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The Oral Mucosa in Childhood
Symposium on Pediatric Dermatology
The Oral Mucosa in Childhood Marshall P. Goldberg, D.D.s., M.D. *
During the first few years of life, the mouth, lips, and tongue are the chief pleasure centers of the infant. Occasionally, one may even see an ecchymosis on the wrist or hand of the newborn from sucking in utero. The excessive apprehension and aversion to dental treatment, although it is not objectively painful, indicates a lasting and important psychological component associated with the oral cavity. It is to this interesting psychologically-charged area of the body that we turn our attention, with a discussion of some of the more common problems.
EXAMINATION PROCEDURE Unfortunately, the oral cavity is often just a conduit to the pharynx, and the tongue, a platform for a tongue blade. Thus the physician may miss many local oral problems as well as certain oral signs which may help in making a diagnosis of a more general disease entity. Oral findings, for example, in Peutz-Jegher syndrome, pemphigus vulgaris (Fig. 1), lichen planus (Fig. 2), Addison's disease, certain Coxsackie viral infections, and some leukemias (Fig. 3), may be most helpful to the diagnostician. The four classical aspects of the general examination (inspection, palpation, percussion, and auscultation) apply to the oral examination.
Inspection 1. Have the patient sit or lie back. 2. Use a strong light (a pocket flashlight is really not adequate). 3. Inspect the lips (contour, color, presence of "freckles," atrophy, papules, swelling, etc.). 4. Have the patient open the mouth as wide as possible and inspect the hard and soft palates. The pharynx is often well visualized. 5. Instruct the patient to point the tongue upward to the left and to the right so that you can see the ventral and lateral aspects. 'Clinical Assistant Professor of Dermatology, Stanford Hospital and Medical Center, Palo Alto, California
Pediatric Clinics of North America- Vol. 25, No.2, May 1978
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Figure 1.
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Figure 2.
Figure 3. Figure 1. Pemphigus vulgaris. Bullae rapidly burst leaving erosions and ulcers. Positive Nikolsky sign is evident. Figure 2. Lichen planus. Lacy white network of Wickham's striae may be of the ulcerative type. Figure 3. Monocytic leukemia. Shiny, swollen, infiltrated gingivae are seen.
All of the above are accomplished without touching the patient, which helps allay any fears associated with the oral examination. The physician's workup proceeds much more smoothly. 6. The inspection portion of the examination continues with the use of a tongue blade. Wetting the tongue blade with water allows it to slide over the mucosa more easily, prevents its sticking to the delicate epithelium, and tends to reduce the gag reflex. One may gently retract the cheek to observe the buccal mucosa and the opening of Stenson's duct. Have the patient merely open wide and take a deep breath, which relaxes and opens the pharynx naturally. The slightest pressure with the tongue blade is generally sufficient. 7. The tongue may be inspected further by wrapping a piece of gauze around it. By tightening the gauze a bit, one has, in effect, a handle to move the tongue into any desired position (Fig. 4).
Palpation 1. Put on rubber or plastic examination gloves. 2. Palpate the lips, cheeks, tongue, floor of the mouth, etc., feeling for rough, swollen, or tender areas (Fig. 5). Bimanual palpation allows an excellent assessment of the floor of the mouth and the cheeks (Fig. 6).
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Figure 4. Gauze is placed about the tongue in a five year old girl.
3. Press and wiggle the teeth, looking for mobility and tenderness. 4. Place fingertips over the mandibular condyles and have patient open and close slowly. Note how much condyles move forward, whether one moves more than the other producing a deviation of the mandible, and so on. Clicking or snapping of the condyle can sometimes be felt. Tenderness indicates possible arthritis (Fig. 7). Percussion Very gentle tapping on a tooth suspected of being abnormal may elicit pain. Ankylosed or fractured teeth may have a duller sound. Auscultation A stethoscope may be placed over the mandibular condylar area. The patient opens and closes several times. Listen for condylar clicks. The above examination procedure may seem lengthy, but can be accomplished in about one minute. Further specific studies, such as radiographs, are best done by a dentist. Figure 5.
Figure 6.
Figure 5. Palpation of the upper lip in a five year old ·girl. Figure 6. Bimanual palpation of floor of the mouth in an 11 year old girl.
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Figure 7. A, Palpation of mandibular condyles with jaws at rest in an 11 year old girl. B, Palpation of mandibular condyles with mouth open wide in an 11 year old girl.
NORMAL APPEARANCE OF THE ORAL MUCOSA AND TEETH The lips should be symmetrical, without clefts or pits, and of a reddish-pink color consistent with the patient's general complexion. Cherry red or blue lips do not always signify carbon monoxide poisoning or congenital heart disease, but rather, may merely be the patient's normal color. Very pale, fair-skinned individuals may have bright red lips, whereas darker individuals may have bluish lips. The buccal and labial mucosa is normally smooth, wet, flexible, and easily stretched. Numerous fine small blood vessels are seen, and in darker-complexioned people, one can see "freckling" and a generally darker red-purple color. Palpation often reveals numerous submucosal 1 to 2 mm soft nodules. These are small sebaceous glands (Fordyce spots) which (if present close to the surface) can be seen as yellow papules, and are of no particular consequence (Fig. 8). The tougher gingival tissue is adapted to withstand the stresses of mastication. It is bound down firmly to the underlying alveolar bone and is pinkish to bluish with a stippled surface texture. The gingival margins should be sharp and scalloped about the necks of the teeth, and the interdental papillae should have a triangular shape and fill the spaces between the teeth (Fig. 9). Edema and inflammation produce swelling, redness, and a loss of stippling resulting in a smooth surface texture. Loss of stippling is thus a sign of disease and occurs early. The hard palatal mucosa receives a great deal of stress due to mastication, which accounts for its very tough appearance. Numerous folds or rugae are seen and felt easily. A small papilla, the incisive papilla, just behind the upper central incisors covers the nasopalatine foramen and houses the nasopalatine nerve and vessels (Fig. 10). The soft palate has more of the appearance of the other nonstress areas and thus resembles the buccal mucous membrane more than it does the hard palate. The dorsal surface of the tongue is well papillated and has a rough velvety texture (Fig. 11). Transient changes in the oral environment as well as antibiotics may alter this texture and color.
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Figure 8.
Fordyce spots.
Figure 9. A, Retraction of the upper lip showing normal mucosa and attached gingiva in a five year old girl. Note primary teeth. B, Retraction of the lower lip in the same girl. C, Retraction of both lips.
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Figure 10. Hard palate of an 11 year old girl. Note rugae and incisive papilla.
The primary and secondary teeth erupt in a fairly predictable pattern. Calcification occurs before eruption so that any given disease may leave a record of its presence on that portion of the enamel undergoing calcification at that time. This may appear as a horizontal line or poorly calcified groove or pits on the crown of the tooth (Fig. 12). Tetracycline and excessive fluoride may cause abnormal maturation-calcification and staining of the teeth (Fig. 13). There are several important points pertinent to the diagram shown in Figure 14. 1. The primary teeth are smaller and lighter in color than the permanent teeth. 2. The pulp chamber is larger in recently erupted teeth and gets smaller over a number of years. Thus in children and adolescents, caries (decay) can reach the pulp very quickly. 3. The permanent first, second, and third molars have no primary predecessors.
Figure 11. Dorsum of the tongue in a five year old girl.
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Figure 13.
Figure 12.
Figure 12. Acute nephritis during calcification and maturation of that portion of the crown resulted in pits on the teeth. Figure 13. Tetracycline staining (see also color plate IVE).
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Figure 14. Left half of mouth is shown. Eruption dates (approximate) of teeth. Primary (in months): cental incisors, 5 to 10; lateral incisors, 7 to 12; cuspid (canine), 16 to 20; first molar, 11 to 18; second molar, 20 to 30. Permanent (in years): central incisors, 6 to 8; lateral incisors, 7 to 9; cuspid (canine), 9 to 12; first premolar, 10 to 12; second premolar, 10 to 13; first molor, 5'/2 to 7; second molar, 12 to 14; third molar (wisdom tooth), 17 to 30. Match teeth on diagram as seen from midline to the reader's right.
