Oral Conditions (2007)

After completing this article, readers should be able to: This review addresses a variety of oral conditions that clinicians likely encounter in their practices, some more often than others. Recognition of normal and abnormal features of a child’s mouth is an important part of the physical examination because oral health is an integral part of a child’s overall health.Candidiasis is the most common oral fungal infection of infants and children. Although this infection can lead to serious complications when systemic, invasive, or manifested in immunocompromised individuals, it is encountered more commonly by the primary care pediatrician in a more benign presentation.A variety of species of the genus Candida can lead to oral disease in humans, including C albicans, C glabrata, and C tropicalis. C albicans is the species associated most commonly with oral candidiasis, accounting for 70% to 80% of the oral isolates. Candida is a dimorphic fungus that can exist in both a yeast phase (blastospore) and a hyphal phase. This ability to exist in two forms contributes to its ability to spread, survive, and cause disease.Even in the absence of disease, as many as 60% of healthy individuals may harbor Candida in their oropharyngeal region, not to mention on the skin and in the intestinal tract and vaginal area. Most commonly, infants acquire Candida during passage through the vagina or postnatally. Oral candidiasis, commonly known as thrush, affects approximately 2% to 5% of otherwise healthy newborns.Although Candida may be present in a host’s oral cavity, the fungus does not cause pathologic change unless that host’s defense mechanism is compromised. Such a decrease in host defense in infants may result from the immaturity of the immune response. Decreased resistance to infection also may result from and be a sign of a compromised immune system (eg, human immunovirus infection [HIV]) or other disease processes (eg, diabetes) in older children. External systemic and local insults to the immune response also may lead to oral candidiasis (eg, antineoplastic or immunosuppressive therapies, inhaled corticosteroids), as can local insults to the natural ecology of the oral flora (eg, frequent courses of antibiotics). Impaired salivary flow caused by disease or medication and poor oral hygiene also may lead to candidal pathology.The symptoms of oral candidiasis can range from none to a sore and painful mouth, a burning feeling on the mucous membranes and tongue, or dysphagia. Infants who cannot verbalize their symptoms may present having difficulty eating, a decrease in oral intake, or refusal to eat due to the discomfort.The most common presentation, pseudomembranous candidiasis (thrush), involves white or whitish-yellow plaques and erythema on the tongue, soft palate, and buccal mucosa. The plaques may be wiped off to reveal raw, erythematous, and sometimes bleeding mucosa underneath. The changes in the mucosal surface are due to the superficial invasion of the mucosa by the fungus and help the clinician separate infection from milk curd. The presence of concomitant diaper rash also may aid in the diagnosis of an oral candidal infection. Less frequently, clinicians may note angular cheilitis, a fissuring or red scaling at the corners of the mouth.Another less common variation of oral candidal infection is erythematous candidiasis, sometimes referred to as atrophic candidiasis. These erythematous patches, seen most often on the palate and dorsum of the tongue, are associated primarily with children who are taking broad-spectrum antibiotics or corticosteroids or children who are HIV-positive.Oral candidiasis usually can be diagnosed clinically, although it should be differentiated from other infections and trauma. Other conditions in the differential diagnosis include the oral mucositis associated with chemotherapy, oral hairy leukoplakia, and burns of the oral mucosa. Although oral candidiasis is the most common oral fungal infection of infants and children, rare oral fungal infections, especially in immunocompromised individuals, are possible and include aspergillosis, cryptococcosis, histoplasmosis, blastomycosis, and mucormycosis.Candidiasis usually is a clinical diagnosis, but it also is possible to test for the yeast cells and pseudohyphae of C albicans by 10% to 20% potassium hydroxide or Gram stain examination under the microscope. This technique is especially useful when patients do not respond to treatment or for immunocompromised individuals.In infants and young children, oral candidiasis usually responds well to treatment with a topical antifungal agent such as nystatin suspension or clotrimazole troches (lozenges). An appropriate regimen for neonates is 100,000 U four times per day or 50,000 U to each side of the mouth four times per day. Older infants require 200,000 U four times per day or 100,000 U to each side of the mouth. Children and adolescents are treated best with 400,000 to 600,000 U four times per day, or if using the troches, 200,000 to 400,000 U four times per day. Treatment duration usually is 2 weeks, but medication should be continued 2 to 3 days beyond the resolution of symptoms. Gentian violet has been used as a treatment for oral candidiasis but is less effective than newer antifungal medications.Systemic antifungal medications may be required for patients who do not respond to topical treatment and children who are immunocompromised. In these cases, fluconazole (6 mg/kg po on day 1 as a loading dose, followed by 3 mg/kg po qd for 14 d; for adolescents, 200 mg po loading dose, followed by 100 mg po qd for 14 d), itraconazole (used as a “swish and spit” of 100 mg/10 mL twice a day for 7 to 14 d), or ketoconazole (5 to 10 mg/kg po divided once or twice a day for 5 to 7 d; for adolescents, 200 to 400 mg po qd for 5 to 7 d) can be prescribed.It is important to remind parents that pacifiers, toothbrushes, vitamin droppers, and other objects that may have come in frequent contact with the infected child also may be harboring Candida and should be discarded and replaced. Oral candidiasis that persists or recurs soon after treatment in children younger than