Download Protecting All Children`s Teeth: Oral Findings

Protecting All Children’s Teeth
Oral Findings
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Introduction
A physician in practice is likely to encounter many oral
findings. It is important to be familiar with the more
common oral findings to ensure proper diagnosis,
management, and reassurance or referral.
Common oral findings in pediatrics are reviewed in this
presentation and are divided into acquired and congenital
or developmental categories.
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Learner Objectives
Permission on ile from IStock
Upon completion of this presentation, participants will be
able to:
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Recognize and appropriately manage common
pediatric oral findings.
State the 3 types of oral ulcers.
Discuss etiologies of parotitis and their management.
List indications for intervention with ankyloglossia.
Recall the management of angular cheilitis, ranulas,
mucoceles, and diastema.
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Acquired Oral Findings
Acquired oral findings include:
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1.
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3.
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5.
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8.
Benign Migratory Glossitis
Morsicatio Buccarum
Pyogenic Granuloma
Ulcers
Angular Cheilitis (Perleche)
Leukoplakia (“White Patch”) in the Oral Cavity
Oral Hairy Leukoplakia
Parotitis
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Benign Migratory Glossitis
AKA “Geographic Tongue”,
Benign migratory glossitis includes
loss of filiform papillae on certain
areas of the tongue, making it
appear smooth, red, and shiny.
Usually noted on the dorsum of the
tongue, etiology is unknown and self-limiting.
Used with permission from Melinda B. Clark, MD; Associate Professor of
Pediatrics at Albany Medical Center
Treatment is unnecessary because it does not pose a problem.
However, it may be irritated by acidic foods.
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Morsicatio Buccarum
Chronic, often subconscious, cheek
biting results in mucosal shredding,
erythema, ulcers or leukoplakia in the
areas of biting.
AKA “Frictional Hyperkeratosis”
Usually symmetric along the buccal
mucosa. Biting may also involve the
labial and lingual mucosal surfaces.
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Used with permission from Dr. Brad W. Neville, DDS, Distinguished
University Professor College of Dental Medicine, MUSC
Diagnosis can be made on clinical findings. If cheek biting is a
manifestation of anxiety, treatment for underlying trigger may
be warranted. No need for treatment if asymptomatic.
Linea Alba
In contrast to Morsicatio Buccarum, linea alba is a single white line
across the buccal mucosa
Results from irritation of the teeth against the buccal mucosa along
the plane of occlusion. No need for treatment if asymptomatic.
Moriscatio Buccarum
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Photos used with permission of Dr. Brad W. Neville, DDS, Distinguished
University Professor College of Dental Medicine, MUSC
Linea Alba
Pyogenic Granuloma
Pyogenic granuloma refers to red,
painless masses usually located on
the gingiva.
Characterized by bleeding with
minor trauma and caused by
vascular overgrowth in response to
a local irritant or trauma. Improving
flossing and brushing can result in
spontaneous regression.
Can be triggered by hormones, such
as in pregnancy and puberty.
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Pyogenic granuloma may require
surgical excision and can recur.
Used with permission from Dr. Brad W. Neville, DDS, Distinguished University
Professor College of Dental Medicine, MUSC
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Ulcers
There are 3 types of ulcers:
1. Traumatic: Typically result from mechanical or thermal
injury. Located on the buccal mucosa, tongue, lips, or
palate.
2. Infectious: Usually caused by HSV (primary or recurrent)
or Coxsackie infections. HSV ulcers can be seen on the
gingiva, lips, tongue, buccal mucosa, palate, pharynx,
tonsils and skin. Coxsackie ulcers are typically prominent
over the posterior soft palate.
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3. Aphthous: Known as stomatitis (“canker sores”), these
ulcers are round, yellowish-grey ulcers with surrounding
erythema (halo) usually located on mucous membranes.
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Primary Herpetic Gingivostomatitis
Primary Herpetic Gingivostomatitis is
caused primarily by herpes simplex
virus type 1. The primary infection is
most severe and usually seen in
children under age 6.
