Oral Lesions in Children

OROPHARYNGEAL CANDIDIASIS (OPC)

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CANDIDIASIS (OPC)" class="wp-image-30815" style="object-fit:cover;width:242px;height:300px"/>

It is also called oral thrush and moniliasis. 60% of the human population carry candida albicans in their mouth, and normally no lesions are produced. But in the case of infants and immunocompromised individuals, candida can cause lesions in the oral cavity and pharynx, producing oropharyngeal candidiasis. They appear as curdy white-coloured plaques, multiple in the oral cavity, and when detached, underlying inflammation and pinpoint bleeding are seen. It can cause odynophagia (difficulty in swallowing) and drooling saliva. Treatment includes topical nystatin and 0.2% chlorhexidine mouth wash can prevent OPC, which can be used in immunocompromised patients.

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DIFFERENTIAL DIAGNOSIS OF ORAL ULCERS IN CHILDREN

Common Causes include: 

• Aphthous Ulcers
• Traumatic Ulcers
• Hand-Foot and Mouth Disease (HFMD)
• Herpangina
• HSV-1: Herpetic gingivostomatitis, Herpes labialis
• Chemical burns
• Heat burns

Rare Causes include:

• Neutrophil defects: Agranulocytosis, Leukemias, Cyclic neutropenia
• SALE
• Behcet Syndrome
• Necrotizing ulcerative gingivostomatitis
• Syphilis
• Oral Crohn's Disease
• Histoplasmosis (Mainly in the lips and tongue)
• SJS
• Pemphigus vulgaris

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Aphthous Ulcer

They are also called aphthous stomatitis and canker disease.  They are benign and self-limited ulcers found in the oral cavity and many of them get cured without any therapy. These lesions are well-defined or well-demarcated punched ulcers having a whitish necrotic base with surrounding erythema.  They are painful, single or multiple. The evolution of the ulcers: Initially, there is an abscess which then breaks down to form an ulcer that has a whitish serous exudate in the centre and later develops into an erythematous hue. Cause of Aphthous ulcers: Multifactorial condition that includes stress, viral infections, atopy or allergies, exposure to hot or spicy food, and multi-nutrient deficiency.

PATHOPHYSIOLOGY 

• Cell-mediated immunity dysregulation leads to excess cytotoxic CD 8+ T cells accumulating in the oral cavity in the oral mucosa-producing lesions. As cell-mediated immunity is the one that is involved, corticosteroids are often helpful in inducing remission. Morphologically it is of three types: Minor ulcers are between 2 to 10 millimeters in diameter and tend to heal in seven to ten days.  Major ulcers are larger and are more painful. They are greater than 10 mm in size and heal within 10 to 30 days. Herpetiform ulcers are small, 1 to 2 mm in size, and later merge to form painful abscesses. This papule may remain an abscess or sometimes break down into a larger ulcer. They also tend to heal in seven to 10 days.

TREATMENT

• Most oral lesions are self-limiting even though probiotics and folic acid supplementation are given. Most multivitamins are not effective. Topical therapy includes lidocaine, benzocaine, and corticosteroids. If there is no response to this therapy, oral therapies, mainly oral tetracycline, can be given. If that fails, oral steroids can be given for a short duration lasting around seven days. Cyclosporine, dapsone, and Thalidomide can also be given. But tetracycline should be avoided in pregnant women and children under eight.

Systemic conditions have aphthous-like lesions.

• IBD- Crohn's Disease 
• Behcet's Disease
• Celiac Disease
• PFAPA Syndrome, where PF stands for Periodic fever, A for Aphthous Stomatitis, P- Pharyngitis, and A- Adenitis 
• HIV Infection- Refractory Recurrent, Slow resolving
• Sweet Syndrome
• Cyclic Neutropenia

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Other oral lesions

•  Herpetic gingivostomatitis and recurrent herpes labialis. Both are caused by Herpes simplex virus. HSV-1 is more common than HSV-2.  Herpetic gingivostomatitis is a more severe form, whereas recurrent herpes labialis is considered to be a mild form.  Herpetic Gingivostomatitis Symptoms:  Fever, odynophagia, multiple painful vesicles. Treated with Acyclovir within 72 hrs · Recurrent Herpes labialis (HSV-1 > 2) → lesion only on lip (mild).

Parulis (Gum Boil) - Localized red papule adjacent to chronic dental abscess.

ANGULAR CHEILITIS

• Angular cheilitis is also called Perleche. Repeated lip-licking will always keep the angle of the mouth moist, and sometimes there may be superimposed candida infection as well. It will produce dryness, scaling, and fissures at the angle of the mouth.  They can develop on the upper and lower lips. Also, since moisture tends to accumulate there, it might cause erosions called angular cheilitis. So, one of the common predisposing factors is repeated lip-licking.  Another reason is children with drooling saliva, which can be seen in atopic disorders and nutritional deficiencies (vitamin B2, iron). So angular cheilitis refers to lesions present at the angle of the mouth. They can be unilateral, more commonly bilateral. They can be erythematous, scaly, painful, and scarring. 

TREATMENT

• Treatment involves the application of petroleum jelly to the affected parts. Treatment of any superimposed candida infection if it is present and treating the underlying cause.

Summary
Oral lesions in children can be due to cell-mediated immunity
dysregulation leads to excess cytotoxic CD 8+ T cells accumulating in
the oral cavity, oral mucosa producing lesions. Some of the common
oral lesions, ulcer are- oral thrush ( appear as curdy white-coloured
plaques, multiple in the oral cavity, and when detached, underlying
inflammation and pinpoint bleeding are seen), aphthous stomatitis
(painful, single or multiple well-demarcated punched ulcers having a
whitish necrotic base with surrounding erythema), Herpetic
gingivostomatitis (more severe form), recurrent herpes labialis
(lesion only on lip) and angular cheilitis (dryness, scaling, and fissures
at the angle of the mouth).

Minor ulcers tend to heal in seven to ten days. Major ulcers are larger and are more painful. Most oral lesions are self-limiting even though probiotics and folic acid supplementation are given.

Topical therapy includes lidocaine, benzocaine, and corticosteroids. If that fails, oral therapies, mainly oral tetracycline, can be given. If that fails, oral steroids can be given for a short duration lasting around seven days.

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