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CHAPTER 5
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Self‐Study Answers
1. A fraction of mucoceles which are superficial will
resolve on their own. Deeper mucoceles are less
likely to resolve
2. No, mucoceles are caused by mechanical disrup-
tion of the ducts from salivary gland acini, typically
minor salivary gland ducts
Bibliography andAdditional Reading
Bagher SM, Sulimany AM, Kaplan M, Loo CY. 2018. Treating
mucocele in pediatric patients using a diode laser: three
case reports. Dent J 9;6(2). p. ii. E13. doi: 10.3390/dj6020013.
Lewandowski B, Brodowski R, Pakla P etal. 2016. Mucoceles
of minor salivary glands in children. Own clinical observations. Dev Period Med 20(3):235–42.
3. Any lesion filled with a fluid or suspension and
close enough to the surface to alter the way light
is reflected back to the observer may appear blue
or gray in color. This includes, but is not limited to,
cystic salivary gland lesions and vascular lesions
Martins‐Filho PR, Santos T de S, da Silva HF et al. 2011.
A
clinicopathologic review of 138 cases of mucoceles in a
pediatric population. Quintessence Int 42(8):679–85.
Mouravas V, Sfoungaris D, Papageorgiou I etal. 2018. Mucoceles
of the lesser salivary glands in neonates demonstrate a particular clinicopathological pattern and mandate urgent management. J Stomatol Oral Maxillofac Surg 119(3):238–41.
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Case 4
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Candidiasis
Figure 5.4.1 Intraoral photograph showing erythematous area
of the mid‐dorsal tongue which is also denuded of papillae.
ORAL MEDICINE ANDOROFACIAL PATHOLOGY
No history of substance abuse
•
• No known food or drug allergies
E.
Medical Consult
• Not applicable
F. Dental History
• Patient has dental home with routine dental care
every six months in a general dentist’s office, including fluoride treatments and sealants
• No history of caries
• Patient began orthodontic treatment three months ago
and had a fixed palatal expander placed three weeks ago
• Patient has age appropriate behavior and interacts
well with staff
• Unsupervised brushing with fluoride toothpaste
oncea day
A. Presenting Patient
• Fourteen‐year‐old Caucasian female
B. Chief Complaint andHistory ofPresent
Illness
Patient accompanied by her father, present with chief
•
complaint of redness on the surface of the tongue.
The patient reports tongue is sensitive when she eats
C. Social History
• Primary caregiver is the father (divorced)
• Oldest of two children
• She is training to be a pianist. She lives away from
home during the week
• Middle class socioeconomic status
D. Medical History
• Healthy
• Review of systems is negative
• No medications
G. Extraoral Exam
• Retrognathic profile
• No skin lesions noted
H. Intraoral Exam
• Soft tissue demonstrates a round‐ to oval‐shaped
erythematous area of the mid‐dorsal tongue which is
denuded of papillae (Figure5.4.1)
Oval‐shaped acrylic/metal palatal expander
•
• Moderate generalized plaque accumulation
• Caries free with sound pit and fissure sealants on molars
I. Diagnostic Tools
• Cytologic smear could be considered
J. Differential Diagnosis
• Erythematous candidiasis
• Allergic reaction to acrylic in palatal expander
• Lichenoid mucositis, lichenoid reaction to dental
product, candy, gum, etc.
• Nutritional deficiency (e.g. vitamin B
Clinical Cases inPediatric Dentistry 199
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FUNDAMENTAL POINT 1
Types ofCandidiasis
• There are several clinical appearances of oral
candidiasis with the two most common types seen
in immunocompetent children being pseudomembraneous and erythematous (see Table5.4.1 for
additional types of candidal infections):
Pseudomembraneous: the oral cavity is germ
free at birth, but is quickly colonized and this is
thought to be from the mother, caregiver, or
theenvironment. Infants frequently present with
pseudomembraneous candidiasis and this is a
reflection of their immune system not being
fullydeveloped. Figure5.4.2 shows an example
of a dorsal tongue hyperkeratosis and, more
posteriorly, candidiasis is noted. This type can
recur if an infant is nursing and the mother is not
treated when the child is treated
Erythematous: the images in Figure5.4.3
illustrate examples of erythematous candidiasis with the presence of papillary hyperplasia.
