This document discusses pediatric orodental disorders, including periodontal disease and dental trauma. It provides details on the anatomy of the periodontium in children and various acute gingival infections such as necrotizing ulcerative gingivitis. Recurrent aphthous ulcers and acute oral candidiasis are also examined. Common dental injuries are outlined, including crown and root fractures. Treatment approaches are provided for many of the disorders.

1. Pediatric Orodental Disorders
By:- Abebaw.Y (BSc, MSc PCHN)
September 2018
Debre Tabor Ethiopia

2. Objective
At the completion of this lesson students will be able to:
List dental disorders in pediatrics
Define different pediatric dental disorders
Discuss causes, s/s, diagnosis and management of dental
disorders in pediatric age group

3. Periodontal disease
Anatomy of the periodontium in children

4. Periodontal disease
Anatomy…..
Marginal gingiva
 For children, marginal gingival tissue around the primary
dentition are more highly vascular
 Contain fewer connective tissue than tissues around the
permanent teeth
Attached gingiva
 The width of attached gingival is less variable in the primary
dentition
 There is less mucogingival problem in the primary dentition

5. Periodontal disease
Anatomy…..
Junctional epithelium
 There continue to be an apical shift when the teeth are fully
erupted
 The gingival margins are frequently at different levels on adjacent teeth
that are at different stages of eruption
 Sometimes it gives an erroneous appearance that gingival recession has
occurred around those teeth that have been in the mouth longest
 Stability is achieved at 12 years for 1 2 3 5 6, 16 years for the other teeth

6. Periodontal disease
Anatomy…..
Periodontal ligament
Periodontal ligament space is wider in children
It is less fibrous and more vascular
Cementum
 Thinner
Alveolar bone
Thinner cortical plates
Larger marrow spaces
Greater vascularity
Fewer trabeculae

7. Periodontal disease
Acute gingival infections
An acute lesion is of sudden onset and short duration
and is painful.
They are manifested with severe pain along with
systemic manifestations
Thus these lesions must be treated at the earliest
with a proper treatment protocol

8. Periodontal disease
Acute gingival infections…
1. Primary herpetic gingivostomatitis
2. Necrotizing ulcerative gingivitis (NUG)
3. Abscesses of periodontium
4. Recurrent Apthous Ulcer
5. Acute Candidiasis

9. Periodontal disease
1. Primary herpetic gingivostomatitis
 An acute infectious disease of the gingiva caused by the herpesvirus
Etiology
 Herpes simplex viruses (HSVs)
Two types exist: type 1 (HSV-1) and type 2 (HSV-2). Both are closely related
but differ in epidemiology
 Type-1 Gingivostomatitis
 Type-2 Genitalia

10. Periodontal disease
Primary herpetic gingivostomatitis…
Transmission
 HSV-1 is transmitted chiefly by contact with infected saliva
 Infected saliva from an adult or another child is the mode of infection
 HSV-2 is transmitted sexually or from a mother's genital tract infection to her newborn
Clinical features:
Age- 6 months to 3 years
Incubation period- 1 week
Prodrome
Febrile illness
Headache, malaise, oral pain
Cervical lymphadenopathy

11. Periodontal disease
Primary herpetic gingivostomatitis…
Symptom
 Gingivitis:
 Gingivitis is the most striking feature, with markedly swollen,
erythematous, friable gums
 Vesicular lesions:
 Vesicular lesions develop on oral mucosa, lip and tongue, can occur
anywhere in the oral cavity, on the perioral skin and on the pharynx
 Diagnosis: According to Clinical features, History and age

12. Periodontal disease
Primary herpetic gingivostomatitis…
Prognosis
 Oral lesions heal without scarring
Course:
Acute disease lasts 5-7 days, and the symptoms subside in 2 weeks.
Viral shedding from the saliva may continue for 3 weeks or more.
Adults also may develop acute gingivostomatitis, but it is less severe and
is associated more often with a posterior pharyngitis

