Aphthous Ulcer

aphthous_ulcerWhat do you see? Child has white sore above teeth and gum on moveable tissue.  It is extremely painful when touched.  The teeth do not hurt to biting pressure.

This is a:  This is a aphthous ulcer or, commonly, a canker sore.

What else it could be: Cut in mouth (treat the same way). Abscess (bulbous not flat, directly over tooth with problem). Cold sore (outside on lip, itchy with scabbed blisters)

Is this an emergency, urgency, or problem?  Problem
An aphthous ulcer is the the body’s over-exuberant immune response to trauma or irritation in the mouth.  It is always  on the moveable soft tissues in the mouth such as the lip, soft palate, underside of tongue. These are often confused with cold sores (viral) or abscess (bacterial) because of the pain they cause.  No treatment is needed and they heal without scarring in 10-14 days.  In rare cases they can become larger than a centimeter across and need dental treatment so a child can swallow or eat comfortably.  Topical anesthetic like anbesol or orajel work for a short time and ibuprofen helps as well.  Leaving them un-traumatized with a toothbrush or finger picking is also important.

What to tell the parent:  Explain the canker sore is an over response of the immune system and will not get better with antibiotics.  Treat for pain.  Rinses with salt water or hydrogen peroxide will not help a child heal faster and are unnecessary.  The natural history is pain for two to three days, getting better after a week and complete healing in 10-14 days.  If they get large talk to your dentist for a steroid ointment or rinse. Anecdotal stories of treatment with lysine or vit C are not scientifically based.

First Aid: Give the child ibuprofen or place topical anesthetic on the sore after briefly drying.

Follow up: None.

Piercing

piercingWhat do you see? Ornamental piercing in the mouth places hard objects up against moveable or non-keratinized tissue with repeated rubbing.  Popular piercings include lips and tongues. In this case the piercing is unusually placed to go through the salivary duct at the base of the tongue.  Infection or swelling below the tongue can quickly spread and result in airway closure called Ludwig’s Angina.

This is a: Tongue piercing, with trauma to teeth, infection or irritation the result.

What else it could be: Brain atrophy.

Is this an emergency, urgency, or problem?  Problem
Unless a tongue piercing is causing immediate pain or obstruction that requires immediate removal, the patient will be highly resistant to suggestions for its removal.  Anecdotal stories of pain or trauma are usually the most effective in getting an adolescent to listen; they want to know what happened to their peers.  But, don’t expect an immediate change in behavior.  Caring and attention will often produce delayed results.  Harassment or belittlement  will produce the continuation of the attention getting behavior.  It’s reverse psychology baby!

What to tell the parent: Explain that the tongue and lips are very vascular and muscular so trauma and infection are likely.  Tell parents they are still in the best position to influence teenage behavior with caring and requesting change. Military school also works, but it is very expensive..

First Aid: Nothing immediate unless underlying trauma or infection.

Follow up: Repeated inquiries show a teenager caring and resolve.

Traumatic Ulceration

traumatic_ulcerationWhat do you see? Child has white or brown sore above near teeth on lip or moveable tissue.  It is extremely painful when touched. The teeth have braces.

This is a: This is a traumatic ulceration from an orthodontic wire or appliance.

What else it could be: Cut in mouth (treat the same way). Cold sore (outside on lip, itchy with scabbed blisters)

Is this an emergency, urgency, or problem? Urgency
This traumatic injury is usually caused by a orthodontic wire that is too long and cutting or rubbing against a cheek or lip.  Once the tissue is traumatized it will not heal on its own without the source of the irritation being removed.  These are simple cases to fix by simply taking out the offending wire or appliance.  A wire can be cut with a finger nail clippers or the ubber bands holding the wire in can be but or teased off.  For short term releif, the wire or appliance can be covered with a piece of chewing gum, chapstick, or orthodontic wax. Topical anesthetic like anbesol or orajel work for a short time and ibuprofen helps as well. Referring back to the orthodontist or dentist is usually necessary to continue treatment pain free.

What to tell the parent:  Explain the problem and what was done to treat for pain.  Rinses with salt water will not help a child heal faster and are unnecessary.  Removing the wire from braces may cause a relapse with tooth movement, so dental follow up is recommended within a couple of days. Admonish the child to keep up good brushing while they are healing to speed it up.

First Aid:  Give the child ibuprofen or place topical anesthetic on the sore after briefly drying. Place some barrier over the poking part, chapstick, ortho wax or chewing gum.

Follow up:  Call the orthodontist and state the child is having pain. They will get him/her in!

