Diagnosis and Management of Lower Labial Mucosa Ulcer in a Hypotonic Infant

Case Report

Austin J Dent. 2018; 5(1): 1097.

Diagnosis and Management of Lower Labial Mucosa Ulcer in a Hypotonic Infant

Yair Schwimmer¹*, Aviv Shmueli¹, Jawad Abu- Tair², Rinat Schwimmer-Noy³ and Alexander Maly4

¹Department of Paediatric Dentistry, The Hebrew University, Israel

²Department of Oral and Maxillofacial surgery, The Hebrew University, Israel

³Department of Oral Medicine, The Hebrew University, Israel

4Hadassah-Hebrew University Medical Center Department of Pathology, Israel

*Corresponding author: Yair Schwimmer, Department of Paediatric Dentistry, The Hebrew University-Hadassah School of Dental Medicine, Jerusalem, Israel

Received: November 23, 2017; Accepted: January 05, 2018; Published: January 12, 2018


We describe a 28-month-old girl with congenital cerebral palsy, uncontrolled epilepsy, failure to thrive, breathing difficulties and secondary diabetes mellitus due to a ketogenic diet. She was brought to our clinic by her parents with the chief complaints of a long lasting ulcer in her lower labial mucosa and feeding difficulties. We describe the diagnosis and treatment of the ulcer over the course of one year. Possible etiological factors for the lesion are discussed.


Reactive oral lesions associated with chronic local irritation or trauma may manifest as tumor-like hyperplasia. These proliferations are painless, pedunculated or sessile masses in different colors, from light pink to red. The surface appearance is variable, from nonulcerated smooth to an ulcerated mass. Lesion size varies from a few millimeters to several centimeters [1].

Most studies on the frequency of oral diseases in paediatric populations examined the presence of dental caries, periodontal diseases or other oral lesions such as tumors or cysts. Zuñiga et al. studied 542 oral biopsy specimens from children (which represented 20.6% of all oral biopsies), with mean patient age of 11.1 years, and female predilection (60.5%). The most common category of oral lesions was inflammatory and reactive (75.8%), followed by tumor/tumor like (16.8%) and cystic (7.4%). The mucocele was the most commonly found lesion, followed by pyogenic granuloma and irritation fibroma. Together, these reactive lesions accounted for 63.8% of all paediatric oral biopsies. The most common site for lesions was the lower lip (50.3%) [2].

Cerebral Palsy (CP) is a condition caused by damage to the brain during or shortly after birth, and during the early years of life. The worldwide incidence is 2-2.5 per 1,000 live births [3]. CP comprises a group of permanent disorders of the development of movement and posture, which limit activity, and which are attributed to nonprogressive disturbances that occurred in the developing fetal or infant’s brain. The motor disorders of CP are often accompanied by disturbances of sensation, perception, cognition, communication and behavior. In some cases, epilepsy and secondary musculoskeletal problems are diagnosed [3]. Patients with CP may show oral clinical manifestations such as lip incompetence, a high rate of Class II malocclusion and an anterior open bite due to hypotonia of the orofacial muscles (poor control of the lips and tongue), which may lead to additional disturbances in swallowing, chewing and sucking. Most young CP patients visit special daycare centers, where they receive some of their medical and para-medical treatment [3,4].

The purpose of this report is to present the diagnostic process and management of a long-lasting ulcerated lesion in the lower labial mucosa in a 28 month old girl with CP.

Case Report

A twenty-eight month old girl with CP, uncontrolled epilepsy, failure to thrive, breathing difficulties and reactive diabetes (subsequent to a ketogenic diet) arrived at the department of paediatric dentistry due to an unhealed ulcer for 3 weeks. Her paediatrician prescribed Oracort E paste (contains 3% Lidocaine hydrochloride and 0.1% Triamcinolone acetonide; TARO Pharmaceutical Industries Ltd, Israel) to relieve the symptoms and enable proper feeding from a bottle. Oral hygiene was maintained by brushing the teeth twice a day; and due to perioral muscular hypotonus she received physical stimulations of the oral soft tissues a few times a day by caregivers.

A shallow ulcer (1 cm diameter) in the lower labial mucosa was observed (Figure 1a). Self-trauma (biting) was unlikely, because the upper teeth had no contact with the lesion in the occlusion position. After consultation with a maxillo-facial surgeon and oral medicine specialist, it was decided to take viral, fungal and bacterial cultures, to stop the physical stimulation, to clean the ulcer with chlorhexidine gluconate 0.12% alcohol-free solution 4-5 times a day; and, to relieve pain before eating with topical Teejel gel (contains 8.7% choline salicylate and 0.01% cetalkonium chloride; Rafa Laboratories Ltd, Jerusalem). A follow up visit was scheduled after 1 week.