Orofacial Infections in Paediatric Dentistry

Question 1

handbook of paediatric dentistry

Answer 1

chapter 10

Question 2

What should be investigated when looking at an oral lesion?

Answer 2

VITAMIN DIC

Vascular
Inflammatory
Traumatic
Autoimmune
Metabolic
Infection
Neoplastic
Degenerative
Idiopathic
Congenital

Question 3

What are the types of orofacial infections?

Answer 3

Viral (Primary herpetic gingiva-stomatitis, herpes labialis, herpangina, hand foot mouth disease, infectious mononucleosis, and varicella)

Bacterial (odontogenic, scarlet fever, TB, etc)

Fungal (candidosis)

Question 4

What are the most common viral aetiologies for infections of the mouth?

Answer 4

Herpes simplex virus type 1 (Primary herpetic gingivostomatitis and herpes labialis)

Epstein Barr virus (Infectious mononucleosis)

Coxsackie A, B, enterovirus 71 (Hand foot mouth disease)

Coxsackie A (herpangina)

Varicella zoster virus (Chickenpox)

Question 5

What is the most common symptom associated with herpes simplex?

Answer 5

Ulceration (usually occurs at 6 months of age and coincides with eruption of primary incisors)

Question 6

How common is infection with herpes simplex type 1?

Answer 6

60% infected 1% show symptoms

Question 7

What is the clinical presentation of primary herpetic gingivostomatitis?

Answer 7

General:

Febrile illness with raised temperature of 37.8 - 38.9 degrees celsius

Headaches, malaise, irritability

Cervical lymphadenopathy

Oral:

Oral pain, mild dysphagia

Stomatitis

Intraepithelial fluid-filled vesicles appear on tongue, lips, buccal and palatal mucosa.

Ulcers can be solitary (Usually small and painful with erythematous margins) or larger and irregular due to coalescence of individual lesions

Question 8

Can secondary herpetic gingivostomatitis occur?

Answer 8

Secondary recurrent infection can occur and usually occurs in older kids

Question 9

What is the incubation time of primary herpetic gingivostomatitits?

Answer 9

3 - 5 days (with a prodromal 48-h history of irritability, pyrexia, and malaise)

Question 10

How is primary herpetic gingivostomatitis transmitted?

Answer 10

Direct contact with lesions

Contact with infected oral secretions (droplet infection)

Question 11

What is the typical course of primary herpetic gingivostomatitis?

Answer 11

Disease is self-limiting

Ulcers heal spontaneously without scarring within 10 - 14 days

Question 12

What are the histological features of primary herpetic gingivostomatitis?

Answer 12

Tzanck cells: Multinucleated giant cells with jig saw nucleus

Question 13

How is primary herpetic gingivostomatitis diagnosed?

Answer 13

History, clinical features and age group of affected children

Exfoliative cytology: presence of multinucleated giant cells and viral inclusion bodies can be used for rapid diagnosis.

Viral antigen

Viral culture

Viral antibody detection in blood samples

Question 14

What are the differentials for primary herpetic gingivostomatitis?

Answer 14

Necrotizing ulcerative gingivitis

Erythema multiforme

Herpangina

Question 15

What are the complications that can arise from primary herpetic gingivostomatitis?

Answer 15

Very rarely, it can lead to:

Aseptic meningitis

Encephalitis

Question 16

How is primary herpetic gingivostomatitis treated?

Answer 16

Encourage oral fluids

Bed rest + soft diet

Analgesics (paracetamol 15mg/kg, 4 - 6 hourly)

Mouthwashes (chlorhexidine can be swabbed over the affected areas in younger children and in older children mouthwash can be used 10mL 4 hourly)

Antiviral chemotherapy: Oral and intravenous acyclovir is approved for use in children (20mg/kg body weight 5 hourly or IV 10mg/kg) although evidence of efficacy is limited.

Question 17

Should topical therapies be used for primary herpetic gingivostomatitis?

Answer 17

No recommended due to concern over systemic overdose.

Question 18

Which mouthwashes can be used for primary herpetic gingivostomatitis?

Answer 18

Young children: Swab chlorhexidine on the ulceration.

Older children: Chlorhexidine mouthwash 0.2%, 10mL 4 hourly

Children >12 years old: Tetracycline or minocycline mouthwashes can be used.

Difflam C can be helpful in addition.

Question 19

What causes herpes labialis?

Answer 19

Recurrence of herpes simplex virus type 1 on the vermilion border and adjacent skin of the lips.