This type and pattern of candidiasis is usually
caused by leaving a removable partial denture
(in this case a “flipper”) in all day without
cleaning it or the underlying tissue. This can
also be seen in patients with asthma who use
Figure 5.4.2 Intraoral photograph of infant tongue
showing hyperkeratosis, and more posteriorly, candidiasis.
corticosteroid inhalers, particularly if they
havea high/narrow arched palate. These
patients should be instructed to rinse with
water after each use to decrease the risk of
candidiasis
Table 5.4.1 Description ofthevarious types ofcandidal infections.
Type of Candidal Infection Clinical Appearance Common Location
Pseudomembraneous (thrush) White plaques which are removable
Hyperplastic Nonremovable white plaque
Erythematous Red macule
Central papillary atrophy (median
rhomboid glossitis)
Angular cheilitis Red, fissuring of skin
Chronic atrophic (denture stomatitis) Red macule
200 Clinical Cases inPediatric Dentistry
Burning sensation
Typically asymptomatic
Burning sensation
Red macule
Asymptomatic
Painful
Asymptomatic
Anywhere in oral cavity
Anywhere in oral cavity
Anywhere in oral cavity
Central dorsal tongue
Corners of the mouth
Under an appliance base (e.g. full or
partial denture, expander, retainer)
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ORAL MEDICINE ANDOROFACIAL PATHOLOGY
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BA
Figure 5.4.3 Intraoral photograph of palate showing (A) erythematous candidiasis and (B) the presence of
papillary hyperplasia.
K. Diagnosis
• Erythematous candidiasis associated with palatal
expander and poor oral hygiene
BACKGROUND INFORMATION 1
Etiology andDiagnosis ofCandidiasis
• Candidiasis is caused by a dimorphic fungal
organism, most often Candida albicans. The
organism is part of the normal flora in 30–50% of
the population. This percentage rises with age and
is over 60% in patients over 60 years old. Disease
(candidiasis) occurs when the body is no longer
able to suppress the growth of Candida organisms
• Children with an underlying immune dysfunction
may present with repeated bouts of the more
hyperplastic type of candidiasis as a result of
chronic mucocutaneous candidiasis. Cytologic
smear of the material from the oral cavity will
demonstrate the hyphae of the organism when
disease is present
•
While often seen when the immune system is
compromised, candidiasis can also be seen in
healthy children given the correct circumstances.
For example, candidiasis can be induced by
inadequate hygiene in the presence of a
removable appliance or with use of
corticosteroid‐containing inhalers by patients
with a high/narrow arched palate
L. Comprehensive Treatment Plan
• Prescribed antifungal suspension and asked to rinse
for one minute and expectorate, four to five times per
day, every day for 14 days
• The patient was instructed on how to improve her oral
hygiene, including brushing her tongue and appropriate cleaning of her orthodontic hardware
FUNDAMENTAL POINT 2
Treatment ofCandidiasis
• Generally, treatment for most types of oral
candidiasis is with topical antifungal medications
• Imidazoles, such as nystatin, are commonly
used and are available in suspension, ointment/
cream and troches/pastille forms. The antifungal
needs to be used multiple times per day to be
effective
•
Systemic antifungal agents, such as uconazole,
are also available. However, uconazole is
approved in children only for esophageal or
systemic candidiasis. Also, uconazole does not
work well if the patient has decreased or no
salivary ow
M. Intraoperative andPostoperative Images
• Dorsal aspect of tongue showing erythematous area
(Figure5.4.1)
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N. Prognosis andDiscussion
• The combination of placement of fixed orthodontic
hardware, living away from home (brushing was no
longer supervised), and recent poor oral hygiene
combined to create an oral environment for Candida
organisms to thrive in this patient
• Eventual removal of fixed palatal expander will
remove harbor for Candida
• Follow‐up at two weeks showed resolution of the
erythema and normal dorsal tongue papillae
• Prognosis is good; if the patient follows oral hygiene
instructions, recurrence is unlikely
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Self‐Study Questions
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ORAL MEDICINE ANDOROFACIAL PATHOLOGY
1. What causes candidiasis?
2. What circumstances would predispose a patient
to developing candidiasis?
