Management Considerations for Pediatric Oral Surgery and Oral Pathology

Purpose

The American Academy of Pediatric Dentistry (AAPD) intends this document to define, describe clinical presentation,and set forth general criteria and therapeutic goals for commonpediatric oral surgery procedures and oral pathological conditions.

Methods

Recommendations on management considerations for pediatric oral surgery and oral pathology were developed by the Council on Clinical Affairs and adopted in 2005.1 This document is a revision of the previous version, last revised in 2015.2 It is based on a review of the current dental and medical literature related to pediatric oral surgery, including a search of the PubMed®/MEDLINE database using the terms: pediatric AND oral surgery, oral pathology, extraction, odontogenic infections, impacted canines, third molars, supernumerary teeth, mesiodens, mucocele, eruption cyst, eruption hematoma, gingival keratin cysts, Epstein pearls, Bohn’s nodules, congenital epulis of newborn, dental lamina cysts, natal teeth, neonatal teeth, squamous papilloma, verruca vulgaris, irritation fibroma, recurrent aphthous stomatitis, localized juvenile spongiotic gingival hyperplasia, and pyogenic granuloma; fields: all; limits: within the last 10 years, humans, English, clinical trials. Papers for review were chosen from the list of articles matching these criteria and from references with selected articles. When data did not appear sufficient or were inconclusive, recommendations were based upon expert and/or consensus opinion by experience researchers and clinicians. In addition, the manual Parameters of Care: Clinical Practice Guidelines for Oral and Maxillofacial Surgery,3 developed by the American Association of Oral and Maxillofacial Surgeons (AAOMS), was consulted.

General considerations

Surgery performed on pediatric patients involves special considerations unique to this population. Several critical issues deserve to be addressed.

Preoperative considerations
Informed consent
Before any surgical procedure, informed consent must be obtained from the parent or legal guardian. For more information, refer to AAPD’s Informed Consent.4

Medical evaluation
Important considerations in treating a pediatric patient include obtaining a thorough medical history, obtaining appropriate medical and dental consultations, anticipating and preventing emergency situations, and being prepared to treat emergency situations.5

Dental evaluation
It is important to perform a thorough clinical and radiographicpreoperative evaluation of the dentition as well as a clinicalexamination of extraoral and intraoral soft tissues.5-7 Radiographs can include intraoral films and extraoral imaging if the area of interest extends beyond the dentoalveolar complex. Surgery involving the maxilla and mandible of young patients is complicated by the presence of developing tooth follicles. Knowledge of the anatomy of a child’s developing maxilla and mandible and the avoidance of injury to the dental follicles can prevent complications.8 To minimize the negative effects of surgery on the developing dentition, careful planning using radiographs, tomography,9 cone beam computed tomo-graphy,10 and/or three-dimensional imaging techniques11 is necessary to provide valuable information to assess the presence, absence, location, and/or quality of individual crown and root development.8,12,13

Growth and development
The potential for adverse effects on growth from injuries and/or surgery in the oral and maxillofacial region markedly increases the potential for risks and complications in the pediatric population. Traumatic injuries involving the maxil-lofacial region can adversely affect growth, development, and function. Therefore, a thorough evaluation of the growing patient must be done before surgical interventions are per-formed to minimize the risk of damage to the growing facial complex.14

Behavioral evaluation
Behavioral guidance of children in the operative and perioperative periods presents a special challenge. Many children benefit from modalities beyond local anesthesia and nitrous oxide/oxygen inhalation to minimize their anxiety.4,14 Management of children under sedation or general anesthesia requires extensive training and expertise.15,16 Special attention should be given to the assessment of the social, emotional, and psycho-logical status and cognitive level of the pediatric patient prior to surgery.14 Children have many unvoiced fears concerning the surgical experience, and their psychological managementrequires that the dentist be cognizant of their emotionalstatus. Answering questions concerning the surgery is important and should be done in the presence of the parent.

