present
(Figure5.2.1)
H. Intraoral Exam
Soft Tissues (Figure 5.2.2)
• The gingival tissues are acutely inflamed with minor
bleeding from the crevicular margin. There are multiple small ulcers, particularly on the dorsum of the
tongue, and some areas of ulceration are noted on
the attached gingiva. The hard palate, the fauces, and
the pharynx are generally unaffected
Hard Tissue andOcclusal Evaluation
• Deferred at this appointment
Other
• Generalized heavy plaque accumulation
I. Diagnostic Tools
• A swab of the affected tissues could be considered
for exfoliative cytology
• Viral culture may be considered (may take many days
to establish a result)
• Viral antibody detection
J. Differential Diagnosis
Infective: Viral Infection
• Primary herpetic gingivostomatitis
• Coxsackie viral infection: herpangina, and hand, foot
and mouth disease
• Other viral infections: infectious mononucleosis
(Epstein–Barr), varicella (chickenpox)
Immunological
• Autoimmune recurrent ulceration
• Erythema multiforme/Stevens–Johnson syndrome
• Behcet syndrome
Neoplasia
• Hematological malignancy
Inflammatory
• Orofacial granulomatosis
Figure 5.2.2 Intraoral photograph showing gingival inflammation and mucosal ulcerations.
190 Clinical Cases inPediatric Dentistry
FUNDAMENTAL POINT 2
Presentation ofHerpetic Lesions
• The presentation of a young child with a prodrome of one to two days of febrile illness
followed by the development of an acute stomatitis is characteristic of primary herpes infection.
Typically, vesicles are not seen because they form
rapidly and break down to form coalesced areas
of ulceration; however, the primary signs are
those of acute gingival inammation. Commonly,
the child will present to their local medical
practitioner, and antibiotics are frequently prescribed, inappropriately, in the absence of a
denitive diagnosis. It is not until the appearance
of the ulcers that the true diagnosis is apparent
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FUNDAMENTAL POINT 3
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Management ofHerpetic Lesions
• The essential component of management of this
case is symptomatic care. Maintenance of uid
balance is essential with a soft bland diet as
tolerated. Pain should be controlled with analgesics and there is evidence that the use of topical
antiseptics may be benecial. Nonalcoholic
chlorhexidine mouthwash may be used to swab
the mouth to debride areas of slough that may
be secondarily infected with oral bacteria
causing more discomfort. It is advisable to use
an aqueous solution of chlorhexidine because
some formulations may contain up to 10%
ethanol, which is particularly painful and dehydrating when applied to open ulcers
K. Provisional Diagnosis andProblem List
Provisional Diagnosis
• Primary herpetic gingivostomatitis (see Fundamental
Point 2 and Background Information 1)
Problem List
• Acute viral infection
• Febrile illness
• Severe stomatitis
• Pain and discomfort resulting in decrease in fluid
intake and possible dehydration
L. Comprehensive Treatment Plan
• Admission to hospital for maintenance fluids, mouthwash and debridement, and pain control
• Soft diet as tolerated (see Fundamental Point 3)
M. Prognosis andDiscussion
• The condition is self‐limiting and should resolve within
10–14 days. If there is no resolution within this time,
then a biopsy is indicated to exclude other conditions.
The patient may be prone to recurrent episodes of
herpes labialis in times of stress or immune compromise or when the lips are exposed to ultraviolet radiation
• Topical anesthetics and coating agents help relieve
pain and facilitate food intake. However, they should
be used with extreme caution in children who cannot
expectorate because of the potential for traumatic
biting. Also, they may reduce the gag reflex and
increase the risk of aspiration
ORAL MEDICINE ANDOROFACIAL PATHOLOGY
• Eating ice cream or popsicles may help relieve oral
discomfort and increase the fluid intake
• Maintenance of oral hygiene is essential and it is
important to warn the parents/caregivers to use
separate utensils, change the child’s toothbrush and
pacifiers, and avoid contact with other children
• Parents should be warned that the child should not
touch his eyes. The child may need to be hospitalized
if ocular involvement occurs
BACKGROUND INFORMATION 1
Oral Herpes
• The causative agent in this condition is the
herpes simplex virus. This is usually the type I
virus, although the presentation and course of a
type II infection is identical
Initial infection comes from direct contact with
•
another infected individual and the virus then
infects the nerve and remains latent in the
trigeminal ganglion
• Because the disease is self‐limiting, care should
be symptomatic, except in severe cases or in
children with immune suppression. Acyclovir®
has been shown to be effective in control of
infection if administered within the first 72 hours
of exposure. The usual dosage is 25–100 mg/kg/
day given five times per day as an oral suspension. Intravenous administration is reserved for
severe cases
• Acetaminophen or paracetamol is the most
appropriate analgesic to prescribe
• Reactivation of the virus is seen in approximately 20% of the population. The most common site of recurrence is the lip (herpes labialis)
but less frequently it can recur in the oral cavity
(gingiva and hard palate) or the skin of the face
and ears
N.
