Common Oral Pathology
Abscess
What is an Abscess?
A dental abscess is a collection of purulent fluid (pus) caused by a bacterial infection. This collection of pus is located in the pulp of the tooth but can spread to the periapical structures of the jaw and beyond if not adequately and appropriately treated.
What causes an Abscess?
The most common cause of a dental abscess is extension of the dental caries process into the pulp of the tooth. Abscesses can also be caused by trauma to the tooth that allows bacteria to enter the pulp. An abscess limited to the tooth structure (ie, pulpitis) will often present with tooth pain from the increased pressure on the nerve endings within the pulp. This pain is often worsened with heat or cold exposure.
If the infection in the pulp extends beyond the tooth, a periapical abscess will develop. The pressure caused by the expanding area of necrosis and inflammation causes visible swelling and may lead to slight extrusion of the tooth from the socket.
As the abscess expands, the pus will spread to contiguous surfaces along the path of least resistance to form a fistula to the maxillary, mandular, or palatal mucosa. If the infection remains unchecked, it can progress to facial, submandibular, or sublingual cellulits. Facial cellulitis presents clinically with swelling, warmth, and tenderness to palpation along the jaw.
What is the treatment for an Abscessed tooth?
Unfortunately, an abscessed tooth often must be extracted, although in cases limited to pulpitis, a root canal may be performed to salvage the tooth. Antibiotic therapy is also required, especially in cases of contiguous spread of the infection. For more severe infections, intravenous delivery of the antibiotics is necessary and patients may require hospitalization.
Canker Sore (Aphthous Ulcer)
What are canker sores?
An Aphthous ulcer, or canker sore, is a type of mouth ulcer which presents as a painful open sore inside the mouth caused by a break in the mucous membrane.
They appear red with a white coating and a white ‘halo’ or border around the red center. They can form on the insides of the lips, cheeks, the base of the gums, under the tongue, or the roof of the mouth.
What causes canker sores?
May be triggered by:
- Stress
- Trauma
- Poor nutrition
- Food allergies
- Menstrual periods
- Sodium Laurel Sulfate (an ingredient found in many types of toothpaste)
What is the recommended treatment for a canker sore?
Canker sores usually go away without any treatment in 7 to 10 days. For pain relief, take your regular OTC pain reliever that you normally use.
Other medicines, such as Anbesol, Oragel, Orabase and Zilactin-B, might keep canker sores from becoming irritated by eating, drinking or brushing your teeth. These can be put right on the sore.
In our office, we use a topical medicine called DeBacterol. It is placed on the canker sore and reduces healing time to 3 to 5 days. The medicine numbs the canker sore for immediate relief.
What can I do to prevent canker sores?
Unfortunately, doctors don't know of anything that prevents canker sores from forming.
However, using toothpaste that does not contain SLS (sodium lauryl sulfate) and other irritating ingredients, avoiding hard, crunchy or spicy foods and chewing gum may help reduce mouth irritation.
Brushing your teeth after meals, using a soft toothbrush and flossing every day will also keep your mouth free of food that might cause a canker sore.
When you notice that you have just gotten a canker sore, and it is not trauma related, write down everything that you have eaten in the last 24 hours. Do that each time you get one and you may see a common food that caused your canker sore.
Oral Herpes (Cold Sores)
What are oral herpes?
Oral herpes in an infection caused by the Herpes Simplex Virus (HSV). This virus can cause painful sores on the lips, tongue, roof of the mouth, and face. Herpes Simplex Virus-1 causes 80% of oral herpes infections.
Between 20% to 40% of initial oral HSV-1 infections recur within one year. Recurrences are milder than the primary infection, and are commonly known as cold sores or fever blisters. Fever blisters on the lips and face is called Herpes Simplex Labialis. This condition lasts about 7-10 days in healthy children.
Oral herpes infections should not be confused with canker sores (aphthous ulcers). Aphthous ulcers are not caused by viruses, and appear as small white or grayish ulcers on the movable (unattached) gingival tissue.
Once you are infected with the herpes virus, it lies dormant in your body and can become reactivated at any time, especially in times of stress.
The Disease Process of Oral Herpes:
Immediately after a child has been infected with the oral herpes virus, the infection proceeds to three distinct stages: primary herpes infection, dormancy, and recurrent herpes infection.