age 6 months merits consideration of these possible external reservoirs of the fungus. Another cause of recurrent or persistent oral Candida infection is frequent or long-term antibiotic use. Children older than 6 months of age who present with persistent or unexplained, frequent relapses of oral candidiasis warrant consideration of a systemic immunodeficiency in addition to the other causes mentioned. Recurrent or persistent oral candidiasis in breastfeeding infants should raise the consideration of maternal breast colonization as a cause. Mothers may complain of unexplained nipple pain, burning, or itching or exhibit erythematous, cracked areolae. In these cases, it is wise to apply an antifungal agent to the maternal nipple while treating the infant. Ankyloglossia, commonly referred to as tongue-tie, is a congenital anomaly characterized by an abnormally short lingual frenulum leading to a variable degree of compromised mobility of the tongue. Reference to ankyloglossia may be found as far back as the Bible: “… and the string of his tongue was loosed, and he spake plain.” (Mark 7:35)The definition and the management of ankyloglossia are somewhat controversial. Definitions range from subjective descriptions of tongue range of motion and frenulum prominence to more objective measures, such as the Hazelbaker Assessment Tool for Lingual Frenulum Function. The Hazelbaker Tool takes into account five appearance and seven function items to calculate an objective score of lingual frenulum function. Currently, the Hazelbaker Tool does not have sufficient validation to warrant widespread use.As might be expected in the absence of a standard definition of ankyloglossia, the incidence of the anomaly varies; it is uncommon, although not rare. In the literature, the incidence of ankyloglossia varies from 0.02% to 4.8%. This variability also may be due to age-related differences because some cases may resolve spontaneously with age. When limiting the age range to the neonatal period, the incidence ranges from 1.7% to 4.8%.A male predominance of the anomaly has been noted in the literature (range, 1.7:1 to 2.6:1). Usually, ankyloglossia is an isolated anatomic variation, although it has been noted to occur with increased frequency in some congenital syndromes (eg, Opitz syndrome).The severity of ankyloglossia varies in degree from a thin membrane that binds the tongue to a severe form wherein a thick, fibrous membrane binds the tongue closely to the floor of the mouth (Fig. 1). The tongue may look heart-shaped, with a notch, due to the tethering of the frenulum (Fig. 2). Children who have severe ankyloglossia may not be able to elevate the tongue to touch the upper lip or protrude it beyond the lower lip. A thickened frenulum also may result in a space or diastasis between the lower incisors.Significant constriction can interfere with breastfeeding. This impairment may manifest as maternal complaints of traumatized nipples, pain with feeding, and incomplete breast drainage. Infants may have difficulty latching onto the breast, prolonged feedings, and even poor weight gain. All of these effects may lead to early weaning. Feeding difficulties are less pronounced in tongue-tied infants using artificial nipples.It is important to note that although a short lingual frenulum can affect speech articulation in later years, it does not cause speech delay. Older children may have difficulty licking their lips or playing wind instruments, but it is extremely difficult to predict which affected children will develop articulation or mechanical difficulties. Once the child has upper posterior teeth (age 2 y), it is important to observe if he or she is able to lateralize the tongue to clean the buccal vestibules. Not being able to self-cleanse the facial surfaces of these teeth can put the child at risk for caries and calculus accumulation.Most children who have ankyloglossia are asymptomatic, and the condition resolves in some spontaneously over time. Thus, most affected children need no intervention beyond reassurance. When there is concern that ankyloglossia may be affecting breastfeeding, it is wise to refer to a lactation consultant for evaluation. In more severe cases, especially when there are obvious effects on breastfeeding that do not respond to lactation consultant intervention, or in older children who have problems in speech articulation, a surgical procedure known as frenectomy may be appropriate.Frenectomy (frenotomy), or clipping of the frenulum, is a relatively benign surgical procedure that often is performed in early infancy with little or no anesthesia. Outcomes are usually good, and there are few postoperative complications. Numerous insurance companies consider the procedure medically necessary when newborn feeding difficulties or childhood articulation problems exist. It is important to remember, however, that neonatal frenectomy is not indicated for every infant who has ankyloglossia.Before deciding which infants might benefit from the procedure, clinicians should examine the oral cavity, assessing both anatomy and function. For infants who are breastfeeding, it is important to discuss with the mother her experience of breastfeeding and to observe a feeding to detect any problems (eg, latch). If the history, physical examination, and feeding observation confirm significant problems with breastfeeding and the continuation of breastfeeding is desired, a frenectomy is indicated and should be performed by a professional experienced in the procedure. This individual could be the pediatrician or a pediatric dentist, surgeon, or otolaryngologist. In an older child who has significant articulation problems attributed to ankyloglossia, frenectomy referral is indicated. Because frenectomy in these cases is more likely to require general anesthesia, referral should be made to an experienced surgical professional.The most common mucous cyst occurring in the oral cavity is the mucocele, also called mucous extravasation phenomenon. Mucoceles occur in the first and second decades and have no sex predilection. The lesion arises from mechanical trauma to the duct of one of the minor salivary glands in the lips