Abstract:
The lesions presenting in the oral cavity of neonates are considerably significant in pediatric dentistry. Although these lesions pertain to the oral cavity however may indicate an underlying systemic condition. They may be clinically misdiagnosed or left untreated owing to lack of parental education, awareness and resources. Since majority is asymptomatic and benign they resolve without any intervention. Hence their management should encompass a thorough clinical examination and knowledge of the various lesions is essential for precise diagnosis, prognosis, treatment outcomes and parental counseling. This article is an overview of recognition and management of the oral lesions prevalent in neonates.
Introduction:
Neonates displaying intraoral lesions decree detailed assessment, diagnosis, management and parental counseling in conjunction with a reassurance. A detailed assessment and significant knowledge can aid timely diagnosis of usual as well as rare presentations affecting the oral tissues in neonates.
EPSTEIN PEARLS:
This non-odontogenic cyst results from epithelial remnants entombed along the fusion line of the palatal halves.1, 2They appear smooth and whitish and are keratin filled.3, 4 Since they disappear during the first three months of life usually treatment is not required.3, 5 It is found in 75 to 80% of newborns.6-14
GINGIVAL/DENTAL LAMINA CYST OF NEONATES:
Dental lamina cysts are consequent to remnants of the dental lamina. They are small, multiple, nodular, and white to creamish lesions seen bilaterally in the region of the first primary molars on the crests of the dental ridges. Histopathology reveals they are keratin-filled true cysts. Since they are self-resolving treatment is not indicated.15, 16
BOHN’S NODULES:
Bohn’s nodules are remnants of salivary gland epithelium. These asymptomatic, smooth, whitish nodules or papules ranging from 1-3 millimeter are filled with keratin. They are found on buccal and lingual aspects of the ridge away from the midline and do not require any treatment as they usually disappear during the first three months of life.3, 6, 15, 16
CONGENITAL EPULIS OF THE NEWBORN:
This is a rare benign tumor seen only in newborns and is also known as granular cell tumor or Neumann’s tumor. It arises from the gingival mucosa as a protuberant mass on the anterior maxillary ridge. Patients typically present with feeding and/or respiratory problems.9,10, 11, 12 A predilection for females is at 8:1 to 10:1. Surgical excision is the treatment of choice however since a newborn heals well future complications or treatment are not probable. Larger lesions may lead to mechanical obstruction in respiration and feeding. Diagnosis is confirmed by site of origin, USG, CT/MRI and histopathology showing scattered odontogenic epithelium, absence of interstitial cells, angulate bodies and vessels.17, 18
ERUPTION CYST:
This soft tissue cyst arises when the dental follicle separates from the crown of an erupting tooth.3, 19 and accumulation of fluid occurs within this follicular space.5, 12, 13 Eruption cysts are found in the mandibular molar region.11 Their color may range from normal to blue-black or brown, depending on the amount of blood in the cystic fluid subsequent to trauma (hematomas). Treatment is not required since the tooth erupts through the lesion. Surgical opening of the roof of the cyst may be necessitated if it does not rupture spontaneously or the lesion becomes infected.20, 21, 22
EPIDERMOID AND DERMOID CYSTS:
This asymptomatic, slow growing cyst in the floor of the mouth and the submental region is diagnosed when enlarged. It poses respiratory distress and feeding difficulty in neonates. Diagnosis is based on magnetic resonance imaging (MRI)/computed tomography (CT), prenatal/natal ultrasonography (USG), FNAB, and histopathology where the epidermoid cyst is lined by epidermis and a dermoid cyst is lined with adnexa glands in addition. Surgical enucleation is the treatment of choice and it rarely recurs.23, 24
MUCOCELE:
