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Print version ISSN 1698-4447
Med. oral patol. oral cir. bucal (Ed.impr.) vol.10 no.5 Valencia Nov.-Dec. 2005
Epidemiology of the most common oral mucosal diseases in children
Epidemiología de la patología de la mucosa oral más frecuente en niños
Mº del Rosario Rioboo Crespo(1), Paloma Planells del Pozo(2), Rafael Rioboo García(3)
(1) Licenciada en Odontología, profesora colaboradora honorífica del departamento IV de Odontología
(2) Profesora titular de Odontopediatría
(3) Catedrático de Odontología Preventiva y Comunitaria. U.C.M.
Rafael Rioboo García,
Departamento IV de la Facultad de Odontología de la Universidad Complutense de Madrid.
Plza Ramón y Cajal s/n 28040 Madrid.
Tlf: 913941931- Fax:913941940
Received: 20-08-2004 Accepted: 15-04-2005
|Rioboo-Crespo MR, Planells-del Pozo P,
Rioboo-García R. Epidemiology of the most common oral mucosal diseases in
children. Med Oral Patol Oral Cir Bucal 2005;10:376-87.
© Medicina Oral S. L. C.I.F. B 96689336 - ISSN 1698-4447
Dentists who treat children must be alert to the possibility of finding diseases of the oral mucosa, especially in younger children. The present study aimed to review the most updated information and the experience of our group in order to yield epidemiological data that assist diagnosis of the most common diseases of the oral mucosa in children. Recent epidemiologic studies have shown a wide variability in the prevalence of oral mucosal lesions in different regions of the world and have led researchers to draw disparate conclusions. Moreover, studies have not been designed using standard criteria, further explaining the wide variability in the percentage of different groups of children with oral lesions, which ranges from 4.1 to 52.6%. The lesions most frequently considered by authors and that most often appear in the different studies are: recurrent aphthous stomatitis (0.9-10.8%), labial herpes (0.78-5.2%), fissured tongue (1.49-23%), geographic tongue (0.60-9.8%), oral candidiasis (0.01-37%) and traumatic injury (0.09%-22.15%). Dentists must be able to detect any of the numerous possible disorders and perform the correct differential diagnosis, key to the treatment plan.
Key words: Oral mucosal lesions, paediatric population, epidemiology, differential diagnosis.
El odontólogo responsable de tratar al niño debe tener en cuenta la posibilidad de encontrar cualquier condición patológica a nivel de la mucosa oral sobre todo a edades tempranas. Por ello, hemos tratado de aunar en nuestro estudio tanto la información más actualizada como nuestra propia experiencia para intentar ofrecer los datos de mayor interés, desde el punto de vista epidemiológico, que nos permita diagnosticar la patología de la mucosa oral más frecuente en la población infantil. Los estudios epidemiológicos realizados estos últimos años han mostrado la dispar apreciación de los diferentes investigadores y una gran variabilidad en las prevalencias de las lesiones mucosas orales en las diferentes zonas del mundo. Tanto lo expuesto con anterioridad como la falta de uniformidad en los criterios de elaboración de los estudios epidemiológicos explica que el porcentaje de las lesiones orales observadas en los diferentes grupos de niños estudiados nos ofrezcan una gran variabilidad con porcentajes comprendidos entre el 4,1% y 52,6%. Las lesiones que más frecuentemente han sido tenidas en cuenta por los diferentes autores y que más aparecen en los diferentes estudios son: la estomatitis aftosa recurrente, el herpes labial, la lengua fisurada, la lengua geográfica, la candidosis oral y las lesiones traumáticas, con prevalencias que respectivamente muestran rangos de 0,9% al 10,8%, del 0,78% al 5,2%, del 1,49% al 23%, del 0,60% al 9,8% y del 0,01% al 3,7%. Frente a la gran cantidad de alteraciones que podemos encontrarnos, debemos ser capaces de detectar dichas lesiones y llevar a cabo un correcto diagnóstico diferencial, eslabón esencial del plan de tratamiento.