PRIMARY INFECTION:
This is the first infection a child will experience with the HSV-1 virus. The virus enters through abraded skin or normal intraoral tissue (mucous membrane). An oral infection called Primary Herpetic Gingivostomatitis can develop at this time.
LATENCY (DORMANCY):
After the primary infection, the viral particles move from the skin through branches of nerve cells that end at the trigeminal nerve ganglia, facial nerve ganglia, or dorsal root spinal ganglia. While residing in the ganglia, the herpes virus reproduces, and then becomes inactive (dormant). It is also possible for the virus to become dormant in the lips.
RECURRENT ORAL HERPES (HERPES SIMPLEX LABIALIS):
Approximately 30 to 40 percent of children who have been exposed to HSV will develop recurrent infections. These recurrent infections are a reactivation of the herpes simplex virus. The first symptoms may include a tingling or itching sensation on the lips or face. Recurrent herpes blisters usually appear around the lips within 12-36 hours after the first symptoms (the prodrome) appear. The blisters (vesicles) rupture quickly, and coalesce into larger lesions that have a crusted surface. In healthy children, these recurrent lesions on the lips and face will heal without scarring within seven to fourteen days.
The body normally produces an immune response to HSV, but the immune system cannot eradicate the virus completely. For patients with a depressed immune system, a herpes virus infection can have life-threatening consequences. Occasionally during the primary infection in infants, the virus can spread to the brain and cause aseptic meningitis, or disseminated neonatal HSV infection.
How does transmission occur?
The herpes virus is transmitted by person to person contact through infectious lesions of the skin and/or secretions. For example:
Kissing an infected child or adult
Eating with contaminated utensils
Mouthing or playing with contaminated toys
Using a contaminated toothbrush
Exposure to another child who has an oral herpes infection
What does herpes look and feel like?
The hallmark of herpes is grouped blisters on a red base. These can form on the lips, tongue, the roof of the mouth, and face. These blisters dry up rapidly and leave scabs that last anywhere from a few days to a few weeks, depending on the severity of the infection. Herpes infections feel dry and crusty and they sometimes itch.
Some patients have a "prodrome," which is the occurrence of certain symptoms before the actual condition becomes fully evident. The prodrome to herpes infections typically involves a burning or tingling sensation that precedes the appearance of blisters by a few hours or a day or two.
Herpes should not be confused with canker sores. Canker sores are not caused by a virus, and appear as small whitish or grayish ulcers on the movable (unattached) gingival tissue.
First Herpes Outbreak aka Primary Herpetic Gingivostomatitis:
The first attack of herpes is the most severe and may cause children to become very sick. It may cause fever, swollen glands, bleeding gums, together with painful sore(s) around the mouth. These signs and symptoms may last several days. Difficulty in eating and drinking may lead to dehydration. The viral infection typically lasts 10 to 14 days.
Recurrent Outbreak aka Herpes Labialis:
These lesions usually appear within 12-36 hours after the initial tingling or itching feeling (prodrome). Where the outbreak appears depends on where the virus has been hibernating. Most often this is the familiar cold sore that appears on the lip margins. When labial herpes reappears, it usually occurs at most a few millimeters away from its previous location(s).
What is the recommended treatment for herpes?
Avoiding certain triggers:
- UVB radiation from sunlight (use sunscreen)
- Oral or lip tissue injury
- Physical or emotional stress
- Common cold and influenza (get adequate rest)
- Malnutrition (drink plenty of liquid and maintain a healthy diet, especially when sick)
OTC topical medications:
Abreva, Docosanol, Zilactin or Anbesol.
Prescribed Oral medications:
“Magic Mouth Wash” may be prescribed to your child if they have a primary oral herpes infection. This can be applied with a cotton swab.
Acyclovir or Valtrex can also be prescribed in a liquid or a tablet form.
Tips for Parents:
For recurrent herpes infection, consider using an OTC product such as Abreva– which will decrease pain and healing time.
For any herpes infection, discourage your child from touching oral sores. Wash your child’s hands frequently to prevent infecting the eyes or other parts of the body.
Do not let an infected child kiss siblings or other loved-ones.
Blisters and cold sores should be kept dry.