13. Periodontal disease
Primary herpetic gingivostomatitis…
Treatment
The goals of treatment are to make the patient comfortable and to prevent
secondary infections or worsening systemic illness
A. Antiviral treatment :
Overall, medical treatment of HSV revolves around specific
antiviral treatment.
Patients should be advised about the potential for autoinoculation if they touch
the herpetic lesion and then touch a mucous membrane or an eye
Controlling autoinoculation can be a challenge if the patient is a young child

14. Periodontal disease
Primary herpetic gingivostomatitis…
B. Symptomatic treatment
Analgesics, such as acetaminophen, may make the patient more comfortable
Aspirin should be avoided in pediatric patients because of the possibility of Reye
syndrome
Topical anesthetics and coating agents may make the patient more comfortable
and may aid in the consumption of food; however, they do not speed healing
Appropriate wound care is needed, and treatment for secondary bacterial skin
infections may be required

15. Periodontal disease
Primary herpetic gingivostomatitis…
C. Supportive treatment
Soft diet
Be kept well hydrated
The patient should maintain fluid intake and a balanced diet with the use of liquid food
replacement and bed rest
Counsel parents
No school, day care etc.
Children are highly contagious
Sterilize eating and drinking utensils
Disease is self-limiting; 10-14 days in duration

16. Periodontal disease
2. Necrotizing ulcerative gingivitis (NUG)
Vincent’s disease
Trench mouth
 Acute necrotizing ulcerative gingivitis (ANUG)
 An infection characterized by gingival necrosis presenting as “punched-
out” papillae, with gingival bleeding and pain

17. Periodontal disease
Necrotizing ulcerative gingivitis…
Etiology- Bacterial flora
Spirochetes (Treponema sp.)
Prevotella intermedia
Fusiform bacteria
Clinical Features
Gingival necrosis, especially tips of papillae
Gingival bleeding, pain, fetid breath, pseudomembrane formation

18. Periodontal disease
Necrotizing ulcerative gingivitis
Predisposing Factors
Emotional stress
Poor oral hygiene
Cigarette smoking
Poor nutrition
Immunosuppression
***Necrotizing periodontal diseases are common in immunocompromised
patients, especially those who are HIV (+) or have AIDS

19. Periodontal disease
Diagnosis of Trench mouth
 Clinical findings (gingival pain, ulceration and bleeding)
 Bacterial smear not definitive
 Microscopic examination of biopsy specimen (TB, neoplastic
disease)

20. Periodontal disease
Necrotizing Ulcerative Periodontitis
 A complicated AUG, characterized by necrosis of gingival
tissues, periodontal ligament, and alveolar bone

21. Periodontal disease
Treatment of necrotizing ulcerative gingivitis
 Local debridement
 Oral hygiene instructions
 Oral rinses
 Pain control
 Antibiotics
 Modify predisposing factors
 Proper follow-up

22. Periodontal disease
Treatment…
Oral rinses – (frequent, at least until pain subsides allowing
effective OH)
Chlorhexidine gluconate 0.12%; 1/2 oz 2 x daily
Hydrogen peroxide/water
Povidone iodine

23. Periodontal disease
Treatment….
Antibiotics (systemic or severe involvement)
Metronidazole
Avoid broad spectrum antibiotics in AIDS patients
Modify predisposing factors
Follow-up
Frequent until resolution of symptoms
Comprehensive periodontal evaluation following acute phase!!!!

