Theme Section

Differential diagnosisof oral enlargementsin children

Catherine M. Flaitz, DDS, MS Gary C. Coleman,DDS, MS

Abstract Oncea specific category has been selected, the char- The purposeof this article is to review soft tissue and acteristics of the lesion can be compared with other bony enlargements that typically occur in the oral and diseases that share commonclinical features and be- perioral region of children. In order to organize these le- havioral patterns. sions into a thoroughbut comprehensibleformat, the prin- Soft tissuelesions ciples of differential diagnosis must be used. All oral en- largementsare broadly classified as soft tissue or bony Papillary enlargementsof the soft tissues are a dis- abnormalities.Determination of the specific lesion category tinct group of lesions that are easy to recognize because is based primarily on a prominent feature that demon- of their commonclinical appearance. Most of these strates the nature of the lesion, followed by the secondary lesions represent a viral-induced epithelial prolifera- clinical features and any contributory patient information. tion resulting in pale, spongy-to-firm enlargementswith Classificationof exophyticsoft tissue entities includes:pap- a pebbly or papillary, rough surface texture. These illary surface enlargements, acute inflammatoryenlarge- slow-growinglesions are painless with a limited growth ments, reactive hyperplasias, benign submucosalcysts and potential. Broadly this group is divided into isolated neoplasms, and aggressive and malignant neoplasms. Bony or multiple lesions to assist in the diagnosis and appro- enlargementsof the maxilla and mandibleare divided into priate managementof the pediatric patient (Fig 2). The three categories: inflammatorylesions, benign cystic and behavior of these lesions is variable, ranging from spon- neoplastic lesions, and aggressive and malignantlesions. taneous resolution to a recurrent, protracted course. This extensive topic is summarizedon flow charts for easy Acute inflammatory enlargements are characterized reference with emphasison groupingtogether lesions with by sudden onset, rapid progression, and compressible commoncharacteristics. ( P ediatr Dent 17:294-300,1995) tissue distention. These fluid-filled or edematousle- sions are frequently tender or painful to palpation and mayfluctuate in size. Systemic manifestations such as n enlargement of the oral cavity may repre- fever, malaise, and lymphadenopathy may develop sent a wide range of entities such as anatomic with lesion progression. As described in Fig 3, this A variations, developmental anomalies, inflam- disease category is divided into infectious and nonin- matory and reactive diseases, cysts, and neoplasms. fectious processes that present with either localized or The goal of differential diagnosis is to determine the diffuse tissue involvement. In most instances, identify- nature of the enlargement as a basis for formulating a ing and eliminating the source of the inflammation rational treatment approach. The symptoms, growth produces rapid resolution of the lesion. rate, palpation characteristics, surface morphology,and Reactive hyperplasias are a benign group of lesions lesion site allow for categorization of the soft tissue that frequently mimic neoplastic disease. Most reac- lesions into one of the five lesion groups as outlined in tive hyperplasias develop in response to a chronic, Fig 1". These descriptive categories consist of: recurring injury that stimulates an exuberant tissue repair. These inflammatory enlargements are defined 1. Papillary surface enlargements (Fig 2) by a moderate growth rate, absence of pain, and lim- 2. Acute inflammatory enlargements (Fig 3) ited growth potential. The degree of vascularity and 3. Reactive hyperplasias (Fig 4) edemaassociated with the soft tissue enlargement de- termines the color and palpation characteristics. As 4. Benign submucosal cysts and neoplasms (Fig 5) illustrated in Fig 4, this disease group is divided into 5. Aggressive and malignant neoplasms (Fig 6). either a primary or multifactorial cause for lesion ini-

* Figs1 through6 were modified with permission from Chapter 18, Differentialdiagnosis of oral soft tissueenlargements. In: Principlesof OralDiagnosis, Coleman GC, Nelson JF, Eds,St Louis:Mosby-Year Book, Inc. 1993,pp 352-88.