Eating utensils should be thoroughly washed either by a dishwasher, or by hand – using hot, soapy water. Infected children must not share utensils, cups or small toys.
Provide children’s Tylenol for fever and muscle aches.
Provide plenty of fluids to prevent dehydration.
Oral Candidiasis (Thrush)
What is Thrush?
White plaques or pseudomembranes are noted on the surface of the tongue or the gum tissue. Removal of the plaques shows underlying raw, red, bleeding mucosa. Oral surfaces may become painful, which can interfere with feeding.
What causes Thrush?
Thrush is a fungal infection caused from C albicans. In children older than 6 months of age who have persistent or frequently recurring candidal, a referral to the child’s pediatrician may be necessary. This may indicate an immunosuppressive condition.
Is Thrush common?
Yes, it is especially common in infants, but triggers for all age groups include systemic antibiotic use, inhaled steroids, diabetes, xerostomia (dry mouth), and poor oral hygiene.
What is the treatment for Thrush?
Topical antifungal agents (eg, Nystatin or Clotrimazole).
If symptoms persist or recur shortly after discontinuation of the antifungal agent, consider re-infection (eg, pacifiers, bottles, breastfeeding with maternal breast colonization) or antifungal medication resistance.
Benign Migratory Glossitis (Geographic Tongue)
What is Geographic tongue?
This is the loss of papillae (tongue projections) on certain areas of the tongue that appear smooth, red, and shiny. The areas “migrate” by progression of papillae loss at the leading edge and regeneration at the other end. Usually noted on the dorsum (top) of the tongue.
What is the cause?
The cause is unknown.
What is the treatment for Geographic Tongue?
Treatment is unnecessary as it poses no problem. May be irritated by acidic foods.
Strawberry Tongue
What is Strawberry tongue?
This refers to a diffusely red tongue with prominent papilla, giving the appearance of a strawberry. The tongue may also be very inflamed and swollen. There is often a white membrane at first, and then it peels off, leaving a red base.
What is the cause of Strawberry Tongue?
Associated with 4 conditions:
1. Group A Beta Hemolytic Strep
2. Kawasaki syndrome
3. Scarlet Fever
4. Bacterial Toxic Shock Syndrome
What is the treatment?
Treatment depends on the diagnosis. Antibiotic treatment may be necessary.
Pyogenic Granuloma
What is a Pyogenic Granuloma?
Red, painless masses usually located on the gingiva. These lesions are characterized by bleeding with minor trauma.
What causes it?
These are caused by vascular overgrowth in response to a local irritant or trauma.
What is the recommended treatment?
A Pyogenic Granuloma may require surgical excision.
Angular Cheilitis
What is Angular Cheilitis?
Angular Cheilitis presents as red fissures or erosions at the corners of the mouth. They may cause a painful or burning sensation.
What is the cause of Angular Cheilitis?
This may be triggered by lip-licking, sensitivity to a compound, vitamin deficiency (riboflavin) or iron deficiency.
May also be caused or worsened by candidal or staph superinfection.
What is the treatment?
Topical yeast treatment (Nystatin), topical antibiotic agents (Mupirocin), or low-dose topical steroids.
Leukoplakia
What is Leukoplakia?
This is a “white patch” that occurs in the oral cavity.
What is the cause?
In children, they are most often the result of chronic irritation, such as cheek or tongue biting.
Etiologies may also include vitamin deficiency and candidiasis.
If the lesions are unusual or persistent, or if the child has other unusual features, it may be a genetic condition, including dyskeratosis congenita.
In adults, especially those who are chronic tobacco users, leukoplakia is considered a pre-malignant lesion, but this is not the case for children.
Morsicatio Buccarum
What is Morsicatio Buccarum?
Chronic, often subconscious, cheek biting that results in mucosal shredding, redness, ulcers or leukoplakia (white patch) in the areas of biting.
What is the cause?
Chronic trauma to the tissue causes a defense mechanism to occur in the body. The tissue responds to friction by producing keratin and becoming thickened in what is termed hyperkeratosis. Depending on the degree of trauma, the tissue may also become ulcerative and eroded in areas.
What is the recommended treatment?
As with all extraoral and internal lesions, evaluation and monitoring is optimal. In some cases, chronic irritation may develop into more serious concerns.
