Orofacial Clefts
Cleft lip and cleft palate are the single most common congenital deformity affecting orofacial structures (13% of all reported facial anomalies).
Because the lip and palate develop separately, it is possible to have a cleft lip without a cleft palate and vise versa, or both together
- Unilateral or bilateral, may involve lip, palate or both
- Factors:
- Genetics
- Maternal age
- Exposures (e.g., alcohol, smoking, hypoxia during pregnancy; folic acid deficiency; vitamin A deficiency; corticosteroids; AEDs such as phenytoin; even zofran has a small absolute increase in oral clefts with 1st trimester exposure)
Treatment is important for cosmetic and feeding reasons.
- Feeding difficulties can occur with cleft lip or palate due to difficulty with generating negative pressure in the oral cavity.
- Most clefts lips are repaired between 3-6 months of age; bilateral clefts may require two separate surgeries
- Most cleft palates are repaired within 9-18 months of age.
- Guides for starting solids with infants with cleft lip/palate are generally similar to other infants, expecting nasal regurgitation or some impacted foods within palate.
Palatal Cyst
Palatal cysts are epithelial inclusion cysts arising from remnants of minor mucous salivary glands or fusion abnormalities. They are also known as Epstein’s pearls (median raphe distribution) or Bohn’s nodules (mucous gland cysts often on alveolar ridge).
- Occur in 65-85% of newborns
- No treatment is required; spontaneous resolution within weeks
Ankyloglossia
Ankyloglossia is commonly known as tongue-tie, or a tight lingual frenulum. Ankyloglossia may result in difficulty sucking, feeding problems, or poor weight gain in infancy, and possibly speech difficulties in childhood.
Developmentally, the frenulum guides the development of central structures of the mouth. It continues to guide the position of incoming teeth during infancy, then recedes and thins. In some children, this cord is especially tight and causes tongue mobility problems.
Exam:
- V-shaped notch at the tip of the tongue
- Inability to extend tongue past upper gums
Neonatal / Natal Teeth
Neonatal or natal teeth are either present at birth or within the first month of life, most commonly the mandibular central incisors.
Treatment:
- Consider extraction if causing problems with feeding or with mother
- Should be left in mouth as long as possible to decrease likelihood of removing permanent tooth buds with natal tooth
Eruption Cyst
Follicular enlargement appearing just before the eruption of tooth, typically blue-black in color (may contain blood).
No treatment is needed as lesions typically spontaneously rupture within 2 weeks, unless it becomes infected, which may require surgical opening.
Parulis
A parulis is also known as a gum boil. It is a soft, solitary papule located over an abscessed tooth at the exit point of a draining fistulous tract. Treatment requires excision of the abscessed tooth. The parulis typically regresses shortly after surgical excision of the abscessed tooth; if not treated, a parulis may persist for years and mature into a fibroma.
Mucocele
Benign lesion characterized by extravasation or retention of mucous from minor salivary glands.
- Single or multiple, spherical, fluctuant nodules, pink to deep blue in color, generally asymptomatic
- Most commonly appears on the lower lip, followed by the floor of mouth (aka ranula) or buccal mucosa
- Ranulas are associated with sublingual glands and submandibular ducts, probably from improper drainage or after oral trauma. Ranulas can “plunge” and extend through the mylohyoid musculature into the neck region.
Mucoceles are rare in infants (usually congenital); in older children can be due to trauma (e.g., lip biting).
Treatment involves transoral removal of salivary gland and marsupialization (creating permanent fistula from ranula to oral cavity).
Candidiasis
Acute pseudomembranous candidiasis is more commonly known as thrush.
- Opportunistic overgrowth of Candida albicans
- Creamy/curdy white plaques that are scrapable, leaving red, raw and painful surface
Risk factors (in children >12 months):
- HIV infection
- Antibiotic exposure, inhaled corticosteroids
- Other immunodeficiency syndrome, cancer, etc
Treatment:
- Initial: Nystatin 100,000 units each cheek QID x 7-14 days
- Refractory: Fluconazole 3-6 mg/kg once daily
- Decolonization measures: boiling pacifiers and nipples after each use; may consider using topical miconazole/clotrimazole to nipple of chestfeeding caregivers; removing visible residual medication prior to each feeding/reapply after feeding
- Evaluation for cellular immune deficiency may be warranted for children ≥12 months who develop thrush in the absence of a predisposing factor.
- Gentian violet is no longer recommended in areas where other alternatives are available – associated with toxicity to the mucous membranes and can cause tattooing of the skin, potentially carcinogenic and may cause allergic hypersensitization
Primary Herpetic Gingivostomatitis
HSV-1 infection transmitted through direct contact.
Roughly 1 week incubation period followed by painful oral vesicles with ulcerations with associated fever, malaise, irritability
Treatment: Supportive care (barrier cream, pain control, hydration) and ACV
- Healing expected within 1 week but up to 3 weeks in severe cases
- ACV within 96 hours of disease onset in immunocompetent patients with severe sx, may decrease the duration fo symptoms by 3-6 days and may decrease duration of viral shedding
Blog post based on Med-Peds Forum talk by Vivian Shi, PGY4