Pediatric Oral Pathology

Developmental anomalies of the oral mucosa

Fordyce granules

Small yellow-white multifocal papules. Discrete or clustered.

Asymptomatic

Second decade of life (puberty)

Male predilection

Found on:

Bilateral buccal mucosa

Retromolar pad

Upper lip vermilion

Fordyce granules

Oral sebaceous glands

May increase in size

No treatment - can laser for cosmetics

DD - Frictional keratosis, scar formation, pustules

White lesions of the oral mucosa

Frictional keratosis

Morsicatio Buccarum

Leukoedema

White sponge nevus

Linea alba

Scar formation (Cicatrix)

Chemical burn

Pseudomembranous candidiasis (thrush)

Localized to diffuse white rough/shredded patches, adherent.

Asymptomatic

First and second decades

No gender bias

Found on:

Mucosa adjacent to occlusal plane: Buccal, labial mucosa, lateral tongue, attached gingiva

Ask: History of habits and ortho appliances?

Frictional keratosis

Chronic biting/sucking habits

Irritation from orthodontic appliances

Fractured teeth

Tooth brushing

Treatment - eliminate cause, lesion will regress

DD - Leukoedema, linea alba, smokeless tobacco keratosis, cinnamon contact, stomatitis, lupus erythematosus

Whitish formation that comes off when rubbing, with superficial mucous tearing.

Small whitish epithelial desquamation, that leave erythematous areas between them.

Asymptomatic

No gender bias

Early childhood/puberty

Found on:

Buccal mucosa

Labial mucosa

Lateral border of tongue

Ask: Chewing habit or Anxiety? Look for adjacent poor restorations + signs of bruxism.

Morsicatio buccarum

Reactive lesion from poor fitting restoration

Mucosa chewing habit in anxiety or bruxism

Treatment - Correct habit - night splints and oral shield. (If iatrogenic correct restoration)

DD - Frictional keratosis, Leukoplakia, lichen planus, pseudomembranous candidiasis

Widespread, filmy white, wrinkled mucosa - Adherent.

Dissapears when stretched

First and second decades

No gender bias

More common in black children

Found on:

Bilateral buccal mucosa

Labial mucosa

Soft palate

Leukoedema

Common variant of normal mucosa

More pronounced in cigarette smokers

No treatment

DD - Frictional keratosis, Linea alba, White sponge nevus

White plaques that are diffuse, symmetric, corrugated or velvety. Adherent

Asymptomatic

First decade

No gender bias

Found on:

Bilateral buccal mucosa

Labial mucosa

Ventral tongue

Floor of mouth

Soft palate

White Sponge Nevus

Autosomal dominant skin disorder - keratin defect

Extraoral sites may be involved

Reaches full expression during adolescensce

Treatment:

None required

Retinoids, topical tetracyclines, systemic penicillin (partially effective)

Surgery most effective

DD - Leukoedema, Hereditary benign intraepithelial dyskeratosis, frictional keratosis, Hyperplastic candidiasis, Syndrome related leukoplakia

White line, may be scalloped

Asymptomatic

No gender bias

Any age after eruption

Found on:

Bilateral buccal mucosa

Along occlusal plane

Linea alba

Biting irritation / sucking habit

May be associated with leukoedema

No Treatment - may spontaneously regress

DD - Cinnamon contact stomatitis, scaar formation, Cheek biting keratosis

White or pale pink line, or smooth irregular patch with crosshatch or starburst pattern

Asymptomatic

First and second decades

No gender bias

Found on:

Any site; common on labial mucosa, lip vermillion, tongue

Ask: history of trauma or surgery?

Scar formation (cicatrix)

Oral trauma or surgery

May represent child abuse or self-mutilation

Treatment - none, unless cosmetic concern or restricts function (then scar revision)

DD - Cinnamon contact stomatitis, Cheek biting keratosis

Localised or widespread, white nonaderent plaques and erythematous erosions or ulcers

Tender/Painful

First and second decades

No gender bias

Found on:

Any site, common on lips, tongue buccal mucosa, gingiva

Ask: Use of any topical medicine/chemicals or mouth rinse?

Chemical burn

Chemicals and drugs, including dental:

Inappropriate use of mouth rinses, topical anesthetics, phenol, formocresol

Treatment - Identify and remove cause, and symptomatic relief

DD - Plaque, Pseudomembranous candidiasis, Coated tongue, Mucosal sloughing, Mucous patch of syphilis

Widespread, white spots or plaques that wipe off leaving red base

Mild burning sensation

Any age, esp. infancy

No gender bias

Found on:

Any mucosal site - common on buccal mucosa, tongue and palate

Ask: Taking any medications, if infant - pacifiers, diaper rash? Orthodontic applianes? Immunosupressive condition?