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4. A given mandibular tooth usually erupts before its maxillary mate. 5. The primary molars are replaced by the permanent premolars. 6. The primary central and lateral incisors and cuspids (canines) are replaced by permanent successors of the same name. 7. Calcification of the crowns of the primary teeth begins in the fourth month in utero. 8. Calcification of the crowns of some permanent teeth begins at birth. 9. Calcification of the root is finished a few years after the crown erupts.
HISTOLOGIC CHARACTERISTICS OF THE ORAL MUCOSA The oral mucosa varies in appearance histologically to conform to its particular function at a given site. Thus the smooth buccal mucosa has one appearance and the tongue and attached gingivae still other modifications for the work they have to do. In general, the oral epithelium is thicker than skin epidermis. The hard palate and attached gingivae are well keratinized in response to friction; buccal mucosa lacks this keratinization. Mucosa of the dorsum of the tongue is highly specialized. The epithelium is of the stratified squamous variety with cuboidal basal cells and a fairly wide prickle cell layer. In addition to the major salivary glands, there are several minor small salivary glands distributed throughout the oral mucosa. These are most numerous on the palatal and labial mucosa. Typically, these glands have numerous acini. The major paired salivary glands-parotid, submandibular (submaxillary) and sublingual-provide fluid designed to lubricate the oral mucosa and food bolus and begin the process of digestion.
BIOPSY PROCEDURE Biopsy of the oral mucosa may occasionally be indicated. The standard skin punch may be used in areas where the mucosa is firmly bound down, such as the hard palate or attached gingivae. On the more movable, friable buccal mucosa, however, the torque of the punch may tear the tissue. Bleeding and access are also problems in the mouth. For these reasons, it is advantageous to use a "two-suture" technique. The following steps are necessary: 1. Place the first suture, a 4-0 silk suture, so that it lies deep to the lesion and beyond its borders. Do not tie it. Let the ends hang out of the mouth (Fig. 15A). 2. Place and tie the second suture, a 4-0 silk suture, so as just to encompass the area to be removed (Fig. 15B). By gentle manipulation, the mucosa can be elevated and moved from one side to the other as though a handle were attached to it. A scalpel blade or curved serrated scissors may be used to excise the area. Be careful not to cut through the first suture (Fig. 15C).
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A
B
c
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Figure 15. A, Placement of first suture to be tied later. B, Placement of second suture. Tie about lesion to help control it during excision. C, Removal of excised specimen. D, First suture tied.
3. Remove the specimen from the mouth and place in biopsy bot-
tle. 4. Now, the ends of the first suture are picked up and tied. Preplacement of this suture eliminates the need to place a suture in a bloody field (Fig. 15D). To remove larger pieces, one may place several initial sutures, and so on.
LOCAL ANESTHETIC TECHNIQUE Local infiltration anesthesia with lidocaine 1 per cent with 1: 100,000 epinephrine is adequate. Remember to wait about four to five minutes after injection to get maximum vasoconstriction at the site. This reduces bleeding and gives better control during the biopsy.
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For the most part, nerve trunk blocks are not necessary for oral biopsy procedures. The mental nerve block can, however, be useful for procedures on the lower lip such as repair of lacerations. This can be accomplished by injecting about 0.25 ml of anesthetic solution just beneath the mucosa overlying the mental foramen. The foramen lies approximately at the depth of the buccal sulcus between the primary first and second molars or the permanent first and second premolars. Other blocks, such as the inferior alveolar injection, are beyond the scope of this discussion.
ANOMALIES Cleft Lip and Palate Cleft lip and palate may result in lifelong functional and emotional scars. Speech patterns may be mislearned so that "nasal" speech persists after surgical repair, unless repair is begun early. Other children may tease the child about the deformity. Thus early definitive treatment is essential for functional and cosmetic reasons. Soft tissue closure can best be accomplished in many patients if combined with various dental orthodontic appliances. Dentists, pediatricians, and plastic surgeons working together can achieve remarkable results. Vascular Nevi Hemangioma is a common vascular nevus and presents as a flat patch or, more often, as an irregular elevated red mass. They are best left alone. Capillary hemangiomas often involute. Occasionally, an intraoral hemangioma may interfere with eating or speech and, of course, bleed, but this is not the usual situation (Fig. 16). Large hemangiomas (Fig. 17) may be associated with the Kasabach-Merritt syndrome in which platelet sequestration may lead to thrombocytopenia. Lymphangiomas may develop as superficial, grouped, clear to pink vesicles or as deeply situated, nodular, soft masses. Pain, swelling, and infection occasionally occur. A more extensive lymphangioma of the Figure 16.
Figure 16. Figure 17.
Figure 17.
Hemangioma. Cavernous hemangioma of the buccal mucosa.
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neck and floor of the mouth is sometimes referred to as cystic hygroma. Macroglossia due to lymphangioma may be corrected surgically by a wedge resection. Tongue Tie Ankyloglossia or tongue tie refers to an abnormality in which the lingual frenum is attached closer to the tip of the tongue. It does not necessarily interfere with speech and need not be treated unless it is subject to trauma from mastication or is producing periodontal problems where it is attached to the gingiva Median Rhomboid Glossitis This entity presents as a reddish diamond-shaped patch on the dorsal aspect of the tongue and represents a normal but unpapillated remnant of the tuberculum impar. No treatment is necessary (Fig. 18). Oral Mucous Membrane Pigmentation Many local and systemic conditions, as well as certain chemicals, can result in pigmentary changes in the oral cavity. Melanin may normally be found in darker races and tends to increase with age. "Freckles," intraorally and on the lips, are seen commonly (Fig. 19). Peutz-Jegher disease (hereditary intestinal polyposis); Addison's disease, and Albright's syndrome (polyostotic fibrous dysplasia) are rather uncommon diseases in which pigmented brownish to blue-black oral mucosal patches and macules may appear. Primary or metastatic melanoma is another cause of increased oral pigmentation. The associated findings in other organ systems may not predominate the clinical picture at a given time so that the oral findings can be quite helpful to the diagnostician. Heavy metals such as lead and bismuth can produce a dark greenish-black line, usually at the gingival margins, or in areas of chronic inflammation. These discolorations are due to the deposition of metallic sulfides. It tends to be less common in children because these metals are preferentially deposited in bones. The most common exogenous pigment is silver amalgam which
Figure 18. Median rhomboid glossitis.
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Figure 19. Focal hyperpigmentation ("freckle") of lower lip.
can be implanted into the oral mucosa either during extraction of a tooth or during placement of a silver amalgam restoration, resulting in a bluish-black macule or patch (Fig. 20). It should not be confused with a melanocytic nevus. An intraoral radiograph will often show small dust-like radiodense silver amalgam particles scattered throughout the tissue. If there is any doubt, a small biopsy can be obtained. Treatment is otherwise not necessary. Melanocytic nevi present as brown to blue-black macules and patches. They are uncommon and need not be treated, although some feel they should be excised. Observation from time to time would probably be adequate in most cases.
HEREDIT ARY DISORDERS There are several hereditary disorders of keratinization with associated epithelial dysplasias of the oral mucosa (Table 1). Clinically, these appear as whitish areas. Thus the total clinical picture and a biopsy may be necessary for diagnosis.
Table 1. Hereditary Disorders of Keratinization DISEASE
AREA OF MOUTH INVOLVED
OTHER AREAS
PROGNOSIS
Darier's disease Dyskeratosis congenita
Labial and buccal mucosa Tongue, buccal mucosa
Skin Dystrophic nails
White sponge nevus Pachyonychia congenita
Labial, buccal mucosa Buccal mucosa and tongue
Benign Carcinoma common Benign Carcinoma common
Hereditary benign in traepithelial dyskeratosis
Buccal and labial mucosa, floor of mouth, undersurface of tongue
Anal and vaginal Anal and laryngeal mucosa, thick nails, keratoderma of palms and soles Eye Benign
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Figure 20.
