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Visual Diagnosis Soft Tissue

Lession In Pediatric

Mouth Sores and Patches

Focal Gum Lesions
Tongue Discoloration and Surface Change
Throat Redness
Mouth Sores and Patches

Mouth sores and patches are commonly found on

careful oral examination of pediatric patients.
Lesions may be asymptomatic or may lead to
ulceration, pain, and decreased oral intake.
Oral lesions may be categorized as anatomic,
traumatic, or infectious.
Many of these lesions are isolated to the oral cavity
and mucosa, but certain systemic illnesses and
conditions can present with oral sores or patches as
part of a constellation of symptoms.
Diagnosis is primarily clinical.
Management is often limited to supportive care,
including pain control andensuring adequate
Oral candidiasis is the most common oral fungal
infection in infants and children, with Candida
albicans being the most frequently identified
When infections are persistent in children older than
6 months, the clinician should consider an
underlying defect in the systemic immune system.
Lesions of oral candidiasis include white or
whitishyellow plaques and erythema of the tongue,
soft palate, or buccal mucosae.
When plaques are scraped off, there is often
underlying raw, erythematous mucosa, which may
These mucosal changes may help the clinician
differentiate the white plaques from milk residue
seen on the tongue of infants.
Traumatic oral lesions arise from mouthing
objects in the period of infancy, and accidental
biting or injury from objects placed in the oral
cavity in older children.
Pain is the predominant symptom, occurring 24 to
48 hours after the initial injury.
Drooling and tenderness may be predominant
features on physical examination when ulcerative
lesions are present.
Small gingival vesicles that progress into painful
ulcerations following high fever, irritability, and
malaise should prompt consideration of primary
herpetic gingivostomatitis caused by herpes
simplex virus (HSV) type 1 as a diagnosis.
Other viruses can cause enanthems, and should
be considered in the diagnosis of oral lesions
when prodromal symptoms are present.
Examples include Koplik spots associated with
measles, and ulcerations found in infectious
mononucleosis and varicella.
Herpangina also produces oral ulcerations and
follows a prodrome that includes malaise, sore
throat, and low-grade fever.
It is caused by coxsackievirus group A, usually
in the summer and early fall.
The oral ulcerations are isolated in herpangina.
When oral ulcerations occur in conjunction with
palmar and plantar papulovesicles, hand, foot,
andmouth disease should be strongly
Location of lesions can help differentiate
between HSV gingivostomatitis and herpangina.
HSV lesions are located in both the anterior and
the posterior oropharynx, and lesions of
herpangina are located predominantly in the
posterior oropharynx, sparing the lips and
Both HSV and herpangina present with painful,
small, grouped vesicles that eventually ulcerate.
Gingival erythema, friability, and edema are
commonly seen in HSV gingivostomatitis, but
not in herpangina
Recurrent aphthous stomatitis (RAS) is the most
common inflammatory ulcerative condition of the
oral mucosa in patients in North America, with up to
20% of the population affected during childhood or
early adulthood.
Its cause is unknown.
It is categorized into major and minor forms based
on size and location of ulcers.
RAS may produce ulcers of nonkeratinized mucosa
(unattached gingiva) and keratinized surfaces.
Lesions of major RAS are larger and can cause
Koplik spots occur early in the course of measles,
before other cutaneous signs, and are often missed.
Focal Gum Lesions

Natal and neonatal teeth are most commonly

primary, but may be supernumerary.
Natal teeth are erupted teeth present at the
time of birth.

Bohn nodules are smooth, translucent, pearly

white cysts that range from approximately 1 to
3 mm in size.
Bohn nodules may be isolated or clustered.
Eruption cysts are usually found in the region of
the incisors on the edge of the alveolar ridge
where a tooth is erupting.
Eruption cysts may feel rubbery, be nontender,
and have a bluish hue. Alveolar cysts are visible
along the alveolar ridges.
A retrocuspid papilla, often bilateral, is a firm,
round, pink to red 2- to 3-mm papule attached
to the lingual gingiva adjacent to the
mandibular canines.