Palabras clave: Lesiones de la mucosa oral, población infantil, epidemiología, diagnóstico diferencial.
Given the large number of alterations that can be found in the oral mucosa of children, we must be able to detect these lesions, perform a correct diagnosis and apply the appropriate treatment (1). Inadequate behaviour in the conventional examination of the oral mucosa and in the differential diagnosis of lesions found can lead to important lesions being overlooked and to the indication of inappropriate treatment (2).
Studies on this issue in children are very scarce, unlike epidemiological studies on caries and periodontal disease. Despite the efforts made by different groups, development of an appropriate data collection system is hampered by a series of methodological problems that have yet to be resolved. Moreover, in Spain there has been an almost complete absence of epidemiological studies that specifically address the prevalence of oral lesions in children, except for a study in Oviedo on a population of six-year-olds.
PREVALENCE STUDIES OF MUCOSAL LESIONS IN CHILDREN
Epidemiological studies performed over the past few years have shown considerable variation in the prevalence of oral mucous lesions among different regions throughout the world. A general idea of the frequencies of the lesions most commonly presented in childrens mouths is given in Table 1, which provides a summary of some of these studies.
Review of the literature in this field faces considerable methodological problems because of the absence of standard protocols and the wide variation in the methods used. Consequently, the prevalences found for each lesion vary widely among research groups (Table 1).
Nevertheless, and taking account of the specific racial features and environments of each sample, the percentage of oral lesions found in Spain, South Africa and Argentina were similar and not far from that detected in Mexico. In contrast, findings in the USA were markedly different, perhaps because distinct clinical criteria and types of sample were used. Thus, the authors of the Spanish research included coated tongue and reported it as the most frequent lesion, whereas it is not included in other studies. On the other hand, Kleiman (3) considered lesions caused by chewing tobacco, which is a common practice among the adolescent population of the USA but practically non-existent in Spain. The same occurs with other lesions that only appear in certain populations, as seen in a study of an Amazonian Indian community (Brazil), where one of the most frequent conditions observed was epithelial focal hyperplasia, absent in other populations. Likewise, commissural lip pits are very common in South Africa, Argentina and Mexico but are not considered in studies elsewhere. The occurrence of these lesions is directly related to the life style of different specific populations (4). (Table 2)
In general, and taking the study performed in Spain (5) as a reference, it can be seen that various authors agree almost completely on the most frequently observed diseases in the paediatric population. Thus, recurrent aphthous stomatitis, labial herpes, geographic, coated and scrotal tongue, candidiasis and traumatic oral lesions are the diseases that stand out when the results are examined. Therefore, our main interest will focus on the study of these diseases.
RECURRENT APHTHOUS STOMATITIS (RAS)
It has been estimated that a third of school-age children have a history of RAS (6). According to Gándara et al., the prevalence varies according to the study setting, with some authors reporting 17% and others 45%. The lesions appear before the age of 10 years in 13-14%, between 11 and 20 years in 46%, and between 21 and 30 years in 24% of cases (7).
Clinical studies have shown that RAS appears to be a disease of childhood- and youth-onset (8), consistent with the experience of our group.
In an interesting study, Crivelli et al. investigated the weight of the socioeconomic factor in the presentation of RAS lesions in two schools with different socioeconomic levels. Whereas the prevalence was 19% in the school with a high level (50% of all lesions observed were in this group), it was only 12% in the school with a low level (9). However, a recent study by Bessa in 2004 found no significant association between the prevalence of RAS lesions and socioeconomic level (10).
With respect to gender, there appears to be no clear predilection for one sex or the other. Nevertheless, some studies found a slightly higher susceptibility in females (1).
These lesions are less frequent in black populations and can appear at any time of the year, although with a slight predominance during spring and autumn (7).
RECURRENT HERPES LABIALIS (RHL)
Because the active lesions of RHL are recurrent and may not be present at the time of examination, the prevalence is usually assessed on the basis of the positive history of individuals (11). As in the case of EAR, different types of prevalence are used by different authors, such as: 1) average point prevalence (APP); 2) self-reported two-year prevalence (STP); 3) self-reported life-time prevalence (SLP) and 4) the sum of STP and APP (17).