Pseudomembranous Candidiasis

Candida albicans fungus (and other species)

Contributing factors: antibiotics, steroids, immune supression

Orthodontic appliances and toothbrushes may harbour fungus

Treatment - Antifungals, proper oral hygiene. Reccurance if cause not eliminated

DD - Plaque, Chemical burn, Coated tongue, Mucosal sloughing, Superficial lip and cheek biting, Koplic spots of rubeola

Pigmented lesions of the oral mucosa

Petechiae, ecchymosis, hematoma

Erythematous candidiasis

Oral melanotic macule

Localised to diffuse pinpoint spots/patches/swelling with smooth surface. Red, blue or black depending if early or late lesion.

May be tender

First and second decades

No gender bias

Found on:

Buccal mucosa

Lips

Lateral tongue

Soft palate

If multiple Lesions are present, what must we exclude?

Petechiae, Ecchymosis, Hematoma

If multiple lesions, must exclude:

Child abuse

Bleeding disorders

Infectious mononucleosis + other viral infections

No treatment - spontaneously resolve

Multiple red macules to diffuse red patches

Depapillation of tongue

Burning sensation

Possible angular chelitis

First and second decades

No gender bias

Found on:

Palate, Buccal mucosa, dorsal tongue

Ask: medications, palatal coverage appliance, check medical history. In infant, use of pacifier?

Erythematous candidiasis

Candida albicans and other species

Contributing factors: Antibiotics, immunosupression, xerostomia, pacfier, palatal coverage appliance

Treatment - Antifungal medication and proper oral hygiene. May recur if cause not eliminated or managed

DD - Contact allergy, Traumatic erythema, Erythema migrans, Thermal burn, Anemia

Brown/ black oval macule with smooth surface and well defined to irregular margins.

Potential opaque fragments in radiograph

First and second decades

Female predilection

Found on:

Lower lip vermillion, Buccal mucosa, Gingiva

Oral melanotic macule

Most common oral pigmentation of fair complexioned children

Multiple lip macules in Peutz-jeghers syndrome

Treatment - None unless menalocytic neoplasm cannot be excluded. Otherwise (if not neoplasm), no potential for malignant transformation.

DD - Amalgam/graphite tatoo, Melanocytic nevus, Smokers melanosis, Late eccymyosis

Ulcerative lesions of the oral mucosa

Apthous ulcer

Traumatic ulcer

Contact allergy

Erythema multiforme

Painful recurrent ulcers. Can be 1-5 superficial and <1cm or multiple deep >1cm. Can also be herpetiform.

First and second decade

Female prediliction

Found on:

Buccal, labial mucosa most common

Non keratinized mucosa

Apthous Ulcers

T-cell mediated reaction

Trauma and ortho are factors in children

Genetic predisposition

Association with systemic disease, food sensitivities, nutritional deficiencies

Minor variant: 1-5 superficial oval ulcers <1cm. Resolves 7-10 days

Major variant: Multiple deep ulcers >1cm. Resolves in 2-6 weeks

Herpetiform variant: Showers of multiple small ulcers

Treatment - Topical anaesthetics and coating agents for symptomatic relief, Corticosteroids (t+s), chlorhexidine rinse, laser treatment, nutritional supplement. Major varients heal with scarring

DD - Traumatic ulcer, Secondary herpetic ulcer, Chrons disease, Behcet syndrome, Celiac disease, neutropenic ulcer, PFAPA syndrome, Gastroesophageal reflux disease

Single (usually), large ulcer, variable shape and irregular margins. Shallow or deep

Painful

First and second decade

No gender bias

Found on:

Lateral tongue, Buccal mucosa, lips and gingiva, ventral tongue

Ask: Recent injury to site?

Traumatic ulcer

Most common oral ulcer

May indicate:

Child abuse

Neurologic impairment

Factitial injuries when peristent and recurrent

Treatment - Typically heals in 1-3 weeks. Symptomatic relief, eliminate cause. Factitial ulcers are diagnostic problem. May heal with scarring.

DD - Apthous ulcer, Mucosal burn Secondary herpetic ulcer, Contact allergy

Focal or widespread erythema, with vesicles and ulcers.

