September 2019 HSC Section 1 Congenital and Pediatric Problems

Benign and Malignant Pediatric Oral Lesions

EPIDEMIOLOGY

Oral cavity lesions encompass a significant yet overlooked clinical concern, because under-appreciation of these lesions has led to a paucity of population-based studies. 1 One analysis of 10,000 children aged between 2 years old and 17 years old in the United States found a greater than 9% incidence of oral mucosal lesions, with the most common site the lip, including lip/cheek bites and aphthous ulcers. More concerning than these seemingly benign entities are oral cavity tumors; in 1 series, the most common benign and malignant tumors included hemangioma and sarcoma, respectively. 2 Although representing less than 10% of oral tumors, malignancies occur in the pediatric population and harbor devastating conse- quences on quality of life and survival. 3 The age-adjusted incidence for oral cavity malignancies in children and adolescents was 0.24 per 100,000 in 2008, although there is evidence suggesting that the incidence of oral and oropharyngeal cancer has increased in adolescents due to the rising prevalence of oral human papilloma- virus (HPV) infection. 4 A thorough patient history is critical for determining which lesions require observation versus further diagnostic work-up. This history should include general questions regarding onset, provoking factors, whether the lesion is painful and how the pain is provoked, the quality of the pain, paresthesias, severity, and onset. In addition to a re- view of systems, including systemic complaints, patients should be specifically asked about whether a lesion bleeds, is associated with numbness, becomes tender or en- larges during meals, is associated with any foul drainage, or causes trismus. Other considerations for either oral or any other head and neck lesions include asking about dysphonia, dysphagia, odynophagia, neck masses, and respiratory history. A detailed dental, medical, and surgical history should be taken. Furthermore, physicians should inquire about family history, with a focus on immunologic pathologies, syndromes, and head and neck lesions, as well as a social history, including alcohol and smoking (both primary and secondhand exposure). A detailed and targeted physical examination directs the decision to pursue further work-up and intervention. Understanding normal oral cavity anatomy is key for per- forming an appropriate evaluation ( Fig. 1 ). Oral cavity subsites include the oral tongue, floor of mouth, upper and lower lips, hard palate, upper and lower alveolar ridges, buccal mucosa, and retromolar trigone (triangular area in the oral cavity posterior to the upper and lower third molar teeth overlying the ramus of the mandible). The sub- lingual ducts can be seen in the floor of mouth adjacent to the lingual frenulum, whereas the parotid duct (Stensen duct) opening can be found adjacent to the upper second molar. Oropharyngeal subsites that can be easily viewed in most patients include the soft palate, tonsil/tonsillar pillars, and posterior pharyngeal wall; the base of tongue is another subsite that cannot be directly viewed without direct or mirror laryngoscopy but can be palpated for irregularities during the physical examination. Proper lighting is crucial for oral cavity evaluation, be it a high-powered flashlight, headlight, or head mirror with a light source, particularly because this examination may be difficult and may have to be done rapidly in a younger or uncooperative pa- tient. In patients with dental appliances, it is important to ask these to be removed PATIENT HISTORY ORAL CAVITY ANATOMY AND PHYSICAL EXAMINATION

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