Protecting All Children’s Teeth
Common Oral Pathology
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Introduction
Mouth pain is a common presenting complaint in the primary care
office.
It is imperative that pediatric health care professionals feel
comfortable in the proper diagnosis, management, and triage of
common oral pathology.
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Learner Objectives
Upon completion of this presentation, participants will be able to:
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Recall the common causes, bacterial flora, management, and
possible sequelae of dental abscesses.
Describe the common clinical signs, symptoms, and
management options of Temperomandibular joint (TMJ)
disorders.
Define and discuss the term referred pain as it relates to the
mouth.
Discuss the clinical presentation, causative agents, diagnosis,
and management of primary gingivostomatitis, herpangina,
hand-foot-mouth disease, and thrush.
List the 2 common conditions that cause "strawberry tongue.”
Abscess
A dental abscess is a collection of
purulent fluid caused by a bacterial
infection.
The most common cause of a dental
abscess is extension of the dental
caries process into the pulp of the
tooth.
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Used with permission from Miller Medical Illustration & Design
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Abscess, continued
Abscesses can also be caused by
trauma to the tooth that allows
bacteria to enter the pulp.
An abscess limited to the tooth
structure (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.
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Used with permission from Melinda B. Clark, MD;
Associate Professor of Pediatrics at Albany Medical Center
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Abscess Progression
If the infection in the pulp extends
beyond the tooth, a periapical
abscess will develop.
Used with permission from Noel Childers, DDS, MS, PhD; Department of Pediatric Dentistry,
University of Alabama at Birmingham
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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 shown in the x-ray to
the left).
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Abscess Progression, continued
As the abscess expands, the pus
will spread to contiguous surfaces
along the path of least resistance
to form a fistula to the maxillary,
mandibular, or palatal mucosa.
Used with permission from Noel Childers, DDS, MS, PhD; Department of Pediatric Dentistry,
University of Alabama at Birmingham
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Cellulitis
If the infection remains unchecked,
an abscess can progress to facial,
submandibular, or sublingual
cellulitis.
Facial cellulitis presents clinically with
swelling, warmth, and tenderness to
palpation along the jaw.
A child with facial cellulitis should be
referred for immediate ER evaluation
or admitted to the hospital for IV
antibiotics.
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Used with permission from Noel Childers, DDS, MS, PhD; Department of Pediatric
Dentistry, University of Alabama at Birmingham
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Symptoms of an Abscess
Patients with abscess may present with the following symptoms:
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Headache
Fever
Periorbital edema or pain
Cranial nerve abnormalities.
This infection can be life-threatening and must be addressed
emergently.
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Abscess Treatment
First-line empiric antibiotic therapy for dental abscesses is penicillin or
amoxicillin and clindamycin for penicillin-allergic patients.
Suspicion of a dental abscess requires urgent referral to a dentist for
definitive care.
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Abscess Treatment, continued
Efforts must be made to locate the site of infection, incise and drain
the pus collection, and collect a specimen for culture and sensitivities.
An abscessed tooth often must be extracted. Antibiotic therapy is
also required, especially in cases of contiguous spread of the
infection.
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Temporomandibular Joint Disorders
The temporomandibular joint (TMJ) is the area directly in front of the
ear on either side of the head where the upper jaw (maxilla) and
lower jaw (mandible) meet.
Temporomandibular joint disorders include a range of problems
related to this joint.
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Signs of TMJ
Signs of TMJ disorders include:
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Bruxism
Wear of the occlusal surfaces of the teeth due to tooth grinding
Joint sounds (clicking and crepitus)
Limited mandibular opening
Pain, including TMJ pain or headache, may occur but is not always
present.
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TMJ Treatment
Referral to a dentist or other professional knowledgeable in treating
TMJ disorders is appropriate.
Treatment is usually initiated when pain is present. Options include:
• Non steroidal anti-inflammatory medication
• Soft diet
• Warm compresses
• Occlusal bite guards
• Counseling
• Physical therapy
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Referred Pain
Referred pain is felt in an area innervated by a nerve different from
that which innervates the primary site of pain.
Dental pain can refer to other teeth, the head, ear, eye, periorbital
region, or jaw.
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Referred Pain, continued
The following non-oral conditions can cause pain felt in the teeth or
mouth:
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Acute maxillary bacterial sinusitis or acute otitis media
Temporomandibular Joint
Atypical facial pain
Trigeminal neuralgia
Migraine headaches
Psychogenic
Neoplasia, such as leukemia
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Primary Herpetic Gingivostomatitis
Primary Herpetic Gingivostomatitis is
caused primarily by herpes simplex
virus type 1.
Used with permission from Rama Oskouian
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The primary infection is most severe
and usually seen in children younger
than 6.
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Primary Herpetic Gingivostomatitis
The clinical syndrome of HSV gingivostomatitis lasts 10-14 days.
Diagnosis is usually based on clinical history and exam findings.
Clinical presentation includes:
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Fever and malaise (precede the anorexia, oral findings, and
cervical lymphadenopathy)
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Significant lip and gum swelling, erythema, and bleeding
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Vesicles on the lips, tongue, and cheeks, which then ulcerate
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Treatment for Primary Herpetic
Gingivostomatitis
Treatment is mainly supportive with hydration maintenance and pain
control.
The acyclovir family of antiviral medications may be used for
immunosuppressed patients.
The infection is life-long, and
recurrences occur as “cold sores”
(herpes labialis), usually at times of
stress or infection.
Used with permission from Rama Oskouian
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Herpes Labialis
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Coxsackie Viral Infections
Herpangina
Coxsackie viral infections include
Herpangina and Hand-Foot-Mouth
Disease.
