Management of Painful Conditions - Pustules, Pox & Plaques

• Children and prescribing:

  • Care with steroid preps that can be ingested
  • Do not prescribe aspirin-based preps
  • Can't use mouth rinse until > 6 years, unless on a swab by parent
  • Prescribing systemic agents (weight-related)
  • Basic rule of thumb:
  • < 5 years old = 1/4 dose
  • > 5 years old = 1/2 dose
  • > 10 years old = adult dose
• Reye's Syndrome:

  • Aspirin plus viral illness (especially 5-10 years)
  • Sudden illness: vomiting
  • Increase levels of NH₃ (ammonia) and H+ in blood
  • Brain swells and liver inflames, but all organs affected
  • Liver failure (mitochondrial liver damage)
  • If undiagnosed - death
  • PARACETAMOL or IBUPROFEN instead of aspirin
• Sepsis in children:

  • Paediatric sepsis is considered a spectrum of disorders that result from infection by bacteria, fungi, viruses or parasites, or the toxic products of these microorganisms.
  • Early recognition and intervention improve outcomes for infants and children.
  • When a child/adult has an infection, the body's immune system kicks into gear to fight it off... This immune overreaction is sepsis and can cause inflammation, blood flow problems, low blood pressure, trouble breathing and vital organ failure.
  • Sepsis in children and adults can be life-threatening.

  
• Signs of sepsis:

  • Fever/shivering or very cold
  • Rapid breathing
  • Extreme pain/physical discomfort
  • Pale/mottled skin
  • Disorientated/confused & sleepy/difficult to wake
  • Elevated heart rate

  
• Call 999 or go to A&E if a baby/young child has any of these signs/symptoms of sepsis:

  • Blue, pale or blotchy skin, lips or tongue
  • A rash that does not fade when you roll a glass over it, like meningitis
  • Difficulty breathing (grunting noises or stomach sucking under ribcage), breathlessness or breathing very fast
  • A weak, high-pitched cry - not like their normal cry
  • Not responding normally, or not interested in feeding or normal activities
  • Sleepier than normal or difficult to wake

  They may not have all these symptoms.
• Teething treatment:

  • Massage
  • Dry the drool
  • Teething foods/toys and reassurance
  • Topical analgesia, systemic analgesia, occasionally - hypnotics/sedatives (only in extreme cases though)
  • Topical analgesia = lignocaine and antibacterial agent such as cetalkonium chloride
  • Systemic analgesia
  • Paracetamol elixir
  • <1 year 120mg/5ml
  • 1-5 years 240mg/10ml bedtime
  • Ibuprofen only from 6 months (reconsider for asthmatics, renal and liver disease)
• Natal/neonatal teeth:

  • Natal = baby was born with the teeth
  • Neonatal = teeth erupt into mouth within 30 days of birth
  • Remove only if:
  • Excessively mobile (airway risk)
  • Interfering with infant feeding (bottle or breast)
  • Inflammation/ulceration of ventral surface of tongue
  • Note the difference in natal and neonatal teeth (birth vs within 30 days of birth)
• Eruption cysts = when tooth follicle expands and becomes blood filled - regress as the tooth erupts - aim to get the tooth to erupt naturally

  
• Gingivitis artefacta/factitious gingivitis is caused by picking at the gingivae, causing them to recede.

  
• In this case a nail has become impacted in the gingiva.

  
• These are examples of burns caused by using air rotors without water.

  
• Symptomatic treatment for physical conditions affecting the gums:

  • Remove cause
  • Oral hygiene
  • Manage ulceration
  • Chlorhex/Difflam/Gengigel
  • Prevent secondary infection
  • Soft diet/fluids
  • Review
• Chemical burn from poorly sealed rubber dam allowing acid etch and bond beneath it.

  
• Deep chemical burn leading to granulation tissue formation.