294American Academy of PediatricDentistry PediatricDentistry-17:4,1995 CHARACTERISTICS OF INTRAORAL SOFT TISSUE ENLARGEMENTS IN CHILDREN

Smooth,bosselated, Dome-shapedenlargement Asymmetricenlargement fissured sudace Superficial mucosaunaffected Fusiformor pelypoidin shape Paleto redin color Widevariability in color Alteredappearance of Maybe ulcerated Solitarylesion with well superftcial mucosa Nodularor polypoldin shape definedmargins Ulcerated,red surface Solitaryor multifocal Freely movable Rapidgrowth (weeks or months) Moderategrowth rate Compressibleto firm Asymptornatic(early lesions) (months) Stowgrowth rate Pain, paresthesia, Painlessuntess secondarily (monthsto years) lymphadenopathy(advanced traumatized Asymptomaticunless lesions) Softor firm incidentallytraumatized or Firmto induretod Limitedgrowth potential interferewith function Fixedto underlyingtissues Causeis often apparent Unlimitedgrowth potential Infiltrative margins Nosystemic features Noapparent cause Invasionof alveolarbone Recuror persistif causeis Nosystemic features Characterizedby tissue not eliminated Characterizedby distortion of destruction Very common anatomiccontours Naso-oropharyngealobstruction Remainslocalized Disseminationand metastasis Uncommon often develop ~= Rare ~’ Papillary Surface Acute Reactive Benign Aggressive Enlargements Inflammatory Hyperplaslas Submucosal and Enlargements Cysts and Malignant Neoplasms Neoplasms

Fig 1. Differential diagnosis of intraoral soft tissue enlargements in children.

ORAL PAPILLARY SURFACE ENLARGEMENTS I I

I I Caulifloweror finger-likeII Nodular, sessile lesion Rough,pale surface Papillary,sessile lesion Plaque-likelesions Red,papular lesions appearance II Rough,stippled surface Sessile base Softto palpation Pale, granular Superficialcandidiasis Narrow,stalk-like baseI I Paleto normalin color Perioralskin, lips and Clustereddistribution surface Clustereddistribution Pink or whitein color I I Gingiva,tongue palate Sexualcontact with Welldefined borders Hardpalate FiKn, rough, nontenderI I andpalate Additionallesions on similargenital lesions Widespreadoral Reactivehyperplasla to palaption I I Reactivehyperplasia hands,fingers Recurrenceis common involvement Associatedwith full Palateand tongue I I Recurrenceis rare Autoinoculation Maybe a sign of Spontaneous palatal coverage Recurrenceis rare I I Commonoral lesion Commonskin lesion sexualabuse regressionmay applianceor na~Tow Commonoral lesion ! Rareoral lesion occur palatalvault Rare Uncommon

Squamous Giant Verruca Condyloma Focal Epithelial Papillary Papilloma Fibroma Vulgaris Acumlnatum Hyperplasia Hyperplasla

Fig 2. Differential diagnosis of papillary surface enlargements in children. tiation and growth. Partial regression of the lesion may tion, this group is subdivided by site predilection and occur if the source of the soft tissue injury is removed. palpation characteristics. Definitive diagnosis of this Benign submucosal cysts and neoplasms are an un- disease category is based on histopathologic examina- commongroup of lesions that are nodular, well delin- tion of the surgical specimen. eated, and freely movable enlargements with normal- Aggressive and malignant soft tissue enlargements appearing, intact mucosal surfaces. The slow and of the oral cavity are the rarest but most important persistent growthpattern results in alteration or dis- group to identify in the pediatric population. Rapid, tortion of the tissues. Most of these lesions are progressive growth of an asymmetric enlargement with asymptomatic unless they are traumatized or impinge infiltrative margins are defining features of this group on vital structures. These lesions are divided into soft of lesions. These firm, fixed tumors demonstrate ir- tissue cysts, benign connective tissue tumors, and sali- regular surface changes with areas of erythema and vary gland neoplasmsas illustrated in Fig 5. In addi- ulceration. Although early lesions are asymptomatic,