Gingiva is friable and bleeds
Used with permission from Rama Oskouian
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Due to painful vesicles and
ulcers, children often
refuse to drink and are at
risk for dehydration.
Used with permission from Martha Ann Keels, DDS, PhD;
Primary Herpetic Gingivostomatitis
Herpes Labialis
Treatment is mainly supportive with
hydration maintenance and pain
control.
The acyclovir family of antiviral
medications may be used, especially
for immunosuppressed patients.
Used with permission from Rama Oskouian
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The infection is life-long, and
recurrences occur as “cold sores”
(herpes labialis), usually at times of
stress or infection.
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Aphthous Ulcers
Divided into 3 categories:
1. Aphthous Minor Ulcers: Characterized
by small (usually 1-5 mm) lesions that
heal without scarring.
2. Aphthous Major Ulcers: Recurrent
major aphthae may take up to 4 weeks
to heal and may scar.
3. Herpetiform Ulcers: Grouped 1-2 mm
papules, vesicles, or ulcers. Often very
painful.
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Used with permission from Rocio B. Quinonez, DMD, MS, MPH;
Associate Professor Department of Pediatric Dentistry, School of
Dentistry University of North Carolina
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Aphthous Ulcers, continued
The etiology of aphthous ulcers is
unknown, but they may be
infectious, autoimmune, allergic,
nutritional, or traumatic in nature.
Treatment includes supportive
care, bland diet (avoid spicy and
citrus), and topical anesthetic
creams or mouthrinses.
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Used with permission from Martha Ann Keels, DDS, PhD; Division Head of Duke
Pediatric Dentistry, Duke Children's Hospital
Recurrence is likely.
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Angular Cheilitis (Perleche)
Angular cheilitis presents as erythema,
fissures, and erosions at the corners of
the mouth.
May be triggered by lip-licking, sensitivity
to a compound, vitamin deficiency
Used with permission from Noel Childers, DDS, MS, PhD;
Department of Pediatric Dentistry, University of Alabama at
Birmingham
(riboflavin), or iron deficiency.
Treatment includes topical yeast treatment (Nystatin), topical
antibiotic agents (Mupirocin), or low-dose topical steroids.
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Leukoplakia in the Oral Cavity
In children, leukoplakia in the oral
cavity is most often the result of
chronic irritation, such as cheek or
tongue biting.
Etiologies may also include vitamin
deficiency and candidiasis.
White plaques on
undersurface of tongue
Used with permission from Dr. Brad W. Neville, DDS, Distinguished University
Professor College of Dental Medicine, MUSC
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In adults, especially those who are
chronic tobacco users, leukoplakia is
considered a pre-malignant lesion,
but this is not the case for children.
Oral Hairy Leukoplakia
Oral hairy leukoplakia present as
white lesions on any surface of the
tongue (most often along the sides
of the tongue) or on the buccal
mucosa.
The lesions are not painful and
may be smooth and flat, irregular,
and “hairy” or “feathery” in
appearance.
Benign and self-limited finding.
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Used with permission from Dr. Brad W. Neville, DDS, Distinguished University
Professor College of Dental Medicine, MUSC
No treatment is usually required.
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Parotitis
Parotitis is the clinical term for inflammation and swelling
of the parotid gland.
With parotitis, the parotid gland is tender to palpation
and the opening to Stenson’s duct appears inflamed and
swollen.
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Viral Causes of Parotitis
Mumps is the classic virus
known to cause parotitis.
Mumps parotitis is bilateral
in 70% of cases and usually
follows a 1-2 day prodrome
of fever, headache, emesis,
and myalgias.
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Used with permission from the AAP Red Book
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Bacterial Causes of Parotitis
Called “purulent parotitis”, bacterial
infection of the parotid gland is
typically unilateral and extremely
painful with visible pus draining
from Stenson’s duct.
Used with permission from Lauren Barone
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The patient often appears ill and
should be empirically treated with
antibiotics after culture obtained.