Authors affirm that this ulcerous disease produced by Herpes Simplex Virus type 1 (HSV-1) is present in approximately 33% of school-age children. Moreover, in the epidemiological study by Kleiman (3), it was observed that most of the studies reviewed were performed on students and that the prevalence in this population group ranged from 21% to 38%. Ramos-Gomez (12) described infection by herpes simplex as a common disease in childhood, occurring in 1.7 -24% of children. Hence, it is a disease of frequent onset at a young age.
Interestingly, the study by Crivelli et al. (9) found that RHL lesions appeared in 1% of a group with high socioeconomic level and in 10% of a group with low socioeconomic group, the inverse of the findings for EAR.
This disease frequently appears in immunologically compromised patients (13). Thus, patients at high risk of severe recurrences include those treated with chemotherapy or immunosuppressant drug therapy and patients with AIDS.
In 1994, the percentage of childhood AIDS in Spain was 2.5% of all declared cases, higher than the worldwide estimate of 0.7% (14). At present, 1.2 million children under 15 years old live with HIV/AIDS. When AIDS was first reported, it was a reasonable assumption that affected patients would be more susceptible to oral infections, and oral manifestations therefore form part of the most important initial indicators of HIV infection and its progression to AIDS in children (12, 15).
According to a study by Diz P et al. (14), RHL was one of the most common oral lesions found in HIV-infected children, observed in 5% of the children studied. A recent study by Fine et al. (15) compared the appearance of oral lesions in an HIV+ group of children with that in a group of HIV- children and reported that 75% of the HIV+ group had oral lesions but only 3% of the same group had RHL lesions, very similar to the percentage observed in the HIV- group. A study by Ramos-Gomez (12) of 91 HIV+ children and 185 HIV- children showed that 3% of the HIV+ group presented RHL lesions compared with 0% in the HIV- group.
It should not be forgotten that diseases such as leukemias and lymphomas and the receipt of transplants or high doses of corticoids are associated with the chronic and aggressive onset of lesions caused by HSV. Bascones et al. found that 40% of a group of patients with leukaemia were infected with HSV (16).
Epidemiological studies have shown a high frequency of tongue diseases among mucosal lesions of the oral cavity, although the prevalence varies in different parts of the world. This variability is produced by differences in the race, sex and age of samples and by the use of different diagnostic criteria, methodologies and procedures by different researchers (17, 18).
Authors like Kleiman have stated that special attention has not been paid to the study of tongue alterations in paediatric populations (3). A study of oral lesions in 2,356 Brazilian children (0-14 years) who had been referred to a department of oral pathology in the previous 15 years (19) found that tongue diseases represented the lowest percentage of all lesions recorded.
Among tongue diseases, the condition of greatest interest to authors has been geographic tongue followed by fissured or scrotal tongue. On the other hand, a study by García-Pola (5) in Oviedo (Spain) included coated tongue as a disease and it was the most frequently observed oral mucosal lesion.
We describe below the diseases reported to occur with highest frequency in the paediatric population.
Many authors have not considered coated tongue as a disease. In most of the studies reviewed, it does not appear in the long list of lesions and conditions observed in different series (2, 3, 4, 5, 9, 10, 20, 21, 22), and some authors do not even consider it to be an abnormal alteration (4). By contrast, as already mentioned, the study in Oviedo (5) included it as an oral mucosal lesion and found it to be the most frequent disease among the six-year-old population, with a percentage of 16.02%. Moreover, a statistically significant association was observed between coated tongue and the presence of dentoalveolar fistulas, indicating that the development of coated tongue may be favoured by the colonisation of more aggressive germs from dentoalveolar fistulas.
Geographic tongue is by far the most frequent tongue disease reported in the different studies reviewed on the paediatric population. The onset of geographic tongue starts in childhood, sometimes at a very early age (2) and occasionally in puberty with a predominant presence in females. Rahamimoff and Muhsam performed repeated clinical examinations on 8,305 young children, providing further opportunities to detect cases that would not have been detected in a cross-sectional study, and found that 1,246 of them (775 under two years old) had geographic tongue, a surprising incidence of practically 15%.
