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Home , Desquamative gingivitis, Epulis, Gingival enlargement, Torus palatinus

Orofacial : Update for the Dental Clinical Team: 7. Complaints Affecting Particularly the or Gingivae

CRISPIAN SCULLY AND STEPHEN PORTER

1999; 26: 123 – 129); an example is Abstract: Certain are exclusively or typically found in specific sites.This article illustrated in Figure 1. discusses in detail conditions that occur mostly on the palate or gingivae.

Dent Update 1999; 26: 308 – 313 Denture-induced Clinical Relevance: A variety of disorders can affect the palate or gingivae. The majority Also known as denture sore mouth or of these are benign and/or congenital, however, some arise secondary to systemic disorder or chronic atrophic candidosis, this is therapy and/or may be the consequence of local or distant . diffuse limited to the denture- bearing area. urprisingly few conditions are swelling is sometimes congenital. S found in the palate, although Discrete gingival lumps (epulides) may Aetiology is a common be fibrous, pyogenic , giant Denture-induced stomatitis is found only developmental abnormality and cell lesions or . in people who wear appliances (usually erythematous candidosis may affect Desquamative is not a dentures or orthodontic plates) and the palate. disease entity but a clinical term for almost exclusively under an upper Acquired palatal swellings are often persistently sore, glazed and red or dental abscesses but neoplasms, ulcerated gingivae. It is fairly common, particularly salivary, Kaposi’s sarcoma arises almost exclusively in middle- and must be excluded. aged or elderly women and is usually a Denture-induced stomatitis is a manifestation of atrophic common complaint in the palate; it is or mucous membrane . usually asymptomatic but there may Gingival ulcers are typical of be an associated angular stomatitis. necrotizing gingivitis and herpetic White lesions may be seen, stomatitis, but may occur rarely in other especially in smoker’s keratosis and , especially in deep fungal candidosis. Ulceration of the palate is infections, in dermatological disorders uncommon except in and and with neoplasms. . The first article in this series Most generalized gingival swellings presented several general observations are due to related to on diagnosis and treatment which plaque and are occasionally secondary should be borne in mind in relation to to hormonal changes (, this article. ) or drugs, although gingival

Crispian Scully, PhD, MD, MDS, FDS RCPS, LESIONS OF THE PALATE FFD RCSI, FDS RCS, FDS RCSE, FRCPath, FMedSci, Professor, and Stephen Porter, PhD, MD, FDS RCSE, FDS RCS, Professor, Erythematous Candidosis Eastman Dental Institute for Oral Health Care This was discussed in Article 5 of this Figure 1. Candidosis: erythematous palatal Sciences, University of London. series (White lesions: Dent Update .

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appear, typically in the palatal vault (Figure 4). Denture-induced stomatitis is usually asymptomatic but there may be an associated angular stomatitis.

Management ● Improve denture hygiene. ● Keep dentures out of the mouth at night. ● Figure 2. Candidosis: early lesions in denture- Clean and store dentures in 1% Figure 5. Smoker’s keratosis. induced stomatitis. hypochlorite or 0.2% aqueous . appliance. The condition appears to be ● Use antifungals—usually related to the proliferation of micro- miconazole (mainly required where is no characteristic type of organisms beneath and within the there is also angular stomatitis). hyperkeratotic lesion associated with the appliance fitting surface. Candida ● Attention to dentures (see Table 1). far more common habit of cigarette albicans seems to be the main causal smoking. agent. It is unclear exactly what Smoker’s Palate Clinical Features predisposes those affected to the candidosis but as they are not This is also known as smoker’s Smoker’s keratosis is distinctive in that: predisposed to candidosis elsewhere, keratosis, nicotinic stomatitis or ● there is white thickening of the local rather than systemic factors are stomatitis palatini. It is an uncommon palatal mucosa associated with likely to be crucial. diffuse white lesion in the palate of small umbilicated swellings with Denture-induced stomatitis affects (usually) pipe smokers. red centres (Figure 5); only the fitting surface—making it ● the palate only is affected; ● quite clear that the condition is not ● This is a common condition any part of the palate protected by a caused by an allergic reaction, which ● It appears mainly in persons wearing denture is spared (Figure 6). dentures throughout the night would affect any mucosa in contact ● It is often caused by overgrowth of yeasts with the appliance. Trauma is also an under, and in the surface of, dentures There are two components to smoker’s unlikely cause, because there is less ● It does not appear to be transmissible keratosis: hyperkeratosis and ● The main consequence can be soreness at trauma beneath an upper appliance the angles of the mouth inflammatory swelling of minor mucous than a lower one. Other likely ● It is best treated by leaving the denture glands. Either may predominate. causative factors may include poor out of the mouth at night Pipe smoking raises the risk of cancer ● A plastic denture should be stored and denture hygiene, xerostomia and, cleaned in an antifungal such as but this typically appears not in the rarely, HIV . hypochlorite palate but low down in the mouth, often ● The dentist may advise you to use an in the lingual retromolar region, possibly Clinical Features antifungal medication as a result of carcinogens pooling in Denture-induced stomatitis presents Table 1. Patient information: denture-induced drainage areas of the mouth. with erythema limited to the denture- stomatitis bearing area, typically beneath a Diagnosis and Management complete upper denture. Early lesions Aetiology The clinical appearance and history are may be punctate (Figure 2) but later Smoker’s keratosis is seen among so distinctive that biopsy is not normally may become diffuse (Figure 3). After heavy, long-term pipe smokers and necessary. The patient should be many years papillary hyperplasia may some cigar smokers. By contrast, there encouraged to stop the causative habit.