Pediatric Dentistry - 17:4, 1995 American Academy of Pediatric Dentistry 295 ACUTE INFLAMMATORY ENLARGEMENTS

FoninfectiousProcess I

Translucentblue Swellingusually Swellingassociated Fluctuatesin size associatedwith a with an unerupted Mucuscontents periapicalor mand~ularmolar Historyof injury periodontallesion Pain, trismus Mandibularlip Redor yellowin color Usually contains Frequentlyrecurs Purulentexudate semisolidmatedal Common Very common Very common

Mucus Retention Phenomenon Soft Tissue Pericoronitis Abscess I Fluctuatesin size Pruritic planes I I Blockageof Suddenonset Introducedby air Extensiveswelling ~ ~ Majorgland involvement Wharton’sduct Smoothsurface syringe or handpiece Suddenonset | ~ Unilateralor bilateral Floor of mouth Allergic reactionor Immediateonset Obviouscause | Ii Viral, bacterialor Unilateralor hereditary Crepit~tionon Fever, pain, tdsmus| | obstructive bilateral pattern palpation Life threatening | | Maybe recurrent Mayherniate Lips Mayresult in complicationsmay | | Painful wheneating throughfascial Life threatenng if.. pneumomediastinum Idevelop | | or drinldng planes larynxis invoived Rare~atmgen~c Common I i Commonwm mumps Uncommon Uncommon complication + Cellulitis Acute Sialadenitis Ranula Angioedema Emphysema

Fig 3. Differential diagnosisof acuteinflammatory soft tissue enlargementsin children.

SOFT TISSUE REACTIVE HYPERPLASIAS I I I PrimaryCause Is RecurringInju~ or I Multifactorial CausesPlus Local Irritation ChronicLocal Irritation I Gingiva Affected I I L Hormoneor Drug-Related I

Red,ulcerated Surface Nontender Surface Smoothsurface I Smooth,pebbly Soft ulceration Maybe ulceration Nontender I Firm Hemorrhagic Bleedswith ulcerated Hemorrhagic Generalized I Generalized Hormonal probing Displacesteeth Nontender enlargement I enlargeme~ fluctuations Nontender Alveolarcuffing Mayoccur at Familymembers I Nontender Nontender Alveolarcuffing of bone othersites affected I Commonwith Females Common of bone Uncommon Common Uncommon I certain drugs

Gingival Drug-induced Peripheral Peripheral Pyogenic Fibromatosls Ginglval Giant Cell Ossifying Granuloma Hyperplasia Normatcolor I!Red,ulcerated I I NontenderII Maybemultiple Tenderwhen II fissured surface I Sites of II Spongytofirm palpated II Lobulated I frequent II MitdlytenderTongueand lips II Rrm Frequently I frauma II Surf’ace II Mucobuccalfold Hormonal II vacularity associated II RelatedtO Pregnancy IITongue. withscar over~ened Tumor Gingivitis I c6mmon Uncommon II acrylic appliances L...._.,.~_...J I floor of mouth ~ ~ IVery IIUnc°mm°n * ;I C°mmon t ; Pulp Epulis Traumatic Reactive Traumatic Inflammatory Polyp Granulomatosum Fibroma Lymphoid Neuroma Fibrous Hyperplasia Hyperplasia

Fig 4. Differential diagnosisof soft tissuereactive hyperplasias in children.

296 AmericanAcademy of Pediatric Dentistry Pediatric Dentistry - 17:4,1995 BENIGN SUBMUCOSAL CYSTS AND NEOPLASMS I Gingival Site Gingiva Not Limited In Location To

