DCA06DT Dental Treatment of Pediatric and Adolescent Patients _ __________________________________
Treatment for hand, foot, and mouth disease is supportive and palliative. Painful oral lesions can complicate a patient’s ability to masticate food and to swallow, so softer, blander foods and liquid nutritional supplements may be required. Analgesics compatible with the patient’s medical history may be used to decrease oral discomfort. Patients with hand, foot, and mouth disease should be instructed not to scratch or manipulate fluid-filled vesicles in any manner as the contents are infectious and can inoculate other areas. There is no current vaccine available to prevent hand, foot, and mouth disease. Recovery from the disease only confers immunity against the viral strain that caused the infection, not against other coxsackievirus genotypes. It is a self-limiting disease, but complications, such as viral meningitis or encepha- litis, can occur. RECURRENT APHTHOUS STOMATITIS Recurrent aphthous stomatitis features painful ulcerative lesions (also known as recurrent aphthous ulcers or more commonly as canker sores) that generally heal without scarring in immunocompetent patients but can recur at any time. The size is a demarcation for the categorization of these lesions. Minor aphthae are less than 1 cm at the greatest diameter; major aphthae exceed this dimension. Each type of lesion only involves nonkeratinized tissues, such as the buccal and labial mucosa, the soft palate, and the surface layer of the floor of the mouth. Movement of the mucosa affected by lesions of either size is painful and can interfere with speaking, eating, and swallowing. Major aphthae tend to have irregular shapes and borders and more depth. The numbers of both can vary, although solitary lesions are uncommon. Lesions of aphthous stomatitis feature a shallow yellow base and an intense ery- thematous halo peripherally. The incidence of these lesions varies from 20% to 60% and can reflect the actual population studied. Many patients develop the condition during the first two decades of life [55]. There has yet to be a bacterial, viral, or fungal etiology that can be attributed to the origin of these lesions, but a genetic predis- position to the occurrence is possible. When both parents have a history of these lesions, there is a 90% chance that their children will be similarly affected [56]. Common predisposing factors include physical and emotional stress and sensitivity to ingredients in toothpaste and/or mouthwash, such as sodium lauryl sulfate and alcohol [57; 58]. Tissue manipulation during dental or medical procedures, during which the oral tissues are stretched or manipulated by instruments, is a source of local trauma that can cause the development of these ulcers. Nutri- tional deficiencies in vitamin C, folic acid, iron, and vitamin B12 are other potential etiologies [58]. Systemic chemotherapy and radiotherapy targeting malignant lesions of the oropharynx can cause the development of overlapping aphthous ulcers of considerable size that can serve as areas of systemic access of pathogenic organisms. Occasionally, these ulcers occur as
part of a disease such as Behçet syndrome. In patients with Behçet syndrome, major aphthae are more frequent than minor aphthae and occur simultaneously on the nonkeratinized oral mucosa, uvula, and genitals [58]. Sensitivity to certain medications, including NSAIDs, angiotensin-converting enzyme inhibitors, and bisphosphonates, may produce an aphthous-like tissue reaction. Given the multitude of medica- tions available and potential untoward effects that can occur in the patients who take them, this could be a potential issue for numerous medications. Treatment and Prognosis The lesions of recurrent aphthous stomatitis usually revolve spontaneously. Minor aphthae resolve within 7 to 14 days from onset with no residual scarring. Major aphthae can take three weeks or longer to heal and usually do so with scar formation. Antibiotics are only needed if the involved areas become secondarily infected. Treatment is usually designed to avoid contact with these lesions, as a traumatic incident will exacerbate the pain and prolong healing. Palliation of the symptoms associated with these lesions consists of topical anesthetic preparations and systemic analgesics, as needed. A diet that minimizes both acidity and extreme temperatures and avoids foods with sharp edges will facilitate proper nutri- tional support and minimize physical trauma to the affected areas [58]. Patients with removable orthodontic retainers may refrain from using them if an aphthous ulcer is adjacent to their extensions. As the name would suggest, these lesions have periodic recurrences. Because more serious lesions such as squamous cell carcinoma can appear in a multitude of different forms, patients should be advised that lesions that do not heal should be re-evaluated for a biopsy. ORAL AND MAXILLOFACIAL TRAUMA FROM CHILD ABUSE AND NEGLECT Traumatic injuries to the teeth and the structures of the oral and maxillofacial complex may be the result of falls, sports injuries, car accidents, or violence. Usually, the maxillary anterior teeth take the brunt of the trauma, as they are the first teeth to encounter traumatic forces. The extent of coronal/ radicular (root) fracture, the age of the patient, the degree of root development and apical closure of permanent teeth, the medical history, and access to dental care can all influence the ability to restore traumatized teeth. Of the most concern are oral injuries, cutaneous and intra-oral mucosal bruising, and other injuries to the head and neck that occur due to child abuse and neglect. The head, neck, and arms of pediatric patients should be assessed for signs of bruising or injuries without plausible explanation. All members of the dental profession should be cognizant of their responsibility as advocates for children and adolescents who are victims of physical and emotional abuse.
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