Question 20

What triggers herpes labialis?

Answer 20

UV light and trauma

Question 21

What are the prodromal signs and symptoms of herpes labialis?

Answer 21

Symptoms most severe in the first 8 hours

Pain, burning, itching, tingling, and warmth

Erythema 6 - 24 hours before lesions develop

Multiple small, erythematous papules develop

Clusters of fluid filled vesicles

Vesicles rupture and crust within 2 days

Question 22

What is the the typical course of herpes labialis?

Answer 22

It is self limiting and heals within 7 - 10 days

Question 23

How is infectious mononucleosis transmitted?

Answer 23

Intimate contact usually:

Main route of transmission is by blood or saliva

Intrafamilial spread is common, once a person is exposed EBV remains in the host for life.

Children get it often from contaminated saliva on fingers, toys, or other objects.

Adults usually contract the virus directly through salivary transfer such as shared straws or kissing.

Question 24

What are the symptoms of infectious mononucleosis?

Answer 24

Low-grade fever

Hepatosplenomegaly

Rhinitis or cough

Malaise, headache

Cervical lymphadenopathy and tenderness

Oral ulcers, palatal petechiae, and gingival ulcerations (necrotizing ulcerative gingivitis), tonsillitis with or without pharyngitis

Question 25

What is the typical course of infectious mononucleosis?

Answer 25

The disease is self-limiting and resolves within one or two weeks

Question 26

What are the histopathological features of infectious mononucleosis?

Answer 26

Downey cells - atypical lymphocytes

Question 27

What are the differentials for infectious mononucleosis?

Answer 27

Trauma Reactive gingival lesions Haematological disorders (Thrombocytopaenia, platelet disorders, and haemorragic telengiactasia)

Question 28

How is infectious mononucleosis diagnosed?

Answer 28

History + clinical features Atypical lymphocytes on blood film Positive heterophile antibody test (Monospot test and Paul-Bunnel agglutination test) Indirect immunofluorescent assays Real-time PCR

Question 29

How is infectious mononucleosis treated?

Answer 29

Most cases resolve within 4 to 6 weeks Otherwise symptomatic treatment.

Question 30

What are the potential significant complications of EBV infection?

Answer 30

Splenic rupture Thrombocytopaenia Autoimmune haemolytic anaemia Aplastic anaemia Neurological problems Myocarditis Haemophagocytic lymphohistiocytosis Patients experience fatigue lasting for several weeks to months in <10% of cases) Increased risk for developing MS later in life Burkitt lymphoma association with EBV

Question 31

What causes herpangina?

Answer 31

Coxsackie group A viruses

Question 32

Who is most commonly affected by herpangina?

Answer 32

Mainly children <10 years of age

Question 33

How is herpangina transmitted?

Answer 33

Faecal-oral route

Question 34

How long is herpangina's incubation time?

Answer 34

4 - 7 days

Question 35

What are the general symptoms fo herpangina?

Answer 35

Low-grade fever, malaise, headache Sore throat, dysphagia, anorexia, rhinorrhea Vomiting diarrheoa Myalgia Oral lesions

Question 36

What do herpangina oral lesions look like?

Answer 36

Red macules (usually 2 - 6) which form fragile vesicles that ulcerate rapidly (2 - 4mm)

Question 37

Where do herpangina oral lesions form?

Answer 37

Palate Pillars of the fauces and pharynx Herpangina lesions do not coalesce to form large areas of ulceration

Question 38

What is the course of disease of herpangina?

Answer 38

Self-limiting healing occurs within 1 - 2 weeks

Question 39

What are the histopathological features of herpangina?

Answer 39

Intraepithelial vesicles containing eosinophilic exudate. Nuclear ballooning degeneration of epithelial cells

Question 40

What is the differential diagnosis of herpangina?

Answer 40

Other viral mucosal ulcers

Question 41

How is herpangina diagnosed?

Answer 41

Known epidemic Viral culture from swab Clinical appearance and history

Question 42

How is herpangina managed?

Answer 42

Symptomatic care Adequate hydration Analgesisa for pain control and antipyretics

Question 43

What are the potential complications of herpangina?

Answer 43

Pneumonia Pulmonary oedema Haemorrhage Acute flaccid paralysis Encephallitis meningitis Carditis

Question 44

What is the viral aetiology of hand foot and mouth disease?

Answer 44

Coxsackie A Coxsackie B Enterovirus 71

Question 45

What age and gender commonly is affected by hand foot and mouth disease?