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Amalgam tattoo.
MISCELLANEOUS CONDITIONS Idiopathic Gingival Fibromatosis and Hypertrichosis This is an autosomal dominant condition characterized by marked enlargement of the attached gingivae. It begins early, before the tenth year of life, and may cause marked malposition of the teeth. The eyebrows and scalp hair are particularly thick and abundant. Gingival enlargement owing to use of phenytoin (Dilantin) has a similar clinical intraoral appearance (Fig. 21). Surgical excision of the excess tissue (gingivectomy) can be beneficial. Enlargements due to either condition often occur. Scrupulous oral hygiene, however, may delay recurrence of enlargement caused by phenytoin. Neither condition is premalignant. Pyogenic Granuloma This condition, neither pyogenic nor granulomatous, is often seen at the site of a previous injury and presents as a friable red shiny
Figure 21. Gingival enlargement resulting from the use of phenytoin.
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papule or pedunculated mass which bleeds easily. The oral lesion can be a problem because it may be traumatized readily during mastication and tends to bleed even more profusely than the skin lesion. Surgical excision is, therefore, indicated. If the lesion is very small, cauterization may be adequate (Fig. 22). Geographic Tongue Also known as benign migratory glossitis, it is a fairly common entity. Irregularly shaped red patches appear on the dorsum of the tongue (Fig. 23). Over a period of several days, these areas enlarge, change shape, and eventually disappear only to be replaced by new similar red patches. Histologically, there is a temporary loss of keratinized papillae in the affected red patch. Keratin, wet by saliva, has a whitish color so that its loss allows the underlying red mucosa to show through. The condition is usually asymptomatic and requires no treatment. It tends to abate or repeat cyclically. Mucocoele (Mucous Retention Cyst) Biting the lip may initiate this problem. It often occurs on the labial aspect of the lower lip as a submucosal mass which is fairly well defined and slightly bluish in color (Fig. 24). Because of trauma, it may have a whitish keratinized surface over one area. These lesions are filled with a clear gelatinous material. Simple excision and closure is generally preferable. Aphthous Stomatitis Also called canker sores, this is a common disorder characterized by recurrent painful, burning shallow ulcers of the oral mucosa (Fig. 25). The exact etiology is unknown, although it has been associated with transitional L-forms of bacteria. Certain elements of an autoimmune nature may also play a role. It is not caused by herpes simplex virus. Stress and various foods such as nuts and chocolate have been thought to trigger episodes of this condition in those predisposed to it. The lesions begin with a burning sensation. After several hours, a small reddish macule appears, followed in short order by a superficial ulcer with a yellowish center and an erythematous halo. One or several of these may occur scattered about the oral mucosa including the pharyngeal mucosa. They may be from a few millimeters to a centimeter or so in diameter. In many recurrent cases, crops of numerous lesions may appear every few weeks, and the patient may have cervical lymphadenopathy, malaise, difficulty eating because of the pain and a slight elevation of temperature. A white blood cell count is useful to rule out cyclic neutropenia, a different condition, which may cause similar lesions. Treatment consists of avoiding any suspected triggering foods, as well as discontinuing any mouthwashes and mint and cinnamonflavored toothpastes or foods with these flavorings. Milk of magnesia may be used as a bland mouthwash and as a dentifrice. A soft toothbrush is best. Hydrogen peroxide preparations can also be helpful as an
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Figure 22.
Pyogenic granuloma.
Figure 23. Geographic tongue (see also color plate IVF).
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Figure 24. lower lip.
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Mucocele of the
additional method of cleansing the mouth. A short course of oral corticosteroids is often helpful during a severe attack with multiple lesions. We have found the following mouthwash formula to be most useful when used four times daily during an attack, and as a prophylactic measure once a day between attacks. Stanford Mouthwash Formula
Tetracycline (Achromycin) suspension Mycostatin Hydrocortisone Chlorpheniramine (Chlor-Trimeton) syrup
250 ml 6 million units 1000 mg enough (to 500 ml)
Refrigerate. One teaspoon held in the mouth for two minutes four times a day. Do not swallow. Do not eat, drink, or rinse your mouth for at least an hour after using the mouthwash.
Angular Cheilitis Cheilitis refers to an inflammation of the lips. Many causes exist. For the child, the most common cause is chapping or irritation due to excessive drying of the lips. Mouth breathers often exhibit this condition. Allergic contact cheilitis or irritant cheilitis from mouthpieces of various woodwind or brass instruments is also seen. The small metal
Figure 25. titis.
Aphthous stoma-
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band holding a pencil eraser atop the wood shaft, as well as the rubber eraser itself, can be a source of cheilitis for pencil chewers. Angular cheilitis, or cracking at the corners of the mouth, is often associated with candida, but the organism is most often a secondary invader rather than the cause of the problem. Incompetence of the oral sphincter due to dental abnormalities or soft tissue irregularities that allow saliva to continually seep out and to accumulate at the corners of the mouth are the underlying causes to be looked for and treated. Vioform-Hydrocortisone cream applied several· times a day is a good temporizing measure while the underlying problems are being treated. Fluorinated hydrocortisone creams tend to further weaken the delicate mucosa and should not be used for long periods of time. For the acute case. a cream base is preferred. Ointment bases are good for the dry, cracked, chronic condition. Bases with propylene glycol may sting and should be avoided in the acute stage.
INFECTIOUS DISEASES (VIRAL) Herpes Simplex Primary herpes simplex infections, caused by herpes virus hominis, often produce an acute herpetic gingivostomatitis characterized by fever, malaise, headache, and small easily eroded vesicles on the lips and oral mucosa. Recurrent infections usually spare the oral mucosa and affect only the skin around the lips (Fig. 26). By contrast, aphthous stomatitis affects the oral mucosa but rarely (if at all) the vermilion portion of the lips or the perioral skin. In immunosuppressed individuals, however, one may see recurrent herpes simplex infections that look like primary herpetic gingivostomatitis. Remember, too, that a recurrent herpetic lesion on the lip may occur along with an episode of aphthou~ stomatitis, both of them perhaps having been triggered by the same underlying set of stimuli. Erythema multiforme (Stevens-Johnson syndrome) may often be triggered by this virus. Stevens-Johnson syndrome requires quick and forthright management with steroids parenterally.
Figure 26. Herpes simplex infection of the upper lip.
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There is no cure for primary herpes simplex infection; therefore, avoidance of any suspected triggering agents such as excessive sun exposure or trauma is of first importance. Sunscreens and bland ointments may be helpful in this regard. During an acute attack, remind the patient that he has a contageous condition. Both types I and II herpes virus can infect any area of the skin or mucous membranes. A drying agent such as acetone rubbed on briskly with a· piece of gauze will open the vesicles and speed the healing process. It stings for an instant, but relieves the symptoms quickly. After this, one may prescribe Vioform-Hydrocortisone cream to be applied several times a day for a few days to help reduce inflammation and to avoid secondary bacterial infection. Ointment bases keep the lesion wet and impair healing.
Hand-Foot-Mouth Disease This entity is caused by a Coxsackie virus and presents as a rather mild illness characterized by low-grade fever, polygonal clear tense vesicles On the fingers and toes, and superficial tiny red vesicles and ulcers scattered over the palate and buccal mucosa No specific treatment is necessary. A bland mouthwash with milk of magnesia may reduce the oral symptoms. Herpangina Another of the Coxsackie viral infections, herpangina produces minute vesicles and ulcers on the palate. Sore throat, mild fever, and abdominal pain complete the picture. No treatment other than supportive is necessary.
Figure 27. Palatal exanthema of primary Varicella.
