Journal of Neonatology & Clinical Pediatrics Category: Clinical Type: Review Article
Oral Pathology in Paediatric Patients
*Corresponding Author:Saleha Shah
Department Of Surgery, Aga Khan University Karachi, Karachi, Pakistan
Received Date: Apr 11, 2018 Accepted Date: Jun 01, 2018 Published Date: Jun 15, 2018
Gingival/Dental lamina cyst of neonates
Congenital epulis of the newborn
Epidermoid and dermoid cysts
Neonatal osteomyelitis of maxilla
Neonatal herpes simplex virus infection
Neonatal pemphigus vulgaris
Melanotic neuroectodermal tumor of infancy
Restrictive mandibular lingual frenum/Ankyloglossia
Mandibular labial frenum
Natal and neonatal teeth
Soft tissue infections of odontogenic origin spread along planes of least resistance from the supporting structures of the affected tooth to various potential spaces in the vicinity. Accumulated pus must perforate bone, generally at the site where it is thinnest and weakest, before extending into the periapical areas or deeper facial spaces. If the pus perforates through either the maxillary or mandibular buccal plate inside the attachment of the buccinator muscle, infection is intraoral. If the perforation is outside this muscle attachment, infection will be extraoral .
If these infections are left untreated they may lead to abscess, pain, cellulitis and discomfort on eating or drinking and dehydration. Infection in the upper part of the face includes facial pain, fever, and inability to eat or drink and difficult to localize. Sinusitis may mimic the symptoms of an odontogenic infection hence should be ruled out. Infections in the lower part of the face include pain, swelling, and trismus . they may be associated with the skin, teeth, lymph nodes, and salivary glands  and a swelling of the lower face is most likely associated with a dental infection .
Management of odontogenic infections includes pulp therapy, incision and drainage or an extraction . Antibiotics are indicated in systemic manifestations such as facial cellulitis, difficulty in swallowing or breathing, fatigue, high temperature (102 to 104 degrees Fahrenheit) and nausea. Rare but severe odontogenic infection complications such as Ludwig’s angina and cavernous sinus thrombosis [26,65] may be life threatening and may require instant hospitalization, intravenous antibiotics, incision and drainage and referral/consultation for an oral and maxillofacial surgeon [26,65] (Table 1).
they are smooth, whitish and keratin filled 1-4 mm papules. they are present along the fusion line of the palatal halves.Differential diagnosis: Bohn nodules.
|Gingival/Dental Lamina Cyst of Neonates||7.3/1000||
Asymptomatic, multiple, 1-3 mm, nodular, creamy white lesions present bilaterally on the anterior aspect of dental ridges.Differential diagnosis: Hemangioma, melanoma, unicystic ameloblastoma, keratinizing cystic odontogenic tumor and mucocele.
Asymptomatic, smooth, firm, whitish keratin filled nodules or papules ranging from 1-3 millimeter arise on the buccal and lingual aspects of the maxillary ridge away from the midline.Differential diagnosis: Epstein pearl (Dental lamina cyst) and natal teeth.
|Congenital Epulis of the Newborn||0.0006||
A protuberant tumor mass of gingival mucosa on the anterior maxillary ridge. It is single, firm with a regular surface. It maybe multilobed, sessile or pedenculated, pink or red mass and not painful on palpation.Differential diagnosis: Granular cell tumor.
Soft tissue benign cyst arising around an erupting tooth when the dental follicle separates from the crown of tooth and results in fluid collection within this space. It is a dome shaped swelling and the color ranges from normal to blue-black, purple or brown. It may be transparent as well.Differential diagnosis: Granuloma, amalgam tattoo and Bohns nodule, dentigerous cyst.
|Epidermoid and Dermoid Cysts||1.6%||
Epidermoid cyst is lined by epidermis. A dermoid cyst is lined with adnexa glands. these soft, cystic lesions are nodular with a sessile base and lined with squamous epithelium.Differential diagnosis: Ranula, lymphatic malformation and heterotypic gastrointestinal cyst, granular cells, schwanoma, lipoma and neurofibroma.