Peri- and post-operative considerations
Metabolic management of children following surgery frequently is more complex than that of adults. Special consideration should be given to caloric intake, fluid and electrolyte management, and blood replacement. Comprehensive management of the pediatric patient following extensive oral and maxillofacial surgery usually is best accomplished in a facility that has expertise and experience in the management of young patients (i.e., a children’s hospital).14

Recommendations

Odontogenic infections
In children, odontogenic infections may involve more than one tooth and usually are due to caries lesions, periodontal problems, pathology (e.g., dens invaginatus), or a history of trauma.17-18 Untreated odontogenic infections can lead to pain, difficulty eating or drinking, abscess, cellulitis, septicemia, airway compromise, and life-threatening infections.19 Facial cellulitis results from unresolved abscess that has spread to cutaneous or subcutaneous soft tissue planes in the head and neck region.19 In these children, dehydration is a significantconsideration; prompt treatment of the source of infection isimperative. With infections of the upper portion of the face, patients usually complain of facial pain, fever, and malaise.20 Care must be taken to rule out sinusitis or non-odontogenic infections, as symptoms may mimic an odontogenic infection. Occasionally in upper face infections, it may be difficult to find the true cause.14 Infections of the lower face usually involve pain, swelling, and trismus.3,17 They frequently are associated with teeth, skin, local lymph nodes, and salivary glands.17 Most odontogenic infections occur in the upper face; however, infections in the mandibular region are more frequent in older children.20 Most odontogenic infections can be managed with pulp therapy, extraction, or incision and drainage.5 Infections of odontogenic origin with systemic manifestations (e.g., elevated temperature [102 to 104 degrees Fahrenheit], facial cellulitis, difficulty in breathing or swallowing, fatigue, nausea) require antibiotic therapy.19 Severe but rare complications of odonto-genic infections include cavernous sinus thrombosis and Ludwig’s angina.17,19 These conditions can be life threatening and may require immediate hospitalization with intravenous antibiotics, incision and drainage, and referral/consultation with an oral and maxillofacial surgeon.17,19

Extraction of erupted teeth
Maxillary and mandibular anterior teeth
Most primary and permanent maxillary and mandibular centralincisors, lateral incisors, and canines have conical single roots. In most cases, extraction of anterior teeth is accomplished with a rotational movement due to their single root anatomy.5 However, there have been reported cases of accessory roots observed in primary canines.21,22 Radiographic examination is helpful to identify differences in root anatomy prior to extraction.21 Care should be taken to avoid placing any force on adjacent teeth that could become luxated or dislodged easily due to their root anatomy.

Maxillary and mandibular molars
Primary molars have roots that are smaller in diameter and more divergent than permanent molars. Root fracture in primary molars is not uncommon due to these characteristics as well as the potential weakening of the roots caused by the eruption of their permanent successors.5 Prior to extraction, the relationship of the primary roots to the developing succedaneous tooth should be assessed. To avoid inadvertentextraction or dislocation of or trauma to the permanent successor, pressure should be avoided in the furcation area or the tooth may need to be sectioned to protect the developing permanent tooth.

Molar extractions are accomplished by using slow continuous palatal/lingual and buccal force allowing for the expansion of the alveolar bone to accommodate the divergent roots and reduce the risk of root fracture.5 When extracting mandibular molars, care should be taken to support the mandible to protect the temporomandibular joints from injury.5

Fractured primary tooth roots
The presence of a root tip should not be regarded as a positive indication for its removal. The dilemma to consider when managing a retained primary tooth root is that removing the root tip may cause damage to the succedaneous tooth, while leaving the root tip may increase the chance for postoperative infection and delay eruption of the permanent successor.5 Radiographs can assist in the decision process. Expert opinion suggests that if the fractured root tip can be removed easily, it should be removed.5 If the root tip is very small, located deep in the socket, situated in close proximity to the permanent successor, or unable to be retrieved after several attempts, it is best left to be resorbed.5 The parent must be informed and a complete record of the discussion must be documented. The patient should be monitored at appropriate intervals to evaluate for potential adverse effects.