3. How do you treat oral candidiasis?
Answers are located at the end of the case
Clinical Cases inPediatric Dentistry 203
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CHAPTER 5
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Self‐Study Answers
1. Candida species are found in the normal oral
flora of many people. When there is a change in the
oral environment the normal checks to the proliferation of Candida species are removed and the organism overgrows, leading to candidiasis
2. A decreased host immune response, xerostomia,
antibiotics (which disturb normal oral flora), and
Additional Reading andResources
Abdul Wahab A, Salah H, Chandra P, Taj‐Aldeen SJ. 2017.
Persistence of Candida dubliniensis and lung function in
patients with cystic fibrosis. BMC Res Notes 10(1):326.
Amadori F, Bardellini E, Conti G, Majorana A. 2017. Oral mucosal
lesions in teenagers: a cross‐sectional study. Ital J Pediatr
43(1):50.
Berdicevsky I, Ben‐Aryeh H, Szargel R, Gutman D. 1984.
Oral Candida in children. Oral Surg Oral Med Oral Pathol
57(1):37–40.
Dadar M, Tiwari R, Karthik K etal. 2018. Candida albicans– biology,
molecular characterization, pathogenicity, and advances in diagnosis and control–an update. Microb Pathog 117:128–38.
poor oral hygiene in the presence of oral appliances
such as dentures or retainers
3. A topical antifungal medication, such as nystatin,
is the first line of defense. The medication comes in
multiple forms including suspension, troche or pastille, or ointment
Domaneschi C, Massarente DB, de Freitas RS etal. 2011. Oral
colonization by Candida species in AIDS pediatric patients.
Oral Dis 17(4):393–8.
Morgan JE, Hassan H, Cockle JV etal. 2017. Critical review of
current clinical practice guidelines for antifungal therapy in
paediatric haematology and oncology. Support Care Cancer
25(1):221–8.
Samaranayake L, Matsubara VH. 2017. Normal oral flora and the
oral ecosystem. Dent Clin North Am 61(2):199–215.
Stecksén‐Blicks C, Granström E, Silfverdal SA, West CE. 2015.
Prevalence of oral Candida in the first year of life. Mycoses
58(9):550–6.
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Case 5
AB
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Celiac Disease
ORAL MEDICINE ANDOROFACIAL PATHOLOGY
C
Figure 5.5.1 Intraoral photographs showing (A) multiple ulcerations, (B) ulcer on lower right lip, and (C) ulcer on the tongue.
A. Presenting Patient
• Eight‐year‐old Caucasian female
B. Chief Complaint andHistory ofPresent
Illness
• Mother reports that the child has had repeated sores
of the oral cavity for the past eight months. Sores are
so bad they make her cry when she eats. Patient has
lost 13 lb over the last six months because she does
not want to eat. Mother reports that as soon as one
sore heals another is developing and the child has had
only short periods of time without sores in the past
eight months
• No other oral or systemic symptoms
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C. Social History
• Primary caregiver is mother
• Patient is the oldest of three children
• Patient plays soccer on a school team
• Middle class socioeconomic status
D. Medical History
• Parent reports no significant medical history
• Review of systems is negative
• No medications
• Vaccinations up to date
• No known food or drug allergies
E. Medical Consult
• Patient was referred to a pediatrician who then
referred to a pediatric gastroenterologist to evaluate
for gastrointestinal disorders associated with recurrent oral ulcers
F. Dental History
• Has dental home with pediatric dentist for routine
visits, last visit three months ago
• Brushes twice per day with fluoridated toothpaste
• No history of caries
• No history of orofacial trauma
• Patient is well behaved, but quiet and reserved when
asked questions
MAGIC syndrome (mouth and genital ulcers with
inflamed cartilage)
Cyclic neutropenia
Celiac disease
J. Diagnostic Tools
• Serologic screening to rule out celiac disease.
Over a period of 13 months, blood was drawn
twice for tissue transglutaminase (tTG) IgA and
was negative. The third time tTG and endomysial
antibody IgA were tested, both came back positive
for celiac disease
• Complete blood count also revealed iron deficiency
anemia
K. Diagnosis andProblem List
Diagnosis
• Recurrent aphthous ulcerations associated with celiac
disease
Problem List
• Multiple, painful oral ulcerations
• Difficulty eating
• Weight loss
G. Extraoral Exam
• Within normal limits
• No skin lesions noted
• Patient is small in stature
H. Intraoral Exam
• Multiple ulcerations were noted in the oral cavity
ranging in size from 0.5 to 2.0 cm. The ulcers have a
fibropurulent surface membrane and are surrounded
by erythematous mucosa (Figure5.5.1)
Differential Diagnosis
I.