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Varicella and Herpes Zoster This virus can also produce intraoral lesions. In varicella, intraoral vesicles may be observed along with the exanthema (Fig. 27). Herpes zoster may affect the trigeminal nerve and produce a readily recognizable picture when it affects the oral mucosa. A unilateral vesicular and ulcerative process is seen. For example, involvement of the third division of the trigeminal nerve results in unilateral glossitis, mandibular gingivitis, and cheilitis. Often, associated but not infectious disturbances in VII and VIII may result in a concomitant Bell's palsy and dysequilibrium, known as the Ramsey-Hunt syndrome. Verruca Vulgaris Intraoral verrucae can occur, and because of their wet, hyperkeratotic surface, they appear to be white. They may be mistaken for a white patch of leukoplakia. The surface, however, is verrucous or warty and the patient may have other intraoral or digital warts which appear to have been gnawed (Fig. 28).
INFECTIOUS DISEASES (BACTERIAL) Among the bacterial diseases affecting the mouth, the most common are dental infections such as acute periapical abscesses and periodontal infections. Poor diet, inadequate oral hygiene, caries, trauma, and neglect are the precursors of these infections. Local drainage is quite important; antibiotics are helpful but should not be the only treatment given. Extraction of the affected teeth should be only a last resort, for they can never be replaced with their equals. Modern endodontic (root canal) treatments and restorative dentistry can painlessly save most teeth, even those fractured below the gingival margin. Pulpitis Pulpitis, or inflammation of the dental pulp, is fairly common in
Figure 28. Verrucous papilloma consistent with verruca vulgaris.
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children. The pulps of the teeth are quite large in the young, and decay quickly reaches this sensitive structure producing pain and infection. Trauma from a fall may also injure the pulp and lead to necrosis and, clinically, a black or discolored tooth. Toothache from pulp disease is initially intermittent and is triggered by cold. It may be reversible if the initiating causes are treated (such as removal of decay and placement of a sedative dressing). As the pulp becomes further inflamed, the toothache becomes constant, exacerbated by heat and relieved by cold. The disease becomes irreversible at this point. The process may then spread outside the tooth to the periapical area, producing a local osteomyelitis with severe pain when the tooth is touched (Fig. 29), known as acute periapical periodontitis. Eventually, the process may work its way through the bone and into the surrounding soft tissues. When the swelling appears, the bone is drained and the severe pain most often ceases (Fig. 30). Early treatment of pulpitis with root canal therapy can often abort the subsequent stages of this process. Antibiotics are often necessary.
Acute Necrotizing Ulcerative Gingivitis (Trench Mouth) In this condition, there is a fairly rapid necrosis of the interdental papillae. A yellowish pseudomembrane covers the gingivae which bleed easily, and there is a characteristic foul odor to the breath. Some patients complain of a metallic taste. This entity was commonly seen in crowded conditions such as in the military and in boarding schools. It is associated with increased numbers of certain normal flora of the mouth such as Borrelia vincentii and Bacillus fusiformis, but is probably not simply a bacterial infection or contagious in the ordinary sense of the word. Poor oral hygiene, diet, crowding, and stress may play roles in precipitating the disease. The exact etiology is still obscure. Local debridement with hydrogen peroxide mouth rinses is a useful adjunct to careful oral prophylaxis by a dentist. Systemic or topical antibiotics can be used, but generally are not necessary. Syphilis Not at all rare in children, syphilis may present in the form of a hard ulcerated chancre on the lips or oral mucosa. Secondary infection with other bacteria may occur more readily intraorally so that the classic "painless" chancre may be, in fact, painful. Regionallymphadenopathy is present. The oral mucous patches of secondary syphilis are characterized by superficially eroded, flattened papules covered with a whitish-grey membrane. About one third of congenital syphilitics exhibit the classic screwdriver-shaped Hutchinson incisor or the multilobulated mulberry molar. Both dental def~rmities represent the effect of the disease on the crowns of these teeth which are undergoing development at that time. Treatment should follow recommendations of the local health authorities or current optimal therapeutic regimens.
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Figure 29. Caries has invaded the pulp. Infection spreads via the root canal to the bone and then by either of two pathways to drain intraorally or extraorally.
Figure 30. Acute alveolar abscess pointing intraorally_
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Gonorrhea In gonococcal stomatitis, the intraoral mucosa is quite red and tender. Numerous erosions covered with a yellow pseudomembrane are usually apparent. As in syphilis, treatment of gonorrhea should follow recommendations of the local health authorities or current optimal treatment regimens. Candidiasis (Candida albicans, Moniliasis, Monilia albicans) This organism, normally a saprophytic yeast-like fungus, can produce a whole range of infections from local and mild, to systemic and serious. It normally colonizes the gastrointestinal tract of most individuals, producing no infection unless underlying systemic disease or local mucous membrane or skin disease reduces resistance to the organism. Immunoincompetence allows the fungus to invade, pulmonary infections being most common. Focal injury to the skin, such as in the wet, macerated diaper area or in moist intertriginous areas beneath the breasts, may result in infection. Oral lesions may be acute or chronic. Acute lesions are typified by infant thrush in which several white curd-like patches are seen (Fig. 31). Characteristically, these may be scraped off rather easily with a tongue blade, leaving a raw bleeding surface. Chronic candidiasis of the atrophic type may be seen with the use of broad spectrum antibiotics. It presents as a bright red stomatitis without curd-like whitish lesions as seen in thrush. Candidal granuloma, a rare type, usually involves the tongue and may produce local swelling. Angular cheilitis from any of the causes mentioned above may harbor candida as a secondary invader. Treatment consists of correction of the underlying causes and suppression of the fungus with mycostatin topically.
Figure 31.
Thrush mouth.
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IRRIT ANT AND ALLERGIC REACTIONS True allergic reactions of the oral mucosa are probably rare, and when they do occur, are often accompanied by skin eruptions. Considering all the antigenic insults to the mouth from foods, flavorings, preservatives, and artificial colorings, the paucity of reactions is striking. Irritant reactions, less rare but not really common, are usually caused by some essential oil in a dentrifrice or chewing gum. Oil of cloves, cinnamon flavorings, and peppermint are often involved. Allergic reactions to dental restorative materials and properly cured acrylic resins are uncommon. Alcohol and perborates in certain mouthwashes can also be quite irritating. Mechanical irritation includes hot or crusty foods such as soups, bread crusts, pizza pie, or overheated rubber nipples. Removal of the offending agents suffices. Milk of magnesia mouthwashes are effective in relieving pain and as a temporary protective coating. Various cytotoxic drugs may disturb the oral epithelial cells and interfere with their normal maturation, resulting in recurrent ulceration. This problem is seen in transplant or tumor patients on immunosuppressive drugs. A combination mouthwash as described above is useful (Fig. 32). ACKNOWLEDGMENT
Grateful acknowledgment is given to Michele Wambaugh Dearborn for her photography in Figures 4-7 and 9-11, and her renderings in Figures 14, 15, and 29.
Figure 32. Oral ulcer in a patient treated with doxorubicin hydrochloride (Adriamycin) for lymphoma.
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REFERENCES 1. Colby, R. A., et al. (eds.): Color Atlas of Oral Pathology. Edition 3. Philadelphia, J. B. Lippincott Co., 1971. 2. Fisher, A. A.: Contact Dermatitis. Edition 2. Philadelphia, Lea and Febiger, 1973. 3. Fitzpatrick, T. B., et al. (eds.): Dermatology in General Medicine. New York, McGraw-Hill Co., 1971. 4. Ingle, J. I.: Endodontics. Philadelphia, Lea and Febiger, 1965. 5. Korting, G. W.: Diseases of the Skin in Children and Adolescents: A Color Atlas. Philadelphia, W. B. Saunders Co., 1970. 6. Rook, A., et al. (eds.): Textbook of Dermatology. Edition 2. Philadelphia, J. B. Lippincott Co., 1972. 7. Solomon, L. M., and Esterly, N. B.: Neonatal Dermatology. Philadelphia, W. B. Saunders Co., 1973. 450 Sutter Street Suite 2001 San Francisco, California 94108
The Oral Mucosa in Childhood Marshall P. Goldberg, D.D.s., M.D. *
During the first few years of life, the mouth, lips, and tongue are the chief pleasure centers of the infant. Occasionally, one may even see an ecchymosis on the wrist or hand of the newborn from sucking in utero. The excessive apprehension and aversion to dental treatment, although it is not objectively painful, indicates a lasting and important psychological component associated with the oral cavity. It is to this interesting psychologically-charged area of the body that we turn our attention, with a discussion of some of the more common problems.
