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Oral Medicine:11. Lumps and Swellings: Mouth OralMedicine-UpdatefortheDentalTeam This series provides an overview of current thinking in the more relevant areas of Oral Medicine, for primary care practitioners. The series gives the detail necessary to assist the primary dental clinical team caring for patients with oral complaints that may be seen in general dental practice. Space precludes inclusion of illustrations of uncommon or rare disorders. Approaching the subject mainly by the symptomatic approach, as it largely relates to the presenting complaint, was considered to be a more helpful approach for GDPs rather than taking a diagnostic category approach. The clinical aspects of the relevant disorders are discussed, including a brief overview of the aetiology, detail on the clinical features and how the diagnosis is made, along with guidance on management David H Felix Jane Luker Crispian Scully and when to refer, in addition to relevant websites which offer further detail. Oral Medicine:11. Lumps and Swellings: Mouth benign to malignant, may present as oral Specialist referral may be indicated if the lumps or swellings (Table 1) including: Practitioner feels: Developmental: unerupted teeth, and The diagnosis is unclear; tori–congenital bony lumps lingual to the A serious diagnosis is possible; mandibular premolars (torus mandibularis; Systemic disease may be present; Figure 1), or in the centre of the palate Unclear as to investigations indicated; (torus palatinus; Figure 2) are common Complex investigations unavailable in causes of swellings related to the jaws primary care are indicated; (Article 13). Unclear as to treatment indicated; Inflammatory: dental abscess is one of Treatment is complex; the most common causes of oral swelling. Treatment requires agents not readily Figure 2. Palatal torus. However, there is a group of conditions available; characterized by chronic inflammation Unclear as to the prognosis; and granulomas, which can present with The patient wishes this. lumps or swellings. These, include Crohn’s disease, orofacial granulomatosis (OFG), and sarcoidosis, which are discussed below. Traumatic: haematoma may cause a Lumps and swellings: lumps in swelling at the site of trauma. The flange the mouth of a denture impinging on the vestibular Lumps and swellings in the mucosa may stimulate a reactive irregular mouth are common, but of diverse hyperplasia (denture-induced hyperplasia) aetiologies (Table 1) and some develop into (Figure 3). Figure 3. Denture-induced hyperplasia. ulcers, as in various bullous lesions (Article Neoplasms: benign epulides (Figure 4), 2) and in malignant neoplasms (Article 3 ). fibrous lumps (Figure 5) or malignant Many different conditions, from tumours such as oral squamous cell carcinoma (OSCC), Kaposi’s sarcoma and other neoplasms may present as swellings, as discussed in Article 3. Occasionally, David H Felix, BDS, MB ChB, FDS RCS(Eng), FDS RCPS(Glasg), FDS RCS(Ed), FRCP(Edin) Postgraduate Dental Dean, NHS Education for Scotland, Jane Luker, BDS, PhD, FDS RCS , DDR RCR, Consultant and Senior Lecturer, University Hospitals Bristol NHS Foundation Trust, Bristol, Figure 4. Epulis. Professor Crispian Scully, CBE, MD, PhD, MDS, MRCS, BSc, FDS RCS, FDS RCPS, FFD RCSI, FDS RCSE, FRCPath, FMedSci, metastatic malignant disease may present FHEA, FUCL, DSc, DChD, DMed(HC), Dr as a lump. HC, Emeritus Professor, University College Fibro-osseous lesions: fibrous dysplasia London, Hon Consultant UCLH and HCA, and Paget’s disease can result in hard jaw London, UK. Figure 1. Mandibular tori. swellings. October 2013 DentalUpdate 683 OralMedicine-UpdatefortheDentalTeam Normal Anatomy Pterygoid hamulus Parotid papillae Lingual papillae Developmental Unerupted teeth Odontogenic cysts Eruption cysts Developmental cysts (eg thyroglossal, dermoid) Haemangioma Lymphangioma Maxillary and mandibular tori Hereditary gingival fibromatosis Figure 5. Fibrous overgrowth. Lingual thyroid Inflammatory Abscess Cellulitis Cysts Sialadenitis Pyogenic granuloma Chronic granulomatous disorders - Orofacial granulomatosis - Crohn’s disease - Sarcoidosis Insect bites Traumatic Denture-induced hyperplasia Epulis Fibro-epithelial polyp Figure 6. Calcium channel blocker-induced Haematoma Mucocele gingival swelling. Surgical emphysema Neoplasms Carcinoma Leukaemia Lymphoma Myeloma Odontogenic tumours Minor salivary gland tumours Others Fibro-osseous Cherubism Fibrous dysplasia Paget ‘s disease Figure 7. Human papillomavirus infection. Hormonal Pregnancy epulis/gingivitis Oral contraceptive pill gingivitis Metabolic Amyloidosis lumps caused by human papillomaviruses Other deposits (HPV; Figure 7). Drugs Phenytoin Calcium channel blockers Ciclosporin Causes of lumps and swellings according to site Allergic Angioedema Carcinomas