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Obstruction
Parotitis from obstruction is
typically the result of a salivary
stone or sialolith, which is
expected to be unilateral.
If the patient is not ill,
expectant management for
passage of the sialolith is
appropriate.
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Sialolith
Used with permission from Martha Ann Keels, DDS, PhD; Division
Head of Duke Pediatric Dentistry, Duke Children's Hospital
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Other Conditions
Other conditions that can result in parotid gland
enlargement (with or without inflammation) include:
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Bulimia or other causes of chronic emesis
Diabetes
Collagen vascular diseases
Local radiation treatment
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Congenital and Other Oral Findings
1.
2.
3.
4.
5.
6.
7.
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Inclusion Cysts
8. Eruption Cyst/Hematoma
Natal and Neonatal Teeth 9. Bony Tori (“Torus
Congenital Epulis
Palatinus or Mandibularis”)
Ankyloglossia
10. Diastema
Cleft Lip/Palate
11. Macroglossia
Bifid Uvula
12. Micrognathia
Ranula/Mucocele
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Inclusion Cysts
Small, white or translucent papules or cysts seen in
newborns. Usually asymptomatic and resolve
spontaneously by 3 months of age.
There are 3 types of inclusion cysts found in newborns:
1. Epstein’s Pearls
2. Bohn’s Nodules
3. Dental lamina cysts
No treatment is necessary.
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Epstein’s Pearls
Epstein’s Pearls
Epstein’s Pearls are
epithelial remnants of
palatal fusion located
along the mid-palatal
raphe of the hard palate.
Resolve spontaneously
with no need for
evaluation or intervention.
Used with permission from Rama Oskouian
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Bohn’s Nodules and Dental Lamina Cysts
Bohn’s Nodules are
heterotopic salivary gland
remnants located on the
buccal or lingual surface of
the alveolar ridge (not the
crest), or on the hard palate,
away from the raphe.
Dental lamina cysts are
located on the crest of the
alveolar ridge.
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Bohn’s Nodules
Used with permission from Rama Oskouian
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Natal and Neonatal Teeth
Natal Teeth
Some infants erupt teeth, usually
lower incisors, before birth (natal
teeth) or shortly thereafter
(neonatal teeth).
Most often primary (not extra)
teeth.
Used with permission from David A. Clark, MD; Chairman and Professor
of Pediatrics at Albany Medical Center
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No treatment is generally indicated.
Extraction may be considered only
if teeth are mobile, interfere with
breastfeeding, or lead to Riga-Fede
ulceration. Avoid wiggling as not to
loosen the tooth.
Congenital Epulis
Pedunculated, non-tender, spongy
mass is usually located on the
anterior maxillary alveolar ridge.
Congenital Epulis is benign in
nature and may regress
spontaneously. If it is large and
interferes with feeding, excision
may be required.
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Epulis
Used with permission from Rocio B. Quinonez, DMD, MS, MPH;
Associate Professor Department of Pediatric Dentistry, School of
Dentistry University of North Carolina
Recurrence is unlikely.
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Developmental Tooth Defects
Enamel hypoplasia can result
from a number of
environmental insults during
development, including
• Infection
• Toxins (lead or mercury),
• Fluoride
• Medications
• Prematurity
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Amelogenesis Imperfecta
Tim Wright DDS, MS
Professor and Chair Department of Pediatric Dentistry
The University of North Carolina School of Dentistry
Developmental Tooth Defects
Inherited enamel defects
include Amelogenesis
Imperfecta (AI, often
autosomal dominant). AI
results in hypoplastic and
hypocalcified enamel,
which appears yellow or
brown and is easily worn
away.
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Tim Wright DDS, MS
Professor and Chair Department of Pediatric Dentistry
The University of North Carolina School of Dentistry
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Developmental Tooth Defects
Inherited dentin defects include
Dentinogenesis Imperfecta
which vary in phenotypic
expression and are usually
inherited in an autosomal
dominant manner.
