Soft tissue pathology

• what do we start doing a BPE?

  once they've got their 6s and central incisals - log in notes
• when wouldn't we do a full BPE on a child over 12?

  if they dont have a full perm dentitions
• what might you advise a patient experiencing recurrent aphthous ulceration?

  Use a SLS free toothpaste
• where do measles spots appear first?

  mouth
• What order do you examine in?

  • Examine in systematic order:

  - Lips

  - Tongue

  - Palate

  - Throat

  - Oral mucosa

  
  

  • Note:

  - Colour changes

  - Ulceration

  - Swelling
• How to document condition/present complaint?

  • Photograph if possible

  • Presenting complaint

  - Location

  - Symptoms and duration

  - Triggers

  - Relieving factors

  - Recurrence

  - Consider any relevant medical conditions
• What is recorded for a lesion?

  - Site

  - Size

  - Colour

  - Consistency

  - Surface

  - Surrounding mucosa

  - Attachment
• how do you screen for perio in children?

  • young children - visual exam only
  • 7-11 years - BPE using who 621 probe, codes 0/1/2 FPM, UR1 and LL1
  • 12 + - full codes
  • for all assess OH%, plaque and calculus levels and record
• What are examples of gingival conditions?

  • Necrotising ulcerative gingivitis

  • Chronic gingivitis

  • Drug induced enlargement

  • Gingivitis artefacta

  • Chronic periodontitis

  • Aggressive periodontitis
• What is Necrotising Ulcerative gingivitis (NUG)?


  • Common acute infection – bacterial / viral?

  • No loss of connective tissue attachment

  • Seen in teenagers and young adults

  • Necrosis and ulceration

  • Ulcers are – “punched out”– yellow -grey sloughing – painful
• What are characteristics of NUG?

  • Often pre-existing gingivitis due to poor OH

  • Profuse bleeding on probing

  • Distinctive halitosis

  • Acute phase 5-7 days

  • Followed by chronic remission

  • Will recur if not treated

  • Treatment: Mechanical debridement, Intensive OHI, Children over 10 - metronidazole

  
• What is Chronic Gingivitis?

  • Directly related to poor OH

  • Incidence increases between 5 – 12 yrs

  • Linked to the onset of puberty

  • Precursor to chronic perio

  • Treatment:–Intensive prevention in line with DBOH
• What is drug induced gingival enlargement?

  side effect of several drugs

  common in children:

  • Phenytoin, Epilepsy, Enlargement seen in 50%
  • Ciclosporin, Immunosuppressant (transplant), Enlargement seen in 30%
  • Nifedipine, Post-transplant pts to reduce nephrotoxic effect of ciclosporin, enlargement seen in 15%
• How is drug induced gingival enlargement managed?

  Management:

  – Change drug therapy if possible– Strict oral home care regime in line with DBOH– Regular PMPR– Severe cases- surgery
• What is Chronic Periodontitis?

  • Begins and progresses during early teenage years (attachment loss uncommon below age 9)

  • Related to presence of subgingival calculus

  • Loss of connective tissue attachment

  • Risk factors same as for adults: diabetes?

  • Treatment same as for adults
• What is Aggressive Periodontitis?


  • Rare• Can affect primary / permanent dentition• May lead to premature tooth loss• Can be localised / generalised• Bacterial infection with immunological defects

  • Treatment:– Intensive OHI – PMPR and RSD – Antibiotics (tetracycline, metronidazole, amoxicillin)
• What is oral ulceration and what must be considered when dealing with it?

  RAU - recurrent Aphthous Ulceration

  • Most common oral mucosal lesion

  • More frequent in younger age groups

  • Affects males and females equally

  • Multiple aetiological factors– genetic + environmental

  • Can be associated with systemic disease

  • Advise blood tests

  • Is it painful?• How many ulcers are there?• How long has this been a problem for?• Which sites of the mouth are affected?
• For recurrent ulcers what should be asked?

  • How long is the healing period?

  • Are there ulcers anywhere else on the body?

  • Predisposing factors?

  • Any known allergies?

  • Any recent new medications?
• What is a

  traumatic ulcer?• Usually singular

  • Patient may recall the incident

  • Causes:– Toothbrushing– Biting (epilepsy, following LA)– Thermal / chemical burn– Orthodontic appliance

  • Treatment:– Remove cause– Monitor, should heal in 2-3 wks

  
• What is minor aphthous ulceration?

  • Account for 80% of cases

  • One to five

  • Less than 10mm in diameter

  • At frequent intervals

  • Non-keratinised mucosa, anterior region

  • Heal within 2 weeks, no scarring

  
• What is Major aphthous ulceration?

  • Account for 10% of cases

  • Cause more disability

  • More than 10mm in diameter

  • Any mucosa, posterior region

  • Healing can take up to 8 weeks

  • Cause scarring

  • Common in HIV infection

  
• What is Herpetiform Aphthous ulceration?

  • Account for 10% of cases

  • Multiple small lesions (up to 100)

  • 1-2mm

  • Coalesce into larger lesion

  • Any mucosa

  • More common in females

  • Heal within 2 weeks, no scarring

  
• What is orofacial granulomatosis?