and other malignant Infective HPV neoplasms (Article 3) and pyogenic granulomas (Figure 8) can present in Table 1. Main conditions which may present as lumps or swellings in the mouth. any site. Gingiva Sometimes, hyperplasia is Hormonal and metabolic: pregnancy may and ciclosporin (Figure 6). congenital. Rapidly developing localized result in a gingival swelling (pregnancy Allergic lesions: angioedema in particular lumps, usually associated with discomfort, epulis). can cause swellings. are most likely to be abscesses, usually a Drug-induced: a range of drugs can Viral lesions: papillomas, common warts dental abscess. Other localized swellings are produce gingival swelling – most common (verruca vulgaris) and genital warts usually inflammatory, such as the pyogenic are phenytoin, calcium channel blockers (condyloma acuminatum) are all among the granuloma, or neoplastic. 684 DentalUpdate October 2013 OralMedicine-UpdatefortheDentalTeam structures above the mylohyoid muscle than below it. The commonest swellings in the floor of the mouth are denture-induced hyperplasia and a salivary calculus. Other lesions producing swellings in this area are a mucocele arising from the sublingual salivary gland (known as ranula because of the resemblance to a frog’s belly) and neoplasms of the sublingual salivary gland (usually malignant), but these are relatively Figure 8. Pyogenic granuloma. Figure 10. Orofacial granulomatosis. uncommon. Patients occasionally describe a lump which proves to be a swelling of the lingual aspect of the mandible (more Most generalized gingival characteristic of ameloblastoma than of swellings are due to hyperplasia with dental abscesses or cysts). Swellings of the oedema related to plaque deposits, submandibular salivary gland and adjacent occasionally exacerbated by hormonal lymph nodes may occasionally be described changes (puberty, pregnancy) or drugs. by patients as being in the floor of the Such changes often develop slowly – over mouth. However, only very large swellings weeks rather than days – and are usually below the mylohyoid muscle are likely to without discomfort. produce a bulge in the mouth. Swellings There are very few serious in the floor of the mouth may inhibit Figure 11. Cobble-stoning of buccal mucosa. causes of generalized enlargements of swallowing and have an effect on speech. the gingivae appearing spontaneously or Mandibular tori produce rapidly, but leukaemia is a prime example. bony hard swellings lingual to the lower premolars. mucoceles, vesiculobullous lesions and, Palate occasionally, insect bites. Tongue and buccal mucosa Lumps of the hard palate may Systemic conditions such as Discrete lumps may be of develop from structures within the palate Crohn’s disease, orofacial granulomatosis various causes – congenital (Figure 9; (intrinsic) or beyond it (extrinsic). Thus, and, occasionally, sarcoid may produce lip haemangioma), inflammatory, traumatic or for example, torus palatinus is an intrinsic swelling (Figure 10) or widespread irregular neoplastic. bone lesion, whereas a dental abscess thickening (cobble-stoning) of the cheek The tongue may be congenitally pointing on the palate (usually from mucosa (Figure 11). enlarged (macroglossia) in, for example, the palatal roots of the first and second Some ‘lumps’ become ulcers, as Down’s syndrome, or may enlarge in maxillary molars, or from upper lateral in various bullous lesions, in primary and angioedema, gigantism, acromegaly or incisors) is extrinsic. Unerupted teeth, tertiary syphilis and in malignant neoplasms. amyloidosis. especially permanent canines, or second The flange of a denture impinging Causes of swellings include premolars are relatively common. Other on the vestibular mucosa may stimulate a haematomas from trauma (such as causes of palatal swellings are uncommon reactive irregular hyperplasia – the so-called occasional biting), infections, angioedema, but it should be remembered that the denture granuloma or denture-induced fibro-epithelial polyps, fibrous lumps, palate is the second most common hyperplasia. Salivary neoplasms in the lip may site (after the parotid) for pleomorphic simulate, but are usually harder than, mucous adenomas and other salivary neoplasms. cysts. Mucoceles are uncommon in the upper Invasive carcinoma from the maxillary lip; discrete swellings there may well be a sinus may produce a palatal swelling. salivary gland neoplasm. Kaposi’s sarcoma, typical of HIV/AIDS, may also present as a lump in the palate, or elsewhere. Developing unilateral Diagnosis of the cause of a hard palatal swellings, characteristically lump or swelling disturbing the fit of an upper denture in When patients refer to a lump in older patients, may denote Paget’s disease. the mouth it is important to establish when it
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