Figure 3. Candidosis: later lesions in denture- Figure 4. Candidosis: papillary hyperplasia in Figure 6. Smoker’s keratosis. induced stomatitis. denture-induced stomatitis.

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SWELLINGS OF THE PALATE exclusively in immunocompromised Lumps of the hard palate may develop persons, mainly adult men. from structures within the palate Aetiology (intrinsic) or beyond it (extrinsic). Swellings include congenital Kaposi’s sarcoma is a malignant conditions such as unerupted teeth, endothelial tumour induced by a especially permanent canines or second recently described virus—human premolars, and torus palatinus. herpesvirus 8. Kaposi's sarcoma of the Acquired conditions causing swellings mouth is almost exclusively seen in include: sexually transmitted AIDS, especially in Figure 8. Fibrous lump. male homosexuals or bisexuals, or other ● pointing on the immunocompromised patients. ● pregnancy ; palate (usually from the palatal ● fibroepithelial epulis; Clinical Features roots of the first and second ● giant cell epulis; maxillary molars or from maxillary Kaposi’s sarcoma occurs primarily in ● Crohn’s disease and orofacial lateral incisors); the skin and mucosa in the head and granulomatosis; ● fibrous lumps; neck. It typically commences as a red, ● ; ● ; bluish or purple (sometimes brown) ● papillomas; ● ; macule which then enlarges to a nodule ● carcinomas; ● Kaposi’s sarcoma; and may ulcerate. The lesions are ● Kaposi’s sarcoma; ● pleomorphic adenomas and other frequently seen in the palate, over the ● ; salivary neoplasms; greater palatine vessels (Figure 7), but ● Wegener’s granulomatosis. ● invasive from the may be seen elsewhere. Usually the oral maxillary sinus; lesions are part of much more ● fibrous dysplasia; widespread disease. Fibrous Epulis ● Paget’s disease. The term ‘epulis’ is applied to any lump Diagnosis and Management arising from gingiva. The fibrous epulis The diagnosis of Kaposi’s sarcoma is resembles a fibroepithelial polyp, but Torus Palatinus often fairly obvious but specialist also usually has an inflammatory This is a common painless exostosis referral is usually indicated. It may be component. with a bony, hard, smooth or nodular necessary to differentiate from other surface. It is developmental in origin pigmented lesions, especially Aetiology and benign in nature. Torus palatinus haemangiomas, purpura and epithelioid Probably chronic irritation. occurs in the centre of the hard angiomatosis. The last is a bacterial palate. The overlying mucosa is infection (Bartonella (Rochalimaea) Clinical Features henselae) and responds to antibiotic normal. Tori are common conditions, The variable inflammatory changes usually of no consequence, apart treatment. Biopsy is confirmatory. The account for the different clinical from occasionally interfering with presentations—from red, shiny and denture construction. underlying predisposing condition should be identified if possible. An HIV soft lumps to those which are pale, test may be indicated after appropriate stippled and firm. Commonly, lesions Kaposi’s Sarcoma counselling. Oral lesions respond are round, painless, pedunculated transiently to radiotherapy, to vinca swellings arising from the marginal This rare sarcoma has a bluish or papillary gingiva, sometimes appearance and is seen almost alkaloids systemically or intralesionally, or to intralesional sclerosing agents or adjacent to sites of irritation (e.g. a interferon. carious cavity); they rarely involve the attached gingiva, and rarely exceed 2 cm in diameter (Figure 8). LOCALIZED GINGIVAL LUMPS AND SWELLINGS Diagnosis and Management Rapidly developing localized lumps, The diagnosis is clinical but most usually associated with discomfort, are lesions need to be removed and most likely to be abscesses. Other examined histologically. Fibrous localized swellings are usually epulides should be removed down to inflammatory or neoplastic, and the periosteum, which should be Figure 7. Kaposi’s sarcoma. include: curetted thoroughly.

