Protecting All Children’s Teeth

1. Protecting All Children’s Teeth Common Oral Pathology http://www.aap.org/oralhealth/pact

2. Introduction • Mouth pain is a common presenting complaint to 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. http://www.aap.org/oralhealth/pact

3. Learner Objectives • Upon completion of this presentation, participants will be able to: • 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.” http://www.aap.org/oralhealth/pact

4. 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. http://www.aap.org/oralhealth/pact

5. 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. http://www.aap.org/oralhealth/pact

6. Abscess Progression • 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 shown in the x-ray to • the left). http://www.aap.org/oralhealth/pact

7. 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, mandular, or • palatal mucosa. http://www.aap.org/oralhealth/pact

8. 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. http://www.aap.org/oralhealth/pact

9. Symptoms of an Abscess • Patients with abscess may present with the following symptoms: • Headache • Fever • Periorbital edema or pain • Cranial nerve abnormalities. • This infection can be life-threatening and must be addressed emergently. http://www.aap.org/oralhealth/pact

10. 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. http://www.aap.org/oralhealth/pact

11. 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. http://www.aap.org/oralhealth/pact

12. 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. http://www.aap.org/oralhealth/pact

13. Signs of TMJ • Signs of TMJ disorders include: • 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. http://www.aap.org/oralhealth/pact

14. TMJ Treatment • Treatment is usually initiated when pain is • present. Options include: • Non steroidal anti-inflammatory medication • A soft diet • Warm compresses • Occlusal bite guards • Counseling • Physical therapy Referral to a dentist or other professional knowledgeable in treating TMJ disorders is appropriate. http://www.aap.org/oralhealth/pact

15. 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. http://www.aap.org/oralhealth/pact

16. Referred Pain, continued • The following non-oral conditions can cause pain felt in the teeth or mouth: • Acute maxillary bacterial sinusitis or acute otitis media  • Temporomandibular Joint   • Atypical facial pain • Trigeminal neuralgia • Migraine headaches • Psychogenic  • Neoplasia, such as leukemia http://www.aap.org/oralhealth/pact

17. Primary Herpetic Gingivostomatitis • Primary Herpetic Gingivostomatitis is • caused primarily by herpes simplex • virus type 1. • The primary infection is most severe and • usually seen in children younger than 6.  http://www.aap.org/oralhealth/pact

18. 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: • Fever and malaise (precede the anorexia, oral findings, and cervical • lymphadenopathy) • Significant lip and gum swelling, erythema, and bleeding • Vesicles on the lips, tongue, and cheeks, which then ulcerate http://www.aap.org/oralhealth/pact

19. Treatment for Primary Herpetic Gingivostomatitis • Treatment is mainly supportive with hydration maintenance and pain control. • The acyclovir family of antiviral medications may be used. The infection is life-long, and recurrences occur as “cold sores” (herpes labialis), usually at times of stress or infection.  http://www.aap.org/oralhealth/pact

20. Coxsackie Viral Infections • 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. • Symptoms last 7-10 days. Treatment is supportive care. Herpangina http://www.aap.org/oralhealth/pact

21. Oral Candidiasis • White plaques or pseudomembranes • are noted on the surface of the tongue • or the buccal, labial, and gingival mucosa. • 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. http://www.aap.org/oralhealth/pact

22. Oral Candidiasis, continued • Oral Candidiasis can be treated with topical antifungal agents, such as • Nystatin or Clotrimazole. If symptoms persist or recur shortly after discontinuation of the antifungal agent, consider re-infection from bottles, pacifiers, or breastfeeding (with maternal breast colonization) or resistance to antifungal medication. http://www.aap.org/oralhealth/pact

23. 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.  http://www.aap.org/oralhealth/pact

24. 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. http://www.aap.org/oralhealth/pact

25. 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. http://www.aap.org/oralhealth/pact

26. 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. http://www.aap.org/oralhealth/pact

27. 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. http://www.aap.org/oralhealth/pact

28. 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. http://www.aap.org/oralhealth/pact

29. 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. http://www.aap.org/oralhealth/pact

30. 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. http://www.aap.org/oralhealth/pact

31. Question #4 • Which of the following statements about Oral Candidiasis is not • true? • A. It can cause angular cheilitis.  • B. It should be treated with antiviral medication.  • C. Re-infection from bottles or pacifiers is possible.  • D. It can be caused by antibiotic use.  • E. It is common in infants. http://www.aap.org/oralhealth/pact

32. Answer • Which of the following statements about Oral Candidiasis is not • true? • A. It can cause angular cheilitis.  • B. It should be treated with antiviral medication.  • C. Re-infection from bottles or pacifiers is possible.  • D. It can be caused by antibiotic use.  • E. It is common in infants. http://www.aap.org/oralhealth/pact

33. 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. http://www.aap.org/oralhealth/pact

34. 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. http://www.aap.org/oralhealth/pact

35. 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. http://www.aap.org/oralhealth/pact