Management of unerupted and impacted teeth
There is a wide clinical spectrum of disorders of eruption in both primary and permanent teeth in children. These may be syndromic or non-syndromic and include ankyloses,27-28 secondary retention,28 tooth impaction, or primary failure oferuption29. Clinically, it may be difficult to differentiate betweenthe various disruptions; however, there have been many
reports30,31 to assist the clinician in making a diagnosis. There is increasing evidence that there is a genetic etiology for some of these eruption disruptions which may help in a definitive diagnosis.29 Management of unerupted teeth will depend on whether the tooth affected is likely to respond to orthodontic forces. If not, surgical extraction is the preferred treatment option.29

Impacted canines
Tooth impaction may occur due to a mechanical obstruction. Permanent maxillary canines are second to third molars in frequency of impaction.32 Early detection of an ectopically erupting canine through visual inspection, palpation, and radiographic examination is important to maximize success of an intervention.33 Routine evaluation of patients in mid-mixed dentition should involve identifying signs such as lack of canine bulges and asymmetry in pattern of exfoliation. Abnormal angulation or ectopic eruption of developing permanent cuspids can be assessed radiographically.33 When the cusp tip of the permanent canine is just mesial to or overlaying the distal half of the long axis of the root of the permanent lateral incisor, canine palatal impaction usually occurs.32 Extraction of the primary canines is the treatment of choice to correct palatally displaced canines or to prevent resorption of adjacent teeth.32 One study showed that 78 percent of ectopically erupting permanent canines normalized within 12 months after removal of the primary canines; 64 percent normalized when the starting canine position overlapped the lateral incisor by more than half of the root; and 91 percent normalized when the starting canine position overlapped the lateral incisor by less than half of the root.32 If no improvement in canine position occurs in a year, surgical and/or orthodontic treatment were suggested.32,33 A Cochrane review34 and a systematic review35 reported no evidence to support extraction of primary canines to facilitate eruption of ectopic permanent maxillary canines. A prospective randomized clinical trial demonstrated that extraction of primary canines is an effective measure to correct palatally displaced maxillary canines and is more successful in children with an early diagnosis.36 Consultation between the practitioner and an orthodontist may be useful in the final treatment decision.

Third molars
Panoramic or periapical radiographic examination is indicated in late adolescence to assess the presence, position, and devel-opment of third molars.7 The AAOMS recommends that a decision to remove or retain third molars should be made before the middle of the third decade.3 Evidence-based research supports the removal of third molars when pathology (e.g., cysts or tumors, caries, infection, pericoronitis, periodontal disease, detrimental changes of adjacent teeth or bone) is asso-ciated and/or the tooth is malpositioned or nonfunctional (i.e., an unopposed tooth).37-39 There is no evidence to support37-40 or refute3 the prophylactic removal of disease-free impacted third molars. Factors that increase the risk for surgical complications (e.g., coexisting systemic conditions, location of peripheral nerves, history of temporomandibular joint disease, presence of cysts or tumors)38,39 and position and inclination of the molar in question41 should be assessed. The age of the patient is only a secondary consideration.41 Referral to an oral and maxillofacial surgeon for consultationand subsequent treatment may be indicated. When a decisionis made to retain impacted third molars, they should bemonitored for change in position and/or development of pathology, which may necessitate later removal.