EXAMINATION PROCEDURE Unfortunately, the oral cavity is often just a conduit to the pharynx, and the tongue, a platform for a tongue blade. Thus the physician may miss many local oral problems as well as certain oral signs which may help in making a diagnosis of a more general disease entity. Oral findings, for example, in Peutz-Jegher syndrome, pemphigus vulgaris (Fig. 1), lichen planus (Fig. 2), Addison's disease, certain Coxsackie viral infections, and some leukemias (Fig. 3), may be most helpful to the diagnostician. The four classical aspects of the general examination (inspection, palpation, percussion, and auscultation) apply to the oral examination.
Inspection 1. Have the patient sit or lie back. 2. Use a strong light (a pocket flashlight is really not adequate). 3. Inspect the lips (contour, color, presence of "freckles," atrophy, papules, swelling, etc.). 4. Have the patient open the mouth as wide as possible and inspect the hard and soft palates. The pharynx is often well visualized. 5. Instruct the patient to point the tongue upward to the left and to the right so that you can see the ventral and lateral aspects. 'Clinical Assistant Professor of Dermatology, Stanford Hospital and Medical Center, Palo Alto, California
Pediatric Clinics of North America- Vol. 25, No.2, May 1978
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Figure 1.
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Figure 2.
Figure 3. Figure 1. Pemphigus vulgaris. Bullae rapidly burst leaving erosions and ulcers. Positive Nikolsky sign is evident. Figure 2. Lichen planus. Lacy white network of Wickham's striae may be of the ulcerative type. Figure 3. Monocytic leukemia. Shiny, swollen, infiltrated gingivae are seen.
All of the above are accomplished without touching the patient, which helps allay any fears associated with the oral examination. The physician's workup proceeds much more smoothly. 6. The inspection portion of the examination continues with the use of a tongue blade. Wetting the tongue blade with water allows it to slide over the mucosa more easily, prevents its sticking to the delicate epithelium, and tends to reduce the gag reflex. One may gently retract the cheek to observe the buccal mucosa and the opening of Stenson's duct. Have the patient merely open wide and take a deep breath, which relaxes and opens the pharynx naturally. The slightest pressure with the tongue blade is generally sufficient. 7. The tongue may be inspected further by wrapping a piece of gauze around it. By tightening the gauze a bit, one has, in effect, a handle to move the tongue into any desired position (Fig. 4).
Palpation 1. Put on rubber or plastic examination gloves. 2. Palpate the lips, cheeks, tongue, floor of the mouth, etc., feeling for rough, swollen, or tender areas (Fig. 5). Bimanual palpation allows an excellent assessment of the floor of the mouth and the cheeks (Fig. 6).
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Figure 4. Gauze is placed about the tongue in a five year old girl.
3. Press and wiggle the teeth, looking for mobility and tenderness. 4. Place fingertips over the mandibular condyles and have patient open and close slowly. Note how much condyles move forward, whether one moves more than the other producing a deviation of the mandible, and so on. Clicking or snapping of the condyle can sometimes be felt. Tenderness indicates possible arthritis (Fig. 7). Percussion Very gentle tapping on a tooth suspected of being abnormal may elicit pain. Ankylosed or fractured teeth may have a duller sound. Auscultation A stethoscope may be placed over the mandibular condylar area. The patient opens and closes several times. Listen for condylar clicks. The above examination procedure may seem lengthy, but can be accomplished in about one minute. Further specific studies, such as radiographs, are best done by a dentist. Figure 5.
Figure 6.
Figure 5. Palpation of the upper lip in a five year old ·girl. Figure 6. Bimanual palpation of floor of the mouth in an 11 year old girl.
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Figure 7. A, Palpation of mandibular condyles with jaws at rest in an 11 year old girl. B, Palpation of mandibular condyles with mouth open wide in an 11 year old girl.
NORMAL APPEARANCE OF THE ORAL MUCOSA AND TEETH The lips should be symmetrical, without clefts or pits, and of a reddish-pink color consistent with the patient's general complexion. Cherry red or blue lips do not always signify carbon monoxide poisoning or congenital heart disease, but rather, may merely be the patient's normal color. Very pale, fair-skinned individuals may have bright red lips, whereas darker individuals may have bluish lips. The buccal and labial mucosa is normally smooth, wet, flexible, and easily stretched. Numerous fine small blood vessels are seen, and in darker-complexioned people, one can see "freckling" and a generally darker red-purple color. Palpation often reveals numerous submucosal 1 to 2 mm soft nodules. These are small sebaceous glands (Fordyce spots) which (if present close to the surface) can be seen as yellow papules, and are of no particular consequence (Fig. 8). The tougher gingival tissue is adapted to withstand the stresses of mastication. It is bound down firmly to the underlying alveolar bone and is pinkish to bluish with a stippled surface texture. The gingival margins should be sharp and scalloped about the necks of the teeth, and the interdental papillae should have a triangular shape and fill the spaces between the teeth (Fig. 9). Edema and inflammation produce swelling, redness, and a loss of stippling resulting in a smooth surface texture. Loss of stippling is thus a sign of disease and occurs early. The hard palatal mucosa receives a great deal of stress due to mastication, which accounts for its very tough appearance. Numerous folds or rugae are seen and felt easily. A small papilla, the incisive papilla, just behind the upper central incisors covers the nasopalatine foramen and houses the nasopalatine nerve and vessels (Fig. 10). The soft palate has more of the appearance of the other nonstress areas and thus resembles the buccal mucous membrane more than it does the hard palate. The dorsal surface of the tongue is well papillated and has a rough velvety texture (Fig. 11). Transient changes in the oral environment as well as antibiotics may alter this texture and color.
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Figure 8.
Fordyce spots.
Figure 9. A, Retraction of the upper lip showing normal mucosa and attached gingiva in a five year old girl. Note primary teeth. B, Retraction of the lower lip in the same girl. C, Retraction of both lips.
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Figure 10. Hard palate of an 11 year old girl. Note rugae and incisive papilla.
The primary and secondary teeth erupt in a fairly predictable pattern. Calcification occurs before eruption so that any given disease may leave a record of its presence on that portion of the enamel undergoing calcification at that time. This may appear as a horizontal line or poorly calcified groove or pits on the crown of the tooth (Fig. 12). Tetracycline and excessive fluoride may cause abnormal maturation-calcification and staining of the teeth (Fig. 13). There are several important points pertinent to the diagram shown in Figure 14. 1. The primary teeth are smaller and lighter in color than the permanent teeth. 2. The pulp chamber is larger in recently erupted teeth and gets smaller over a number of years. Thus in children and adolescents, caries (decay) can reach the pulp very quickly. 3. The permanent first, second, and third molars have no primary predecessors.
Figure 11. Dorsum of the tongue in a five year old girl.
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Figure 13.
Figure 12.
Figure 12. Acute nephritis during calcification and maturation of that portion of the crown resulted in pits on the teeth. Figure 13. Tetracycline staining (see also color plate IVE).
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Figure 14. Left half of mouth is shown. Eruption dates (approximate) of teeth. Primary (in months): cental incisors, 5 to 10; lateral incisors, 7 to 12; cuspid (canine), 16 to 20; first molar, 11 to 18; second molar, 20 to 30. Permanent (in years): central incisors, 6 to 8; lateral incisors, 7 to 9; cuspid (canine), 9 to 12; first premolar, 10 to 12; second premolar, 10 to 13; first molor, 5'/2 to 7; second molar, 12 to 14; third molar (wisdom tooth), 17 to 30. Match teeth on diagram as seen from midline to the reader's right.