  
• Symptomatic treatment for chemical conditions affecting the gums:

  • Oral hygiene
  • Fluids +++ if dehydrated
  • Bed rest if systematically unwell
  • Possibly chlorhexidine digluconate
  • Possibly Benzydamine chloride (Difflam)
  • Review
• Necrotising ulcerative gingivitis:

  • Eliminate cause (immunosuppression, malnutrition, smoking)
  • Oral hygiene
  • Debridement (necrotic interdental papilla)
  • Systemic antimicrobial (metronidazole)
  • Support and maintain

  
• Cancrum oris/noma:

  • Borrelia vincenti (spirochaete)
  • Fusobacterium (anaerobes)
  • Occurs when pt is malnourished, or has had a previous bacterial/viral infection
  • It destroys soft and hard tissues
  • It is aggressive and gangrenous
  • Occurs in environments with poor sanitation
  • Treated with: debridement +++, nourishment/nutrition, systemic antibiotics and good hydration

  
• Treatment of bacterial dental infections:

  • Symptomatic treatment as necessary
  • May need to be aggressive
  • Remove source of infection: drainage/debride/nutrition
  • Obtain swab wherever possible
  • Antimicrobial
  • Penicillin (Pen V, Amoxicillin)
  • Metronidazole
  • Think about dosage, preparation and sugar-free options
• Candida albicans:

  • Commensal - can be carried without causing any issues
  • Opportunistic pathogen
  • Broadly ~ mucosal or systemic infections
  • Hyphal form more virulent (due to toxins secreted)
  • Immune deficient or suppressed
  • Low iron can predispose
  • Other fungi can infect eg Aspergillosis of lungs
• Mucosal candidiasis:

  • Usually caused by Candida albicans
  • Others = Candida glabrata & tropicalis
  • AKA oral thrush
  • Acute pseudomembranous candidiasis
  • Peels away, raw underneath

  
• Standard treatment for mucosal candidiasis:

  • Investigate underlying cause
  • Iron deficiency, steroids (show how to use properly), poor appliance hygiene
  • Remove underlying cause
  • Ferrous sulphate, OHI, appliance hygiene, feeding bottle teats
  • Consider antifungal treatment
  • Miconazole (Daktarin oral gel) - 25mg miconazole/ml
  • Nystatin suspension and pastilles
• Chronic mucocutaneous candidiasis is associated with endocrine problems. Plaques of candidiasis around the lips and tongue - sore gingivae too.

  
• In chronic mucocutaneous candidiasis, tongue will not get coated so extensively with candida unless there is something seriously wrong systemically. In the photo the nail has been destroyed by infection.

  
• Vesicle visible on the chin. Blood crusted lips - classic herpes gingivostomatitis. Generalised gingival erythema - sore sloughing of the gingiva and ulcers present in the mouth too.

  
• Viral conditions:

  • Human Herpes simplex viruses 1 & 2
  • Coxsackie viruses
  • Varicella zoster

  
• Herpetic gingivostomatitis - since patient has picked at vesicles, the infection has spread over the face.

  
• In this example, the herpes virus has infected the nail bed - v painful.

  
• All patients here will have had primary herpetic gingivostomatitis - in 30-40% of patients who have it, the virus will lie dormant and may reactivate to a dermatome to cause herpes labialis (cold sores).

  
• Hand, foot and mouth disease is usually caused by Coxsackie A16 virus. It is characterised by vesicles on hands and feet - palms and soles of feet easiest place to see them because skin is palest there.

  
• Pts with hand, foot and mouth disease (caused by Coxsackie A16) may just want bland foods so that they don't irritate the mouth (fruit particularly bad; acidic).

  
• Herpangina:

  • Rarer disease
  • Posterior aspect of oropharynx affected
  • Progresses to painful ulceration
  • Causes sore throat and vomiting, as well as general malaise
  • Caused by Coxsackie virus A
  • Not linked to herpes nor angina

  
• Chicken pox:

  • Runny nose/cold-like symptoms precede rash - most infectious then
  • Skin rash, vesicles, ulcers, scabs
  • Very itchy
  • Oral lesions can occur but never alone
  • Varicella virus (Herpes family)
  • Intraoral vesicles like these can be hard to spot - easier to see ulcers

  
• Management of viral infections:

  • Symptomatic
  • Bed rest, fluids, topical/systemic analgesia - NOT IBUPROFEN
  • Ulcer coverage (use Orabase alone)
  • If severe, or the child is immunosuppressed
  • Antiviral agent
  • Aciclovir (only Herpes and Varicella respond)
  • Tablets (200mg), suspension (200mg/5ml), or cream (5%)
  • Only use systemic Aciclovir if EARLY or SEVERE or IMMUNOCOMPROMISED
• Management of minor ulcers:

  • Investigate underlying cause
  • Medical history, haematinic - (bowel, dietary intake, bleeds), stress, hormones, allergies, familial, trauma
  • Correct underlying cause (iron, folate, B₁₂)
  • Prevent secondary infection of ulcer (Chlorhexidine or Difflam)
  • Cover ulcer up and reduce inflammation (Adcortyl in Orabase, Gengigel)