Supernumerary teeth
Supernumerary teeth and hyperdontia are terms to describe an excess in tooth number. Supernumerary teeth are thought to be related to disturbances in the initiation and proliferationstages of dental development.21 Although some supernumeraryteeth may be syndrome-associated (e.g., cleidocranial dysplasia)or of familial inheritance pattern, most supernumerary teeth occur as isolated events.21

Supernumerary teeth can occur in either the primary or permanent dentition.21,42,43 In 33 percent of the cases, a super-numerary tooth in the primary dentition is followed by the supernumerary tooth complement in the permanent dentition.44 Reports in incidence of supernumerary teeth can be as high as three percent, with the permanent dentition being affected five times more frequently than the primary dentition and males being affected twice as frequently as females.21

Supernumerary teeth will occur 10 times more often in the maxillary arch versus the mandibular arch.21 Approximately 90 percent of all single tooth supernumerary teeth are found in the maxillary arch, with a strong predilection to the anterior region.21,42 The maxillary anterior midline is the most common site, in which case the supernumerary tooth is known as a mesiodens; the second most common site is the maxillary molar area, with the tooth known as a paramolar.21,42 A mesiodens can be suspected if there is an asymmetric eruption pattern of the maxillary incisors, delayed eruption of the maxillary incisors with or without any over-retained primary incisors, or ectopic eruption of a maxillary incisor.45 The diagnosis of a mesiodens can be confirmed with radiographs, including occlusal, periapical, or panoramic films,46 or computed tomography.9,10 Three-dimensional information needed to determine the location of the mesiodens or impacted tooth can be obtained by taking two periapical radiographs using either two projections taken at right angles to one another or the tube shift technique (buccal object rule or Clark’s rule)47 or by cone beam computed tomography.10,12,13

Complications of supernumerary teeth can include delayed and/or lack of eruption of the permanent tooth, crowding, resorption of adjacent teeth, dentigerous cyst formation, peri-coronal space ossification, and crown resorption.42,48 Early diagnosis and appropriately timed treatment are important in the prevention and avoidance of these complications. Because only 25 percent of all mesiodens erupt spontaneously, surgical management often is necessary.44,49 A mesiodens that is conical in shape and is not inverted has a better chance for eruption than a mesiodens that is tubular in shape and is inverted.48 The treatment objective for a non-erupting permanent mesiodens is to minimize eruption problems for the permanent incisors.48 Surgical management will vary depending on the size, shape, and number of supernumeraries and the patient’s dental development.48 The treatment objective for a non-erupting primary mesiodens differs in that the removal of these teeth usually is not recommended, as the surgical intervention may disrupt or damage the underlying developing permanent teeth.50 Erupted primary tooth mesiodens typically are left toshed normally upon the eruption of the permanent dentition.50 Extraction of an unerupted primary or permanent mesiodens is recommended during the mixed dentition to allow the normal eruptive force of the permanent incisor to bring itself into the oral cavity.43 Waiting until the adjacent incisors have at least two-thirds root development will present less risk to the developing teeth but still allow spontaneous eruption of the incisors.3 In 75 percent of the cases, extraction of the mesiodens during the mixed dentition results in spontaneous eruption and alignment of the adjacent teeth.50,51 If the adjacent teeth do not erupt within six to 12 months, surgical exposure and orthodontic treatment may be necessary to aid their eruption.45,47

Frenulum attachments
Frenulum attachments and their role in oral function increasingly have become topics of interest among a variety of health care specialists. Ankyloglossia (tongue-tie) and hypertrophic/restrictive maxillary frenula have been implicated in difficulties breastfeeding53, incorrect speech articulation54,55, caries formation56,57, gingival recession58, and aberrant skeletal growth59. Studies have shown differences in treatment recommendations among pediatricians, otolaryngologists, lactation consultants, speech pathologists, surgeons, and dental specialists.54,60-66 Clear indications and timing of surgical treatment remain controversial due to lack of consensus regarding accepted anatomical and diagnostic criteria for degree of restriction and relative impact on growth, development, feeding, or oral motor function.54,60-66 When indicated, frenuloplasty/frenotomy (various methods to release the frenulum and correct the anatomic situation) or frenectomy (simple cutting of the frenulum) may be a successful approach to alleviate the problem.54,60,65,67 Each of these procedures involves surgical incision, establishing hemostasis, and wound management.68 Dressing placement or the use of antibiotics is not necessary.68 Recommendations include maintaining a soft diet, regular oral hygiene, and analgesics as needed.69 The use of electrosurgery or laser technology for frenectomies has demonstrated a shorter operative working time, a better ability to control bleeding, reduced intra- and post-operative pain and discomfort, fewer post-operative complications (e.g., swelling, infection), no need for suture removal, and increased patient acceptance.62,69,70 These procedures require extensive training as well as skillful technique and patient management.54,60,65,67,71-75