Fever, malaise, sore throat, and
anorexia precede appearance of the
vesicles. Cervical lymphadenopathy is
also present.
Used with permission from the AAP Red Book
Symptoms last 7-10 days.
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Treatment is supportive care.
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Oral Candidiasis
White plaques or pseudomembranes
are noted on the surface of the tongue
and/or the buccal, labial, and gingival
mucosa.
Used with permission from Noel Childers, DDS, MS, PhD; Department of Pediatric Dentistry,
University of Alabama at Birmingham
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Removal of the plaques shows
underlying raw, red, bleeding mucosa.
Oral surfaces may become painful,
which can interfere with feeding.
Oral Candidiasis is common in infants, but triggers for all age groups
include systemic antibiotic use, inhaled steroids, diabetes, xerostomia,
and poor oral hygiene.
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Oral Candidiasis, continued
Oral Candidiasis can be treated with topical antifungal agents, such as
Nystatin or Clotrimazole.
Used with permission from ANZ Photography
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If symptoms persist or recur shortly
after discontinuation of the
antifungal agent, consider reinfection from bottles, pacifiers, or
breastfeeding (with maternal breast
colonization) or resistance to
antifungal medication.
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Strawberry Tongue
Strawberry Tongue refers to an
inflamed tongue.
It presents as either a diffusely
erythematous tongue with prominent
fungiform papillae or a tongue
covered by a white membrane
except for the fungiform papillae
that appear red.
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Used with permission from the AAP Red Book
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Strawberry Tongue, continued
Strawberry Tongue is associated with Group A Beta Hemolytic Strep
and Kawasaki syndrome.
Group A Beta Hemolytic Strep causes erythematous and enlarged
tonsils with white exudates, anterior cervical lymphadenopathy, and
fever.
Clinical presentation of Kawasaki syndrome is 5 days of fever
associated with other clinical criteria, including oral mucosal findings
such as a strawberry tongue.
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Question #1
Which of the following signs is not expected to be seen in a
Temporomandibular Joint (TMJ) disorder?
A. Swelling and erythema over the joint
B. Clicking of the joint
C. Wearing of the occlusal surfaces of the teeth
D. Limited jaw opening
E. Crepitus over the joint
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Answer
Which of the following signs is not expected to be seen in a
Temporomandibular Joint (TMJ) disorder?
A. Swelling and erythema over the joint
B. Clicking of the joint
C. Wearing of the occlusal surfaces of the teeth
D. Limited jaw opening
E. Crepitus over the joint
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Question #2
What is the most common cause of a dental abscess?
A. Trauma to the tooth
B. Ludwig's angina
C. Extension of the dental caries process into the pulp of the tooth
D. Bruxism
E. Facial cellulitis
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Answer
What is the most common cause of a dental abscess?
A. Trauma to the tooth
B. Ludwig's angina
C. Extension of the dental caries process into the pulp of the tooth
D. Bruxism
E. Facial cellulitis
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Question #3
Which of the following conditions can cause pain in the teeth
or mouth?
A. Migraine headaches
B. Acute maxillary bacterial sinusitis
C. Leukemia
D. Acute otitis media
E. All of the above
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Answer
Which of the following conditions can cause pain in the teeth
or mouth?
A. Migraine headaches
B. Acute maxillary bacterial sinusitis
C. Leukemia
D. Acute otitis media
E. All of the above
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Question #4
Which of the following statements about Oral Candidiasis is
not true?
A. The same fungus causes angular cheilitis
B. It should be treated with antiviral medication
C. Re-infection from bottles or pacifiers is possible
D. It can be triggered by antibiotic use
E. It is common in infants
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Answer
Which of the following statements about Oral Candidiasis is
not true?
A. The same fungus causes angular cheilitis
B. It should be treated with antiviral medication
C. Re-infection from bottles or pacifiers is possible
D. It can be triggered by antibiotic use
E. It is common in infants
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Question #5
Which of the following statements is true when treating an
abscess?
A. The first step is to locate the site of infection
B. In severe cases, intravenous antibiotics are necessary and
hospitalization may be required
C. An abscessed tooth often must be extracted
D. In cases limited to pulpitis, a root canal may be performed to
salvage the tooth
E. All of the above
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Answer
Which of the following statements is true when treating an
abscess?
A. The first step is to locate the site of infection
B. In severe cases, intravenous antibiotics are necessary and
hospitalization may be required
C. An abscessed tooth often must be extracted
D. In cases limited to pulpitis, a root canal may be performed to
salvage the tooth
E. All of the above
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References
1. Avcu N, Gorduysus M, Omer Gorduysus M. Referred dental pain. The Pain Clinic. 2003;
15(2): 173-178.
2. Ferretti GA, Cecil JC. Kids Smile: Oral Health Training Program Lecture Series.
Sponsored by the Kentucky Department for Public Health and the University of Kentucky
College of Dentistry.
3. Handbook of Pediatric Dentistry. 2nd ed. Cameron AC, Widmer RP (Eds). Mosby; 2003.
4. Krol DM, Keels, MA. Oral Conditions. Pediatr Rev. 2007; 28(1): 15-22.
5. Okeson JP, Falace DA. Nonodontogenic toothache. Dental Clinics of North America.
1997; 41(2): 367-83.
6. Oral Pathology: Clinical Pathologic Correlations. 4th ed. Regezi JA, Sciubba JJ, Jordan
RCK (Eds) WB Saunders, St Louis Mo. 2003.
7. Pediatric Dentistry: Infancy through Adolescence. 4th ed. Pinkham JR, Casamassimo
PS, Fields HW, McTigue DJ, Nowak AJ (Eds). WB Saunders, St Louis, Mo. 2005.
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