  • Rarely seen in children

  • Affects males + females equally

  • Characteristics:

  - Recurrent / persistent swelling of lips and face

  - Angular cheilitis

  - Multiple mucosal tags

  - Cobblestoning of the buccal mucosa

  • May be related to dietary triggers

  • May go on to develop Crohn's disease➢ refer to GP

  
• What are types of viral infections?

  • Herpetic infections (HHV1-HHV4)

  • Mumps

  • Measles

  • Rubella

  • Herpangina

  • Hand, foot and mouth disease
• What is primary herpes simplex infection and how is it managed?

  • HHV1 and HHV2 (Human herpes virus)

  • Usually under 5s

  • Characteristics: Widespread oral ulceration, gingival inflammation, Blood encrusted lips, High temperature, enlarged lymph nodes

  • Management: Self-limiting (10-14 days), Soft diet, high fluid intake, Discourage touching infected area, Chlorhexidine m/wash (swab)- child can end up in hospital, CONTAGIOUS!

  
• What is recurrent herpes simplex infection?

  • HHV1 and HHV2 remain latent after primary infection

  • Reactivated by triggers

  • Preceded by a tingling sensation

  • “Coldsore”

  • Small cluster of vesicles on the vermillion border

  • Enlarge, coalesce, scab, heal (10 days)

  • Aciclovir cream

  
• What is the varicella zoster virus?

  • HHV3

  • Primary infection = chicken pox

  – Highly contagious

  – Initial spots present on trunk

  – Rapid proliferation including in mouth

  – Rupture into itchy vesicles

  – Systemic illness, general malaise, high temp

  • Latent reactivation = shingles

  
• What is Epstein - Barr virus? (Glandular fever) (Mono)

  • HHV4

  • Infectious mononucleosis (glandular fever)

  • Teenagers

  • Salivary transmission (kissing disease)

  • Resembles primary herpetic gingivostomatitis

  Lymphadenopathy, fever, fatigue - persists
• What is Measles, Mumps, Rubella?

  • Vaccinated against in the UK (MMR)

  • All self-limiting (within 14 days)

  •Measles– current outbreak in West Midlands, vaccination rate low– Fever, cough, Koplik’s spots, rash

  •Mumps– Bilateral swollen parotid glands, fever

  • Rubella– Rare, red/pink rash, fever, ltd oral symptoms

  
• What is Herpangina?

  • Coxsackie A virus

  • Vesicles on tonsils, soft palate, pharyngeal regions

  • Differentiated from primary herpes by location

  • General malaise

  • Short lived (3-5 days)
• What is hand, foot and mouth disease?

  • Coxsackie A virus

  • Maculopapular rash on hands and feet

  • Intra-oral vesicles => painful ulcers

  • Highly contagious

  • Outbreaks common in primary schools

  • Self-limiting (7-10 days)

  
• What are some bacterial infections?

  • Staphylococcus

  • Streptococcus

  • Congenital syphilis

  • Tuberculosis

  • Actinomycosis
• What are Staphylococcal & Streptococcal infection?

  • Impetigo

  • Crusting vesicles

  • Angles of mouth + lips

  • Vesicles coalesce

  • Highlycontagious

  • Self-limiting

  
• What is congenital syphilis?

  • Rare (7 cases in England + Wales 2016/17)

  • Caused by aspirochaete – Treponema pallidum

  • Transmitted in utero / during birth from infected mother

  • Oral effects:– Rhagades (fissuring at angles of mouth)– Hutchinson’s incisors (– Mulberry molars

  
• What is Tuberculosis?


  • Oral lesions rare (chronic ulcer)

  • tuberculous lymphadenitis affecting submandibular and cervical lymph nodes

  • Seen in children cared for by family members from TB endemic areas

  • BCG vaccination now offered at birth to "at risk" children

  
• What is Actinomycosis?

  • Rare

  • Actinomyces israelii

  • Can follow intra-oral trauma (eg: extraction)

  • Abscess formation, spreads, may rupture on to skin

  • Long-term penicillin
• What is Candida Albicans?

  • Acute pseudomembranous candidiasis
  • Easily removed white patches on a red base
  • Neonatal thrush is common
  • Seen with inhaler use in asthma/immunocompromised
  • Chronic atrophic candidiasis - Associated with removable ortho appliances (poor hygiene practices)
  • Chronic mucocutaneous candidiasis– Rare, inherited condition
• What are types of cysts?

  • Mucocoele

  • Ranula

  • Haemangioma

  • Bohn's nodules

  • Epstein's pearls

  • Eruption cyst

  • Epidermolysis bullosa

  • Erythema multiformed
• What is a Mucocoele?


  • 2 types – Mucous extravasation or Mucous retention

  • Mostly seen inside lower lip

  • Fluctuant, bluish cyst, up to 1cm in diameter

  • Caused by low level recurrent trauma

  • Rupture spontaneously

  • Recurrence is common

  • Surgical excision rarely indicated

  
• What is a Ranula?


  • Type of mucocoele

  - Extravasation

  
  

  • Arises from sublingual / submandibular glands

  • Large, painless, bluish swelling

  • Floor of mouth

  • Usually unilateral

  • Requires surgical removal