BEST PRACTICES: ORAL SURGERY AND ORAL PATHOLOGY

Management Considerations for Pediatric Oral

Surgery and Oral Pathology
Latest Revision How to Cite: American Academy of Pediatric Dentistry. Management
2020 considerations for pediatric oral surgery and oral pathology. The
Reference Manual of Pediatric Dentistry. Chicago, Ill.: American
Academy of Pediatric Dentistry; 2020:433-42.

Purpose Medical evaluation

The American Academy of Pediatric Dentistry (AAPD) Important considerations in treating a pediatric patient include
intends this document to define, describe clinical presentation, obtaining a thorough medical history, obtaining appropriate
and set forth general criteria and therapeutic goals for common medical and dental consultations, anticipating and preventing
pediatric oral surgery procedures and oral pathological emergency situations, and being prepared to treat emergency
conditions. situations.5

Methods Dental evaluation

Recommendations on management considerations for pediatric It is important to perform a thorough clinical and radiographic
oral surgery and oral pathology were developed by the preoperative evaluation of the dentition as well as a clinical
Council on Clinical Affairs and adopted in 2005.1 This examination of extraoral and intraoral soft tissues.5-7 Radio-
document is a revision of the previous version, last revised in graphs can include intraoral films and extraoral imaging if the
2015.2 It is based on a review of the current dental and med- area of interest extends beyond the dentoalveolar complex.
ical literature related to pediatric oral surgery, including a Surgery involving the maxilla and mandible of young patients
®
search of the PubMed /MEDLINE database using the terms:
pediatric AND oral surgery, oral pathology, extraction,
is complicated by the presence of developing tooth follicles.
Knowledge of the anatomy of a child’s developing maxilla and
odontogenic infections, impacted canines, third molars, mandible and the avoidance of injury to the dental follicles
supernumerary teeth, mesiodens, mucocele, eruption cyst, can prevent complications.8 To minimize the negative effects
eruption hematoma, gingival keratin cysts, Epstein pearls, of surgery on the developing dentition, careful planning
Bohn’s nodules, congenital epulis of newborn, dental lamina using radiographs, tomography,9 cone beam computed tomo-
cysts, natal teeth, neonatal teeth, squamous papilloma, verruca graphy,10 and/or three-dimensional imaging techniques11 is
vulgaris, irritation fibroma, recurrent aphthous stomatitis, necessary to provide valuable information to assess the presence,
localized juvenile spongiotic gingival hyperplasia, and pyogenic absence, location, and/or quality of individual crown and root
granuloma; fields: all; limits: within the last 10 years, humans, development.8,12,13
English, clinical trials. Papers for review were chosen from
the list of articles matching these criteria and from references Growth and development
with selected articles. When data did not appear sufficient The potential for adverse effects on growth from injuries and/
or were inconclusive, recommendations were based upon or surgery in the oral and maxillofacial region markedly
expert and/or consensus opinion by experience researchers increases the potential for risks and complications in the
and clinicians. In addition, the manual Parameters of Care: pediatric population. Traumatic injuries involving the maxil-
Clinical Practice Guidelines for Oral and Maxillofacial Surgery,3 lofacial region can adversely affect growth, development, and
developed by the American Association of Oral and Maxil- function. Therefore, a thorough evaluation of the growing
lofacial Surgeons (AAOMS), was consulted. patient must be done before surgical interventions are per-
formed to minimize the risk of damage to the growing facial
General considerations complex.14
Surgery performed on pediatric patients involves special
considerations unique to this population. Several critical issues
deserve to be addressed.
ABBREVIATION
Preoperative considerations AAOMS: American Association of Oral and Maxillofacial Surgeons.
Informed consent AAPD: American Academy of Pediatric Dentistry. HPV: Human
Before any surgical procedure, informed consent must be papilloma virus. VKDB: Vitamin K deficiency bleeding.
obtained from the parent or legal guardian. For more infor-
mation, refer to AAPD's Informed Consent.4

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Behavioral evaluation Ludwig’s angina.17,19 These conditions can be life threatening