DI can be a clinical feature of
Osteogenesis Imperfecta
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Tim Wright DDS, MS
Professor and Chair Department of Pediatric Dentistry
The University of North Carolina School of Dentistry
Teeth appear blue-gray or yellow-brown because the
abnormal dentin shines through the enamel. Teeth have
increased susceptibility to fracture and spontaneous abscess.
Ankyloglossia
Ankyloglossia refers to a
congenitally short lingual
frenulum that ties the tongue
to the floor of the mouth,
decreasing its mobility.
Martha Ann Keels, DDS, PhD; Division Head of Duke
Pediatric Dentistry, Duke Children's Hospital
The tongue appears notched or heart-shaped at the tip.
In general, no intervention is recommended. Treat with
frenectomy if severe enough to interfere with feeding or speech.
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Cleft Lip/Palate
Cleft lip and/or palate may cause
feeding, swallowing, and respiratory
difficulties in infancy, along with
speech and cosmetic concerns.
Surgical repair is typically
approached in a step-wise fashion.
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Outcomes are best with a team
treatment approach. Primary care
providers are encouraged to utilize
an interdisciplinary team for cleft lip
and palate management.
Used with permission from David A. Clark, MD; Chairman
and Professor of Pediatrics at Albany Medical Center
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Bifid Uvula
Bifid uvula can be an isolated finding but is often
associated with a congenital submucosal cleft, which may
be difficult to appreciate on examination.
Children with submucosal clefts may develop hypernasal
speech. Children with a bifid uvula should be referred for
speech therapy and for ENT evaluation if speech
concerns arise.
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Mucocele
A mucocele is a bluish or translucent
cyst resulting from accumulation of
mucous from trauma to a minor
salivary gland.
Mucoceles generally require no
treatment and many resolve
spontaneously. Fluctuations in size are
common.
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Used with permission from Martha Ann Keels, DDS, PhD; Division Head of
Duke Pediatric Dentistry, Duke Children's Hospital
If the lesion is large or uncomfortable,
excision may be warranted.
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Ranula
A ranula is a larger
collection of mucous under
the tongue that is unilateral.
Used with permission from Martha Ann Keels, DDS, PhD; Division Head
of Duke Pediatric Dentistry, Duke Children's Hospital
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Unlike mucoceles, ranulas
require surgical excision
with marsupialization of
larger lesions because they
are likely to recur.
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Eruption Cyst or Hematoma
Eruption hematoma
Used with permission from Martha Ann Keels, DDS, PhD; Division Head
of Duke Pediatric Dentistry, Duke Children's Hospital
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Eruption cysts develop 1 to 3
weeks prior to tooth eruption as
a dome shaped soft tissue
lesion overlying the erupting
tooth.
When mixed with blood, it
appears more bluish and is
referred to as an eruption
hematoma.
No treatment is recommended
because the cyst will resolve
spontaneously when the tooth
completely erupts.
Bony Tori (“Torus Palatinus” or
“Mandibularis”)
Bony tori refer to benign bony overgrowth (exostosis) in
the midline of the hard palate (palatinus) or the lingual
aspect of the mandible (mandibularis), where they are
often bilateral and symmetric.
Bony tori do not require intervention unless the lesion
becomes painful, ulcerated, or interferes with speech or
eating.
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Diastema
Diastema refers to the space
between the central incisors
associated with a prominent
maxillary frenum.
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Diastema is normal in childhood,
but a diastema greater than 3
mm after eruption of the
permanent upper canines (ages
10 to 13) should be evaluated
for treatment.
Diastema
Used with permission from Melinda B. Clark, MD; Associate Professor of
Pediatrics at Albany Medical Center
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Macroglossia
Macroglossia refers to enlargement of the tongue.
With macroglossia, airway maintenance and feeding are
paramount.
Involve appropriate specialists (ENT, genetics) to ensure
timely evaluation and management.
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Micrognathia
Micrognathia denotes a
small jaw, commonly
from hypoplasia of the
mandible.
