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Differential Diagnosis of Oral Enlargements in Children

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Differential Diagnosis of Oral Enlargements in Children 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
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