~tS~L"~c~n d~:a nt

Infant Infant [ Connectivetissue origin Female Bluish, cystic predileciton Anterior Posterioralveolar Usuallynot site specific Uncommonto rare lesions maxillary mucosa Vascularlesions are Anyintraoral site possibleexcluding mucosa Multiple,bilateral common,others are gingivaand antedor hard palate. Pink, red nOdule Black ma~e rare in children Posterior palate is mostcommon oral predilectlon location. Parotldis the majorgland Epstein’s Thyroglossa! Cyst ,| Uncommon mostoften affected. Pearls Neck Moderaterecurrence rata Dermoid Cyst Floor of mouth ! Congenital Neonatal Nasolabial Cyst Soft,compressibleI Gingival Alveolar Maxillarylip Granular Cell Lymphangloma Lymphoepithellal Cyst I Tumor Floor of mouth, tongue ~c°miressib!~I ’-- Pleomorphlc Lipoma Neuroflbroma Adenoma I . I (most common) Infants Yellow Tongue, palate II Unerupted II Incisive Buccal mucosa Schwannoma Myoepithelioma super~ialgingivaII tooth II ~a Basal Cell Adenoma Multiple II Bluish II Uncommon Hemangloma Encapsulated Spontaneoos Red, blue, blanches Tongue, palate regression II regresses~ I~ Parotid, tongue,lips Rhabdomyoma I ve~commo~II commo~I~ Lymphangloma Parotid, tongue, Cystadenoma ~ Pink, red, pebbly surface soft palate Warthln’s Tumor Tongue,lips, (Cystic Leiomyoma Hygroma in neck) Occasionally red Dental Eruption Cyst of the Plexlform Lips, tongue, palate Lamina Cyst Incisive Neurofibroma Granular Cell Tumor Cyst Papilla Feature of White, rough surface neurofibromatosis Tongue Mucosal Neuroma Feature of multiple endo~ine neoplasia syndrome Fig 5. Differentialdiagnosis of benignsubmucosal cysts and neoplasms in children.

AGGRESSIVE AND MALIGNANT SOFT TISSUE ENLARGEMENTS

I Submucosal Malignancies I I Benign, Aggressive Conditions I I Surface Epithelial Mal~nancios] I [ ’ I I Maybe congenital Youngmalss White, thickenedor Cutaneouslesion Infiltrative Nasalobstruction red granular Flesh-coloredor Rapid growth Epistaxis surface p/gmented Surface Facial palatal Nonhealingulcer Nodulewith ulceration expansion Posterior tongue depressedcenter High recurrence Ulcerated, vascular Cofactors(alcohol, Associatedwith rate Intracranial tobacco,UV light, navoidbasal cell extension common viruses and immune carcinoma systemdeficiency) syndmme Rhabdom osarcoma Leukemi= Veryrare in children Veryrare in children Tongue,soft palate and Generalizedgingival Aggressive Nasopharyngeal tonsillar pillar region enlargement FIbromatosis Angiofibroma Flbrosar¢oma Petechiee and ecchymoses Mandibular alveolar mucosa, Oral ulcers Squamous Cell Basal Cell chin and angle of the Mobility of teeth Carcinoma Carcinoma Hodgkln’s Lymphoma Other Sarcomas Painless lymphedenopathy Site depends on neoplasm Cervical lymph node chain Malignant Salivary Weightless, fever, night sweats Gland Neoplasms Non-Hodgkln’s Lymphoma Most common: Painless lymphadenopathy M ucoepidermoid carck’~ma Asymmetric enlargement of Early lesions mimic pha~ngealtonsils, palatal benign neoptasm mucusa, buccai muceaa,giegiva Paro~dand posterior Metastatic disease hard palate Gingiva most commonsoft tissue site Malignancies of Bone Tumorextrusion from exl~action sits with Soft Tissue Extension See Figure 10

Fig 6. Differentialdiagnosis of aggressiveand malignant soft tissueenlargements in children.

