Oral Disorders

20 Oral Disorders

Assessment Techniques

Because oral and oropharyngeal problems and disorders are common and cause a wide variety of symptoms, a thorough oral examination is an essential component of a complete physical examination, enabling the practitioner to make appropriate diagnosis without undue delay.

Key elements of the oral/dental history include the following:

A systematic approach to the examination of a child’s dentition is essential and should include assessment of the following:

Successful examination requires close visual inspection of the face; palpation of suspected areas of abnormality; and systematic inspection of the dentition, its supporting structures, and the oral soft tissues. This can be challenging with young children, but patience and a gentle, even playful manner can be of great help. At least initially, young children should be allowed to sit on the parent’s lap. Toys, puppets, and a rubber glove blown up into a balloon can serve as useful distractions. Drawing a face on a tongue depressor and giving it to the child to hold, as well as letting the child look in the dental mirror, are good ways to introduce these basic instruments and make them less threatening. If an otoscope is being used as a light source in a medical office setting, letting the child “blow out the light” is another good introductory game, as is demonstrating the examination on the parent or examiner. Then the examiner can gradually begin the hands-on assessment. In younger children, a “lap exam” may be a useful way to examine an apprehensive child (Fig. 20-1). The parent places the child in their lap, facing them, and the child’s head reclines into the examiner’s lap. It is important to have the parent hold the child’s hand during the examination. A lap examination is not advised if the mother is pregnant, as the child may accidentally kick the mother. If cooperation cannot be achieved despite these measures, immobilization in a papoose board may be necessary. With older children, examination of the patient in the supine or semirecumbent position with good lighting assists visualization and may be more practical.

Use of a tongue depressor may be necessary to ensure direct visual access to all intraoral areas, and a dental mirror can be quite helpful, especially in assessing the lingual surfaces of the anterior teeth and gingiva and the buccal surfaces of rear molars. Extra effort and patience may be required to ensure that the mucobuccal folds, sublingual space, lingual surface of the anterior teeth, and anterior palate are adequately visualized.

The special aspects of the history and physical assessment of dental and orofacial trauma are detailed in Trauma to the Dentition, later in this chapter.

Normal Oral Structures

The oral cavity, including the teeth, gingiva, and periodontal ligaments, is in a constant state of evolution during infancy and childhood. From the early teething stage, through the eruption and exfoliation of the primary dentition, and finally to the eruption of all permanent teeth, the oral cavity provides one of the most visible signs of development.

To assist understanding of this chapter and communication when consulting dentists, a review of basic terminology is in order. Each tooth is composed of an outer protective enamel layer; an inner layer of dentin consisting of tubules, which are thought to serve a nutritional function; and a central neurovascular core termed the pulp. The roots of the teeth are anchored in the sockets of the alveolar processes of the mandible and maxilla by an encompassing periodontal membrane or ligament. The neurovascular supply to the root apex also passes through this structure. The bony processes between the teeth are referred to as the interdental septae (Fig. 20-2).

After eruption, the visible portions of teeth are referred to as the crowns, and the interface between them and the gingiva is termed the gingival crevice. Finally, the portions of the gingiva located between teeth are called interdental papillae.

Oral Cavity in the Newborn

The lips of an infant reveal a prominent line of demarcation at the vermilion border. The mucosa may look wrinkled and slightly purple at birth, but within a few days it exhibits a drier appearance, with the outer layer forming crusty “sucking calluses.” This callus formation affects the central portion of the mucosa and persists for a few weeks to a few months.

The maxillary alveolar arch is separated from the lip by a shallow sulcus. In the midline the labial frenulum extends posteriorly across the alveolar ridge to the palatine incisive papilla. Two lateral miniature frenula are also evident. The alveolar ridge peaks anteriorly and gradually flattens as the ridge extends posteriorly, forming a pseudoalveolar groove medial to the ridge along its palatal side. This flattened appearance is seen in young infants and gradually disappears with the growth of the alveolar process and the formation and calcification of posterior tooth buds. The mandibular alveolar ridges also peak anteriorly and flatten posteriorly. The mandibular labial frenulum connects the lower lip to the labial aspect of the alveolar ridge. Careful visual inspection and palpation of the ridges should confirm the presence and location of tooth buds. Anterior tooth buds are located on the labial side of the alveolar ridges, whereas posterior tooth buds are often located closer to the crests of the alveolar ridges. Palatal morphology and color are variable. The tongue and the floor of the mouth differ only slightly from those of older children.