• Recurrent aphthous stomatitis
• Recurrent herpes (see Table5.5.1 for information on
oral ulcers)
• Systemic diseases associated with aphthous‐like
ulcerations:
Crohn’s disease
PFAPA syndrome (periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis)
BACKGROUND INFORMATION 1
Celiac Disease
• Celiac disease is one of the most frequently
diagnosed chronic gastrointestinal disorders. It
affects approximately 1% of the US population
• Celiac disease is an immune‐mediated enteropathy
which is a result of gluten sensitivity in patients
who are genetically susceptible. Gluten is the
storage protein found in wheat and also in rye and
barley. It can cause injury to the intestinal mucosa
and can in turn lead to nutritional deficiencies
Symptoms can include diarrhea, abdominal
•
cramping, weight loss, and fatigue. However,
abdominal symptoms are not always present
• If diet restrictions are not in place patients
are at an increased risk to develop long‐term
complications such as osteoporosis, infertility,
autoimmune diseases, and malignancies such
as gastrointestinal lymphoma
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Table 5.5.1 Oral ulcers.
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ORAL MEDICINE ANDOROFACIAL PATHOLOGY
Ulcer Type Cytology Vesicle
Stage
Recurrent aphthous stomatitis
(minor form)
Acute herpetic gingivostomatitis
(primary herpes simplex virus)
Recurrent herpes (reactivation
herpes simplex virus)
Chicken pox (primary varicella
zoster virus)
Shingles (reactivation varicella
zoster virus)
Nonspecific No Typically, 1–3 ulcers 1–3 mm
Virally altered
cells
Virally altered
cells
Virally altered
cells
Virally altered
cells
Ye s Multiple to confluent ulcers
Ye s Multiple to confluent ulcers
Ye s Multiple ulcers 1–3
Ye s Multiple ulcers 1–3
L. Comprehensive Treatment Plan
• Patient was referred to a pediatric gastroenterologist
to manage disease
• Patient was started on a gluten‐restricted diet and has
since had only infrequent aphthous ulcers
• When needed, the ulcers are treated with a topical
corticosteroid such as fluocinonide
• After initial follow‐up, patient is monitored at three‐
month recall visits for any signs of ulceration
M. Intraoperative Images
• Intraoral photographs showing multiple ulcerations on
lip and tongue (Figure5.5.1)
N. Prognosis andDiscussion
• At one month follow‐up mother reports that the
patient is eating well and is no longer anemic. No
enamel malformations were noted. The prognosis is
good if the child remains on the restricted diet
If celiac disease is present and untreated while teeth
•
are developing, then teeth may present with enamel
defects such as enamel pitting and discoloration. This
is most commonly seen in the permanent dentition
Ulcer Feature Location
in diameter
(crops)
(crops)
mm in
diameter scattered
throughout mouth
mm in
diameter unilaterally
along one dermatone
Moveable mucosa only
Moveable and
nonmoveable mucosa
Nonmoveable mucosa
only
Moveable and
nonmoveable mucosa
Moveable and
nonmoveable mucosa
FUNDAMENTAL POINT 1
Oral Manifestations ofCeliac Disease
• When children present with a history of
repeated episodes of aphthous‐like ulcerations
of the oral cavity or if they have multiple episodes of major aphthous‐like ulcers, an underlying systemic condition should be investigated.
Conditions such as PFAPA syndrome, MAGIC
syndrome, and gastrointestinal disease should
be investigated
• Oral lesions of celiac disease can mimic recurrent aphthous stomatitis. Aphthous ulcers are
round or ovoid and have erythematous halos
surrounding a yellow or gray fibropurulent
membrane. Patients with celiac disease are also
at risk for developing enamel defects such as
discoloration or hypoplasia
Self‐ Study Questions
1. How can you differentiate recurrent aphthous
ulcers from recurrent herpes simplex lesions?
2. Can celiac disease be present if there are no
abdominal symptoms?
Answers are located at the end of the case
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