Behavioral guidance of children in the operative and periopera- and may require immediate hospitalization with intravenous
tive periods presents a special challenge. Many children benefit antibiotics, incision and drainage, and referral/consultation
from modalities beyond local anesthesia and nitrous oxide/ with an oral and maxillofacial surgeon.17,19
oxygen inhalation to minimize their anxiety.4,14 Management
of children under sedation or general anesthesia requires Extraction of erupted teeth
extensive training and expertise.15,16 Special attention should be Maxillary and mandibular anterior teeth
given to the assessment of the social, emotional, and psycho- Most primary and permanent maxillary and mandibular central
logical status and cognitive level of the pediatric patient prior incisors, lateral incisors, and canines have conical single roots.
to surgery.14 Children have many unvoiced fears concerning In most cases, extraction of anterior teeth is accomplished
the surgical experience, and their psychological management with a rotational movement due to their single root
requires that the dentist be cognizant of their emotional anatomy.5 However, there have been reported cases of ac-
status. Answering questions concerning the surgery is impor- cessory roots observed in primary canines.21,22 Radiographic
tant and should be done in the presence of the parent. examination is helpful to identify differences in root anatomy
prior to extraction.21 Care should be taken to avoid placing
Peri- and post-operative considerations any force on adjacent teeth that could become luxated or
Metabolic management of children following surgery fre- dislodged easily due to their root anatomy.
quently is more complex than that of adults. Special consider-
ation should be given to caloric intake, fluid and electrolyte Maxillary and mandibular molars
management, and blood replacement. Comprehensive Primary molars have roots that are smaller in diameter and
management of the pediatric patient following extensive oral more divergent than permanent molars. Root fracture in
and maxillofacial surgery usually is best accomplished in a primary molars is not uncommon due to these characteristics
facility that has expertise and experience in the management as well as the potential weakening of the roots caused by the
of young patients (i.e., a children’s hospital).14 eruption of their permanent successors.5 Prior to extraction,
the relationship of the primary roots to the developing suc-
Recommendations cedaneous tooth should be assessed. To avoid inadvertent
Odontogenic infections extraction or dislocation of or trauma to the permanent
In children, odontogenic infections may involve more than successor, pressure should be avoided in the furcation area or
one tooth and usually are due to caries lesions, periodontal the tooth may need to be sectioned to protect the developing
problems, pathology (e.g., dens invaginatus), or a history of permanent tooth.
trauma. 17-18 Untreated odontogenic infections can lead to Molar extractions are accomplished by using slow conti-
pain, difficulty eating or drinking, abscess, cellulitis, septicemia, nuous palatal/lingual and buccal force allowing for the
airway compromise, and life-threatening infections.19 Facial expansion of the alveolar bone to accommodate the divergent
cellulitis results from unresolved abscess that has spread to roots and reduce the risk of root fracture.5 When extracting
cutaneous or subcutaneous soft tissue planes in the head and mandibular molars, care should be taken to support the
neck region.19 In these children, dehydration is a significant mandible to protect the temporomandibular joints from
consideration; prompt treatment of the source of infection is injury.5
imperative.
With infections of the upper portion of the face, patients Fractured primary tooth roots
usually complain of facial pain, fever, and malaise.20 Care must The presence of a root tip should not be regarded as a positive
be taken to rule out sinusitis or non-odontogenic infections, indication for its removal. The dilemma to consider when
as symptoms may mimic an odontogenic infection. Occasionally managing a retained primary tooth root is that removing the
in upper face infections, it may be difficult to find the true root tip may cause damage to the succedaneous tooth, while
cause.14 Infections of the lower face usually involve pain, swelling, leaving the root tip may increase the chance for postopera-
and trismus.3,17 They frequently are associated with teeth, skin, tive infection and delay eruption of the permanent successor.5
local lymph nodes, and salivary glands.17 Most odontogenic Radiographs can assist in the decision process. Expert opinion
infections occur in the upper face; however, infections in the suggests that if the fractured root tip can be removed easily,
mandibular region are more frequent in older children.20 it should be removed.5 If the root tip is very small, located
Most odontogenic infections can be managed with pulp deep in the socket, situated in close proximity to the permanent
therapy, extraction, or incision and drainage. 5 Infections of successor, or unable to be retrieved after several attempts, it is
odontogenic origin with systemic manifestations (e.g., elevated best left to be resorbed.5 The parent must be informed and a
temperature [102 to 104 degrees Fahrenheit], facial cellulitis, complete record of the discussion must be documented. The
difficulty in breathing or swallowing, fatigue, nausea) require patient should be monitored at appropriate intervals to eval-
antibiotic therapy.19 Severe but rare complications of odonto- uate for potential adverse effects.
genic infections include cavernous sinus thrombosis and