|Mucocele||2.4 per 1000||
this is a bluish, well-circumscribed, translucent, fluctuant swelling. It arises on the lower lip lateral to the midline when the excretory duct of a minor salivary gland ruptures due to mechanical trauma and mucin leaks into the surrounding connective tissues with in a fibrous capsule.Differential diagnosis: Mucous retention cyst, benign or malignant salivary gland neoplasms, hemangioma, lymphangioma, venous varix or venous lake, lipoma, soft irritation fibroma, oral lymphoepithelial cyst, gingival cyst in adults, soft tissue abscess, cysticercosis (parasitic infection), anterior lingual mucoceles (Blandin-Nuhn mucoceles) may resemble hemangioma, Pyogenic granuloma, fibroepithelial polyp.
|Riga-Fede Disease||1:6000 to 1:800||
the rubbing of natal or neonatal tooth during feeding on the ventral tongue surface, lip, gingiva, vestibular mucosa, palate and floor of the mouth leads to ulcers.Differential diagnosis: Fungal infection, tuberculosis, cytomegalovirus. Neoplasms like lymphoma, leukemia, sarcoma and granular cell myloblastoma. Others include recurrent aphthae, bechets disease, pernicious anemia, chemical burns and granulocytosis
|Neonatal Osteomyelitis of Maxilla||1/1000-3/1000||
the characteristic feature of this condition is gross swelling of the affected side. Acute fever follows redness and edema of cheek, swollen eyelids with conjunctivitis and unilateral nasal discharge attributed to risk factors like catheterization, parenteral nutrition status, prolonged hospitalization, ventilatory support and nosocomial infection or iatrogenic.Differential diagnosis: Ewing’s sarcoma, langerhans cell histiocytosis, bone metastases, and chronic recurrent multifocal osteomyelitis.
It manifests as white plaques of hyphae, epithelial cells and necrotic tissues on the oral mucosa.Differential diagnosis: Chemical burn, reactive keratosis, hairy leukoplakia, plaque type lichen planus, erosive lichen planus, premalignant leukoplakia, thermal burns, migratory glossitis.
|Neonatal Herpes Simplex Virus Infection||31/1000||
the vesicles arise in the mouth, face, scalp, palms and feet. they may be single or clustered; 1-3 mm in diameter and eventually ulcerate. Other symptoms include hepatitis, pneumonitis and seizure and disseminated intravascular coagulation.Differential diagnosis: Neonatal sepsis, pediatric chickenpox, pediatric cytomegalovirus infection, pediatric enteroviral infections, pediatric erythema toxicum, pediatric sepsis, zoster workup.
|Neonatal Pemphigus Vulgaris||0.68/100,000||
An autoimmune, vesiculobullous disease manifests as multiple mucosal, cutaneous or mucocutaneous ulcerations after birth. the intraepithelial blisters may arise on soft palate, buccal mucosa, verntra surface of the tongue, gingiva and lower lip. In more advanced stages desquamative or erosive gingivitis may be present. the other oral manifestations include sialorrhea, halitosis and brown or blackish crusts at the vermillion border.Differential diagnosis: Recurrent aphthous stomatitis, behçet disease, erythema multiforme, erosive lichen planus, and oral candidiasis, disseminated erythematous lupus, enteropathic acrodermatitis, crohn’s disease, hemorrhagic rectal colitis; and deficiencies in folic acid, vitamin B12, or hypochromic iron.
this is a benign vascular neoplasm emerging as a macule on birth but may appear a few weeks after and regresses into spotted pigments. the course of disease follows a rapid proliferating phase (0-1 yr), involuting phase (1-5 yr) and involuted phase (5-10 yr). It appears on neck and head, trunk, extremities, lips, tongue, buccal mucosa, palate and uvula.Differential diagnosis: Angiosarcoma, Capillary Malformation, cherry hemangioma, cobb syndrome, congenital hemangioma (noninvoluting and rapidly involuting), dabska tumor, dermatofibrosarcoma protuberans, cutaneous lipomas, pyogenic granuloma (lobular capillary hemangioma), diffuse neonatal hemangiomatosis, gorham syndrome, infantile fibrosarcoma, infantile myofibromatosis, kaposiform hemangioendothelioma, lipoblastoma of infancy, lymphatic malformation, oral lymphangiomas, pediatric rhabdomyosarcoma, pediatric teratomas and other germ cell tumors, riley-smith syndrome, venous malformations.