24. Periodontal disease
3. Abscesses of the Periodontium
1. Gingival Abscess
2. Periodontal Abscess
3. Pericoronal Abscess
Gingival abscess
 A localized purulent infection that involves the marginal gingiva or
interdental papilla
Etiology
Acute inflammatory response to foreign substances forced into the gingiva

25. Periodontal disease
Gingival Abscess…..
Clinical Features
Localized swelling of marginal gingiva or papilla
A red, smooth, shiny surface
 May be painful and appear pointed
Purulent exudate may be present
No previous periodontal disease
Treatment
Elimination of foreign object
Drainage through sulcus with probe or light scaling
Follow-up after 24-48 hours

26. Periodontal disease
Gingival Abscess…..
Clinical Features
Localized swelling of marginal gingiva or papilla
A red, smooth, shiny surface
 May be painful and appear pointed
Purulent exudate may be present
No previous periodontal disease
Treatment
Elimination of foreign object
Drainage through sulcus with probe or light scaling
Follow-up after 24-48 hours

27. Periodontal disease
Periodontal Abscess
 A localized purulent infection within the tissues adjacent to the periodontal pocket that
may lead to the destruction of periodontal ligament and alveolar bone
Treatment
Anesthesia
Establish drainage
Via sulcus is the preferred method
Surgical access for debridement
Incision and drainage
Extraction

28. Periodontal disease
Pericoronal Abscess
 A localized purulent infection within the tissue surrounding the
crown of a partially erupted tooth
 Most common adjacent to mandibular third molars in young
adults; usually caused by impaction of debris under the soft
tissue flap

29. Periodontal disease
Peri-coronal Abscess…
Treatment Options
Debride/irrigate under pericoronal flap
Tissue recontouring (removing tissue flap)
Extraction of involved and/or opposing tooth
Antimicrobials (local and/or systemic as needed)
Culture and sensitivity
Follow-up

30. Periodontal disease
4. Recurrent Aphthous ulcer (Canker sores)
 It is a painful ulceration on the unattached mucous membrane that
occurs in school-aged children and adults, also referred to as Recurrent
Aphthous Stomatitis (RAS)
The peak age is between 10 and 19 years of age

31. Periodontal disease….
Aphthous ulcer….
Characterized by :
 Recurrent ulcerations on the moist mucous membranes of the mouth, in
which both discrete and confluent lesions form rapidly in certain sites and
feature
 Round to oval crateriform base, raised reddened margins, and pain

32. Periodontal disease ….
Predisposing factors
 The cause of RAU is unknown
But it is possible that the lesions are caused by :
Local and systemic conditions & gastrointestinal disorders
Genetic predisposition
Immunologic and infectious microbial factors
Delayed hypersensitivity to the L form of streptococcus sanguis
Autoimmune reaction of the oral epithelium

33. Periodontal disease
Treatment
Promoting ulcer healing
Reducing ulcer duration and patient pain
Maintaining the patient’s nutritional intake
And preventing or reducing the frequency of recurrence of the disease
Analgesic medicines and/or systemic immunomodulation and
immunosuppression agents
Ex : Topical corticosteroid is applied to the area with a mucosal adherent before
meals and before sleeping may also be helpful or four times daily

34. Periodontal disease
Acute oral candidiasis (thrush, candidosis, moniliasis)
 Acute oral condition appear as raised, furry, white patches, which can be
removed easily to produce a bleeding underlying surface
 Neonatal candidiasis is common occurred with the first 2 weeks of life
 Immunosuppression and local antibiotic therapy may increase the
susceptibility

35. Periodontal disease
Acute oral candidiasis….
Treatment- Antifungal antibiotics control thrush
 Nystatin suspension of 1 mL (100,000 U) may be dropped into the mouth
for local action QID
 Clotrimazole suspension (10 mg/mL), 1 to 2 mL QID
 Systemic fluconazole suspension (10 mg/mL) 1 to 2ml QID

36. Dental trauma
Epidemiology
 Most affected teeth are incisors
Peak ages- 2 - 3 years and 7 – 11 years
Sex distribution- m > f = 3:1
Prevalence
50% of all children under 15
30% affecting deciduous teeth
20% affecting permanent teeth

37. Dental trauma…
Patient Examination
 When patient is received for treatment of trauma, the oral
region is usually heavily contaminated so the first step is to
wash the patient’s face

38. Dental trauma…
Ask questions for diagnosis and treatment planning
 Where/How/When did the injury occur?
 Was there a period of unconsciousness?
 Is there any disturbance in the bite?
 Is there any reaction in the teeth to cold and/or
heat exposure?
 Ask about medical history (allergies/medical conditions)