Pediatric oral pathology
A wide spectrum of oral lesions occurs in children and adolescents, including soft and hard tissue lesions of the oral maxillofacial region. There is limited information on the prevalence of oral lesions in the pediatric population. The largest epidemiologic studies in the U.S. place the prevalence rate in children at four to 10 percent with the exclusion of infants.76,77 Although the vast majority of these lesions represent mucosal conditions, developmental anomalies, and reactive or inflammatory lesions, it is imperative to be vigilant for neoplastic diseases.

Regardless of the age of the child, it is important to establish a working diagnosis for every lesion. This is based on obtaining a thorough history, assessing the risk factors and documenting the clinical signs and symptoms of the lesion. Based on these facts, a list of lesions with similar characteristics is rank ordered from most likely to least likely diagnosis. The entity that is judged to be the most likely disease becomes the working diagnosis and determines the initial management approach.

For most oral lesions, a definitive diagnosis is best made by performing a biopsy. By definition, a biopsy is the removal of a piece of tissue from a living body for diagnostic study and is considered the gold standard of diagnostic tests.78 The two most common biopsies are the incisional and excisional types. Excisional biopsies usually are performed on small lesions, less than one centimeter in size, for the total removal of the affected tissue. An incisional biopsy is performed when a malignancy is suspected, the lesion is large in size or diffuse in nature, or a multifocal distribution is present. Multiple incisional biopsies may be indicated for diffuse lesions, inorder to obtain a representative tissue sample. Fine needle aspiration, the cytobrush technique, and exfoliative cytology may assist in making a diagnosis, but they are considered adjunctive tests because they do not establish a definitive diagnosis.79,80

It is considered the standard of care that any tissuere moved from the oral and maxillofacial region be submitted for histopathologic examination.81 Exceptions to this rule include carious teeth that do not have soft tissue attached, extirpated pulpal tissue, and clinically normal tissue, such as tissue from gingival recontouring.81 Gross description of all tissue that is removed should be entered into the patient record. In general,a soft tissue biopsy should be performed when a lesion persists for greater than two weeks despite removal of the suspected causative factor or empirical drug treatment. It is also imperative to submit hard or soft tissue for evaluation to a pathologist if the differential diagnosis includes at least one significant disease or neoplasm. Histopathologic examination not only furnishes a definitive diagnosis, but it provides information about the clinical behavior and prognosis and determines the need for additional treatment or follow-up. Another valuable outcome is that it allows the clinician to deliver evidence-based medical/dental care, increasing the likelihood for a positive result.78 Furthermore, it presents important documentation about the lesion for the patient record, including the pro-cedures taken for establishing a diagnosis.78

Many oral biopsies are within the scope of practice for a pediatric dentist to perform. However, if the tissue is excised, the following steps should be taken for optimum results:78-81

  1. select the most representative lesion site and not the areathat is the most accessible.
  2. remove an adequate amount of tissue. If the biopsy is toosmall or too superficial, a diagnosis may be compromised.
  3. avoid crushing or distorting the tissue. Damage is most often observed from the forces of the tissue forceps,tearing the tissues or overheating the tissue from the use of electrosurgery or laser removal.
  4. immediately place the tissue in a fixative, which for most samples is 10 percent formalin. It is critical not to dilute the fixative with water or other liquids because tissue autolysis will render the sample nondiagnositic.
  5. proper identification of the specimen is essential. The formalin container should be labelled with the name of the patient and the location. Multiple tissue samples from different locations should not be placed in the same container, unless they are uniquely identified, such as tagged with a suture.
  6. complete the surgical pathology form including patientdemographics, the submitting dentist’s name and address,and a brief but accurate history. It is important to havelegible records so that the diagnosis is not delayed. Clinical photographs and radiographs often are very useful for correlating the microscopic findings.