Primary Dentition

Development of the alveolar bone is directly related to the formation and eruption of teeth, and normal patterns of dental development occur symmetrically. Eruption times and sequence may be extremely variable, but typically at approximately 6 months of age, the mandibular central incisors erupt. This stage is often preceded by a period of increased salivation, local gingival irritation, and irritability. These symptoms may vary in intensity, but they respond well to oral analgesics and usually subside when the primary tooth erupts into the oral cavity. Other symptoms such as fever or diarrhea have never been proven to be directly related to teething. The lower incisors are soon followed by the maxillary central incisors and the maxillary and mandibular lateral incisors (Fig. 20-3). By the end of the first year, all eight anterior teeth are usually visible. At 2 years, all primary teeth have erupted with the exception of the second primary molars, which erupt shortly thereafter. By the age of 3 years, the full primary dentition is typically present and functional (Fig. 20-4).

Any variation in the time and sequence of eruption in an otherwise normal infant may call for early dental referral. In most instances, careful observation is the best course of action. For example, delayed eruption of primary teeth for up to 8 months is occasionally observed, and if seen in the absence of other abnormalities may be a normal variation. Delayed dentition can be a feature of moderate to severe cases of failure to thrive, where it is seen in association with and is a visible reflection of delayed bone age. More rarely, delayed eruption is associated with Down syndrome, hypothyroidism, hypopituitarism, achondroplastic dwarfism, osteopetrosis, rickets, or chondroectodermal dysplasia. A significant variation affecting a single tooth or only a few teeth should be carefully investigated as well.

Spacing (extra space between teeth) during this stage is normal and desirable and often indicates that more space is available for the larger permanent teeth. The completed primary dentition establishes a baseline that dictates to a great extent the future alignment of permanent teeth and the future relationship between the maxillary and mandibular arches.

During most of the primary dentition stage, the gingiva appears pink, firm, and not readily retractable. A well-defined zone of firmly attached keratinized gingiva is present, extending from the bottom of the gingival sulcus to the junction of the alveolar mucosa. Rarely, local irritation may develop into acute or subacute pericoronitis, with elevated temperature and associated lymphadenopathy (see Fig. 20-50). Topical and/or systemic therapy may be required for treatment; however, lancing the gingiva to relieve such symptoms is not usually indicated.

Mixed Dentition

The mixed dentition stage of development begins with the eruption of the first permanent molars at about 6 years of age and continues for approximately 6 years. During this period, the following teeth erupt from the gums in sequence: mandibular central incisors, maxillary central incisors, mandibular lateral incisors, maxillary lateral incisors, mandibular cuspids, maxillary and mandibular first premolars, maxillary and mandibular second premolars, maxillary cuspids, and mandibular and maxillary second molars (Fig. 20-5).

The mixed dentition during this stage undergoes certain physiologic changes including root resorption followed by exfoliation of primary teeth, eruption of their successors, and eruption of the posterior permanent teeth. During the period of root resorption of primary teeth, and for several months after the eruption of permanent teeth, the teeth are relatively loosely embedded in the alveolar bone and more vulnerable to displacement by trauma. Other minor complications may occur during resorption and exfoliation of primary teeth and eruption of permanent teeth. Gingival irritation can occur as a result of increased mobility of primary teeth but usually disappears spontaneously when the tooth is lost or extracted. Two transient deviations of eruption pattern may occur: the mandibular incisors may erupt in a lingual position behind the primary incisors (“double teeth”) (Fig. 20-6), and the maxillary incisors may assume a widely spaced and labially inclined position (“ugly duckling” stage). Finally, the occlusal surfaces of newly erupted permanent teeth are relatively “rough” (see Figs. 20-5 and 20-43), assisting plaque accumulation that increases the risk of staining, gingivitis, and formation of caries.