Herpetic Cold Sore

herpetic_cold_soreWhat do you see? Child has water blisters clustered near lip on outside of mouth. They are itchy and painful. Older children may recall having these before.

This is a:  This is a herpetic cold sore (viral)

What else it could be: Yeast overgrowth at corner of mouth (nonpainful, nonhealing) Canker sore (only occur in moveable tissue inside mouth)

Is this an emergency, urgency, or problem?  Urgency
An cold sore is a recurrent herpes infection.  Some time ago (usually at age 2-3 yrs) a child was exposed to the herpes virus that causes cold sores.  In 50% of kids, this virus infects the nerves near or in the mouth and then lies dormant in the nerve cells.  When the child becomes fatigued, gets a cold, sunburns the lips, or otherwise compromises their immunity, the herpes infection reappears in the form of a cold sore.

The cold sore starts as a series of tiny, itchy water blisters that quickly scab over and grow together. The child is highly infectious during this time, but most of their peers have already been exposed so missing school is unnecessary.  An antiviral medication used right when the water blisters appear will help to control the severity and size of the cold sore, but will not cure the disease.

What to tell the parent:  Explain the cold sore to the parent and the viral etiology.  Suggest a prescription from the pediatrician or dentist for the next onset, this one is likely too late for medication. It will need to run its course. The natural history is itchy pain for two to three days, getting better after 10 days depending on size, and healing in 14 days.  If they get large, keeping the scab intact with lip balm will promote healing.  Lots of over the counter medicines are available with limited effectiveness but some ability to lessen pain.  Talk to your dentist for a prescription for generic pills or ointment.  One medication is Acyclovir; it has a long shelf life.

First Aid:  Reassure the child everyone is so busy worrying about their own face that no one really cares about a little scab.  Place carmex on scab, but do not cross contaminate bottle.

Follow up:  Mention to dentist at next visit.

Mucocele

mucoceleWhat do you see? Child has bump on inside of lip that is round and squishy. It may or may not have been bitten. It has a history of swelling then going away and coming back.

This is a: This is a mucocele. Traumatized minor salivary gland that swells when saliva is made.

What else it could be: Irritation fibroma (scar tissue children habitually bite on) Abscess (contains pus, wide base, directly over  carious tooth).

Is this an emergency, urgency, or problem?  Problem
A Mucocele is a relatively common problem that arises when one of the thousands of minor saliva glands of the lip (can also be on soft palate or uvula, but very rare) is traumatized.  The duct that allow saliva to escape the gland is severed the saliva builds in the goblet shaped gland until it bursts.  Scar tissue is formed when it bursts and the process starts again. These will be round and rubbery to the touch without a lot of pain, but they can begin to interfere with eating and kids play with them.  If they become secondarily infected, pus may be expressed.  They usually do not self heal, and a dentist visit is necessary to cut them out of the lip.

What to tell the parent:  Explain the nature of the bump and that it will not go away on its own if it has been present for more than two weeks.  Caution the child not to play or bite the bump and make appointment with the dentist.

First Aid:  Give the child ibuprofen or place topical anesthetic if the mucocele has been recently bitten or traumatized.  If a sharp tooth or orthodontic appliance is nearby that may have started the problem, address that as well.

Follow up:  A dentist will need to surgically remove this mucocele.  They have a high rate of reoccurrence.

Viral Papilloma

viral_papillomaWhat do you see? Child has raised bump near mouth, on lip or on gum.  Bump is nonpainful, 1 to 3 mm in size and flat with a white head when dried.

This is a:  This is a viral papilloma or common wart.  It can have a stalk or be flat and numerous.

What else it could be: Fibroma (scar). Abscess (bulbous not flat, directly over carious tooth, recent). Cold sore (outside on lip, itchy with scabbed blisters)

Is this an emergency, urgency, or problem?  Problem
An Papilloma is caused by one of several strains of the HPV or human papilloma virus.  Often the strains can infect both fingers and mouths, so auto-innoculation is common.  A vaccine exists that can prevent the type of HPV that can cause cancer, but no other cure exists.  Since this virus lies in skin cells it will eventually clear.  Common treatment involves irritating the skin around the papilloma to drive up the immune response for quicker healing.  Removal of the papilloma around the face may be problematic.  Papillomas inside the mouth can be more easily removed and is the treatment of choice to prevent growth in size and spread.

What to tell the parent:  Explain the papilloma is a very common viral disease of childhood. They are rarely painful unless traumatized, so treat palliatively only.  Suggest a discussion with a pediatrician for a lesion outside the mouth and a pediatric dentist if inside the mouth.

First Aid: None.

Follow up:  None.