Worldwide, the most frequently oral biopsied lesions in children include82:

  • mucocele;
  • fibrous lesions;
  • pyogenic granuloma;
  • dental follicle;
  • human papillomavirus (HPV) lesion;
  • chronic inflammation;
  • giant cell lesions (soft tissue);
  • hyperkeratosis;
  • peripheral ossifying fibroma;
  • gingivitis;
  • gingival hyperplasia;
  • hemangioma;
  • ulcer;
  • lymphangioma;
  • sialadentis;
  • Burkitt’s lymphoma;
  • melanotic macule;
  • pleomorphic adenoma;
  • nevus; and
  • neurofibroma.

Lesions of the newborn
Palatal cysts of the newborn include Epstein pearls and Bohn nodules. These cysts are found in up to 85 percent of new-borns.53,83-90 Epstein pearls occur in the median palatal raphe area53,83-85 as a result of trapped epithelial remnants along the line of fusion of the palatal halves.49,51 Bohn nodules are remnants of salivary gland epithelium and usually are found on the buccal and lingual aspects of the ridge, away from the midline.83,85 Gingival cysts of the newborn, or dental lamina cysts, are found on the crests of the dental ridges, and are most commonly are seen bilaterally in the region of the first primary molars.84 They result from remnants of the dental lamina. Palatal and gingival cysts of the newborn typically present as asymptomatic one to three millimeter nodules or papules. They are smooth, whitish in appearance, and filled with keratin.83,84 No treatment is required, as these cysts usually disappear during the first three months of life.53,83

Congenital epulis of the newborn
Congenital epulis of the newborn, also known as granular cell tumor or Neumann’s tumor, is a rare benign tumor seenonly in newborns.91 This lesion is typically a protuberant mass arising from the gingival mucosa. It is most often found on the anterior maxillary ridge.86,87 Patients typically present with feeding and/or respiratory problems.87 Congenital epulis has a marked predilection for females at 8:1 to 10:1.86-88 Treatment normally consists of surgical excision.86-88 The newborn usually heals well, and no future complications or treatment should be expected. Congenital epulis never recurs after excision.88 There have been reports of spontaneousregression of untreated congenital epulis.88,91

Melanotic neuroectodermal tumor of infancy
Melanotic neuroectodermal tumor of infancy is a rare occurrence that develops during the first year of life.88 This lesion may be present at birth. It occurs in the anterior maxilla 70 percent of the time.83 Less frequently, melanotic neuroectodermal tumor of infancy occurs in the skull, mandible, epididymis and testis, and brain.83,88 The classic presentation is a bluish or black rapidly expanding mass of the anterior maxilla. Radiographic findings include an ill-defined unilocular radiolucency with the displacement of tooth buds.88 There can be a floating tooth appearance.83 Surgical excision is required, and there is a 20 percent recurrence rate. Although this is a benign lesion, seven percent of reported cases have behaved malignantly resulting in metastasis and death.88

Natal and neonatal teeth
Natal and neonatal teeth can present a challenge when decidingon appropriate treatment. Natal teeth have been defined as those teeth present at birth, and neonatal teeth are those that erupt during the first 30 days of life.92,93 The occurrence of natal and neonatal teeth is rare; the incidence varies from 1:1,000 to 1:30,000.92,93 The teeth most often affected are the mandibular primary incisors.94 In most cases, anterior natal and neonatal teeth are part of the normal complement of the dentition.92,93 Natal or neonatal molars have been identified in the posterior region and may be associated with systemic conditions or syndromes (e.g., Pfieffer syndrome, histiocytosis X).94-96 Although many theories exist as to why the teeth erupt prematurely, currently no studies confirm a causal relationship with any of the proposed theories. The superficial position of the tooth germ associated with a hereditary factor seems to be the most accepted possibility.93

If the tooth is not excessively mobile or causing feeding problems, it should be preserved and maintained in a healthy condition if possible.93,95,96 Close monitoring is indicated to ensure that the tooth remains stable and is not an aspiration risk to the infant.