Early Permanent Dentition

The stage of early permanent dentition marks the beginning of a relatively quiescent period in dental development. Activities are limited to root formation of a few permanent teeth and the calcification of the third molars. By this time the length and width of the dental arches are well established (Fig. 20-7); however, the jaws undergo a major growth spurt during puberty that alters their size and relative position. The gingiva begins to assume adult characteristics, becoming firm and pink in color, with an uneven, stippled surface texture and a thin gingival margin. Puberty is occasionally associated with gingivitis, thought to be secondary in part to hormonal changes (Fig. 20-8). The gingivae become mildly edematous and erythematous and bleed with brushing (the common chief complaint). Inattention to careful dental hygiene may also contribute to development of this disorder, which necessitates good oral hygiene for control.

In Figure 20-9 the primary and permanent dentition are presented diagrammatically.

Harmful Oral Habits

Natal and Neonatal Abnormalities


Teeth that are present in the oral cavity at birth are called natal teeth, whereas those erupting during the neonatal period (30 days after birth) are called neonatal teeth. The incidence of natal teeth has been reported to be approximately 1 in 2000 births. Although seen in normal infants, this anomaly is more frequent in patients with cleft palate (Fig. 20-12) and is often associated with the following syndromes: Ellis-van Creveld syndrome, Hallermann-Streiff syndrome, and pachyonychia congenita. The majority, about 90%, of such teeth are true primary teeth, but occasionally they are supernumerary. Some are abnormal, with either hypoplastic defects or poor crown or root development. Natal teeth may cause feeding problems for both the infant and mother. Ulceration of the ventral surface of the tongue by sharp tooth edges (Riga-Fede disease) may develop if natal teeth remain in the oral cavity. This condition is usually transient, but in persistent cases symptomatic treatment or extraction of such teeth may be indicated. Most normal-appearing natal teeth can be retained, but those that are supernumerary, abnormal, or very loose may have to be removed.

Congenital Epulis in the Newborn

Congenital epulis is a benign, soft tissue tumor seen on the alveolar mucosa at birth or shortly after. It is usually found on the anterior maxilla as a pedunculated swelling (Fig. 20-16) but may appear on the mandible or occasionally on both jaws. The mass is firm on palpation, and the overlying mucosa appears normal. Histologically, sheets of large granular cells are seen. Differential diagnosis should include rhabdomyoma and melanotic neuroectodermal tumor of infancy. The lesion is amenable to conservative surgical excision, and recurrence is infrequent.

Developmental Abnormalities

Soft Tissue Abnormalities

Abnormalities of the Frenula

During embryonic life, the maxillary labial frenulum extends as a band of tissue from the upper lip over and across the alveolar ridge and into the incisive (palatine) papilla. Postnatally, as the alveolar process increases in size, the labial frenulum separates from the incisive papilla and becomes relatively smaller. With the eruption of primary and later permanent teeth, the frenulum attachment moves apically and further atrophies as a result of vertical growth of the alveolar process. The developmental gap (diastema) between the maxillary central incisors tends to close with the full eruption of the maxillary permanent canines. On occasion the maxillary frenulum fails to atrophy and the diastema persists (Fig. 20-19). The mandibular midline frenulum only rarely maintains a lingual extension and therefore only rarely causes a diastema between the mandibular central incisors.

The lingual frenulum extends almost to the tip of the tongue in early infancy and then gradually recedes. On occasion, ankyloglossia (tongue tie) is seen (Fig. 20-20), but this is rarely associated with feeding or speech difficulties. Various surgical procedures have been advocated to correct this condition. In general, frenulectomy is seldom indicated and should be recommended only after appropriate justification. Congenital anomalies may include an enlarged frenulum, labiolingual frenulum extensions, or supernumerary frenula as seen in orofaciodigital syndrome (Fig. 20-21).