Pediatric Dentistry - 17:4, 1995 American Academy of Pediatric Dentistry 297 CHARACTERISTICS OF JAW ENLARGEMENTS IN CHILDREN

Clinical Radiographic Clinical Radiographic Clinical Radiographic Features: Features: Features: Features: Features: Features: Tenderor painful to Widenedperiodontal Nontenderto palpation Intact periodontal Maybe tenderor painful Lossof the laminadura palpation ligament space, Slowgrowth I~jament space Moderategrowth rate anddental crypt Rapid entargement especiallyapica~ 113 (monthsto years) Laminadura anddental (weeksto months) Roaringtooth (days to weeks) or furca Localized expansion crypt present Diffuse enlargement appearance Diffuseor localized Loss of lamina dura Normalsurrounding Occursin alveolus and Mayhave a multitocal Bodyof Jaws, may enlargement anddental crypt mucosa bedyof the jaws distribution extepdto the Red,fender swoilan Irregularinternal or Progressesin size Interior or lateral tooth Mucosais red, ulcerated, alveolus mucosa external resorption Usually no apparent displacement firm andftxed Symmetricwidening of Fluctuatesin size Locatedin alveolar cause Displacementof Vital, mobileteeth the periodontal Drainage,sinus tract bone,may extend to No systemicfeatures anatomicstructures Extrusionof teeth ligament space foRnation body of bone Maydelay tooth Blunt root resorptionwith Progressiveincrease in Irregular root Causeis often apparent Usuallyradiolucent, eruption large lesions size resorption Mobile,nonvital tooth mayappear mixad Subtlefacial Radiolucent,mixed or No apparent cause Irregular wideningof Systemicfeatures such Poorly defined margins asymmetry radiopaque Systemicfeatures maybe maedibularcana~ as fever, Indistinct trabecular Uncommon Unilocularor muitilocular present Radiolucentor mixed lymphadenopathyff pattern shape Frequentparesthesle, lesion advanced Proliferativeperiostitis Well delineated margins anesthesia Poorly defined margins Trismus, occasional is common Cortical expansion Trlsmuswith advanced Lossof trebecular pere~hesle disease pattern Regression(healing) Uncommonor rare Occasional Common proliferative periostitis Cortica~destn~ction

Inflammatory Benign Cystic and Aggressive and Lesions of the Neoplastic Lesions Malignant Lesions Jaws of the Jaws of the Jaws

Fig 7. Differential diagnosis of intraoral lesions characterized by bony enlargement in children.

INFLAMMATORY LESIONS OF THE JAWS IN CHILDREN

I I I Localized Lesions I I Diffuse Lesions I , I I i I I I Periapical Location I ! Nonperiapical Location I [ IRnfead~t(~loUu(:nt’ Idiopathic I I I I I I nadiopaque I I Peripheral Codex Pain, trismus Inherited disease I Cedes,trauma, Occurspdor to six months I idiopathic of age Radiolucent Chronicpulpal Swelling, purulence Tender,soft tissue disease Associatedwith Facial trauma Febrile, swelling Nonexpansile erupting mandibular Inferior borderof molars lymphadenopa~y Febdle, lymphedenopathy Posterior mandible mandible Posterior mand~le Bilateral mand~ular Sharp margins History of pericoronitis Maybe associated Buccal expansion involvement Static with time with jaw fracture "Onion-skin" appaarence Deepperiodontal Irregular or sunburst Spontaneousresolution pocket pattem Acute Proliferativeperlostitis Osteomyelitis Focal Scleroslng Osteomyelltla Infantile Cortical Inflammatory Traumatic Hyperostosis Paradental Cyst Osteoma I Chronic dental dentalinfection lnfestion II Chronic Indistinct margins IIlesionDi"use’expansi’e Tender,painful Chmnic Maybe tender Mottled bonypattern i IndiStinct margins History of infection Distinct hyperostotlc SequestnJmIs : Mottled bonepattern = caries, trauma Periodsof acute borders common "Onion.skin Untlocular, exacerbation Nonvital tooth Ankylosis mayoccur appearance indistinct Unlfocular, Expensile Posterior mandible Posterior mandible man:J~ns distinct margins Displacementof Nonvital tooth Nonvital tooth developingtooth

Chronic Diffuse Chronic Scleroslng Osteomyelitls Perlaplcal Perlaplcal Perlaplcal Osteomyelltis wlth Proliferative Abscess Granuloma Cyst Periostltls

RURO= mixed radiolucent and radiopaque lesion Fig 8. Differential diagnosisof inflammatorylesions of the jawsin children.