Complications
• Dehydration due to inadequate fluid intake
• Recurrent herpes labialis
• Contamination of other body parts (eyes, fingers, etc.)
• Transmission to other family members and children in
school and daycare
• Disseminated herpes infection in children who are
severely immunocompromised
Clinical Cases inPediatric Dentistry 191
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Self‐Study Questions
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ORAL MEDICINE ANDOROFACIAL PATHOLOGY
1. When should a child with primary herpes be
admitted to hospital?
2. Should an antiviral medication be prescribed?
3. Should antibiotics be prescribed?
4. Will this child have another episode of this type
of infection?
Answers are located at the end of the case
Clinical Cases inPediatric Dentistry 193
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Self‐Study Answers
1. Hospital admission is only necessary if there is
a risk of dehydration due to an inability to maintain
an adequate intake of fluids. This is an uncommon
event; however, the clinician must be aware of the
dangers of inadequate fluid balance and should
stress to the parents or caregivers that it is essential
to encourage the child to drink as much as possible.
Intake of solid food is not as important as fluids, but
bland soft foods should also be encouraged. Young
children will be hesitant to take anything orally in
the acute phase
2.
The prescription of antivirals is contentious, and
common practice dictates that acyclovir is only
effective if administered within the first 72 hours
of the appearance of the prodrome. In reality, few
Additional Reading andResources
AAOM Clinical Practice Statement: Subject: Dental Care for the
Patient with an Oral Herpetic Lesion. 2016. Oral Surg Oral
Med Pathol Oral Radiol 121(6):623–5.
Chung NY, Batra R, Itzkevitch M etal. 2010. Severe methemo-
globinemia linked to gel‐type topical benzocaine use: a case
report. J Emerg Med 38:601–6.
Drugge JM, Allen PJ. 2008. A nurse practitioner’s guide to the
management of herpes simplex virus‐1 in children. Pediatr
Nurs 34:310–18.
Krol DM, Keels MA. 2007. Oral conditions. Pediatr Rev 28:15–21.
children will present to the dentist within this time
period and have commonly visited their medical
practitioner prior to the dentist. Acyclovir should
always be used when managing children who are
immunosuppressed
There is really no indication for the prescription
3.
of antibiotics in cases of primary herpes because it
is a viral infection
4. Patients will not have another episode of this
form of acute infection; however, they will be subject to recurrent cold sores appearing along the
terminal distribution of the nerve pathways that
have been involved (i.e. the particular division of the
trigeminal nerve)
Nasser M, Fedorowicz Z, Khoshnevisan MH, Shahiri Tabarestani
M. 2008. Acyclovir for treating primary herpetic gingivostomatitis. Cochrane Database Syst Rev 4:CD006700.
Usatine RP, Tinitigan R. 2010. Nongenital herpes simplex virus.
Am Fam Physician 82:1075–82.
Wilson SS, Fakioglu E, Herold BC. 2009. Novel approaches in
fighting herpes simplex virus infections. Expert Rev Anti
Infect Ther 7:559–68.
Woo SB, Challacombe SJ. 2007. Management of recurrent oral
herpes simplex infections. Oral Surg Oral Med Oral Pathol
Oral Radiol Endod 103(suppl 1):S12.e1–S12.e18.
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Case 3
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Mucocele
ORAL MEDICINE ANDOROFACIAL PATHOLOGY
E.
Medical Consult
• Not applicable
F. Dental History
• Sees a pediatric dentist once a year
• No caries history
• Patient has moderate anxiety and apprehension
regarding dental treatment
• History of oral trauma about 1 month ago
Figure 5.3.1 Intraoral photograph showing mucocele on lowerlip.