or cheeks. Although mucoceles appear cystic, they are not true cysts because they are not lined by epithelium.A mucous cyst arising from the floor of the mouth is known as a ranula, a name derived from the Latin word rana, which means frog, because the lesion is suggestive of a frog’s belly. Ranulas also occur in the first and second decades of life and have no sex predilection.Mucoceles are caused most often by lip biting or minor injury to the lip, with the lower lip being the most common site (Fig. 3). They appear well-circumscribed, have smoothed surfaces, and are soft and bluish or translucent. Mucoceles are usually painless and can range from 1 mm to several centimeters in diameter. The cystic lesions are filled with mucin from the underlying damaged minor salivary duct.A ranula is caused by injury to the duct of the sublingual gland, submandibular salivary gland, or one of the minor salivary glands in the floor of the mouth. A ranula appears as a soft, bluish swelling on one side of the floor of the mouth (Fig. 4). A plunging ranula develops when the cyst herniates through the mylohyoid muscle to involve the neck.Some mucoceles resolve when the patient bites (unroofs) the cyst with his or her teeth. The cyst ruptures, and the resulting lesion heals spontaneously. Children who have not developed teeth may require surgical excision, as might children who have developed keratinized mucoceles. A mucocele can enlarge, becoming unsightly and more firm in consistency, from the child chewing or sucking on the lesion. The enlargement and the fibrotic nature can make self-rupture of the lesion unlikely and can be an indication for excision. Removal of the mucocele must include excision of the underlying damaged minor salivary gland to avoid recurrence. Surgical excision of a mucocele can result in damage to another minor salivary gland, and patients must be warned of this potential outcome. All excised tissue should be submitted for pathologic examination to confirm the diagnosis. Ranulas are removed by surgical excision. Larger ranulas may require marsupialization. To minimize recurrence, removal of the associated gland is critical. Ulcers in the oral cavity, regardless of cause, present similarly, manifesting as areas of yellow, pseudomembranous slough with an erythematous border. Intraoral ulcerations vary in size and location, but it is important to obtain a thorough history to differentiate viral from nonviral ulcerations.This infection is caused primarily by herpes simplex virus (HSV) type 1, although some children, such as those who have been sexually abused, are infected by HSV type 2. The clinical manifestation of infection by either type is identical in the oral cavity. These lesions rarely are cultured to differentiate the HSV type. A history and physical examination should be used to determine if inoculation was due to child abuse. The peak incidence is around age 2 years. The disease typically presents 3 to 50 days after the exposure. Frequently, the inoculation is from contact with an infected family member who is shedding the virus, such as a parent who has a recurrent herpetic lesion on the lip. Two days prior to the outbreak of oral lesions, the child experiences a high fever, irritability, and malaise. Initially, several small vesicles develop on the gingiva that subsequently rupture and form large, painful ulcerations. The gingiva appears “fire engine red,” hemorrhagic, and edematous (Fig. 5). HSV infection usually is diagnosed by clinical presentation and history. Culture, polymerase chain reaction (PCR) testing, or antigen testing can help differentiate HSV infection from other conditions. Whether the clinician obtains a viral culture, PCR testing, or antigen testing depends on the testing available at the hospital or clinic, and testing becomes necessary only when the condition is not obvious clinically.HSV infection generally can be managed with supportive care, including hydration and analgesia. Milk products are helpful in coating the ulcerations as well as hydrating the child. The disease usually resolves spontaneously within 10 to 14 days without any scarring. If the child is unable to take oral fluids, intravenous fluids are indicated. Some institutions elect to treat children with acyclovir 200 mg administered five times a day, or the equivalent, until all lesions have resolved.Parents should help the child avoid developing lesions in other areas by not touching the infected area and then touching other mucosal surfaces, such as the eyes or genitalia. After primary oral infection with HSV, the virus resides in the trigeminal ganglion and remains latent until reactivated. Secondary infections with HSV typically occur on the lower lip following a stressful event.These infections are caused by the Coxsackie group A viruses and tend to occur primarily in epidemics during the fall and winter months when children are clustered. Both conditions have a prodromal phase of malaise, sore throat, and low-grade fever lasting for several days prior to the appearance of vesicles in the mouth. In herpangina, a cluster of four to five vesicles usually is found on the soft palate or tonsillar pillars. The lesions start as red macules, which transform into fragile vesicles that rapidly ulcerate. The ulcerations are 2 to 4 mm in diameter. Hand, foot, and mouth disease presents with intraoral vesicles in the as herpangina, but typically with more lesions, as well as vesicles in other such as the surfaces of the and surfaces of the The skin lesions are by an erythematous Most of the ulcerations from and foot, and mouth disease resolve spontaneously within 10 days and are less severe than those of primary herpetic The treatment is is a condition that affects the surface of the tongue in infants (Fig. It is caused by and of the tongue over the lower Treatment varies from observation to the of the lower If the lower have at or within days of the treatment for is unless the teeth are in which is indicated. is of the lower indicated unless the child has a oral condition such as due to trauma are common in childhood following to the mouth. 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