The presence of fever in association with a focal

gum lesion should raise suspicion for a dental
Dental abscesses may appear as erythema and
swelling of the gum, often in the region of
dental caries, and may be associated with
purulent drainage.
Tongue Discoloration
and Surface Changes
The surface of the tongue may develop changes
in color or texture because of intrinsic or
extrinsic factors.
Discolorations may be related to chewed,
ingested, or topical products, or certain
Medications, such as antibiotics, antifungal
agents, antimalarial drugs (primarily on the
hard palate), psychotropic agents (including
selective serotonin reuptake inhibitors),
phenothiazines, benzodiazepines, and
phenytoin, may cause tongue discoloration.
Minocycline-associated pigmentary changes
may persist for years.
White lesions

A white plaque that wipes off easily may be due

to milk or food. If it cannot be scraped off
easily, bleeds, or leaves a denuded surface
after scraping, the white plaque is usually the
result of a fungal infection.
The use of antibiotics, immunosuppressive
agents, systemic steroids, or inhaled
corticosteroids may predispose patients to oral
Immunodeficiency, recent radiation, or
cytotoxic therapy predisposes patients to oral
thrush and oral hairy leukoplakia.
Hairy leukoplakia is caused by EpsteinBarr virus
and is seen more commonly in adults affected by
human immunodeficiency virus (HIV), but is rare
in children affected by HIV.
White plaques associated with lichen planus are
more common in patients with thyroid disease,
particularly hypothyroidism.
Lichen planus, an immunological disorder, may
cause lacy white plaques on the buccal mucosae
and may coexist with oral candidiasis.
White sponge nevus is a rare autosomal
dominant condition that starts in childhood and
is characterized by bilateral white plaques on
the buccal mucosae, and sometimes on the
lateral border of the tongue and other mucosal
Linea alba is caused by repeated trauma from
biting or chewing and appears as a thin white
line on the lateral margins of the tongue (or the
buccal mucosae) bilaterally.
White tongue plaques associated with nail
dystrophy and reticular skin pigmentation are
hallmarks of ZinsserColeEngman syndrome,
also known as dyskeratosis congenita, a rare, X-
linked disorder associated with bone marrow
Black grey lesions

Argyria is an irreversible blue gray

mucocutaneous staining caused by exposure to
silver and includes ingestion of a silver-
containing supplement known as colloidal silver.
Ingestion of bismuth-containing products may
lead to black tongue staining.
Darkly pigmented adults and children are more
likely to have pigmented fungiform papillae of
the tongue.
Dark pigmentation of the fungiform papillae
may be seen in iron deficiency.
The third involves hyperpigmentation of all the
fungiform papillae on the dorsal surface of the
Hairy tongue discoloration may be brown, black,
green, or yellow depending on the particles,
chromogenic bacteria, or fungi that are
entrapped; hence, it is no longer known as
black hairy tongue.

Glossitis may be precipitated by the use of

cytotoxic agents. Allergy
Fixed drug eruptions occur at the same location on
the tongue with each exposure.
A red tongue that is smooth indicates glossitis,
whereas a red tongue with enlarged papillae is
more consistent with strawberry tongue.
The raised papillae of strawberry tongue may be
visualized better with indirect lighting from the side.
Median rhomboid glossitis is a reddened and
smooth rhomboid-shaped area of papillary
atrophy just anterior to the circumvallate papillae.
Overgrowth papillae

Hairy tongue, or elongated filiform papillae in

the midline tongue, is associated with the
following: tobacco, tea, coffee, antibiotics,
griseofulvin, or certain mouthwashes containing
an oxidizing agent, such as sodium perborate,
sodium peroxide, or hydrogen peroxide.
Hairy tongue has been linked to herbal tea
ingestion in an infant.
Throat Redness

Throat redness is a familiar complaint to the

general pediatrician or family practitioner.
Erythema of the posterior oropharynx suggests
an inflammatory or infectious process, but can
also be caused by exposure to environmental
allergens, airborne irritants, or acid from chronic
laryngopharyngeal reflux.
Pharyngitis may cause neck pain and stiffness.
Throat redness associated with upper
respiratory tract symptoms (rhinorrhea, cough,
and conjunctivitis) and/or lower gastrointestinal
tract manifestations (vomiting with diarrhea)
are characteristic of viral infection and rarely
represent a bacterial throat infection.
Increased throat pain after meals or when
supine suggests pain related to
gastroesophageal reflux.
Chronic mouth breathing associated with
obstructive sleep apnea leads to dry, irritated
mucosae and a sore throat, which is worse in
the morning and improves throughout the day
as the patient drinks fluids.
Asking about ambient room temperatures,
especially in the winter months, can provide
useful history to support this diagnosis.
Ulcerations are typically seen with viral
pharyngitis and stomatitis. Ulcerations on the
tonsillar pillars suggest the diagnosis of
herpangina caused by coxsackievirus or
Ulcerations from herpes simplex virus are
typically more anterior but may occur posteriorly
and in association with gingivitis.
Infectious mononucleosis may present with
pharyngeal and tonsillar erythema, fever,
difficulty swallowing, and posterior cervical
Fatigue is a prominent symptom, and may
persist in up to 22% of cases beyond 2 to 3
weeks of illness.
Drooling results from the inability to swallow
ones secretions.
Watch for drooling in patients with severe
pharyngitis, pharyngeal ulcerations, or a
retropharyngeal abscess.
Thank You