A. Presenting Patient
• Five‐year‐old Caucasian female
B. Chief Complaint andHistory ofPresent
Illness
• History of swelling of the lower lip of about one
month’s duration
Parents believe it developed a few days after patient
•
fell and hit her lip on the edge of a table. Has been
slowly getting bigger
C. Social History
• Mother works from home and is the primary
caregiver
• Patient is the only child of middle class parents
D. Medical History
• Review of medical history showed no significant
findings, no known food or drug allergies, no medications, vaccinations are up to date
G. Extraoral Exam
• Normal height and Body Mass Index (BMI)
• There is fullness of the lower right lip which is not
tender to palpation. Overlying skin is normal in
appearance
H. Intraoral Exam
• A dome‐shaped nodule measuring 1.1 cm in diameter
and elevated 0.7 cm from the surrounding tissue is
noted on the lower right labial mucosa. The overlying
mucosa is smooth and appears slightly gray in color.
The nodule can be moved around within the lip tissue
(Figure5.3.1)
Primary dentition all within normal limits, no caries
•
I. Diagnostic Tools
• Excision and submission for microscopic exam is
indicated
J. Differential Diagnosis
• Reactive: mucocele, salivary duct cyst, or mucous
retention cyst
• Neoplastic/hamartomatous: salivary gland tumor
(benign or malignant), vascular lesions (e.g.
hemangioma or arteriovenous malformation,
neuroma, lipoma)
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FUNDAMENTAL POINT 1
Differential Diagnosis foraMass oftheLower Lip
• In children, a discrete mass in the lower lip of
short duration is most likely of a traumatic or
reactive etiology, and therefore mucocele would
be the most likely diagnosis in this case.
However, other soft tissue and salivary gland
tumors may mimic a mucocele and therefore
mucoceles should be excised and submitted for
microscopic exam
• Salivary gland tumors are rare in children, but
when they occur pleomorphic adenoma is the
most common benign neoplasm and mucoepidermoid carcinoma is the most common
malignant neoplasm. Mucoepidermoid carcinoma is known to present with a similar clinical
appearance to mucocele and is therefore in the
differential diagnosis even in children
K. Diagnosis
• Mucocele
L. Comprehensive Treatment Plan
• The mucocele will need to be surgically removed with
a traditional approach, or the use of a diode laser
could be considered (Bagher 2018). Sedation should
be considered for the surgery depending on behavior
• Follow‐up at postoperative visit in one week and then
within two to three months to evaluate for recurrence
BACKGROUND INFORMATION 1
Etiology ofMucoceles
• In most cases, damage to minor salivary gland
excretory ducts, often due to trauma, leads to
mucin being spilled into the surrounding connective tissue. The build‐up of mucin compresses
the brous connective tissue and creates a
cyst‐like cavity lled with mucin, cellular debris,
and white blood cells
• In some cases, often the more superficial
mucoceles (see example in Figure5.3.2), the
surface will be broken in some way allowing
the mucin to escape into the oral cavity
deflating the lesion. After the overlying mucosa
heals, the process will begin again. This is why
some patients report waxing and waning of
the lesion
• Salivary duct cysts or mucous retention cysts
may also appear clinically like a mucocele, but
the etiology is obstruction or blockage of the
duct rather than damage to the duct. Instead
of mucin spilling into the connective tissue, it
builds up within the duct creating a cystic
space. Histologically, this means the epithelium is lining the space rather than fibrous
connective tissue lining the space (as seen
with mucocele)
M. Intraoperative andPostoperative Images
• Preoperative photograph of mucocele of lower lip
prior to excision (Figure5.3.1)
N. Prognosis andDiscussion
• The prognosis is good. Excision of mucoceles is
typically the definitive treatment. However, recurrence is not uncommon and the patient and their
caregivers should be advised of this
O. Common Complications andAlternative
Treatment Plans
• Repeated biting of the mucocele can lead to bleeding
and to fibrous build up around the lesion, similar to
the development of fibromas of the oral cavity
196 Clinical Cases inPediatric Dentistry
Figure 5.3.2 Superficial mucocele.
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Self‐Study Questions
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ORAL MEDICINE ANDOROFACIAL PATHOLOGY
1. Do mucoceles resolve on their own?
2. Are mucoceles infectious?
3. What submucosal lesions may appear in the oral
cavity with a bluish or gray color?
Answers are located at the end of the case
Clinical Cases inPediatric Dentistry 197
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