Riga-Fede disease is a condition caused by the natal or neonatal tooth rubbing the ventral surface of the tongue during feeding, leading to ulceration.75,92 Failure to diagnose and properly treat this lesion can result in dehydration and inadequate nutritional intake for the infant.96 Treatment should be conservative and focus on creating round, smooth incisal edges.93-96 If conservative treatment does not correct the condition, extraction is the treatment of choice.93-96

An important consideration when deciding to extract a natal or neonatal tooth is the potential for hemorrhage. Extraction is contraindicated in newborns due to risk of hemorrhage.97 Unless the child is at least 10 days old, consultation with the pediatrician regarding adequate hemostasis may be indicated prior to extraction of the tooth. In particular, infants may be at risk for vitamin K deficiency bleeding (VKDB) if they did not receive a dose of vitamin K shortly after birth (within 6 hours of birth).98 Infants can be at risk for VKDB until the age of 6 months if they do not receive a vitamin K injection.98

Lesions occurring in children and adolescents
Eruption cyst (eruption hematoma)
The eruption cyst is a soft tissue cyst that results from a separation of the dental follicle from the crown of an erupting tooth.83,99 Fluid accumulation occurs within this created follicular space.85,89,100 Eruption cysts most commonly are found in the mandibular molar region.89 Color of these lesions can range from normal to blue-black or brown, depending on the amountof blood in the cystic fluid.85,89,100 The blood is secondary to trauma. If trauma is intense, these blood-filled lesions sometimes are referred to as eruption hematomas.85,89,100 Because the tooth erupts through the lesion, no treatment is necessary.85,89,100 If the cyst does not rupture spontaneously or the lesion becomesinfected, the roof of the cyst may be opened surgically.85,89

Mucocele
The mucocele is a common lesion in children and adolescents resulting from the rupture of a minor salivary gland excretory duct, with subsequent leakage of mucin into the adjacent connective tissues that later may be surrounded in a fibrous capsule.83,85,99-101 Most mucoceles are well-circumscribed bluish translucent fluctuant swellings that are firm to palpation, although deeper and long-standing lesions may range from normal in color to having a whitish keratinized surface.85,99,100 Mucoceles most frequently are observed on the lower lip, usually lateral to the midline.88 Mucoceles also can be found on the buccal mucosa, ventral surface of the tongue, retromolar region, and floor of the mouth (ranula).99-101 Superficial mucoceles and some other mucoceles are short-lived lesions that burst spontaneously, leaving shallow ulcers that heal within a few days.85,100 Local mechanical trauma to the minor salivary gland is often the cause of rupture.50,53,86,87 Many lesions, however, require treatment to minimize the risk of recurrence.

Squamous papilloma
Squamous papilloma is a benign human papillomavirus-induced lesion caused by HPV types 1 and 6.83 Squamous papilloma presents as soft painless, pink to white, pedunculated (stalked) lesions. The surface may display multiple fingerlike projections and may have a cauliflower like appearance.83,102,103 These lesions can occur anywhere in the oral cavity, but the tongue, lips and soft palate are the most common sites.103 Squamous papilloma generally occurs in adulthood, but 20 percent have been noted prior to age 20.91 Although they are viral in origin, the infectivity is low.83,102 Squamous papilloma do not have malignant potential.103 Excision is the treatment of choice, and recurrence is uncommon.83,103

