General dentists usually serve as first-line providers for pediatric patients and the gateway to their oral health. Even though general dentists are trained to be able to treat children, dental education instruction can vary greatly. These differences heavily influence the individual practitioner’s knowledge base and comfort level in providing care to this vulnerable population. It is important for general dentists to be able to identify the presence of pediatric oral lesions. This article provides an overview of common pediatric oral lesions that general dentists may encounter in everyday practice.
Key points
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This article educates dentists on some of the more common oral diseases seen in pediatric patients.
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This article reviews diseases that are easily overlooked by practitioners.
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This article provides guidance on possible treatment modalities for pediatric oral diseases.
Introduction
Dental caries, periodontal disease (gingivitis and periodontitis), malocclusions, and traumatic injuries of the teeth are frequent dental concerns from pediatric population. Whereas benign epithelial or soft tissue pathologies, lesions secondary to trauma, and oral signs and symptoms in systemic diseases are prevalent pathologies occurring in the oral tissues, malignant lesions in the pediatric age group are rare. The concern is that most oral pathologies correlate with definable age groups and their presentations may have an impact on the growth and development of oral structures. Jones and Franklin analyzed data on archived oral pathology specimens over a 30-year period and concluded that 10% of specimens were from children less than 16 years of age, many of them were benign, and only 1% of cases were malignant lesions. Oral lesions presenting in the pediatric population do not generally require extensive surgical intervention because most are benign growths. Odontogenic tumors are relatively rare in the pediatric age group, except for adenomatoid odontogenic tumor and ameloblastoma. Ameloblastoma is discussed in Arvind Babu Rajendra Santosh and Orrett E. Ogle’s article, “ Odontogenic Tumors ,” in this issue. This article discusses the causes, clinical description, and treatment of common oral lesions in pediatric population ( Box 1 ).
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Hyperdontia
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Hypodontia
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Measles
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Gingival cyst of the newborn
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Epstein’s pearl
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Bohn’s nodules
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Natal and neonatal teeth
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Eruption cyst (eruption hematoma)
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Epidermoid cyst
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Dermoid cyst
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Oropharyngeal candidiasis
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Ankyloglossia
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Parulis
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Herpes simplex virus infection
Hyperdontia
Hyperdontia is a dental developmental anomaly that causes patients to have an excess number of teeth. This is more commonly known as supernumerary teeth. These extra teeth can be classified in 2 different ways: supplemental or rudimentary. Usually, supernumerary teeth will present with normal morphology, which classifies them as supplemental. Rudimentary hyperdontia are when teeth differ from normal morphology and have conical, tuberculate, or molariform structures.
Frequency and Prevalence
Supernumerary teeth are most commonly seen in the anterior maxilla of permanent dentition. A standard example of hyperdontia is the mesiodens, which occurs when a supernumerary tooth presents in between the central incisors ( Fig. 1 ). Males are more likely to display some form of hyperdontia than females.
Etiology and Genetics
The exact process and genetics of hyperdontia is not well-understood. However, hyperdontia is often associated with a number of syndromes and conditions, such as (but not limited to) Apert syndrome, cleidocranial dysplasia, Gardner syndrome, and Crouzon syndrome.
Treatment and Management
Management of supernumerary teeth differs based on severity. In many cases, hyperdontia may lead to crowding, impaction, root resorption, periodontal disease, and increased susceptibility to caries. Frequently, the recommended treatment is extraction to prevent future complications.
Hypodontia, oligodontia, and anodontia
Hypodontia, oligodontia, and anodontia are developmental anomalies that indicate the absence of teeth with the difference being in the number of teeth missing. Hypodontia is used to classify the absence of fewer than 6 teeth, oligodontia for the absence of 6 or more teeth, and anodontia when all the teeth are missing. Some of the more common terms that practitioners use to describe these conditions are tooth agenesis or congenitally missing teeth. Congenitally missing teeth is a result of disturbances during the early stages of development and is suggested as a mild dysplastic expression of the ectoderm ( Fig. 2 ).
Frequency and Relevance
Tooth agenesis in the deciduous dentition, although a rare finding, is often associated with maxillary lateral incisors or mandibular central incisors. Excluding third molars, the mandibular second premolar and the maxillary lateral incisors are the most commonly affected teeth in permanent dentition. However, when a missing tooth is observed in the primary dentition, then an associated permanent tooth is likely to be absent.