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Management of unerupted and impacted teeth supports the removal of third molars when pathology (e.g.,
There is a wide clinical spectrum of disorders of eruption in cysts or tumors, caries, infection, pericoronitis, periodontal
both primary and permanent teeth in children. These may disease, detrimental changes of adjacent teeth or bone) is asso-
be syndromic or non-syndromic and include ankyloses,27-28 ciated and/or the tooth is malpositioned or nonfunctional
secondary retention,28 tooth impaction, or primary failure of (i.e., an unopposed tooth).37-39 There is no evidence to
eruption29. Clinically, it may be difficult to differentiate between support37-40 or refute3 the prophylactic removal of disease-free
the various disruptions; however, there have been many re- impacted third molars. Factors that increase the risk for
ports30,31 to assist the clinician in making a diagnosis. There is surgical complications (e.g., coexisting systemic conditions,
increasing evidence that there is a genetic etiology for some of location of peripheral nerves, history of temporomandibular
these eruption disruptions which may help in a definitive joint disease, presence of cysts or tumors)38,39 and position
diagnosis.29 Management of unerupted teeth will depend on and inclination of the molar in question41 should be assessed.
whether the tooth affected is likely to respond to orthodontic The age of the patient is only a secondary consideration.41
forces. If not, surgical extraction is the preferred treatment Referral to an oral and maxillofacial surgeon for consultation
option.29 and subsequent treatment may be indicated. When a decision
is made to retain impacted third molars, they should be
Impacted canines monitored for change in position and/or development of
Tooth impaction may occur due to a mechanical obstruction. pathology, which may necessitate later removal.
Permanent maxillary canines are second to third molars in
frequency of impaction.32 Early detection of an ectopically Supernumerary teeth
erupting canine through visual inspection, palpation, and Supernumerary teeth and hyperdontia are terms to describe
radiographic examination is important to maximize success of an excess in tooth number. Supernumerary teeth are thought
an intervention.33 Routine evaluation of patients in mid-mixed to be related to disturbances in the initiation and proliferation
dentition should involve identifying signs such as lack of ca- stages of dental development.21 Although some supernumerary
nine bulges and asymmetry in pattern of exfoliation. Abnormal teeth may be syndrome-associated (e.g., cleidocranial dysplasia)
angulation or ectopic eruption of developing permanent cus- or of familial inheritance pattern, most supernumerary teeth
pids can be assessed radiographically.33 When the cusp tip of occur as isolated events.21
the permanent canine is just mesial to or overlaying the distal Supernumerary teeth can occur in either the primary or
half of the long axis of the root of the permanent lateral incisor, permanent dentition.21,42,43 In 33 percent of the cases, a super-
canine palatal impaction usually occurs.32 Extraction of the numerary tooth in the primary dentition is followed by the
primary canines is the treatment of choice to correct palatally supernumerary tooth complement in the permanent denti-
displaced canines or to prevent resorption of adjacent teeth.32 tion.44 Reports in incidence of supernumerary teeth can be
One study showed that 78 percent of ectopically erupting as high as three percent, with the permanent dentition being
permanent canines normalized within 12 months after removal affected five times more frequently than the primary dentition
of the primary canines; 64 percent normalized when the and males being affected twice as frequently as females.21
starting canine position overlapped the lateral incisor by more Supernumerary teeth will occur 10 times more often in
than half of the root; and 91 percent normalized when the the maxillary arch versus the mandibular arch.21 Approxi-
starting canine position overlapped the lateral incisor by less mately 90 percent of all single tooth supernumerary teeth are
than half of the root.32 If no improvement in canine position found in the maxillary arch, with a strong predilection to the
occurs in a year, surgical and/or orthodontic treatment were anterior region.21,42 The maxillary anterior midline is the most
suggested.32,33 A Cochrane review34 and a systematic review35 common site, in which case the supernumerary tooth is known
reported no evidence to support extraction of primary canines as a mesiodens; the second most common site is the maxillary
to facilitate eruption of ectopic permanent maxillary canines. molar area, with the tooth known as a paramolar.21,42 A me-
A prospective randomized clinical trial demonstrated that siodens can be suspected if there is an asymmetric eruption
extraction of primary canines is an effective measure to correct pattern of the maxillary incisors, delayed eruption of the
palatally displaced maxillary canines and is more successful in maxillary incisors with or without any over-retained primary
children with an early diagnosis.36 Consultation between the incisors, or ectopic eruption of a maxillary incisor. 45 The
practitioner and an orthodontist may be useful in the final diagnosis of a mesiodens can be confirmed with radiographs,
treatment decision. including occlusal, periapical, or panoramic films,46 or com-
puted tomography.9,10 Three-dimensional information needed
Third molars to determine the location of the mesiodens or impacted tooth
Panoramic or periapical radiographic examination is indicated can be obtained by taking two periapical radiographs using
in late adolescence to assess the presence, position, and devel- either two projections taken at right angles to one another or
opment of third molars.7 The AAOMS recommends that a the tube shift technique (buccal object rule or Clark’s rule)47
decision to remove or retain third molars should be made or by cone beam computed tomography.10,12,13
before the middle of the third decade.3 Evidence-based research