For Kleiman (3), geographic tongue is the third tongue disease in importance after scrotal tongue and tongue varices, while García-Pola reported it to be the third most common lesion among all mucosal lesions found.
We present below brief details of some of the studies on geographic tongue in the paediatric populations of different countries.
García-Pola (Spain) (5) 4.48% of 6-yr-old children studied.
Sedano et al. (Mexico) (21) .2% of schoolchildren studied.
Bessa et al. (Brazil) (10) ...9.08% of children from 0 to 12 years studied.
Arendorf et al. (South Africa) (20) 1.6% of pre-schoolchildren studied.
Kleiman (USA) (3) 0.6% of schoolchildren studied.
Bezerra (Brazil) (2) ...21% of children from 0 to 5 years studied.
We can see that the prevalence varies among populations due to the different clinical criteria used, although most of the studies showed geographic tongue to be one of the most common lesions.
Some authors concluded that there is a difference among different age groups with a higher prevalence at younger ages. Thus, Bessa that reported a significantly higher prevalence in children aged between 0 and 4 years (10).
In general, it is affirmed that geographic tongue starts in childhood (between 6 and 12 months) and that it is most frequently observed in children aged approximately four to four-and-a-half years old. However, some authors sustain that it can be diagnosed in adults, and Banoczy et al. (18) reported that the highest incidence was in individuals older than 40 years, demonstrating its persistence. According to these authors, the difference in prevalence among different age groups may indicate that genetic factors do not participate in the multifactorial aetiology of geographic tongue.
After geographic tongue, scrotal tongue is the second most frequently observed tongue disease in various studies. Its prevalence ranges from 0.6% (in South Africa) to 27.7% (in Brazil). Grispan detected scrotal tongue in 2.4% of 620 children younger than 12 years old, with the highest incidence at eight-and-a-half years old (23). This condition varies from being the most frequently observed mucosal disease in studies carried out in Brasil and Mexico (10, 21) to being a condition that was not even considered in the study carried out in Oviedo.
Scrotal or fissured tongue has been associated with more advanced ages, as affirmed by Banoczy et al. (18) after their study of the prevalence of tongue diseases in an adult population. They reported the most frequent lesion to be scrotal tongue, found in 18.52% of their series and with a higher frequency among the women. These authors reported that prevalences of this lesion and atrophic lesions increased with higher age, whereas the prevalence of geographic tongue was higher in younger groups. The same conclusions were reached by Darwazeh (17) in a study performed in Jordan.
Other authors such as Grispan et al. (23) and Benevides et al. (4) supported a difference in prevalence between the sexes, with a higher frequency among males. Benavides et al. (4) supported the idea that it appears with higher frequency in more advanced age groups.
On the other hand, numerous authors have observed a relationship between scrotal tongue and geographic tongue. Sedano et al. (21) even considered cases of scrotal tongue plus geographic tongue separately from cases of scrotal tongue without geographic tongue, concluding that the prevalence of scrotal tongue is higher in indivduals with geographic tongue and vice-versa. The explanation of these differences is based on arguments that support a genetic association between these lesions.
Bessa et al. (10) reported that the prevalence of this condition is three-fold higher in children with a history of allergy and is also more frequent in children with congenital extra-oral anomalies. This suggests that it may be a hereditary condition, although it is notable that different statistics show that its incidence increases with age, indicating that the classic characteristics of this disease develop and are acquired with growth.
Among superficial mycoses of the mouth, oropharyngeal candidiasis is the most important. Its agent is Candida albicans, which is transformed by host reaction into a pathogenic agent, and the opportunistic mycotic infection known as oral candidiasis can become a real clinical problem. All of this occurs when the local and general predisposing factors that potentiate this transformation are present and active (23).
Ellepola and Samaranayake (24) described candidiasis as the most common fungal infection, which can sometimes manifest as an adverse effect of certain drug therapies such as the use of topical or inhaled corticosteroids in the treatment of bronchial asthma and oral mucosal diseases. This fact must be taken into account given that these diseases are relatively common in children.
