Periodontal and Soft-Tissue Abnormalities

Source:  Periodontal and Soft-Tissue Abnormalities    Tag:  herpangina in adults

Resident: Avani Khera
Article: Periodontal and Soft-Tissue Abnormalities
Date: 1995
Author: Jayne E Delaney DDS, MSD

Main Purpose: Review different periodontal conditions in pediatric patients and how to treat them. It also covers some of the soft tissue lesions.

Normal Findings:  The color of the gingiva in the preschool child may be more reddish because of an increased vascularity and a thinner, less keratinized, more translucent epithelium.  Probing depth averages approximately 2 mm.

Periodontal problems of the preschool child :

Gingivitis in young children:   Generally less severe than in adults with similar plaque levels, rarely progresses into periodontitis in the pre-schooler.

Localized and generalized periodontitis .  6-7% of children approximately age 5 have been shown to have radiographic periodontal bone loss. Treatment is scaling and root planning as well as antibiotics as needed.
--Bitewing radiographs detect alveolar bone loss along with probing
--Bone loss most pronounced between primary first and second molars

Prepubertal Periodontitis – Usually seen inconjunction with systemic diseases. Most successfully treated when localized.
--Begins with the eruption of primary teeth, characterized by severe gingival inflammation, rapid bone loss, mobility and tooth loss.
--Tx: Scaling/RP, chlorohexidine rinses, excellent OH, and penVK or augmentin
--Associated with neutropenia, papillon-lefevre syndrome, diabetes, hypophsphatasia, histiocytosis X

Neutropenias - Neutrophils play a protective role in the periodontium. In their absence, disease and bone loss can occur quickly.
--Clinical symptoms: Oral ulcers, severe gingivitis, alveolar bone loss, gingival recession, mobility and early tooth loss.
--Treatment is scrupulous oral hygiene, antibiotic therapy, and administration of granulocyte colony stimulating factor (G-CSF).

Papillon-Leferve Syndrome – This is usually manifested in hyperkeratosis on the palms and soles of teeth and premature loss of teeth are common manifestations of this disease. Primary teeth are often lost by age 5. Treatment includes a heavy course of antibiotics and allow later eruption of any unerupted teeth, which can erupt into an oral environment lacking in periodontal bacteria.

Metabolic disorders - Diabetic children may manifest with early periodontal disease due to altered neutrophil chemotaxis.

Histiocytosis X - aka Langerhans cell disease. Mostly a radiographic finding of "teeth floating in space" but gingival inflammation is also common.

Hypophosphatasia - Most common oral finding is early loss of teeth, sometimes with primary tooth exfoliation at age 1 and a half.
--Radio graphically you see abnormally large pulp chambers.

Soft Tissue problems:

Ankyloglosia - Most children will have some frenum growth with age, but others may need surgical intervention. A speech pathologist should be consulted in any case affecting speech and before any decision for surgery.

Geographic tongue - Asymptomatic and most common in girls.

Fissured tongue - Associated with geographic tongue, also benign. Food debris may get trapped causing fungal infections/malodor.

Retrocuspid Papillae - Present in most children behind the mandibular cuspids. No Tx necessary.

Gingival Fibromatosis - Can be drug induced, inherited or associated with leukemia. Poor OH exacerbates this problem.

Hemangioma - Benign tumor of mesenchymal origin., enlarged/vascular.  Most commonly found on dorsum of the tongue, gingiva, and buccal mucosa as red or bluish raised lesions moderately firm to palpation. Usually painless. Surgical removal is the usual treatment.

Lymphangioma - Benign tumor of lymphatic origin, tongue is the most common site.. They are soft and compressible sometimes bluish in color. Usually present at birth.

Mucocele - Retention of mucous in subepithelial tissues, most common in children and adolescents. Treatment of choice is surgical removal. Most commonly in the lower lip.

Fibroma - One of the most common benign lesions found in palate, tongue, lip and cheek. Treatment is surgical removal with low recurrence.

Odontogenic Cysts:

Parulis - End point of draining sinus tract associated with an abscessed tooth.

Infectious Diseases:

Herpesvirus Infection : viral infection.  Primary herpetic gingivostomatitis is the initial infection in young children---flu like symptoms, fiery red gingiva, clusters of vesicles. Following this outbreak, there is herpes labialis.

Herpangina - Acute viral infection usually in summer or early fall. Usually has gray, pinhead-size vesicles on tonsillar fauces.

Hand-Foot-and-Mouth Disease - Caused by coxsackie. Ulcerating and crusting vesicles on palate, tongue, and buccal mucosa. treatment is palliative only.

Recurrent Apthous Ulceration - Cause is unknown, but suspect food allergies, trauma, stress and hormonal changes. Mouth rinse and topical anesthetics are treatment.

Candidiasis -  AKA Thrush, can be wipes off leaving a red, raw, and painful surface. Treat with topical application of antifungals.

Impetigo - Perioral purulent bacterial infection found along the base of the nose. Usually due to strep A or Staph aureus; treat with topical or systemic antibiotics.

HIV - Usually children will present with candidiasis. Parotid swelling is also more common in HIV children than adults.

Leukemias - Leukemic gingival enlargement is most common.  Characterized by shiny, red, edematous, and boggy appearance of the gingiva with extensive bleeding. But mucositis is also common due to chemotherapy associated with leukemia. Poor OH can really worsen the situation.

Traumatic Ulcer – The most common ulcer in children. Often seen with post-anesthesia bites or burns in the palate from eating hot foods.

Assessment : Great review for boards.