Burning sensation and pain

First and second decade

No gender bias

Found on:

Any mucosal site

Ask: Use of new oral hygiene products/topical medications/cosmetic products? New/ rarely eaten food?

See if any dental materials near site

Contact allergy

Mucosa coming into contact with allergens - food/dental materials/ oral hygeine products/topical medications/ cosmetic products

Treatment - Identify (patch testing helpful) and eliminate allergen. Topical steroids for symptoms

DD - Mucosal burn, Secondary herpetic ulcer, Apthous ulcer, Angular cheilitis, Erythema multiforme

Widespread and painful, red macules, vesicles, bullae and ulcers. Blood crusted lesions on lips. Target lesions on skin.

Acute onset, fever, malaise

Second decade

Male prediliction

Found on:

Oral lesions: Lips, tongue, buccal mucosa, soft palate

Skin ‘Target’ lesions on: Extremities and head and neck region

Erythema multiforme

Common precipitating factors:

HSV

Medications

Major and minor forms exist

Treatment - Withdrawl of medication, lubricate lips, symptomatic relief. Hospitalization of severe. Reccurences common if triggered by HSV

DD - Primary herpetic gingivostomatitis, Necrotizing ulcerative gingivitis, Apthous major ulcers, Chemical burn

Papillary lesions of the oral mucosa

Multifocal epithelial hyperplasia (Hecks disease)

Multifocal sessile papules and nodules with pink grainy/stippled surface. Lesions coalesce. Cobblestone appearance.

Not tender

First and second decades

No gender bias

Found on:

Labial and buccal mucosa and tongue

Ask: Family history of same condition? Living conditions? Diet? Oral hygeine habits?

Multifocal epithelial hyperplasia (Hecks disease)

HPV 13, 32

Genetics

Poor hygeine, crowded living conditions and nutritional deficiencies

Treatment - Excisional biopsy, laser ablation. Reccurence common, but may spontaneously regress. No malignant transformation

DD - Verruca vulgaris, Conyloma acuminata, Multiple hamartoma syndrome, Multiple endocrine neoplasia syndrome

Tumor like lesions of the oral mucosa

Irritation fibroma

Mucosal neuromas (multiple endocrine neoplasia syndrome, type 2b)

Pedunculated or sessile nodule, has a pink smooth surface, firm and non tender. Doesnt grow beyond a certain size

First and second decades

No gender bias

Found on:

Buccal and labial mucosa

Tongue

Attached gingiva

Irritation fibroma

Reactive hyperplastic lesion caused by chronic trauma and mimics tumor.

Limited growth potential

Treatment - Excisional biopsy, may reccur if irritation continues.

DD - Fibrosing mucocele, Peripheral ossifying fibroma, Giant cell fibroma, Benign submucosal neoplasm.

Multiple pink papules and nodules, soft and nontender. Marfanoid body type (disproportionately long limbs, fingers toes). Narrow face, full lips.

First decade

No gender bias

Found on:

Labial and buccal mucosa

Anterior tongue

Gingiva

Conjunctiva and eyelids

Mucosal neuromas (Multiple endocrine neoplasia syndrome, type 2B)

Autosomal dominant syndrome (genetic).

Other stigmata include pheochromocytoma, medullary carcinoma of the thyroid gland

Treatment - Surgical excision of neuroma for cosmetics. Aggresive thyroid cancer develops in second decade - refer patient for testing and possible preventative surgery.

DD - Neurofibromatosis, Focal epithelial hyperplasia, Multiple hamartoma syndrome

Developmental anomalies of the tongue

Fissured tongue (scrotal tongue)

Ankyloglossia

Lingual thyroid

Bifid tongue

Deep central groove in tongue, multiple short furrows, fissured.

Tender if irritated. May be seen with erythema migrans. Possible halitosis.

First and second decades

No gender bias

Found on:

Dorsal and lateral tongue

Fissured tongue (scrotal tongue)

Polygenic or autosomal dominant trait

Down syndrome

Dry mouth

Diabetes

Becomes more prominent with age

Treatment - Brush/scrape tongue (proper oral hygiene). Cant cure but hygeine may reduce prominence.

