Two-for-one pathology punch

What I thought would be a routine first dental visit on a 12-year-old male turned into something that had his mom looking at me with pleading eyes to help her son, who clearly was not in a good way.

These are the moments when we must be on our game. We have to examine, diagnose, treat, and subsequently comfort and reassure our patients of their situation. We need to immediately recall what we’ve been taught and successively apply it to clinical situations.

Case presentation

This 12-year-old presented with his mom for a dental visit. The chief complaint was that he was not feeling well, his mouth hurt, he couldn’t eat, it was painful to swallow, and he’d missed out on the last week of school. In general, his health history was unremarkable, temp was low-grade (99.8), and despite not being 100%, he was a trouper. Fist bumps, kiddo.

My hygienist had taken radiographs prior to me coming in.

Pathology point no. 1

First off, radiographically (figures 1 and 2), I noted a radiopaque lesion nestled at the apex of teeth nos. 7 and 8. It measured approximately 8 mm x 12 mm and had a distinct radiolucent center. Clinically, the anterior teeth were erupted, in fair alignment with the laterals, and aside from an overbite and overjet, all was within normal limits.

Diagnosis: Mesiodens tooth

For a recap on mesiodens teeth, diagnosis, and treatment, please refer to another case report I wrote that you might find of interest. Here is a quick

summation of that read:

The lesions may occur “as single, multiple, unilateral, or bilateral (lesions); the presence of multiple supernumerary teeth is called ‘mesiodentes.’”¹
By way of appearance, they typically manifest in a conical- or peg-shaped form.²
In general, supernumerary teeth—also referred to as hyperdontia or extra teeth—can occur in any location, but they are more prevalent in the maxilla (90%) as opposed to the mandible (10%).²
The most common type of supernumerary teeth are mesiodentes.¹ Their etiology remains unclear, although it is theorized that they are either an isolated finding or part of a “syndrome, specifically cleft lip and palate, cleidocranial dysostosis, and Gardner’s syndrome.”¹
Diagnosis is primarily via radiograph and can be confirmed by taking multiple angles using intraoral and extraoral radiographs (i.e., panoramic, periapicals, etc.). Furthermore, three-dimensional CBCT scans allow dialing in on the palatal location of the mesiodentes and their relationship to adjacent teeth. Delayed or altered eruptions of adult dentition also give rise to the suspicion of mesiodentes. Other common signs include cyst formation and crowding.
Treatment of mesiodens varies. Although typically asymptomatic, they are “often extracted for aesthetic reasons, to allow the eruption of other teeth, orthodontic reasons, and/or suspected pathology.”³

Pathology point no. 2

Regarding the patient’s chief complaint, here are the clinical highlights (figures 3–8):

Note: The pictures are not of the highest quality as the patient was in extreme discomfort when I took them.

Duration of symptoms was approximately one week.

The patient was experiencing generalized malaise but was still optimistic and in good spirits.

As mentioned in the introduction,

it was painful for the patient to swallow, open, and move his tongue around; his appetite was subdued due to the pain and inability to put anything in his mouth or masticate.

Crusted lesions were present in the perioral and nasal proximities.

Intraorally, there were scattered multiple oral ulcerations presenting as white lesions surrounded by an erythematous base on the dorsal and ventral surfaces of the tongue; the hard and soft palates were also covered. Some of the lesions appeared to combine.

Gingival tissue was

red, inflamed, and bled upon the slightest touch.

Moderate amounts of plaque coated the dentition; several primary teeth were loose with their adult counterparts erupting.

There was a fetid odor to the patient’s breath.

Slight lymphadenopathy was observed in the submandibular glands and neck areas.

Differential considerations include:

Hand, foot and mouth disease

Herpangina

Acute primary herpetic gingivostomatitis (APHG)

Varicella (chicken pox)

Definitive diagnosis is likely one of two: Herpangina or acute primary herpetic gingivostomatitis

The saying “nothing is for certain unless it’s in a petri dish” stands true in all pathology cases, including this one. However, based on the symptoms and clinical presentation, I was able to surmise that it was more than likely either herpangina or APHG, although I’m leaning toward APHG.

Since the presentations for this patient are similar for herpangina and APHG, the treatment modalities are as well: palliative care and time to allow the virus to run its course. The patient should be encouraged to take liquids with nutritional value along with plenty of fluids and rest. Furthermore, it’s important to note that the patient must be monitored for secondary infections, especially if the patient is young and tends not leave the area alone.

Prescriptions include:

Topical oral anesthetics: Orabase with benzocaine or lidocaine HCl 2% viscous solution

Acyclovir ointment 5%

Acyclovir 5%

and lidocaine 2% compounded into a paste for perioral application

Magic mouthwash elixir: One part viscous 2% lidocaine, one part Maalox, and one part diphenhydramine 12.5 mg/5 ml; 1–2 tsp. 2–3x/day prn. (I will usually give 1–2 refills with a 150 ml bottle)

For my patient, I prescribed Magic mouthwash, told him to rest (mom was on board with that), keep his oral cavity as clean as possible (several of my patients have found a diluted Listerine or chlorhexidine rinse to be helpful, but not all can tolerate it), and let it run its course. Mom was to contact me if it didn’t start to improve or get better after 10–14 days.

Pathology refresher

Here is a quick go-to reference table

taken from a previous pathology case I wrote up a few years ago.⁴

Here are some additional informational tidbits on the Coxsackievirus and herpesvirus⁴

Coxsackievirus (for herpangina)

Picornavirus family (largest and most prevalent of RNA viruses)
Includes rhinoviruses of the common cold
Portal of entry via oropharynx and gastrointestinal tract
Two types: A and B

o Type A includes herpangina, hand, foot and mouth disease, and lymphonodular pharyngitis.
o Type B causes GI illnesses, pericarditis, and myocarditis.

Herpesvirus (includes herpes simplex 1 and 2, acute primary herpetic gingivostomatitis, varicella zoster virus, Epstein-Barr virus, cytomegalovirus, human herpesvirus)

HSV-1 (primary lesions above the waist), HSV-2 (primarily lesions below the waist, 10% crossover)
Enters the body through breaks in the skin
Primary infection followed by latency
Neurotropic—infects the peripheral nerves and migrates to regional ganglion and remains dormant, therefore protected
Activated by emotional stress, trauma, cold, sunlight, gastric upset, fever, menstrual cycle, and other factors that result in immune system depression

Keeping it real, raw, and everyday...

Dr. Stacey

References

Meighani G, Pakdaman A. Diagnosis and management of supernumerary (mesiodens): a review of the literature. J Dent (Tehran). 2010;7(1):41-49.
Sapp JP, Eversold LR, Wysocki GP. Contemporary Oral and Maxillofacial Pathology. Mosby; 1997:4-5.
Hyperdontia. Wikipedia. Updated May 5, 2020. Accessed March 15, 2020. https://en.wikipedia.org/wiki/Hyperdontia
Wood NK, Goaz PW. Differential Diagnosis of Oral and Maxillofacial Lesions. 5th ed. Mosby; 1997:73-74, 167-168.

Editor’s note: This article first appeared in Through the Loupes newsletter, a publication of the Endeavor Business Media Dental Group. Read more articles and subscribe to Through the Loupes.