Verruca vulgaris
Verruca vulgaris, or the common wart, is an HPV type 2 induced lesion that is generally found on the skin of the hand.102 Finger or thumb sucking can cause auto inoculation resulting in the development of intraoral lesions.102 Verruca vulgaris is similar in appearance to the squamous papilloma. This lesion can be sessile (broad based) or pedunculated and can display a rough bumpy surface.103 Verruca vulgaris can be found on the lips, tip of tongue, and labial mucosa.83 There is no risk of malignant transformation.83 Excision of the entire lesion is recommended and recurrence is uncommon.103

Irritation fibroma
The irritation fibroma is a reactive lesion occurring as a response to chronic trauma of the mucosa. The irritation fibroma presents as a firm nontender pink nodule and is composed of fibrous connective tissue.103 The lesion does not exceed two millimeters in diameter.104 The irritation fibroma can be found on buccal and labial mucosa, the tongue, and attached gingiva. Excisional biopsy is recommended. These can reoccur if the source of the irritation is not removed.103,104

Recurrent aphthous stomatitis
Recurrent aphthous stomatitis is one of the most common orallesions, occurring in 20-30 percent of children.83 Recurrentaphthous stomatitis is caused by a T-cell mediated immunologic reaction to a triggering agent.105 Three variants of aphthous ulcers are recognized:

  1. Minor aphthous ulcerations. Minor aphthous ulcerationsare the most common form, accounting for almost 80 percent of aphthous ulcers.105 They have a yellowish-white membrane and are surrounded by an erythematous halo. These ulcers are 3-10 millimeters in diameter. Minor aphthous ulcers occur on nonkeratinized mucosa.105 One to five ulcers often present during asingle outbreak, and they heal in seven to 14 days without scarring.106
  2. Major aphthous ulcerations. Major aphthous ulcerationsare larger and deeper and have a longer duration than the minor aphthous ulcer. These occur most commonly on the labial mucosa, soft palate, and the tonsillar fauces.105 The major aphthous ulcer can take up to six weeks to heal with potential scarring.105
  3. Herpetiform aphthous ulcerations. Herpetiform aphthousulcerations can occur on any intraoral site.106 As many as 100 small ulcerations can be present in a single occurrence.105 The ulcerations may resemble primary herpeticstomatitis. These ulcerations may coalesce to form alarger ulceration.105 Herpetiform aphthous ulcers heal within seven to ten days, but recurrences are frequent.106

Aphthous ulcers may be treated with topical anesthetics for relief of pain. Topical and systemic steroids, chlorhexidine rinses, and laser treatments can be used to manage these lesions.83

Localized juvenile spongiotic gingival hyperplasia
Localized juvenile spongiotic gingival hyperplasia was originally known as puberty gingivitis.107 It is thought to be an isolated patch of sulcular or junctional epithelium that is subjected to local factors such as mouth breathing or orthodontic appliances.83 The lesion presents as an isolated bright red velvety patch or enlargement of anterior facial gingiva. This lesion bleeds easily and does not respond to oral hygiene measures. There is a female predilection.83 Most lesions occur under the age of 20, with the median age at diagnosis being 12 years.107 Excision is the treatment of choice, and up to 16 percent will recur.83

Pyogenic granuloma
Pyogenic granuloma is a painless smooth or lobulated vascular lesion. The pyogenic granuloma is usually ulcerated and bleeds easily.83,107 This lesion can occur at any age but is most common in children and young adults. There is a female predilection,83 and the pyogenic granuloma can occur in up to five percent of pregnancies.108 The pyogenic granuloma is thought to be an exuberant tissue response to a local irritant or trauma.108 Pyogenicgranuloma most commonly occurs on maxillary anterior attached gingiva (75 percent) but can be found on tongue, lower lip, or buccal mucosa.108 Treatment is complete excision with the removal of the source of irritant.83,108 This lesion can recur in 3-15 percent of cases.83

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