298American Academy of PediatricDentistry PediatricDentistry -17:4,1995 BENIGN CYSTIC AND NEOPLASTIC LESIONS OF THE JAWS I

Radiolucent I I Mixed Radi°lucent-Radi°paque I i Radi°paque I t , I , 2 I I PericoronalLocation ’ ’ L~ I~entrat Location I IC~=Location I , I I Un"ocu’arI Unilocular when smatl’ I-~I--- I

Eruption Cyst Bluealveolar mucesa (S~ple Bo~ C~t) Un~ Dentigerous Cyst Mandibutarpremolar-molar area Mostcernmon in maxiila I Odontoma Torus/Exostosls Third molarand canine Maycross midline Adenomatoid I Mayocc~ in Nonneoplaaticprocess periapicalarea Obviousclinically Unicysti¢ Usuallynonexpansile Odontogenic Tumor I Ameloblastoma Scallopedinttaradicular margins Unilocular cou~oued: Osteoma I tooth-l~e Maybe centTal Mandibularsece~d and Oftenextends between tooth Mostcommoo in anterior maxilla I roots withouttooth movement Ameloblastic Fibro-odontoma cak~cations th~’dmolar regio~ I Complex: Associatedw~h 10%recurrence rate Mulfilocular / Mostcommon in posterior mandible~ amorphous Gardner’ssyndrome calcifica~on Central Giant Cell Granuloma Central Ossifying Fibroma Fibrous Dysplasla Mandibularcanine-premolar region Maybe unilocular o¢ multilccular Nonneoplasticcondition Maycross midline Progressesfrom RL* to Maybe multifocal Odontogenic Keratocyet Moderaterecurrence rate mixedto RO**with time Maxillarypremolar-moist region Posteriormandible Aneurysmal Bone Cyst Mandibularpremotarhnolar region Progressesf~em RL to Maycross midline Eccentricballooning of mandible Juvenile Ossifying Fibroma mixedtoRO wi~ time 50%cause pain Multilocular lesion Poorlydefined margins Maybe associatedwith nevoid Associatedwith concurrentlesion Maxima Elliptical expansion basalcell carcinomasyndrome Central Hemangloma Aggressivelesion Stabilizeswith time Ameloblastic Fibroma Vaguemargins Cementoblastoma Mand~ulsrfirst, second Gingivalbleeding, bruit, pulsation Postario~mandible molarregiee Toothmobility Progressesfi’om RLto Recurrencesuncommon Life threateninglesion mixedto ROwith t~ne Odontogenl¢ Myxoma Interrn~entmild pain, vital tooth Faint radiopaquestri~ons Attachedto toothroot Posterio~mandible Osteoblastoma Moderaterecurrence rate Posteriormandible Cherublsm Progresses~’om RL to Inheriteddisordar, bilateral * RL= radioluceot mixedto ROwi~ ~me Regresseswith time °" RO= radiopaque Severepain, vital tooth Radiating,"sunburst" pa~em Fig 9. Differentialdiagnosis of benigncysts and neoplastic lesions of the jawsin children.

AGGRESSIVE AND MALIGNANT NEOPLASMS OF THE JAWS I Unifocal and Unifocal and Mixed Multifocal and Radiolucent IRadiolucent-Radiopaque Radiolucent I

Posterior Posteriormandible Mandibleor I mandibleand Early symme~ic Palnf%li~aswellingI ramus wideningof Anteriormaxilla Maybe multifocal Painfulexpansion periodontal Poorlydelineated "Punched-out" Expansile radiolucancy Febrile, ligament tad o ucent "Floating Usuallynonexpansile leukccytosls Occasional toothbuds" "Floatingtooth" "Moth-eaten" periosteat Pigmentedor red appearance pattem proliferation surface Occasional Periosteal Sunburstpattern is proliferativeperioatitls proliferation uncomrnon