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Giant Cell Epulis and is seen mainly in adults. ● ; ● plasma cell gingivostomatitis. Aetiology Aetiology The resorption of deciduous teeth and Unknown, possibly Staphylococcus remodelling of the alveolus at the aureus. There is necrotizing Hereditary Gingival mixed dentition stage indicate the granulomatosis. Fibromatosis osteoclastic potential of the area from Clinical Features which giant-cell epulides originate. Aetiology The lesion probably arises because This typically initially affects the chronic irritation triggers a respiratory tract. It is followed by Hereditary gingival fibromatosis is an reactionary hyperplasia of widespread arteritis of small vessels, uncommon condition often transmitted mucoperiosteum and excessive and renal damage. It may produce by an autosomal dominant gene. production of granulation tissue. painless, progressive gingival Clinical Features Giant-cell granulomas are also a enlargement that may have a fairly feature of hyperparathyroidism. characteristic ‘strawberry-like’ The condition presents as generalized appearance. , especially Clinical Features Swelling of the gingiva in a obvious during the transition from The giant cell epulis characteristically previously healthy mouth, deciduous to permanent dentition. arises interdentally, adjacent to particularly if associated with The changes involve the papillae and permanent teeth which have had swollen, inflamed papillae, should later the attached gingiva (Figure 9). deciduous predecessors. Classically, arouse suspicion of this condition. If the enlargement is gross, it may the most notable feature is the deep red move or cover the teeth and bulge out Diagnosis and Management colour, although older lesions tend to of the mouth. The affected gingiva is be paler. The diagnosis requires biopsy and usually of normal colour but firm in pulmonary and renal investigations. consistency, and the surface, although Diagnosis and Management Specialist care is needed. Cytotoxic initially smooth, becomes coarsely Biopsy is usually required to establish therapy is usually needed, though there stippled. The family history is the diagnosis. In order to exclude are reports of beneficial responses to typically positive, and patients may hyperparathyroidism, levels of plasma antibiotics. also complain of calcium, phosphate and alkaline (excess hair). Rare patients have phosphatase should be assayed and the systemic syndromes of which this is GENERALIZED GINGIVAL area examined radiographically: one part. SWELLING specialist referral is thus indicated. Diagnosis and Management Treatment depends on the cause. Any Sometimes swelling is congenital but hyperparathyroidism must be most generalized gingival swellings are Diagnosis is clinical. Surgery (scalpel, medically treated. Treatment otherwise due to hyperplasia with oedema related laser, or electro-) is often indicated. is surgical. to plaque deposits, occasionally exacerbated by hormonal changes (puberty, pregnancy) or drugs. Drug-induced Hyperplasia Wegener’s Granulomatosis There are very few serious causes Drug-induced hyperplasia is usually (Disseminated Malignant of generalized enlargements of the aggravated by poor . ) gingiva appearing spontaneously or Papillae are firm and pale and enlarge This is a rare, potentially lethal, rapidly but leukaemia is a prime to form false vertical clefts (Figure disseminating granulomatous condition suspect. 10). Hypertrichosis (excess hair) may Causes of generalized enlargement be associated with drug-induced include: gingival hyperplasia, as in congenital hyperplasia. ● gingival fibromatosis; The often ● leukaemia; produces a variable amount of ● gingival hyperplasia due to mouth gingival enlargement, which breathing, pregnancy or drugs such characteristically affects the as phenytoin, cyclosporin or interdental papillae first but may later calcium-channel blockers; involve the marginal and even ● vitamin C deficiency; attached gingiva. The buccal and ● sarcoidosis; labial gingivae are mainly involved. Figure 9. Hereditary gingival fibromatosis. ● Crohn’s disease; The enlargement rarely affects

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predisposes to changes which are a result of increased progestogen levels.