DD - Erythema migrans, Macroglossia with crenations, Hemihyperplasia of tongue, Orofacial granulamatosis

Short and thick lingual frenum, or attachment of fremum to tip of tongue - may cause a slight cleft at tip

Present at birth

No gender bias

Found on:

Ventral tongue

Floor of mouth

Ankyloglossia (tongue tie)

Can cause:

Language and swallowing problems

Lower incisor gingival recession

Treatment - Frenectomy

DD - bifid tongue, microglossia

Nodular mass with smooth pink or red surface. Potential suffering from dysphagia, dysphonia or dyspnea

Second decade - symptoms developed during puberty or pregnancy

Female prediliction

Found on:

Midline base of tongue

Thyroglossal duct cys (in neck midline)

Lingual thyroid

Normal thyroid absent in 70% of cases

Cause of infantile hypothyroidism

Carcinomas arise in <1%

Treatment - thyroid hormone therapy, excision or radioactive iodine ablation

DD - Lymphoid hyperplasia, Hemangioma, Lymphangioma, Epiglotis

Deep groove in midline of dorsal tongue.

Bifid Tongue

Rare congenital anomaly, lack of fusion of the two lateral parts of the tongue

Most common partial cleft

Treatment - None required, possible accumulation of food debris and bacteria at base of cleft - clean well to avoid irritation.

DD - Partial ankyloglossia

White lesions on tongue

Hairy tongue

Coated tongue (furred tongue)

Cream to brown discolouration of tongue, with diffuse elongation of filliform papillae. Possible halitosis

Second decade

No gender bias

Found on:

Dorsal tongue

Ask: Smoking? Oral hygiene habits and use of mouth rinses? Use of antibiotics?

Hairy tongue

Associated with cigarettes, poor oral hygeine, antibiotics, dry mouth, overuse of mouth rinses.

Coated tongue more common in children

Treatment - Eliminate cause, Brush tongue

DD - Coated tongue, Frictional keratosis, Hyperplastic candidiasis

White or yellow nonadherent coating on dorsal tongue, potential halitosis

Asymptomatic

First and second decades

No gender bias

Coated tongue (furred tongue)

Common, associated with mouth breathing, febrile ilnesses dehydration and poor oral hygiene

Treatment - Brush tongue and adequate hydration. Tends to reccur

DD - Pseudomembranous candadiasis, Hairy tongue, White strawberry tongue

Pigmented lesions of the tongue

Erythema migrans (benign migratory glossitis) “Geographic tongue”

Median romboid glossitis

Lymphangioma

Multiple oval oral circular red patches on tongue with white scalloped border, loss of foliform papillae and pattern changes.

May be burning sensation

May occur with fissured tongue

First and second decades

Female prediliction

Found on:

Dorsal and lateral tongue, rarely at other mucosal sites

Erythema migrans (benign migratory glossitis) “Geographic tongue”

More common in children

Treatment - none required. Topical steroids in symptomatic cases Avoid hot or spicy foods.

DD - Median rhomboid glossitis, Contact allergy, Erythematous candidiasis, Transient lingual papillitis, Lichen planus

Localized red depapilated patch on midline of posterior dorsal tongue. Oval to rhomboid shape, smooth or lobulated durface. May be seen with kissing lesion

Asymptomatic

First and second decades

No gender bias

Median rhomboid glossitis

Caused by candidal infection, may palatal erythema (kissing lesion) may be present.

Treatment - Antifungals and proper oral hygiene

DD - Erythema migrans, Contact allergy, Hemangioma, Lingual thyroid

Localised/diffuse, translucent/red/purple swelling with smooth/pebbly surface. Soft and compressible.

Crepitus may be palpated

Infancy, detectable by 2 years

Found on:

Oral sites - tongue, lip, buccal mucosa

Up to 75% on head and neck

Lymohangioma

May cause - Malocclusion, dysphagia, respiratory problems

Variants - Cystic hygroma and neonatal alveolar lymphangioma

Can also cause airway obstruction and death with large neck or tongue lesions

Most cases detected by 2 years old

Treatment - Surgical excision, reccurances are common

DD - Hemangioma, Squamous papilloma, Lingual papillitis, Mucocele, Plunging ranula

Tumor and tumor like lesions of the tongue

Neurofibroma

Single of multiple nodules with smooths surface. Discrete or diffuse, and can be soft or firm on palpation.

Nontender

Second decade

No gender bias

Found on:

Tongue, buccal mucosa, vestibule and palate

Syndrome lesions occur at any site, especially skin

Neurofibroma

Neurofibromatosis is autosomal dominant trait with neurofibromas, Cafe-a-lait macules, axillary freckling and lisch nodules on iris.

5% malignant transformation of syndrome type

Treatment - Surgical excision if solitary lesion, Selective excision of syndrome type.

DD - Neurilemmoma, Mucosal neuroma, Irriation fibroma, Benign submucosal neoplasm, Salivary gland neoplasm