39. Dental trauma…
Clinical exam
 Examine: face, lips and oral muscles for soft tissue lesions
 Palpate: facial skeleton for signs of fractures
 Inspect: dental trauma region for fractures or infarctions, tooth
mobility, and abnormal response to percussion
 Pulp testing
Percussion test

40. Dental trauma…
Clinical exam…
 Mobility of group of teeth indication for
alveolar fracture
 Tenderness to percussion in axial direction indication for PDL damage
 Diagnose infarction by directing the light beam
parallel to the labial surface of the injured tooth

41. Dental trauma….

42. Dental trauma….
Crown fracture
 Crown fractures comprise the most frequent injuries in the
permanent dentition
 Apart from the loss of hard tissue; this injury can represent a
hazard to the pulp
 The closeness of the fracture to the pulp and the risk of
bacteria or bacterial toxins penetrating dentin into the pulp
are the primary sources of pulpal complications after crown
fracture

43. Dental trauma….
Crown fracture….

44. Dental trauma….
Crown root fracture
 Most of these fractures occur as the result of a horizontal
impact
 Crown-root fractures may or may not involve the pulp
 Clinical diagnosis depends upon mobility of the coronal
fragment
 Radiographic diagnosis, however, is uncertain as it is usually
impossible to determine the oral extent of fracture

45. Dental trauma….
Root fracture
 Root fractures are relatively uncommon injuries, but represent
complex healing patterns due to concomitant injury to the pulp,
periodontal ligament, dentin and cementum
 The fracture usually results from a horizontal impact Fractures in the
apical- and middle-thirds of root normally take an oblique course,
being placed more apically on the labial aspect than on the palatal
 Take radiographs with various angulations to diagnose fracture type
and location

46. Dental trauma….
Concussion
 Mechanism of concussion injury : A frontal impact leads to
hemorrhage and edema in the periodontal ligament
 Least severe luxation injuries
 Radiography: no signs of pathology

47. Dental trauma….
Sub luxation
 Tooth tender to touch & slightly mobile (1+) but not displaced,
possible hemorrhage from gingival crevice
 No radiographic abnormalities
 Mechanism of sub luxation injury: If the impact has greater
force, periodontal ligament fibers may be torn resulting in
loosening of the injured tooth

48. Dental trauma….
Extrusive luxation
 Pathogenesis of extrusive luxation : oblique forces displace the
tooth out of socket
 Only the gingival fibers palatally prevent the tooth from being
avulsed
 Both the PDL and the neurovascular supply to the pulp are severed
 Radiographically, a periapical bisecting angle exposure is more
useful than an occlusal exposure

49. Dental trauma….
Lateral luxation
 Horizontal forces displace the crown palatally and the
apex labially
 The neurovascular supply to the pulp, compression of
the PDL is found on the palatal aspect of the root
 Occlusally radiograph or eccentrically oriented exposure
will tend to come between the root of the tooth and the
empty socket

50. Dental trauma….
Intrusion
Intrusion is the result of an axial, apical impact and results in
extensive damage to the pulp and PDL
 Pathogenesis of intrusion: Axial impact leads to extensive injury
to the pulp and periodontium

51. Dental trauma….
Avulsion
 Avulsion of permanent teeth is most common in the young
dentition, where root development is still incomplete and the
periodontium very resilient

52. References
1. HOCKENBERRY., M. J. & WILSON., D. 2013. WONG’S ESSENTIALS OF
PEDIATRIC NURSING., Philadelphia, Elsevier Inc.
2. KYLE, T. & CARMAN, S. 2013. Essentials of pediatric nursing, Philadelphia,
Lippincott Williams & Wilkins.
3. MORTON., P. G. & FONTAINE., D. K. 2013. Essentials of critical care nursing :
a holistic approach, Philadelphia, Lippincott Williams & Wilkins.

53. Lecture
Self study
Practice