Gingival Hyperplasia

Generalized gingival hyperplasia is a fairly common nonspecific pathologic entity. This disorder is frequently a complication of drug therapy, as it is seen in patients given phenytoin and cyclosporine. Gingival hyperplasia may also be idiopathic or genetically transmitted as in familial fibromatosis. Differentiation of various types of hyperplasia must be based on thorough physical evaluation and appropriate medical history. Histopathologically, it is impossible to differentiate among these various disorders; therefore the final diagnosis and recommendations for therapy should be based on all available clinical data and an appropriate dental consultation.

Phenytoin-induced Gingival Hyperplasia

The administration of phenytoin over a period of time frequently causes generalized hyperplasia of the gingiva (Fig. 20-22, A and B). The gingiva may become secondarily inflamed, edematous, and boggy, especially if proper oral hygiene is not practiced. The severity is often related to the degree of local irritation, stemming from poor oral hygiene, mouth breathing, caries, or poor occlusion (alignment). Because hyperplasia tends to recur after surgical excision, gingivectomy is usually reserved for those patients whose overgrowth interferes with function and for those whose therapy has been discontinued.

Eruption Cysts (Eruption Hematoma)

An eruption cyst is a fluid-filled swelling, nontender in the majority of cases, over the crown of an erupting tooth. When the follicle is dilated with blood, the lesion takes on a bluish color and is termed an eruption hematoma (Fig. 20-23). Although the eruption cyst is a superficial form of dentigerous cyst, it rarely impedes eruption. Surgical exposure of the crown is seldom necessary. Rarely, such a cyst may become secondarily infected. In such cases, patients complain of headache or facial pain and the cyst is tender on palpation. Incision and drainage are required typically when infection has developed.

Mucocele and Ranula

A mucocele is a painless, translucent or bluish lesion of traumatic origin, most often involving minor salivary glands of the lower lip (Fig. 20-24). The lesion may alternately enlarge and shrink. The treatment of choice is surgical excision of the lesion and the associated minor salivary gland.

A simple ranula is a retention cyst in the floor of the mouth that is confined to sublingual tissues superior to the mylohyoid muscle. It appears clinically as a bluish, transparent, thin-walled, fluctuant swelling (Fig. 20-25). Herniation of the ranula through the mylohyoid muscle results in a cervical or plunging ranula that becomes more apparent in the oral cavity with the muscle contraction associated with jaw opening. Simple incision and drainage of the ranula is not an acceptable treatment because healing is followed by recurrence. Marsupialization by suturing the edges of the opened cystic wall to the mucous membrane is the recommended treatment. The plunging ranula must be removed in its entirety along with the associated salivary gland to avoid recurrence.

Salivary Calculus (Sialolithiasis)

Formation of a salivary calculus is rare in the pediatric population, but when it does occur it may affect either the Wharton duct or Stensen duct (Fig. 20-26, A). Partial obstruction of the duct results in pain and enlargement of the gland, especially at mealtime. Although palpation of the stone may be possible, dental radiographs confirm the diagnosis and give appropriate information about its size and location (Fig. 20-26, B). Larger salivary stones wedged within the ducts may cause localized irritation and secondary infection. If the calculus cannot be manipulated through the duct, surgical intervention may be necessary.

Hard Tissue Abnormalities

Hyperdontia and Hypodontia

Variations in tooth number include both hyperdontia and hypodontia. Supernumerary teeth occur in about 3% of the normal population, but patients with cleft lip and/or cleft palate and cleidocranial dysplasia have a significantly higher incidence. The most common site is the anterior palate (Fig. 20-27). Supernumerary teeth may have the size and morphology of adjacent teeth or may be small and atypical in shape. They may erupt spontaneously or remain impacted. Early consideration of removal is justified because of complications such as impeded eruption, crowding, or resorption of permanent teeth; cystic changes; or ectopic eruption into the nasal cavity, the maxillary sinus, or other sites (Fig. 20-28).

Congenital absence of teeth is more often seen in the permanent dentition than in the primary. Most frequently missing are third molars, second premolars, and lateral incisors. Hypodontia is frequently associated with several ectodermal syndromes such as anhidrotic ectodermal dysplasia and chondroectodermal dysplasia (Fig. 20-29).

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Jul 11, 2016 | Posted by in PEDIATRICS | Comments Off on Oral Disorders

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