Used with permission from David A. Clark, MD; Chairman and Professor of
Pediatrics at Albany Medical Center
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This can be an isolated
finding or can be
associated with a number
of syndromes.
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Question #1
A small jaw from hypoplasia of the mandible is
known as
A. Macroglossia
B. Micrognathia
C. Bony Tori
D. Diastema
E. Angular Cheilitis
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Answer
A small jaw from hypoplasia of the mandible is
known as
A. Macroglossia
B. Micrognathia
C. Bony Tori
D. Diastema
E. Angular Cheilitis
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Question #2
Which of the following is indicative of a
geographic tongue?
A. Chronic cheek biting
B. Erosions at the corner of the mouth
C. Loss of filiform papillae on areas of the tongue that
appear smooth, red, and shiny
D. White lesions on the tongue
E. Yellowish-grey cysts
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Answer
Which of the following is indicative of a
geographic tongue?
A. Chronic cheek biting
B. Erosions at the corner of the mouth
C. Loss of filiform papillae on areas of the tongue that
appear smooth, red, and shiny
D. White lesions on the tongue
E. Yellowish-grey cysts
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Question #3
In deciding whether to intervene when a newborn is
diagnosed with ankyloglossia, the most important
factor is:
A. The input of a professional lactation consultant
B. How far the baby can extend his or her tongue
C. Breastfeeding success and maternal pain with latching
D. Parental input. This is an elective procedure and should be
done only if the parents request it
E. None of the above because intervention is rare for
newborns and recommended only in severe cases
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Answer
In deciding whether to intervene when a newborn is
diagnosed with ankyloglossia, the most important
factor is:
A. The input of a professional lactation consultant
B. How far the baby can extend his or her tongue
C. Breastfeeding success and maternal pain with latching
D. Parental input. This is an elective procedure and should be
done only if the parents request it
E. None of the above because intervention is rare for
newborns and recommended only in severe cases
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Question #4
Which of the following statements about aphthous
ulcers is correct?
A. Aphthous ulcers can be divided into 3 categories
B. Aphthous ulcers etiology is unknown
C. Aphthous ulcers are more common in individuals with
inflammatory bowel disease
D. All of the above
E. None of the above
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Answer
Which of the following statements about aphthous
ulcers is correct?
A. Aphthous ulcers can be divided into 3 categories
B. Aphthous ulcers etiology is unknown
C. Aphthous ulcers are more common in individuals with
inflammatory bowel disease
D. All of the above
E. None of the above
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Question #5
What is the most appropriate course of action
when a ranula is diagnosed?
A. Incise and drain the lesion
B. Refer for excision
C. Observe for spontaneous resolution
D. Prescribe a 10-day course of oral antibiotics
E. None of the above
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Question #5
What is the most appropriate course of action
when a ranula is diagnosed?
A. Incise and drain the lesion
B. Refer for excision
C. Observe for spontaneous resolution
D. Prescribe a 10-day course of oral antibiotics
E. None of the above
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References
1. Brown GC et al. Partners in Prevention- Infant Oral Health Manual for
Health Professionals. New York University College of Dentistry; Department
of Pediatric Dentistry. 2nd Edition, 2000.
2. Ferretti GA, Cecil JC. Kids Smile: Oral Health Training Program Lecture
Series. Sponsored by the Kentucky Department for Public Health and the
University of Kentucky College of Dentistry.
3. Krol DM, Keels, MA. Oral Conditions. Pediatr Rev. 2007; 28(1): 15-22.
4. Messadi DV, Waibel JS, Mirowski GW. White lesions of the oral cavity.
Dermatologic Clinics. 2003; 21: 63-78.
5. Witman PM, Rogers RS. Pediatric Oral Medicine. Dermatol Clin. 2003;
21:157-170.
6. US Department of Health and Human Services. Oral Health in America: A
Report of the Surgeon General. Rockville, MD: National Institute of Dental
and Craniofacial Research, National Institutes of Health; 2000.
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