|Melanotic Neuroectodermal Tumor of Infancy||10-15%||
this rare pigmented benign neoplasm appears in the first 6 months arises from the neural crest cells and may be located on the tongue, buccal mucosa, palate or floor of the mouth, or maybe in the craniofacial region, brain, skull, maxilla, mandible and the genitals. It is a painless, expansile, nonulcerative rapidly growing, pigmented, lesion with a locally aggressive behavior.Differential diagnosis: Periapical cyst, dentigerous cyst, odontogenic keratocyst, calcifying odontogenic cyst
|Restrictive Mandibular Lingual Frenum/Ankyloglossia||0.1% to 4.8%||
A short, thick and tight fibrous vertical band of tissue formed by small band or fold of mucosal membrane may limit tongue movement (partial ankyloglossia/tongue tie) or fuse the tongue to the floor of the mouth (total ankyloglossia).Differential diagnosis: Complete ankyloglossia, bifid tongue, microglossia
|Mandibular Labial Frenum||63%||
A high frenum present in the shallow vestibular region of the mandibular permanent central incisor region inserts into the free or marginal gingival tissue. Lower lip movements pull the fibers and lead to food and plaque entrapment, inflammation, pocket formation, recession and alveolar bone loss.Differential diagnosis: Traumatic scar, frenal tag.
|Natal and Neonatal Teeth||1:1,000 to 1:30,000||
Natal teeth are present at birth and neonatal teeth erupt during the first 30 days of life. Riga-Fede disease is an ulceration caused by rubbing of the natal or neonatal tooth against the ventral tongue surface during feeding.Differential diagnosis: Carious lesion, pulp polyp or premature eruption of successor teeth.
they are secondary to caries, trauma or periodontal problems and may involve more than one tooth. If these infections are left untreated they may lead to abscess, pain, cellulitis and discomfort on eating or drinking and dehydration. Infection in the upper part of the face includes facial pain, fever, and inability to eat or drink and difficult to localize.Differential diagnosis.
PEDIATRIC ORAL PATHOLOGY MANAGEMENT
The biopsy specimen from the oral and maxillofacial region is submitted for histopathology. Tissues excluded include carious teeth without soft tissue attachment, extirpated pulp and normal tissue from gingival recontouring . Gross description of the tissue removed should be entered into the patient record. A lesion which persists for more than two weeks despite removing the causative agent or drug therapy warrants a soft tissue biopsy. If the differential diagnosis indicates more than one disease or neoplasm the hard or soft tissue must be evaluated by a pathologist. Histopathology informs about the clinical behavior, a definitive diagnosis, prognosis, the need for additional treatment or follow-up, allows evidence-based care provision with an increased likelihood for a positive result . Oral biopsies can be performed by a pediatric dentist however. the lesions which should have a biopsy include gingival hyperplasia unresponsive to oral hygiene regimen, mucocoele, pyogenic granuloma and other reactive lesions of gingiva, squamous papilloma or oral wart, irritation fibroma, periapical cyst or granuloma which may or may not be attached to an extracted tooth, inflamed operculum, hyperkeratosis of uncertain cause, benign migratory glossitis with an atypical or stationary pattern, smokeless tobacco keratosis, persistent oral ulcers, mucocutaneous diseases, odontoma and dentigerous or dental follicle cyst [69,70].
- Kleinman DV, Swango PA, Pindborg JJ (1994) Epidemiology of oral mucosal lesions in United States schoolchildren: 1986-87. Community Dent Oral Epidemiol 22: 243-253.
- Shulman JD (2005) Prevalence of oral mucosal lesions in children and youths in the USA. Int J Paediatr Dent 15: 89-97.
- Neville BW, Damm DD, White DK (2003) Pathology of the teeth. In: Color atlas of clinical oral pathology, (2nd edn). Williams & Wilkins, Baltimore, USA, Pg no: 58-60.
- Howard RD (1967) the unerupted incisor. A study of the postoperative eruptive history of incisors delayed in their eruption by supernumerary teeth. Dent Pract Dent Rec 17: 332-341.
- Flaitz CM (2013) Differential diagnosis of oral lesions and developmental anomalies. In: Casamassimo PS, Fields HW, McTigue DJ, Nowak A (eds.). Pediatric dentistry: Infancy through adolescence, (5th edn). Elsevier Saunders, St. Louis, USA.