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Complications of supernumerary teeth can include delayed a soft diet, regular oral hygiene, and analgesics as needed.69 The
and/or lack of eruption of the permanent tooth, crowding, use of electrosurgery or laser technology for frenectomies has
resorption of adjacent teeth, dentigerous cyst formation, peri- demonstrated a shorter operative working time, a better ability
coronal space ossification, and crown resorption. 42,48 Early to control bleeding, reduced intra- and post-operative pain and
diagnosis and appropriately timed treatment are important in discomfort, fewer post-operative complications (e.g., swelling,
the prevention and avoidance of these complications. Because infection), no need for suture removal, and increased patient
only 25 percent of all mesiodens erupt spontaneously, surgical acceptance.62,69,70 These procedures require extensive training as
management often is necessary.44,49 A mesiodens that is conical well as skillful technique and patient management.54,60,65,67,71-75
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 Pediatric oral pathology
treatment objective for a non-erupting permanent mesiodens A wide spectrum of oral lesions occurs in children and ad-
is to minimize eruption problems for the permanent incisors.48 olescents, including soft and hard tissue lesions of the oral
Surgical management will vary depending on the size, shape, maxillofacial region. There is limited information on the
and number of supernumeraries and the patient’s dental prevalence of oral lesions in the pediatric population. The
development.48 The treatment objective for a non-erupting largest epidemiologic studies in the U.S. place the prevalence
primary mesiodens differs in that the removal of these teeth rate in children at four to 10 percent with the exclusion of
usually is not recommended, as the surgical intervention may infants.76,77 Although the vast majority of these lesions rep-
disrupt or damage the underlying developing permanent resent mucosal conditions, developmental anomalies, and
teeth.50 Erupted primary tooth mesiodens typically are left to reactive or inflammatory lesions, it is imperative to be vigilant
shed normally upon the eruption of the permanent dentition.50 for neoplastic diseases.
Extraction of an unerupted primary or permanent mesio- Regardless of the age of the child, it is important to estab-
dens is recommended during the mixed dentition to allow the lish a working diagnosis for every lesion. This is based on
normal eruptive force of the permanent incisor to bring itself obtaining a thorough history, assessing the risk factors and
into the oral cavity.43 Waiting until the adjacent incisors have documenting the clinical signs and symptoms of the lesion.
at least two-thirds root development will present less risk to Based on these facts, a list of lesions with similar characteris-
the developing teeth but still allow spontaneous eruption of tics is rank ordered from most likely to least likely diagnosis.
the incisors. 3 In 75 percent of the cases, extraction of the The entity that is judged to be the most likely disease becomes
mesiodens during the mixed dentition results in spontaneous the working diagnosis and determines the initial management
eruption and alignment of the adjacent teeth.50,51 If the adja- approach.
cent teeth do not erupt within six to 12 months, surgical For most oral lesions, a definitive diagnosis is best made by
exposure and orthodontic treatment may be necessary to aid performing a biopsy. By definition, a biopsy is the removal
their eruption.45,47 of a piece of tissue from a living body for diagnostic study
and is considered the gold standard of diagnostic tests.78 The
Frenulum attachments two most common biopsies are the incisional and excisional
Frenulum attachments and their role in oral function increas- types. Excisional biopsies usually are performed on small
ingly have become topics of interest among a variety of health lesions, less than one centimeter in size, for the total removal
care specialists. Ankyloglossia (tongue-tie) and hypertrophic/ of the affected tissue. An incisional biopsy is performed when
restrictive maxillary frenula have been implicated in difficulties a malignancy is suspected, the lesion is large in size or diffuse
breastfeeding53, incorrect speech articulation54,55, caries forma- in nature, or a multifocal distribution is present. Multiple
tion56,57, gingival recession58, and aberrant skeletal growth59. incisional biopsies may be indicated for diffuse lesions, in
Studies have shown differences in treatment recommendations order to obtain a representative tissue sample. Fine needle
among pediatricians, otolaryngologists, lactation consultants, aspiration, the cytobrush technique, and exfoliative cytology
speech pathologists, surgeons, and dental specialists.54,60-66 Clear may assist in making a diagnosis, but they are considered
indications and timing of surgical treatment remain controver- adjunctive tests because they do not establish a definitive
sial due to lack of consensus regarding accepted anatomical and diagnosis.79,80
diagnostic criteria for degree of restriction and relative impact It is considered the standard of care that any tissue
on growth, development, feeding, or oral motor function.54,60-66 removed from the oral and maxillofacial region be submitted
When indicated, frenuloplasty/frenotomy (various methods for histopathologic examination.81 Exceptions to this rule in-
to release the frenulum and correct the anatomic situation) or clude carious teeth that do not have soft tissue attached, extirpated
frenectomy (simple cutting of the frenulum) may be a successful pulpal tissue, and clinically normal tissue, such as tissue from
approach to alleviate the problem.54,60,65,67 Each of these proce- gingival recontouring.81 Gross description of all tissue that is
dures involves surgical incision, establishing hemostasis, and removed should be entered into the patient record. In general,
wound management.68 Dressing placement or the use of antibi- a soft tissue biopsy should be performed when a lesion persists
otics is not necessary.68 Recommendations include maintaining for greater than two weeks despite removal of the suspected