Most epidemiological studies of oral candidiasis have shown very varied results. Research has been carried out into the presence of Candida in the general population and in many different study groups, including newborns and breastfeeding children (25). Variations in data collection methods, sampling sites, culture media, population subgroups and analysis techniques are responsible for the relatively wide ranges of prevalence of Candida carrier status. According to the majority of authors, the imprint culture technique is the most reliable method to determine the presence of C albicans (1).
Another aspect to take into consideration in epidemiological studies of oral candidiasis is the wide range of clinical manifestations, including the following four types: 1) acute pseudomembranous; 2) acute erythematous (most common form in children); 3) chronic erythematous and 4) chronic hyperplastic.
Studies were performed on two groups of children from three to six and from six to twelve years old. The older children generally had higher indexes of carrier status compared with the younger (65% vs. 45%, respectively). This research suggested that a mixed dentition and the concomitant presence of salivary film may have some effect on the adherence of Candida to the dental surface (25).
Candidiasis is frequently present in breastfeeding children, probably because of their immature immune system and their passage through the birth canal, without forgetting the possibility of exogenous fungal infection, such as from a babys dummy. Nowadays, it must be taken into account that oral candidiasis is one of the early signs of AIDS. It has been demonstrated that the number of C Albicans colony-forming units increases with a reduction in CD4 cells. Erythemous candidiadis, pseudomembranous candidiasis and angular cheilitis are the most frequently observed clinical forms in patients with AIDS.
Numerous studies have shown candidiasis to be the most common oral lesion in children with AIDS and very often the first manifestation of HIV infection. Various authors described oral candidiasis as present in 75% of children infected with HIV. Thus, candidiasis plays a major role in predicting the development of HIV infection in children (12).
In the study by García-Pola (5), traumatic ulcerations were the second most commonly diagnosed lesions, with a prevalence of 12.17%. This observation is compatible with the classical concept that ulcers are the most frequently observed intraoral soft tissue lesions.
When classified as traumatic lesions, they also showed a high prevalence in studies carried out by Benevides dos Santos (4) and Arendorf (20). By contrast, their prevalence was very low (0.09%) in the study by Kleiman in the USA (3).
The category traumatic lesions can include multiple entities that may or may not be considered by different authors in their studies. Thus, the research by Bessa et al. (10) only included bite injuries.
There is an association between the occurrence of all traumatic lesions and age, with a reduction in their prevalence with increasing age. A traumatic ulcer rapidly heals within a few days after elimination of the causal agent, confirming its traumatic origin and therefore its diagnosis.
DISCUSSION AND CONCLUSIONS
This review of the current state of knowledge on the frequency of appearance of alterations of the oral cavity mucosa was as exhaustive and objective as possible. It highlights the disorders of greatest interest for the frequency of their appearance or for being the expression, sometimes the first, of systemic diseases. This study has led us to the conclusion that further studies on this issue are required. Moreover, the lack of uniformity in the criteria adopted by the epidemiological studies makes it difficult to draw coherent conclusions. Therefore, we take this opportunity to encourage the creation of the appropriate protocols for use in future studies.
Throughout the study, greater attention has been paid to the epidemiological studies on lesions that most frequently appear at school age. Nevertheless, we should not for that reason forget younger children, including newborns, in whom the appearance of numerous oral mucosal issue remains an important issue (26, 27) to be addressed in another study.
We only considered the lesions that we are going to encounter most frequently in our dental practice. On the other hand, there are other lesions with a high incidence in adults but uncommon in children, such as lichen planus, whose clinical and family characteristics must also be known (28, 29).
With the increases in life expectancy achieved by advances in medical diagnosis and treatment modalities, there is an associated increase in the likelihood of receiving dental patients with concomitant medical problems. This is also true in the paediatric population. Consequently, the responsibility of the dentist to be able to identify and differentiate oral mucosal lesions that signal an underlying systemic disease from those that frequently appear in benign form is of special importance at the time of diagnosis in the dental surgery.
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