Maybe multilocular Ewing’s SarcomaOsteosarcoma Mesenchymal Poorlydelineated Chondrosar¢oma Localized Expaesile Idiopathic I I "Floatingtoothbuds" Hlstiocytosls Multiplehone, Postariormaxilla widespread Pceterior I Softtissue exqension (Eosinophilic argan andmandible involvement mandible IHighrecurrence rate Granuloma) involvement Oneto four Occasional Poorlydefined Pain, quadrants gingival i radiolucescy lymphadenopathy involved enlargement Softtissue Well to poody Gingival Painfulswelling Lossof lamina Neuroectodermal Paresthesia definedmargins enlargement First sign:tooth dura Paresthesia Tumorof Infancy Unilccularor "Cupped-out" Premature mobility Toothmobility ~ mutlilocular appearance exfoliafionof "Moth-eaten"or Diffuse,poorly Desmoplastic I CorticalBodyof mandible Fine"ground teeth multilocular defined Fibroma of Bone pedocation glass"berdars "Floatingtooth" radiolucency radiolucency appearance Periostealbone Occasionat formation periosteaJbone Central+ SarcomasPrimary Soft forrnafion of Bone Tissue ~ Malignancies ~--I Adjacent to Bone Disseminated Burkltt’s Leukemia Metastatic Idiopathic Lymphoma Disease Histiocytosls

Fig 10. Differential diagnosis of aggressive and malignant neoplasms of the jaws in children.