They arise on the lower lip lateral to the midline; secondary to the rupture of the excretory duct of the minor salivary gland and mucin leakage into the surrounding connective tissues which may later be surrounded in a fibrous capsule. 13, 19, 25This bluish, well-circumscribed, translucent, fluctuant swelling is firm to palpation. The long-standing and deeper lesions may range from normal to whitish color and a keratinized surface. 7, 13, 19, 25 Mucoceles may also appear on the retromolar region buccal mucosa, ventral surface of the tongue and floor of the mouth (ranula).13, 19, 25 Superficial mucocele resolves on bursting spontaneously with a shallow ulcer which resolves within a few days.13, 19, 25 usually due to mechanical trauma to the minor salivary gland. 10, 26 Treatment minimizes the risk of recurrence.13, 19
RIGA-FEDE DISEASE:
This condition is caused by the rubbing of natal or neonatal tooth along the ventral surface of the tongue during feeding; leading to ulceration.27, 28 The other sites may include lip, gingiva, vestibular mucosa, palate and floor of the mouth. Inability to diagnose and treat this lesion may result in dehydration and inadequate nutritional intake.29 Treatment should be conservative and focus on creating round, smooth incisal edges. 30-33If conservative treatment does not correct the condition, extraction is the treatment of choice.30-33 Diagnosis is confirmed by clinical examination and histopathology to rule out other possible cause of ulcerations caused by bacterial or fungal infections, immunologic diseases, and neoplasia.34-36
NEONATAL OSTEOMYELITIS OF MAXILLA:
This rare infection of the neonatal period has a high mortality rate. The attributable risk factors include catheterization, iatrogenic, parenteral nutrition status, prolonged hospitalization, ventilatory support, and nosocomial infections.36 The organisms primarily implicated include Staphylococcus aureus, group B Streptococcus (Streptococcus agalactiae)and Gram-negative organisms (Escherichia coli and Klebsiella pneumonia).36, 37 The initial presentation includes an acute fever followed by redness and edema of cheek, swollen eyelids with conjunctivitis and unilateral nasal discharge.38 In children chronic osteomyelitis is manifested very seldom. Diagnosis is ascertained by positive blood cultures and tests (erythrocyte sedimentation rate, C-reactive protein, leukocyte count).38 It is treated by antimicrobial drugs with or without surgery. Morbidity is high and prognosis is poor.37, 39
NEONATAL CANDIDIASIS:
The second most common cause of mortality in preterm newborns is disseminated or invasive candidiasis is. Transmission may be vertical or via external contamination. The most common opportunistic Candida species include Candida albicans (75%) Candida krusei , glabrata, tropicalis and parapsilosis. Risk factors comprise prolonged hospital stay, immature immune system and prolonged catheterization. It manifests in the oral mucosa as white plaques consisting of hyphae, epithelial cells, and necrotic tissues. The systemic features include endolphthalmitis, meningitis, urinary tract infections and cardiovascular manifestations.40 Diagnosis is confirmed by blood culture, urine and CSF. Treatment depends on preventive measures.41
NEONATAL HERPES SIMPLEX VIRUS INFECTION:
Herpes simplex virus (HSV1) causes orolabial lesions whereas HSV1 and HSV2 cause genital lesions. It is transmitted during parturition and is assisted by maternal infection (primary or recurrent) maternal antibody, integrity of mucocutaneous barriers, duration of rupture of membranes and mode of delivery (cesarean or normal).42 The incubation period ranges from 4-21 days postdelivery and the symptoms become apparent between 6- 21 days. It manifests clinically as vesicular eruptions in the mouth, face, scalp, palms of the hand and soles of the feet. Vesicular eruptions may be single unit or in clusters; measure 1- 3 mm in diameter and ulcerate after a few days. Other systemic symptoms include hepatitis, pneumonitis, seizures and disseminated intravascular coagulation.43 Diagnosis includeviral culture, serology and a polymerase chain reaction amplification analysis of cerebrospinal fluid (CSF). The antiviral therapy with acyclovir is the treatment of choice.42
NEONATAL PEMPHIGUS VULGARIS:
This rare autoimmune, vesiculobullous disease stems from a transplacental transmission of maternal immunoglobulin G autoantibodies which act counter transmembrane glycoprotein desmoglein three. The clinical features include multiple mucosal, cutaneous or mucocutaneous ulcerations after birth. Histopathology and immunofluorescence confirm the diagnosis and symptoms resolve in 2 to 3 weeks.44
HEMANGIOMA:
This most common manifestation in a child is benign vascular neoplasm. It emerges as a macule at birth but may appear a few weeks after and regresses into spotted pigments. The course follows a rapid proliferating phase (0–1 yr), an involuting phase (1–5 yr) and finally an involuted phase (5–10 yr) Prevalence is 2- 3& in neonates and 22-30% in underweight preterm newborns. It involves areas such as 60% neck and head, 25% trunk , 15% extremities, lips, tongue, buccal mucosa, palate and uvula.3 Predisposing factors include infantile age, infant birth weight , childbearing age and gestational hypertension. Kasabach–Merritt syndrome has been associated with extensive hemangiomas in infants.45. Diagnosis is confirmed by investigations including history, FNAC, MRI, and/color Doppler USG, histopathology, and immunohistochemistry ruling out other vascular malformations.46 Treatment is based on stages of the lesion and includes drugs (α-interferon, propranolol, corticosteroids), surgical corrections and lasers (CO2, flash lamp pulsed dye, diode ). Some cases may resolve completely however others may show permanent skin changes (hypopigmentation, telangiectases, anetoderma stippled scarring, fibro-fatty residues) without any deformity.47
MELANOTIC NEUROECTODERMAL TUMOR OF INFANCY:
This rare pigmented benign neoplasm is apparent in the first6 months with a male predilection. It arises from the neural crest cells and may be located on the tongue, buccal mucosa, palate or floor of the mouth. It may be present in the craniofacial region (92.8%), brain (5.7%) skull (15.7%), maxilla (61.4%), mandible (6.4%) and the genitals. It is a painless, expansile, nonulcerative rapidly growing, pigmented, lesion with a locally aggressive behavior. Diagnosis is based on clinical assessment, histopathology and CT/MRI. It is a biphasic tumor microscopically comprising of melanocytic and neuroblast-like round cells. Differential diagnosis includes desmoplastic small round cell tumor, Ewing’s sarcoma, neuroblastoma rhabdomyosarcoma, peripheral neuroepithelioma, peripheral primitive neuroectodermal tumor, malignant melanoma and neuroblastoma. Treatment includes chemotherapy and radiotherapy either alone or in combination and surgical excision. It shows high recurrence, metastases and malignant transformation rate. 48, 49
CONGENITAL HEART DISEASE:
Congenital heart disease makes up the largest group of paediatric cardiovascular diseases. Risk factors include diabetes, maternal rubella, alcoholism, drugs (phenytoin sodium(Dilantin), thalidomide, warfarin sodium(Coumadin). They are classified into cyanotic (tetralogy of fallot, transposition of great vessels, Tricuspid artresia, Pulmonary Artresia and Eisenmengers syndrome) and acynaotic ( Atrial septal defect, Ventricular septal defect, Aortic stenosis, Pulmonary stenosis and coarctation or localized constriction of the aorta). Other cardiomyopathies include cardiac arrythomias, infective endocarditis, rheumatic heart disease, myocardial and pericardial disease. Infants with acyanotic conditions present with feeding difficulties, breathlessness and failure to thrive. Heart in children with congenital heart disease and rheumatic heart disease is prone to bacterial and fungal infections (infectious endocarditis) leading to deposition of blood cells and organisms on the lining of the heart. Hence invasive treatment for such children requires prophylactic antibiotic and 0.2% chlorhexidine gluconate mouthwash. Information of medication (anticoagulants, antihypertensives and antiarrythmics ) is advised. Use of devices such as electrosurgery, uktrasonic cleaning and electric pulp teters should be avoided.50
Conclusion:
Hence management of oral pathology in neonates should encompass a thorough knowledge of various oral lesions and the ability to clinical and radiographic examination inclusive of any added investigation for precise diagnosis, prognosis, treatment outcomes and parental counseling.