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4. A given mandibular tooth usually erupts before its maxillary mate. 5. The primary molars are replaced by the permanent premolars. 6. The primary central and lateral incisors and cuspids (canines) are replaced by permanent successors of the same name. 7. Calcification of the crowns of the primary teeth begins in the fourth month in utero. 8. Calcification of the crowns of some permanent teeth begins at birth. 9. Calcification of the root is finished a few years after the crown erupts.
HISTOLOGIC CHARACTERISTICS OF THE ORAL MUCOSA The oral mucosa varies in appearance histologically to conform to its particular function at a given site. Thus the smooth buccal mucosa has one appearance and the tongue and attached gingivae still other modifications for the work they have to do. In general, the oral epithelium is thicker than skin epidermis. The hard palate and attached gingivae are well keratinized in response to friction; buccal mucosa lacks this keratinization. Mucosa of the dorsum of the tongue is highly specialized. The epithelium is of the stratified squamous variety with cuboidal basal cells and a fairly wide prickle cell layer. In addition to the major salivary glands, there are several minor small salivary glands distributed throughout the oral mucosa. These are most numerous on the palatal and labial mucosa. Typically, these glands have numerous acini. The major paired salivary glands-parotid, submandibular (submaxillary) and sublingual-provide fluid designed to lubricate the oral mucosa and food bolus and begin the process of digestion.
BIOPSY PROCEDURE Biopsy of the oral mucosa may occasionally be indicated. The standard skin punch may be used in areas where the mucosa is firmly bound down, such as the hard palate or attached gingivae. On the more movable, friable buccal mucosa, however, the torque of the punch may tear the tissue. Bleeding and access are also problems in the mouth. For these reasons, it is advantageous to use a "two-suture" technique. The following steps are necessary: 1. Place the first suture, a 4-0 silk suture, so that it lies deep to the lesion and beyond its borders. Do not tie it. Let the ends hang out of the mouth (Fig. 15A). 2. Place and tie the second suture, a 4-0 silk suture, so as just to encompass the area to be removed (Fig. 15B). By gentle manipulation, the mucosa can be elevated and moved from one side to the other as though a handle were attached to it. A scalpel blade or curved serrated scissors may be used to excise the area. Be careful not to cut through the first suture (Fig. 15C).
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A
B
c
o
Figure 15. A, Placement of first suture to be tied later. B, Placement of second suture. Tie about lesion to help control it during excision. C, Removal of excised specimen. D, First suture tied.
3. Remove the specimen from the mouth and place in biopsy bot-
tle. 4. Now, the ends of the first suture are picked up and tied. Preplacement of this suture eliminates the need to place a suture in a bloody field (Fig. 15D). To remove larger pieces, one may place several initial sutures, and so on.
LOCAL ANESTHETIC TECHNIQUE Local infiltration anesthesia with lidocaine 1 per cent with 1: 100,000 epinephrine is adequate. Remember to wait about four to five minutes after injection to get maximum vasoconstriction at the site. This reduces bleeding and gives better control during the biopsy.
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For the most part, nerve trunk blocks are not necessary for oral biopsy procedures. The mental nerve block can, however, be useful for procedures on the lower lip such as repair of lacerations. This can be accomplished by injecting about 0.25 ml of anesthetic solution just beneath the mucosa overlying the mental foramen. The foramen lies approximately at the depth of the buccal sulcus between the primary first and second molars or the permanent first and second premolars. Other blocks, such as the inferior alveolar injection, are beyond the scope of this discussion.
ANOMALIES Cleft Lip and Palate Cleft lip and palate may result in lifelong functional and emotional scars. Speech patterns may be mislearned so that "nasal" speech persists after surgical repair, unless repair is begun early. Other children may tease the child about the deformity. Thus early definitive treatment is essential for functional and cosmetic reasons. Soft tissue closure can best be accomplished in many patients if combined with various dental orthodontic appliances. Dentists, pediatricians, and plastic surgeons working together can achieve remarkable results. Vascular Nevi Hemangioma is a common vascular nevus and presents as a flat patch or, more often, as an irregular elevated red mass. They are best left alone. Capillary hemangiomas often involute. Occasionally, an intraoral hemangioma may interfere with eating or speech and, of course, bleed, but this is not the usual situation (Fig. 16). Large hemangiomas (Fig. 17) may be associated with the Kasabach-Merritt syndrome in which platelet sequestration may lead to thrombocytopenia. Lymphangiomas may develop as superficial, grouped, clear to pink vesicles or as deeply situated, nodular, soft masses. Pain, swelling, and infection occasionally occur. A more extensive lymphangioma of the Figure 16.
Figure 16. Figure 17.
Figure 17.
Hemangioma. Cavernous hemangioma of the buccal mucosa.
r
r
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neck and floor of the mouth is sometimes referred to as cystic hygroma. Macroglossia due to lymphangioma may be corrected surgically by a wedge resection. Tongue Tie Ankyloglossia or tongue tie refers to an abnormality in which the lingual frenum is attached closer to the tip of the tongue. It does not necessarily interfere with speech and need not be treated unless it is subject to trauma from mastication or is producing periodontal problems where it is attached to the gingiva Median Rhomboid Glossitis This entity presents as a reddish diamond-shaped patch on the dorsal aspect of the tongue and represents a normal but unpapillated remnant of the tuberculum impar. No treatment is necessary (Fig. 18). Oral Mucous Membrane Pigmentation Many local and systemic conditions, as well as certain chemicals, can result in pigmentary changes in the oral cavity. Melanin may normally be found in darker races and tends to increase with age. "Freckles," intraorally and on the lips, are seen commonly (Fig. 19). Peutz-Jegher disease (hereditary intestinal polyposis); Addison's disease, and Albright's syndrome (polyostotic fibrous dysplasia) are rather uncommon diseases in which pigmented brownish to blue-black oral mucosal patches and macules may appear. Primary or metastatic melanoma is another cause of increased oral pigmentation. The associated findings in other organ systems may not predominate the clinical picture at a given time so that the oral findings can be quite helpful to the diagnostician. Heavy metals such as lead and bismuth can produce a dark greenish-black line, usually at the gingival margins, or in areas of chronic inflammation. These discolorations are due to the deposition of metallic sulfides. It tends to be less common in children because these metals are preferentially deposited in bones. The most common exogenous pigment is silver amalgam which
Figure 18. Median rhomboid glossitis.
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Figure 19. Focal hyperpigmentation ("freckle") of lower lip.
can be implanted into the oral mucosa either during extraction of a tooth or during placement of a silver amalgam restoration, resulting in a bluish-black macule or patch (Fig. 20). It should not be confused with a melanocytic nevus. An intraoral radiograph will often show small dust-like radiodense silver amalgam particles scattered throughout the tissue. If there is any doubt, a small biopsy can be obtained. Treatment is otherwise not necessary. Melanocytic nevi present as brown to blue-black macules and patches. They are uncommon and need not be treated, although some feel they should be excised. Observation from time to time would probably be adequate in most cases.
HEREDIT ARY DISORDERS There are several hereditary disorders of keratinization with associated epithelial dysplasias of the oral mucosa (Table 1). Clinically, these appear as whitish areas. Thus the total clinical picture and a biopsy may be necessary for diagnosis.
Table 1. Hereditary Disorders of Keratinization DISEASE
AREA OF MOUTH INVOLVED
OTHER AREAS
PROGNOSIS
Darier's disease Dyskeratosis congenita
Labial and buccal mucosa Tongue, buccal mucosa
Skin Dystrophic nails
White sponge nevus Pachyonychia congenita
Labial, buccal mucosa Buccal mucosa and tongue
Benign Carcinoma common Benign Carcinoma common
Hereditary benign in traepithelial dyskeratosis
Buccal and labial mucosa, floor of mouth, undersurface of tongue
Anal and vaginal Anal and laryngeal mucosa, thick nails, keratoderma of palms and soles Eye Benign
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Figure 20.