- Hayes PA (2000) Hamartomas, eruption cyst, natal tooth and epstein pearls in a newborn. ASDC J Dent Child 67: 365-368.
- Faridi MM, Adhami S (1989) Prepucial epstein pearls. Indian J Pediatr 56: 653-655.
- Regezi JA, Sciubba JJ, Jordan RCK (2012) Cysts of the jaws and neck. In: Oral pathology: clinical-pathologic correlations, (6th edn). Elsevier Saunders, St. Louis, USA, Pg no: 245-256.
- Rajendra R, Sivapathasundharam B (2009) Shafer’s textbook of oral pathology. (6th edn), Elsevier, New Delhi, India.
- Kumar A, Grewal H, Verma M (2008) Dental lamina cyst of newborn: A case report. J Indian Soc Pedod Prev Dent 26: 175-176.
- Chi AC, Damm DD, Neville BW, Allen CM, Bouquot J, (2009) Developmental defects of the oral and maxillofacial region. In: Oral and maxillofacial pathology, (3rd edn). Elsevier Saunders, St. Louis, USA, Pg no: 25-27.
- George D, Bhat SS, Hegde SK (2008) Oral findings in newborn children in and around Mangalore, Karnataka State, India. Med Princ Pract 17: 385-389.
- Aldred MJ, Cameron AC (2008) Pediatric oral medicine and pathology. In: Nowak A, Casamassimo P (eds.). Handbook of Pediatric Dentistry, (3rd edn). Elsevier Saunders, Philadelphia, USA. Pg no: 192-216.
- Chi CA, Damm DD, Neville BW, Allen CM, Bouquot JE (2009) Soft tissue tumors. In: Oral and Maxillofacial Pathology, (3rd edn). Elsevier Saunders, St. Louis, USA, Pg no: 537-538.
- Lapid O, Shaco-Levy R, Krieger Y, Kachko L, Sagi A (2001) Congenital epulis. Pediatrics 107: 22.
- Marakoglu I, Gursoy UK, Marakoglu K (2002) Congenital epulis: Report of a case. ASDC J Dent Child 69: 191-192.
- Bosanquet D, Roblin G (2009) Congenital epulis: A case report and estimation of incidence. Int J Otolaryngol 2009: 508780.
- Shear M, Speight P (2007) Cysts of the oral and maxillofacial regions, (4th edn). Oxford: Blackwell Munksgaard, Copenhagen, Denmark.
- Alemán Navas RM, Martínez Mendoza MG, Leonardo MR, Silva RA, Herrera HW, et al. (2010) Congenital eruption cyst: A case report. Braz Dent J 21: 259-262.
- Melrose RJ, Handlers JP, Kerpel S, Summerlin DJ, Tomich CJ (2007) the use of biopsy in dental practice. the position of the American Academy of Oral and Maxillofacial Pathology. Gen Dent 55: 457-461.
- Lee JM, Kim UK, Shin SH (2013) Multiple congenital epulis of the newborn: A case report and literature review. J Ped Surg Case Rep 1: 32-33.
- McGuire TP, Gomes PP, Freilich MM, Sándor GK (2006) Congenital epulis: A surprise in the neonate. J Can Dent Assoc 72: 747-750.
- Sonis A, Keels MA (2007) Oral pathology/oral medicine/syndromes. In: Nowak AJ, Casamassimo PS (eds.). the Handbook: Pediatric Dentistry, (3rd). American Academy of Pediatric Dentistry, Chicago, USA. Pg no: 29-53.
- Bodner L (2002) Cystic lesions of the jaws in children. Int J Pediatr Otorhinolaryngol 62: 25-29.
- Mallya SM, Lurie AG (2014) Panoramic imaging. In: White S, Pharoah M (eds.). Oral radiology: Principles and interpretation, (7th edn). Elsevier Saunders, St. Louis, USA. Pg no: 166-184.
- Kaban LB, Troulis MJ (2004) Infections of the maxillofacial region. In: Dodson TB, Kaban LB (eds.). Pediatric Oral and Maxillofacial Surgery. Elsevier Saunders, Philadelphia, USA, Pg no: 171-186.
- American Academy of Pediatric Dentistry (2015) Guideline on management of the developing dentition and occlusion in pediatric dentistry. Pediatr Dent 37: 253-265.