Patients with hypodontia may have an association with other dental or oral anomalies. Hypodontia can be associated with syndromic conditions, such as (but not limited to) ectodermal dysplasia, Crouzon syndrome, Williams syndrome, achondroplasia, orofaciodigital syndrome I, and Rieger syndrome. Furthermore, patients with hypodontia can have issues with other ectodermal organs, including salivary glands, skin, and sweat glands.
Etiology and Genetics
Similar to hyperdontia, hypodontia has unclear genetic mechanisms. It is speculated that hypodontia may occur owing to tooth induction issues, lamina abnormalities, and obstructions during lamina formation. Genetic mutations that could play a role in hypodontia are the PAX9, MSX1, and AXIN2 genes.
Treatment and Management
Timing is a priority in the management of missing teeth in the pediatric population. A multidisciplinary approach is required and coordination of treatment with the pedodontist plays an important role in the management of missing teeth in a pediatric population with the aim to preserve space for permanent dentition. Interceptive and preventive orthodontic procedures assist in space management. Restoration with adhesive bridges or dentures are treatment options, depending on the severity of the missing teeth.
Measles
Frequency and Prevalence
In 2000, the United States reported that measles has been eliminated. However, a resurgence of measles has occurred as of early 2019 with more than 600 reported cases and rising. Transmission occurs through respiratory droplets, aerosols, and close contact. The main reservoir of measles are humans and nonhuman primates.
Etiology
Measles is caused by the single-stranded, negative-sense RNA virus called rubeola. It is a highly contagious disease where management levels vary based on each country’s immunization rates. The primary receptor for the measles virus is CD150 expressed on various lymphocytes and nectin-4 on epithelial cells. Owing to the mode of transmission for the virus, the respiratory tract is usually the first place of infection. The lymphocytes that are affected eventually reach lymphoid tissues where replication occurs and dissemination follows.
Description
Symptoms of measles usually begin with a rising fever associated with the 3 Cs: cough, coryza, and conjunctivitis. These symptoms gradually intensify for 2 to 4 days before a maculopapular rash can be seen. The onset of the maculopapular rash typically begins in the head and neck region and can spread generally throughout the body. Preceding the initial rash appearance, small raised white lesions called Koplik spots may be seen on the buccal mucosa and soft palate. Koplik spots are not visible in all cases, but are pathognomonic for measles infection. Owing to the primary target of rubeola being lymphocytes, measles may even cause immunosuppression in individuals. This condition leads to secondary bacterial infections and increases the risk of morbidity.
Measles may cause a variety of complications in different organ systems depending on the severity. The most commonly affected organ systems are the respiratory, gastrointestinal, and ocular tracts. Pneumonia can occur owing to the measles infection itself or from secondary infection from induced immunosuppression. In already immunocompromised patients, progressive pneumonia is the leading cause of death from measles. Otitis media and laryngotracheobronchitis (measles croup) are other respiratory symptoms that practitioners should be aware of when suspecting measles infection. Diarrhea is the primary gastrointestinal symptom and may cause severe dehydration. As mentioned, conjunctivitis is frequently seen in patients with measles and usually heals without long-term effects. In malnourished or immunocompromised patients, conjunctivitis and keratitis can lead to severe consequences such as blindness.
Treatment and Management
Measles vaccination is the key method of prevention in countries that are able to attain high immunization rates. Patients who present with rising fever and a maculopapular rash should be suspected for measles infection. Confirmatory diagnosis is done through plaque reduction neutralization assay to detect for measles-specific antibodies. There are no specific or targeted methods to eliminate measles infection. Thus, supportive therapy is the primary method of treatment. Patients are usually given vitamin A supplements and antibiotic therapy to manage nutritive levels and secondary infection risks.
Gingival cyst of the newborn (dental laminar cysts)
Frequency and Prevalence
Gingival cyst of the newborn occurs in approximately 13% of infants. They are rarely seen after 3 months of age.
Etiology and Genetics
Dental laminar fragments can remain in the alveolar mucosa after tooth formation. These fragments then proliferate into small keratinized cysts.
Description
Gingival cyst of the newborn occurs on alveolar ridges of newborns and young infants. They are white or yellow cystic lesions, measuring approximately 2 to 3 mm in diameter. They are asymptomatic and do not cause the newborn any discomfort. They can be subdivided into palatal or alveolar depending on location. Radiographs are not indicated for these lesions.
Treatment and Management
These lesions are usually self-limiting and only require observation. If the cysts persist or interfere with feeding, they can be surgically opened to drain.
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