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causative factor or empirical drug treatment. It is also imper- • lymphangioma;

ative to submit hard or soft tissue for evaluation to a pathologist • sialadentis;
if the differential diagnosis includes at least one significant • Burkitt’s lymphoma;
disease or neoplasm. Histopathologic examination not only • melanotic macule;
furnishes a definitive diagnosis, but it provides information • pleomorphic adenoma;
about the clinical behavior and prognosis and determines the • nevus; and
need for additional treatment or follow-up. Another valuable • neurofibroma.
outcome is that it allows the clinician to deliver evidence-based
medical/dental care, increasing the likelihood for a positive Lesions of the newborn
result.78 Furthermore, it presents important documentation Palatal cysts of the newborn include Epstein pearls and Bohn
about the lesion for the patient record, including the pro- nodules. These cysts are found in up to 85 percent of new-
cedures taken for establishing a diagnosis.78 borns.53,83-90 Epstein pearls occur in the median palatal raphe
Many oral biopsies are within the scope of practice for a area53,83-85 as a result of trapped epithelial remnants along the
pediatric dentist to perform. However, if the tissue is excised, line of fusion of the palatal halves. 49,51 Bohn nodules are
the following steps should be taken for optimum results:78-81 remnants of salivary gland epithelium and usually are found
1. select the most representative lesion site and not the area on the buccal and lingual aspects of the ridge, away from the
that is the most accessible. midline.83,85 Gingival cysts of the newborn, or dental lamina
2. remove an adequate amount of tissue. If the biopsy is too cysts, are found on the crests of the dental ridges, and are most
small or too superficial, a diagnosis may be compromised. commonly are seen bilaterally in the region of the first pri-
3. avoid crushing or distorting the tissue. Damage is most mary molars.84 They result from remnants of the dental lamina.
often observed from the forces of the tissue forceps, Palatal and gingival cysts of the newborn typically present as
tearing the tissues or overheating the tissue from the use asymptomatic one to three millimeter nodules or papules.
of electrosurgery or laser removal. They are smooth, whitish in appearance, and filled with
4. immediately place the tissue in a fixative, which for most keratin.83,84 No treatment is required, as these cysts usually
samples is 10 percent formalin. It is critical not to dilute disappear during the first three months of life.53,83
the fixative with water or other liquids because tissue
autolysis will render the sample nondiagnositic. Congenital epulis of the newborn
5. proper identification of the specimen is essential. The Congenital epulis of the newborn, also known as granular
formalin container should be labelled with the name cell tumor or Neumann’s tumor, is a rare benign tumor seen
of the patient and the location. Multiple tissue samples only in newborns. 91 This lesion is typically a protuberant
from different locations should not be placed in the mass arising from the gingival mucosa. It is most often
same container, unless they are uniquely identified, such found on the anterior maxillary ridge.86,87 Patients typically
as tagged with a suture. present with feeding and/or respiratory problems.87 Congenital
6. complete the surgical pathology form including patient epulis has a marked predilection for females at 8:1 to 10:1.86-88
demographics, the submitting dentist’s name and address, Treatment normally consists of surgical excision. 86-88 The
and a brief but accurate history. It is important to have newborn usually heals well, and no future complications or
legible records so that the diagnosis is not delayed. treatment should be expected. Congenital epulis never recurs
Clinical photographs and radiographs often are very after excision. 88 There have been reports of spontaneous
useful for correlating the microscopic findings. regression of untreated congenital epulis.88,91