- Mirza S, Fadl S, Napaki S, Abualruz A (2014) Case report of complicated epidermoid cyst of the floor of the mouth: Radiology-histopathology correlation. Qatar Med J 2014: 12-16.
- Kara C (2008) Evaluation of patient perceptions of frenectomy: A comparison of Nd: YAG laser and conventional techniques. Photomed Laser Surg 26: 147-152.
- Suga K, Muramatsu K, Uchiyama T, Takano N, Shibahara T (2010) Congenital epidermoid cyst arising in soft palate near uvula: A case report. Bull Tokyo Dent Coll 51: 207-211.
- Humpery PA, Dehner LP, Feifer JP (2004) Salivary Gland Pathology. Section I, Head Neck. the Washington manual of surgical pathology. Lippincott Williams and Wilkins, Philadelphia, USA. Pg no: 70-72.
- Baurmash HD (2003) Mucoceles and ranulas. J Oral Maxillofac Surg 61: 369-378.
- Russell KA, Folwarczna MA (2003) Mesiodens--diagnosis and managemMesiodens--diagnosis and management of a common supernumerary tooth. J Can Dent Assoc 69: 362-366.
- Park SW, Lee JJ, Chae SA, Yoo BH, Kim GJ, et al. (2013) Congenital epidermoid cyst of the oral cavity: Prenatal diagnosis by sonography. Clin Exp Otorhinolaryngol 6: 191-193.
- Slayton RL (2000) Treatment alternatives for sublingual traumatic ulceration (Riga-Fede disease). Pediatr Dent 22: 413-414.
- Leung AK, Robson WL (2006) Natal teeth: A review. J Natl Med Assoc 98: 226-228.
- Joseph BK, BairavaSundaram D (2010) Oral traumatic granuloma: Report of a case and review of literature. Dent Traumatol 26: 94-97.
- Costacurta M, Maturo P, Docimo R (2012) Riga-Fede disease and neonatal teeth. Oral Implantol (Rome) 5: 26-30.
- 3van der Meij EH, de Vries TW, Eggink HF, de Visscher JG (2012) Traumatic lingual ulceration in a newborn: Riga-Fede disease. Ital J Pediatr 38: 20.
- Rao RS, Mathad SV (2009) Natal teeth: Case report and review of literature. J Oral Maxillofac Pathol 13: 41-46.
- Korakaki E, Aligizakis A, Manoura A, Hatzidaki E, Saitakis E, et al. (2007) Methicillin-resistant Staphylococcus aureus osteomyelitis and septic arthritis in neonates: Diagnosis and management. Jpn J Infect Dis 60: 129-131.
- Polin R, Spitzer A (2014) Fetal and neonatal secrets, (3rd). Elsevier Saunders, Philadelphia, USA.
- Dunphy DL, Frazer JP (1947) Acute osteomyelitis of the maxilla in a newborn: Report of a case successfully treated with penicillin and sulfadiazine. Yale J Biol Med 19: 877-881.
- Benjamin DK, Stoll BJ, Fanaroff AA, McDonald SA, Oh W, et al. (2006) Neonatal candidiasis among extremely low birth weight infants: Risk factors, mortality rates, and neurodevelopmental outcomes at 18 to 22 months. Pediatrics 117: 84-92.
- Kitterman JA, Hamrick SEG, Keller RL (2003) Candidiasis, Section III, Intensive care nursery house staff manual. University of California San Francisco, San Francisco, USA. Pg no: 128-129.
- Tinoco-Araujo JE, Araújo DF, Barbosa PG, Santos PS, Medeiros AM (2013) Invasive candidiasis and oral manifestations in premature newborns. Einstein (Sao Paulo) 11: 71-75.
- Brown ZA, Wald A, Morrow RA, Selke S, Zeh J, et al. (2003) Effect of serologic status and cesarean delivery on transmission rates of herpes simplex virus from mother to infant. JAMA 289: 203-209.
- Kimberlin DW (2004) Neonatal herpes simplex infection. Clin Microbiol Rev 17: 1-13.
- Bialynicki-Birula R, Dmochowski M, Maj J, Gornowicz-Porowska J (2011) Pregnancy-triggered maternal pemphigus vulgaris with persistent gingival lesions. Acta Dermatovenerol Croat 19: 170-175.