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Amalgam tattoo.
MISCELLANEOUS CONDITIONS Idiopathic Gingival Fibromatosis and Hypertrichosis This is an autosomal dominant condition characterized by marked enlargement of the attached gingivae. It begins early, before the tenth year of life, and may cause marked malposition of the teeth. The eyebrows and scalp hair are particularly thick and abundant. Gingival enlargement owing to use of phenytoin (Dilantin) has a similar clinical intraoral appearance (Fig. 21). Surgical excision of the excess tissue (gingivectomy) can be beneficial. Enlargements due to either condition often occur. Scrupulous oral hygiene, however, may delay recurrence of enlargement caused by phenytoin. Neither condition is premalignant. Pyogenic Granuloma This condition, neither pyogenic nor granulomatous, is often seen at the site of a previous injury and presents as a friable red shiny
Figure 21. Gingival enlargement resulting from the use of phenytoin.
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papule or pedunculated mass which bleeds easily. The oral lesion can be a problem because it may be traumatized readily during mastication and tends to bleed even more profusely than the skin lesion. Surgical excision is, therefore, indicated. If the lesion is very small, cauterization may be adequate (Fig. 22). Geographic Tongue Also known as benign migratory glossitis, it is a fairly common entity. Irregularly shaped red patches appear on the dorsum of the tongue (Fig. 23). Over a period of several days, these areas enlarge, change shape, and eventually disappear only to be replaced by new similar red patches. Histologically, there is a temporary loss of keratinized papillae in the affected red patch. Keratin, wet by saliva, has a whitish color so that its loss allows the underlying red mucosa to show through. The condition is usually asymptomatic and requires no treatment. It tends to abate or repeat cyclically. Mucocoele (Mucous Retention Cyst) Biting the lip may initiate this problem. It often occurs on the labial aspect of the lower lip as a submucosal mass which is fairly well defined and slightly bluish in color (Fig. 24). Because of trauma, it may have a whitish keratinized surface over one area. These lesions are filled with a clear gelatinous material. Simple excision and closure is generally preferable. Aphthous Stomatitis Also called canker sores, this is a common disorder characterized by recurrent painful, burning shallow ulcers of the oral mucosa (Fig. 25). The exact etiology is unknown, although it has been associated with transitional L-forms of bacteria. Certain elements of an autoimmune nature may also play a role. It is not caused by herpes simplex virus. Stress and various foods such as nuts and chocolate have been thought to trigger episodes of this condition in those predisposed to it. The lesions begin with a burning sensation. After several hours, a small reddish macule appears, followed in short order by a superficial ulcer with a yellowish center and an erythematous halo. One or several of these may occur scattered about the oral mucosa including the pharyngeal mucosa. They may be from a few millimeters to a centimeter or so in diameter. In many recurrent cases, crops of numerous lesions may appear every few weeks, and the patient may have cervical lymphadenopathy, malaise, difficulty eating because of the pain and a slight elevation of temperature. A white blood cell count is useful to rule out cyclic neutropenia, a different condition, which may cause similar lesions. Treatment consists of avoiding any suspected triggering foods, as well as discontinuing any mouthwashes and mint and cinnamonflavored toothpastes or foods with these flavorings. Milk of magnesia may be used as a bland mouthwash and as a dentifrice. A soft toothbrush is best. Hydrogen peroxide preparations can also be helpful as an
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Figure 22.
Pyogenic granuloma.
Figure 23. Geographic tongue (see also color plate IVF).
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Figure 24. lower lip.
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Mucocele of the
additional method of cleansing the mouth. A short course of oral corticosteroids is often helpful during a severe attack with multiple lesions. We have found the following mouthwash formula to be most useful when used four times daily during an attack, and as a prophylactic measure once a day between attacks. Stanford Mouthwash Formula
Tetracycline (Achromycin) suspension Mycostatin Hydrocortisone Chlorpheniramine (Chlor-Trimeton) syrup
250 ml 6 million units 1000 mg enough (to 500 ml)
Refrigerate. One teaspoon held in the mouth for two minutes four times a day. Do not swallow. Do not eat, drink, or rinse your mouth for at least an hour after using the mouthwash.
Angular Cheilitis Cheilitis refers to an inflammation of the lips. Many causes exist. For the child, the most common cause is chapping or irritation due to excessive drying of the lips. Mouth breathers often exhibit this condition. Allergic contact cheilitis or irritant cheilitis from mouthpieces of various woodwind or brass instruments is also seen. The small metal
Figure 25. titis.
Aphthous stoma-
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band holding a pencil eraser atop the wood shaft, as well as the rubber eraser itself, can be a source of cheilitis for pencil chewers. Angular cheilitis, or cracking at the corners of the mouth, is often associated with candida, but the organism is most often a secondary invader rather than the cause of the problem. Incompetence of the oral sphincter due to dental abnormalities or soft tissue irregularities that allow saliva to continually seep out and to accumulate at the corners of the mouth are the underlying causes to be looked for and treated. Vioform-Hydrocortisone cream applied several· times a day is a good temporizing measure while the underlying problems are being treated. Fluorinated hydrocortisone creams tend to further weaken the delicate mucosa and should not be used for long periods of time. For the acute case. a cream base is preferred. Ointment bases are good for the dry, cracked, chronic condition. Bases with propylene glycol may sting and should be avoided in the acute stage.
INFECTIOUS DISEASES (VIRAL) Herpes Simplex Primary herpes simplex infections, caused by herpes virus hominis, often produce an acute herpetic gingivostomatitis characterized by fever, malaise, headache, and small easily eroded vesicles on the lips and oral mucosa. Recurrent infections usually spare the oral mucosa and affect only the skin around the lips (Fig. 26). By contrast, aphthous stomatitis affects the oral mucosa but rarely (if at all) the vermilion portion of the lips or the perioral skin. In immunosuppressed individuals, however, one may see recurrent herpes simplex infections that look like primary herpetic gingivostomatitis. Remember, too, that a recurrent herpetic lesion on the lip may occur along with an episode of aphthou~ stomatitis, both of them perhaps having been triggered by the same underlying set of stimuli. Erythema multiforme (Stevens-Johnson syndrome) may often be triggered by this virus. Stevens-Johnson syndrome requires quick and forthright management with steroids parenterally.
Figure 26. Herpes simplex infection of the upper lip.
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There is no cure for primary herpes simplex infection; therefore, avoidance of any suspected triggering agents such as excessive sun exposure or trauma is of first importance. Sunscreens and bland ointments may be helpful in this regard. During an acute attack, remind the patient that he has a contageous condition. Both types I and II herpes virus can infect any area of the skin or mucous membranes. A drying agent such as acetone rubbed on briskly with a· piece of gauze will open the vesicles and speed the healing process. It stings for an instant, but relieves the symptoms quickly. After this, one may prescribe Vioform-Hydrocortisone cream to be applied several times a day for a few days to help reduce inflammation and to avoid secondary bacterial infection. Ointment bases keep the lesion wet and impair healing.
Hand-Foot-Mouth Disease This entity is caused by a Coxsackie virus and presents as a rather mild illness characterized by low-grade fever, polygonal clear tense vesicles On the fingers and toes, and superficial tiny red vesicles and ulcers scattered over the palate and buccal mucosa No specific treatment is necessary. A bland mouthwash with milk of magnesia may reduce the oral symptoms. Herpangina Another of the Coxsackie viral infections, herpangina produces minute vesicles and ulcers on the palate. Sore throat, mild fever, and abdominal pain complete the picture. No treatment other than supportive is necessary.
Figure 27. Palatal exanthema of primary Varicella.