Pediatric Dentistry - 17:4, 1995 American Academy of Pediatric Dentistry 299 pain, paresthesia, lymphadenopathy,and naso-oropha- space, and a floating tooth appearance frequently are ryngeal obstruction develop with tumor progression. observed. Aggressive and malignant neoplasms of bone These diseases have been divided into: benign, aggres- are categorized as radiolucent or mixed radiolucent- sive conditions; submucosal malignancies; and surface radiopaque lesions demonstrating unifocal or multifo- epithelial malignancies to compare commonclinical cal presentation (Fig 10). features (Fig 6). In general, prognosis of this category Conclusion of lesions depends on the size of the lesion, proximity In summary,this review article arranges exophytic to vital structures, and evidence of metastasis. oral lesions according to common,pertinent character- Bony enlargements istics to allow differential diagnosis in the pediatric age Bony enlargements of the maxilla and mandible in group. Flow charts for both soft tissue and bony en- children rely on both clinical features and radiographic largements of the oral cavity have been designed to interpretation in order to develop a differential diag- assist the pediatric dentist in this important decision- nosis. To managethis comprehensive topic, there are making process. Although the outline of this material three distinct categories of bony enlargements: 1) in- is fairly comprehensive,its utility is as a supplementto flammatorylesions of the jaws (Fig 8), 2) benign cystic more comprehensiveoral pathology and diagnosis text- and neoplastic lesions (Fig 9), and 3) aggressive books. In addition, it is not the goal of this material to malignant lesions (Fig 10). The pertinent clinical and allow the practitioner to arrive at a definitive diagno- radiographic characteristics of jaw lesions in children sis, but rather, to determine appropriate treatment based are summarizedin Fig 7. on the most likely cause for the soft tissue or bony Inflammatorylesions of the jaws have similar clini- enlargement. Although neoplastic diseases in children cal findings as those described for the soft tissue coun- are uncommon,early detection frequently has a sig- terpart. Rapid enlargement, pain, erythema, and drain- nificant impact on the treatment regimen, surgical re- age are characteristic. An apparent cause, in particular sults, and overall prognosis. a mobile, nonvital tooth, frequently is observed. Im- Dr. Flaitz is associate professor and director, Surgical Oral portant radiographic features include a poorly defined PathologyService, Divisionof Oral Pathologyand Divisionof Pediatric Dentistry, TheUniversity of Texas---HoustonHealth radiolucent or mixed radiolucent-radiopaque lesions Science Center Dental Branch, Houston. Dr. Coleman is associate of the alveolar bone. Additional findings maydemon- professor, Division of Oral Diagnosis, Baylor College of Dentistry, strate a widened periodontal ligament space, loss of Dallas,Texas. the lamina dura or dental crypt, and internal or exter- 1. ColemanGC: Differential diagnosisof radiographicabnor- nal root resorption. Proliferative periostitis is common malities. In: Principles of Oral Diagnosis.Coleman GC, NelsonJF, Eds. St Louis: Mosby-YearBook Inc, 1992, pp in this age group. 389-449. Broadly, inflammatory lesions of the jaws are 2. CunninghamMJ, Meyers EN, Bluestone CD:Malignant tu- classified as localized or diffuse entities with a radio- morsof the head and neck in children: a twenty-year re- lucent, radiopaque, or mixed radiolucent-radiopaque view.Int J PediatrOtorhinolaryngol 13:279-92, 1987. appearance (Fig 8). 3. DasS, DasAK: A reviewof pediatric oral biopsies froma surgical pathologyservice in a dental school.Pediatr Dent Benign cystic and neoplastic lesions of the jaws are 15:208-11,1993. defined as locally expansile lesions with a slow but 4. Flaitz CM:Differential diagnosis of oral soft tissue enlarge- progressive growth pattern, Delayed tooth eruption and ments.In: Principlesof OralDiagnosis. Coleman GC, Nelson subtle facial asymmetryare associated with this group JF, Eds. St Louis: Mosby-YearBook Inc, 1992,pp 352-88. of lesions. The pertinent radiographic features include 5. Flaitz CM:Oral pathologicconditions and soft tissue anoma- lies. In: Pediatric DentistryInfancy through Adolescence, a well-delineated unilocular or multilocular lesion with 2nd Ed. PinkhamJR, CasamassimoPS, Fields HW,McTigue cortical expansion. These bony lesions may appear DJ, NowakA, Eds. Philadelphia: WBSaunders Co, 1993, pp radiolucent, radiopaque, or mixed. Inferior or lateral 29-56. movementof teeth, blunt apical root resorption, and 6. Greer RO,Mierau GW, Favare BE: Tumorsof the Headand displacement of anatomic structures are detected when Neck in Children. New York: Greenwood, 1983. 7. Neville BW, DammDD, Allen CM, Bouquot JE: Oral & large lesions are present. As outlined in Fig 9, benign Maxillofacial Pathology. Philadelphia: WBSaunders Co, cystic and neoplastic lesions of the jaws are classified 1995. according to radiographic appearance and lesion site. 8. Neville BW, Damm DD, White DK, Waldron CA: Color Aggressive and malignant neoplasms of the jaws Atlas of Clinical Oral Pathology. Philadelphia: Lea &Febiger, are characterized by a diffuse enlargement with a mod- 1991. 9. Regezi JA, Sciubba JJ: Oral Pathology, Clinical-Pathologic erate growth rate. Pain, mucosal ulceration, extrusion Correlations. 2nd Ed. Philadelphia: WBSaunders Co, 1993. of teeth, and paresthesia are commoncomplaints. 10. Scully C, Welbury R: Color Atlas of Oral Diseases in Chil- Important radiographic features include a poorly de- dren and Adolescents. London: Wolfe Publishing, 1994. fined radiolucent or mixed radiolucent-radiopaque le- 11. Skinner RL, Davenport WDJr, Weir JC, Carr RF: A survey sion with cortical destruction. Irregular root resorp- of biopsied oral lesions in pediatric dental patients. Pediatr Dent 8:163-67, 1986. tion, loss of the lamina dura and dental crypt, 12. WoodNK, Goaz PW: Differential Diagnosis of Oral Le- symmetrical widening of the periodontal ligament sions. 4th Ed. St Louis: CVMosby Co, 1991.

300 American Academyof Pediatric Dentistry Pediatric Dentistry-17:4,1995