- Parker LA, Montrowl SJ (2004) Neonatal herpes infection: A review. NAINR 4.
- Amer YB, Al Ajroush W (2007) Pemphigus vulgaris in a neonate. Ann Saudi Med 27: 453-455.
- Barnes L (2001) Surgical pathology of the head and neck, (2nd edn). Marcel Dekker, New York, USA.
- Kilcline C, Frieden IJ (2008) Infantile hemangiomas: How common are they? A systematic review of the medical literature. Pediatr Dermatol 25: 168-173.
- North PE (2010) Pediatric Vascular Tumors and Malformations. Surg Pathol Clin 3: 455-494.
- Zheng JW, Zhang L, Zhou Q, Mai HM, Wang YA, et al. (2013) A practical guide to treatment of infantile hemangiomas of the head and neck. Int J Clin Exp Med 6: 851-860.
- Chaudhary A, Wakhlu A, Mittal N, Misra S, Mehrotra D, et al. (2009) Melanotic neuroectodermal tumor of infancy: 2 decades of clinical experience with 18 patients. J Oral Maxillofac Surg 67: 47-51.
- Kruse-Lösler B, Gaertner C, Bürger H, Seper L, Joos U, et al. (2006) Melanotic neuroectodermal tumor of infancy: Systematic review of the literature and presentation of a case. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 102: 204-216.
- Segal LM, Stephenson R, Dawes M, Feldman P (2007) Prevalence, diagnosis, and treatment of ankyloglossia: Methodologic review. Can Fam Physician 53: 1027-1033.
- Kupietzky A, Botzer E (2005) Ankyloglossia in the infant and young child: Clinical suggestions for diagnosis and management. Pediatr Dent 27: 40-46.
- Ochi JW (2014) Treating tongue-tie: Assessing the relationship between frenotomy and breastfeeding symptoms. Clin Lactation 5: 20-27.
- Dollberg S, Botzer E, Grunis E, Mimouni FB (2006) Immediate nipple pain relief after frenotomy in breast-fed infants with ankyloglossia: A randomized, prospective study. J Pediatr Surg 41: 1598-1600.
- Webb AN, Hao W, Hong P (2013) the effect of tongue-tie division on breastfeeding and speech articulation: a systematic review. Int J Pediatr Otorhinolaryngol 77: 635-646.
- Kaban LB, Troulis MJ (2004) Intraoral soft tissue abnormalities. In: Kaban LB, Troulis MJ (eds.). Pediatric Oral and Maxillofacial Surgery. Elsevier Saunders, Philadelphia, USA, Pg no: 147-153.
- Seow WK (2003) Diagnosis and management of unusual dental abscesses in children. Aust Dent J 48: 156-168.
- Wilson S, Montgomery RD (2013) Local anesthesia and oral surgery in children. In: Casamassimo PS, Fields HW Jr, McTigue DJ, Nowak A, (eds.). Pediatric Dentistry: Infancy through Adolescence, (5th edn). Elsevier Saunders, St Louis, USA. Pg no: 398-410.
- Rethman MP, Carpenter W, Cohen EE, Epstein J, Evans CA, et al. (2010) Evidence-based clinical recommendations regarding screening for oral squamous cell carcinomas. J Am Dent Assoc 141: 509-520.
- Kazanowska K, Halon A, Radwan-Oczko M (2014) the role and application of exfoliative cytology in the diagnosis of oral mucosa pathology - Contemporary knowledge with review of the literature. Adv Clin Exp Med 23: 299-305.
- American Academy of Oral and Maxillofacial Pathology (2015) Submission policy on excised tissue. American Academy of Oral and Maxillofacial Pathology, Illinois, USA.
- McDonald R, Avery D, Dean J (2011) Examination of the mouth and other relevant structures. In: Dean J, Avery D, McDonald R (eds.). McDonald and Avery’s Dentistry for the Child and Adolescent (9th edn). Elsevier Saunders, Maryland Heights, USA. Pg no: 3.
- AAPD Reference Manual (2015). Guideline on management considerations for pediatric oral surgery and oral pathology. AAPD Reference Manual, Pg no: 16.
Citation:Shah S (2018) Oral Pathology in Paediatric Patients. J Neonatol Clin Pediatr 5: 022.
Copyright: © 2018 Saleha Shah, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.