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Varicella and Herpes Zoster This virus can also produce intraoral lesions. In varicella, intraoral vesicles may be observed along with the exanthema (Fig. 27). Herpes zoster may affect the trigeminal nerve and produce a readily recognizable picture when it affects the oral mucosa. A unilateral vesicular and ulcerative process is seen. For example, involvement of the third division of the trigeminal nerve results in unilateral glossitis, mandibular gingivitis, and cheilitis. Often, associated but not infectious disturbances in VII and VIII may result in a concomitant Bell's palsy and dysequilibrium, known as the Ramsey-Hunt syndrome. Verruca Vulgaris Intraoral verrucae can occur, and because of their wet, hyperkeratotic surface, they appear to be white. They may be mistaken for a white patch of leukoplakia. The surface, however, is verrucous or warty and the patient may have other intraoral or digital warts which appear to have been gnawed (Fig. 28).
INFECTIOUS DISEASES (BACTERIAL) Among the bacterial diseases affecting the mouth, the most common are dental infections such as acute periapical abscesses and periodontal infections. Poor diet, inadequate oral hygiene, caries, trauma, and neglect are the precursors of these infections. Local drainage is quite important; antibiotics are helpful but should not be the only treatment given. Extraction of the affected teeth should be only a last resort, for they can never be replaced with their equals. Modern endodontic (root canal) treatments and restorative dentistry can painlessly save most teeth, even those fractured below the gingival margin. Pulpitis Pulpitis, or inflammation of the dental pulp, is fairly common in
Figure 28. Verrucous papilloma consistent with verruca vulgaris.
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children. The pulps of the teeth are quite large in the young, and decay quickly reaches this sensitive structure producing pain and infection. Trauma from a fall may also injure the pulp and lead to necrosis and, clinically, a black or discolored tooth. Toothache from pulp disease is initially intermittent and is triggered by cold. It may be reversible if the initiating causes are treated (such as removal of decay and placement of a sedative dressing). As the pulp becomes further inflamed, the toothache becomes constant, exacerbated by heat and relieved by cold. The disease becomes irreversible at this point. The process may then spread outside the tooth to the periapical area, producing a local osteomyelitis with severe pain when the tooth is touched (Fig. 29), known as acute periapical periodontitis. Eventually, the process may work its way through the bone and into the surrounding soft tissues. When the swelling appears, the bone is drained and the severe pain most often ceases (Fig. 30). Early treatment of pulpitis with root canal therapy can often abort the subsequent stages of this process. Antibiotics are often necessary.
Acute Necrotizing Ulcerative Gingivitis (Trench Mouth) In this condition, there is a fairly rapid necrosis of the interdental papillae. A yellowish pseudomembrane covers the gingivae which bleed easily, and there is a characteristic foul odor to the breath. Some patients complain of a metallic taste. This entity was commonly seen in crowded conditions such as in the military and in boarding schools. It is associated with increased numbers of certain normal flora of the mouth such as Borrelia vincentii and Bacillus fusiformis, but is probably not simply a bacterial infection or contagious in the ordinary sense of the word. Poor oral hygiene, diet, crowding, and stress may play roles in precipitating the disease. The exact etiology is still obscure. Local debridement with hydrogen peroxide mouth rinses is a useful adjunct to careful oral prophylaxis by a dentist. Systemic or topical antibiotics can be used, but generally are not necessary. Syphilis Not at all rare in children, syphilis may present in the form of a hard ulcerated chancre on the lips or oral mucosa. Secondary infection with other bacteria may occur more readily intraorally so that the classic "painless" chancre may be, in fact, painful. Regionallymphadenopathy is present. The oral mucous patches of secondary syphilis are characterized by superficially eroded, flattened papules covered with a whitish-grey membrane. About one third of congenital syphilitics exhibit the classic screwdriver-shaped Hutchinson incisor or the multilobulated mulberry molar. Both dental def~rmities represent the effect of the disease on the crowns of these teeth which are undergoing development at that time. Treatment should follow recommendations of the local health authorities or current optimal therapeutic regimens.
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Figure 29. Caries has invaded the pulp. Infection spreads via the root canal to the bone and then by either of two pathways to drain intraorally or extraorally.
Figure 30. Acute alveolar abscess pointing intraorally_
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Gonorrhea In gonococcal stomatitis, the intraoral mucosa is quite red and tender. Numerous erosions covered with a yellow pseudomembrane are usually apparent. As in syphilis, treatment of gonorrhea should follow recommendations of the local health authorities or current optimal treatment regimens. Candidiasis (Candida albicans, Moniliasis, Monilia albicans) This organism, normally a saprophytic yeast-like fungus, can produce a whole range of infections from local and mild, to systemic and serious. It normally colonizes the gastrointestinal tract of most individuals, producing no infection unless underlying systemic disease or local mucous membrane or skin disease reduces resistance to the organism. Immunoincompetence allows the fungus to invade, pulmonary infections being most common. Focal injury to the skin, such as in the wet, macerated diaper area or in moist intertriginous areas beneath the breasts, may result in infection. Oral lesions may be acute or chronic. Acute lesions are typified by infant thrush in which several white curd-like patches are seen (Fig. 31). Characteristically, these may be scraped off rather easily with a tongue blade, leaving a raw bleeding surface. Chronic candidiasis of the atrophic type may be seen with the use of broad spectrum antibiotics. It presents as a bright red stomatitis without curd-like whitish lesions as seen in thrush. Candidal granuloma, a rare type, usually involves the tongue and may produce local swelling. Angular cheilitis from any of the causes mentioned above may harbor candida as a secondary invader. Treatment consists of correction of the underlying causes and suppression of the fungus with mycostatin topically.
Figure 31.
Thrush mouth.
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IRRIT ANT AND ALLERGIC REACTIONS True allergic reactions of the oral mucosa are probably rare, and when they do occur, are often accompanied by skin eruptions. Considering all the antigenic insults to the mouth from foods, flavorings, preservatives, and artificial colorings, the paucity of reactions is striking. Irritant reactions, less rare but not really common, are usually caused by some essential oil in a dentrifrice or chewing gum. Oil of cloves, cinnamon flavorings, and peppermint are often involved. Allergic reactions to dental restorative materials and properly cured acrylic resins are uncommon. Alcohol and perborates in certain mouthwashes can also be quite irritating. Mechanical irritation includes hot or crusty foods such as soups, bread crusts, pizza pie, or overheated rubber nipples. Removal of the offending agents suffices. Milk of magnesia mouthwashes are effective in relieving pain and as a temporary protective coating. Various cytotoxic drugs may disturb the oral epithelial cells and interfere with their normal maturation, resulting in recurrent ulceration. This problem is seen in transplant or tumor patients on immunosuppressive drugs. A combination mouthwash as described above is useful (Fig. 32). ACKNOWLEDGMENT
Grateful acknowledgment is given to Michele Wambaugh Dearborn for her photography in Figures 4-7 and 9-11, and her renderings in Figures 14, 15, and 29.
Figure 32. Oral ulcer in a patient treated with doxorubicin hydrochloride (Adriamycin) for lymphoma.
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REFERENCES 1. Colby, R. A., et al. (eds.): Color Atlas of Oral Pathology. Edition 3. Philadelphia, J. B. Lippincott Co., 1971. 2. Fisher, A. A.: Contact Dermatitis. Edition 2. Philadelphia, Lea and Febiger, 1973. 3. Fitzpatrick, T. B., et al. (eds.): Dermatology in General Medicine. New York, McGraw-Hill Co., 1971. 4. Ingle, J. I.: Endodontics. Philadelphia, Lea and Febiger, 1965. 5. Korting, G. W.: Diseases of the Skin in Children and Adolescents: A Color Atlas. Philadelphia, W. B. Saunders Co., 1970. 6. Rook, A., et al. (eds.): Textbook of Dermatology. Edition 2. Philadelphia, J. B. Lippincott Co., 1972. 7. Solomon, L. M., and Esterly, N. B.: Neonatal Dermatology. Philadelphia, W. B. Saunders Co., 1973. 450 Sutter Street Suite 2001 San Francisco, California 94108