Worldwide, the most frequently oral biopsied lesions in Melanotic neuroectodermal tumor of infancy
children include82: Melanotic neuroectodermal tumor of infancy is a rare occur-
• mucocele; rence that develops during the first year of life.88 This lesion
• fibrous lesions; may be present at birth. It occurs in the anterior maxilla 70
• pyogenic granuloma; percent of the time.83 Less frequently, melanotic neuroecto-
• dental follicle; dermal tumor of infancy occurs in the skull, mandible,
• human papillomavirus (HPV) lesion; epididymis and testis, and brain.83,88 The classic presentation
• chronic inflammation; is a bluish or black rapidly expanding mass of the anterior
• giant cell lesions (soft tissue); maxilla. Radiographic findings include an ill-defined
• hyperkeratosis; unilocular radiolucency with the displacement of tooth buds.88
• peripheral ossifying fibroma; There can be a floating tooth appearance.83 Surgical excision is
• gingivitis; required, and there is a 20 percent recurrence rate. Although
• gingival hyperplasia; this is a benign lesion, seven percent of reported cases have
• hemangioma; behaved malignantly resulting in metastasis and death.88
• ulcer;

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Natal and neonatal teeth Mucocele

Natal and neonatal teeth can present a challenge when deciding The mucocele is a common lesion in children and adolescents
on appropriate treatment. Natal teeth have been defined as resulting from the rupture of a minor salivary gland excretory
those teeth present at birth, and neonatal teeth are those that duct, with subsequent leakage of mucin into the adjacent
erupt during the first 30 days of life.92,93 The occurrence of connective tissues that later may be surrounded in a fibrous
natal and neonatal teeth is rare; the incidence varies from capsule.83,85,99-101 Most mucoceles are well-circumscribed bluish
1:1,000 to 1:30,000.92,93 The teeth most often affected are the translucent fluctuant swellings that are firm to palpation,
mandibular primary incisors.94 In most cases, anterior natal although deeper and long-standing lesions may range from
and neonatal teeth are part of the normal complement of the normal in color to having a whitish keratinized surface.85,99,100
dentition.92,93 Natal or neonatal molars have been identified in Mucoceles most frequently are observed on the lower lip, usually
the posterior region and may be associated with systemic condi- lateral to the midline.88 Mucoceles also can be found on the
tions or syndromes (e.g., Pfieffer syndrome, histiocytosis X).94-96 buccal mucosa, ventral surface of the tongue, retromolar region,
Although many theories exist as to why the teeth erupt prema- and floor of the mouth (ranula).99-101 Superficial mucoceles and
turely, currently no studies confirm a causal relationship with some other mucoceles are short-lived lesions that burst spon-
any of the proposed theories. The superficial position of the taneously, leaving shallow ulcers that heal within a few
tooth germ associated with a hereditary factor seems to be the days.85,100 Local mechanical trauma to the minor salivary gland
most accepted possibility.93 is often the cause of rupture.50,53,86,87 Many lesions, however,
If the tooth is not excessively mobile or causing feeding require treatment to minimize the risk of recurrence.85,100
problems, it should be preserved and maintained in a healthy
condition if possible.93,95,96 Close monitoring is indicated to Squamous papilloma
ensure that the tooth remains stable and is not an aspiration Squamous papilloma is a benign human papillomavirus-
risk to the infant. induced lesion caused by HPV types 1 and 6. 83 Squamous
Riga-Fede disease is a condition caused by the natal or papilloma presents as soft painless, pink to white, pedunculated
neonatal tooth rubbing the ventral surface of the tongue (stalked) lesions. The surface may display multiple fingerlike
during feeding, leading to ulceration.75,92 Failure to diagnose projections and may have a cauliflower like appearance.83,102,103