Answer 45

Mainly children <10 years old No gender predilection

Question 46

What are the general features of hand foot mouth disease?

Answer 46

Low-grade fever Sore throat, dysphadia Cough, rhinorrhea, anorexia, vomiting, diarrhoea, myalgia and headache Cutaneous lesions on the palms and soles and ventral surfaces and sides of he fingers and toes, buttocks

Question 47

What do the oral lesions in hand foot mouth disease look like?

Answer 47

Resemble those of herpangina (more numerous and frequently involve anterior regions of the mouth) Appearance of red macules which form fragile vesicles that rapidly ulcerate Number of lesions ranges from 1 to 30

Question 48

Where are the oral lesions usually appear in the oral mucosa?

Answer 48

Buccal and labial mucosa Tongue Palate Pillars of the fauces and the pharynx

Question 49

How do the cutaneous lesions in hand foot mouth disease form?

Answer 49

Cutaneous lesions begin as erythematous macules that develop central vesicles and heal without crusting Nail loss or ridges form and may ensure after several weeks

Question 50

What is the typical course of disease hand foot mouth disease?

Answer 50

Usually a self limiting disease

Question 51

What are the histopathological features of hand foot mouth disease?

Answer 51

Intraepithelial vesicles: early stages with intracytoplasmic eosinophilic inclusion bodies Later stages: Shallow ulcerations and erosions with regeneration of the amrginal epithelium Superficial inflammatory cell infiltrate in submucosa

Question 52

What are the differentials for hand foot and mouth disease?

Answer 52

Herpetic gingivostomatitis Herpangina Varicella Aphthous stomatitis

Question 53

How is hand foot and mouth disease diagnosed?

Answer 53

Clinical appearance and history Known epidemic Viral culture from swab

Question 54

What are the complications of hand foot mouth disease?

Answer 54

Neurological complications Viral meningitis Encephalitis Cerebellar ataxia

Question 55

Who most commonly gets varicella?

Answer 55

Chicken pox in children Shingles in older adults

Question 56

How is varicella transmitted?

Answer 56

Spread through air droplets Direct contact with active lesions

Question 57

What is the incubation period of varicella?

Answer 57

10 to 21 days (avg 15 days)

Question 58

How does chickenpox present in immunized children?

Answer 58

Maculopapular, cutaneous rash with only a small number of lesions Oral: Few or no vesicles.

Question 59

What is the typical course of varicella?

Answer 59

A shortened disease course of 4 - 6 days

Question 60

How does chickenpox present in unimmunized children?

Answer 60

General: Malaise, pharyngitis, nausea, anorexia, and vomiting. Skin: intensely pruritic exanthema Vesicular stage (each vesicle is surrounded by a zone of erythema. Lesions continue to erupt for 4 or more days and old crusted lesions intermixed with newly formed, intact vesicles

Question 61

What do the oral lesions of varicella look like?

Answer 61

Begin as 3 to 4mm, white, opaque vesicles. Vesicles rupture to form 1 to 3 mm ulcerations.

Question 62

Which sites on the oral mucosa are mostly affected by varicella?

Answer 62

Vermillion border and palate most frequently Buccal mucosa and gingival less frequently

Question 63

How long do oral ulcerations last in varicella infections?

Answer 63

In mild cases = 1 to 3 days. (1 - 2 ulcers) In severe cases = 5 - 10 days. (up to 30 ulcers)

Question 64

When is the immunization to chickenpox provided?

Answer 64

at 18 months MMR, and chickenpox

Question 65

What are the histopathological features of varicella?

Answer 65

Cytological alterations identical to HSV Virus causes acantholysis, formatino of numerous free-floating Tzanck cells, which exhibit nuclear margination of chromatin and occasional multinucleation

Question 66

How is varicella diagnosed?

Answer 66

Viral cytology PCR on vesicular fluid/cells from base of lesion/scab from resolving skin lesion Direct fluorescent antibody assay

Question 67

How is varicella treated?

Answer 67

Symtomatic treatment: Warm baths with soap, baking soda, or colloidal oatmeal. Application fo calamine lotion Antihistamines Antipyretics Antiviral meds have been shown to reduce duration if administered with 24 hours of the rash

Question 68

What are the potential complications of a varicella infection?

Answer 68

Encephalitis Pneumonia Necrotizing fasciitis Septicemia Toxic shock syndrome Other life threatening conditions