and properly treat this lesion can result in dehydration and These lesions can occur anywhere in the oral cavity, but the
inadequate nutritional intake for the infant. 96 Treatment tongue, lips and soft palate are the most common sites. 103
should be conservative and focus on creating round, smooth Squamous papilloma generally occurs in adulthood, but 20
incisal edges.93-96 If conservative treatment does not correct the percent have been noted prior to age 20.91 Although they are
condition, extraction is the treatment of choice.93-96 viral in origin, the infectivity is low.83,102 Squamous papilloma
An important consideration when deciding to extract a natal do not have malignant potential.103 Excision is the treatment
or neonatal tooth is the potential for hemorrhage. Extraction of choice, and recurrence is uncommon.83,103
is contraindicated in newborns due to risk of hemorrhage.97
Unless the child is at least 10 days old, consultation with the Verruca vulgaris
pediatrician regarding adequate hemostasis may be indicated Verruca vulgaris, or the common wart, is an HPV type 2
prior to extraction of the tooth. In particular, infants may be induced lesion that is generally found on the skin of the
at risk for vitamin K deficiency bleeding (VKDB) if they did hand.102 Finger or thumb sucking can cause autoinoculation
not receive a dose of vitamin K shortly after birth (within 6 resulting in the development of intraoral lesions. 102 Verruca
hours of birth).98 Infants can be at risk for VKDB until the vulgaris is similar in appearance to the squamous papilloma.
age of 6 months if they do not receive a vitamin K injection.98 This lesion can be sessile (broad based) or pedunculated and
can display a rough bumpy surface.103 Verruca vulgaris can be
Lesions occurring in children and adolescents found on the lips, tip of tongue, and labial mucosa.83 There is
Eruption cyst (eruption hematoma) no risk of malignant transformation.83 Excision of the entire
The eruption cyst is a soft tissue cyst that results from a lesion is recommended and recurrence is uncommon.103
separation of the dental follicle from the crown of an erupting
tooth.83,99 Fluid accumulation occurs within this created fol- Irritation fibroma
licular space.85,89,100 Eruption cysts most commonly are found in The irritation fibroma is a reactive lesion occurring as a re-
the mandibular molar region.89 Color of these lesions can range sponse to chronic trauma of the mucosa. The irritation fibroma
from normal to blue-black or brown, depending on the amount presents as a firm nontender pink nodule and is composed of
of blood in the cystic fluid.85,89,100 The blood is secondary to fibrous connective tissue.103 The lesion does not exceed two
trauma. If trauma is intense, these blood-filled lesions some- millimeters in diameter.104 The irritation fibroma can be found
times are referred to as eruption hematomas.85,89,100 Because the on buccal and labial mucosa, the tongue, and attached gingiva.
tooth erupts through the lesion, no treatment is necessary.85,89,100 Excisional biopsy is recommended. These can reoccur if the
If the cyst does not rupture spontaneously or the lesion becomes source of the irritation is not removed.103,104
infected, the roof of the cyst may be opened surgically.85,89

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Recurrent aphthous stomatitis attached gingiva (75 percent) but can be found on tongue,
Recurrent aphthous stomatitis is one of the most common oral lower lip, or buccal mucosa.108 Treatment is complete ex-
lesions, occurring in 20-30 percent of children.83 Recurrent cision with the removal of the source of irritant. 83,108 This
aphthous stomatitis is caused by a T-cell mediated immu- lesion can recur in 3-15 percent of cases.83
nologic reaction to a triggering agent. 105 Three variants of
aphthous ulcers are recognized: References
1. Minor aphthous ulcerations. Minor aphthous ulcerations 1. American Academy of Pediatric Dentistry. Pediatric oral
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