Clinical Features Pregnancy gingivitis is characterized by:

● soft, reddish enlargements, usually of the gingival papillae; Figure 10. Drug-induced gingival hyperplasia. ● mainly labial location of swelling; Figure 12. . ● gingival bleeding, particularly on eating or toothbrushing. edentulous sites. It is characteristically Desquamative Gingivitis firm, pale and tough, with coarse Desquamative gingivitis is not a disease Sometimes there is a localized . entity but a clinical term for persistently gingival lump—a pregnancy epulis The immunosuppressive cyclosporin sore, glazed and red or ulcerated (Figure 11). may produce gingival hyperplasia, gingivae. It is fairly common, seen Changes appear first about the second initially of the papillae. almost exclusively in middle-aged or month of pregnancy, and reach a peak at (an antihypertensive elderly women. the eighth month. agent) and other calcium-channel Changes may revert soon after blockers may cause gingival Aetiology parturition to the previous level of hyperplasia typically affecting the Desquamative gingivitis is usually a gingival health. papillae, which become red and puffy manifestation of atrophic lichen planus and tend to bleed. Diagnosis and Management or mucous membrane pemphigoid, and occasionally seen in pemphigus or other Enlargements related to use of oral Histologically, a pregnancy epulis is a dermatoses. contraceptives may rarely arise. . Conservative Diagnosis and Management treatment is indicated unless an epulis Clinical Features interferes with occlusion or is extremely Such changes often develop slowly— The main features include: unsightly—when it may be excised. In over weeks rather than days—and are any event, oral hygiene should be usually painless. It may be possible to ● persistent gingival soreness, which meticulous. change or reduce the dose of the worsens on eating; causative drug in consultation with the ● red and glazed (patchily or patient’s physician. Otherwise, Scurvy uniformly) gingivae, especially improvements to the oral hygiene and Deficiency of vitamin C (ascorbic acid) labially (Figure 12); ● loss of the distinct junction gingival surgery are the mainstays of results when no fresh fruit or vegetables between attached gingivae and therapy. are eaten for a long period. This is rare vestibular mucosae. in developed countries. The gingival margins and edentulous Pregnancy Gingivitis and Clinical Features Pregnancy Epulis ridges tend to be spared. The erythema Lesions include: is exaggerated where oral hygiene is Aetiology poor. ● diffusely swollen, boggy and Other oral or cutaneous lesions of Exacerbation of chronic gingivitis by purplish gingivae with purpura and dermatoses may be associated. pregnancy. Poor oral hygiene haemorrhage; and ● perifollicular haemorrhages of the Diagnosis and Management skin. The diagnosis is usually obvious from the history, with clinical findings, but Diagnosis and Management other causes of red gingival lesions The diagnosis will be clear from the should be excluded (Table 2). Biopsy dietary history and clinical features. and immunostaining may be required to The classic investigation is assay of establish the precise cause, and thus white cell ascorbic acid; however, specialist referral may be indicated. this is rarely required. Vitamin C Treatment should be of the underlying supplements should be given and the condition; if there are extra-oral lesions Figure 11. Pregnancy epulis. diet reformed. systemic therapy, usually with

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Textbook of Dermatology, 6th ed. Oxford: Royal College of Surgeons of England, 1993; Gingivitis: Blackwell, 1998; pp.3125-3148. pp.25-33. ● Inflammatory Eversole LR. Immunopathology of oral mucosal Scully C. Prevention of oral mucosal disease. In: ● Desquamative ulcerative, desquamative and bullous . Murray JJ, ed. Prevention of Oral and Dental ● Trauma ● Drugs Selective review of the literature. Oral Surg Oral Disease, 3rd ed. Oxford: Oxford University Med Oral Pathol 1994; 77: 555-571. Press, 1995; pp.160-172. ● Infections such as primary herpetic stomatitis Eveson JW, Scully C. Colour Atlas of Oral Pathology. Scully C. The oral cavity. In: Champion RH, Burton J, ● Crohn’s disease ● Orofacial granulomatosis London: Mosby-Wolfe, 1995. Burns DA, Breathnach SM, eds. Textbook of ● Sarcoidosis Jones JH, Mason DK. Oral Manifestations of Systemic Dermatology, 6th ed. Oxford: Blackwell, 1998; ● Erythroplasia Disease, 2nd ed. London: Baillière-Tindall, 1980. pp.3047-3124. ● Plasma cell gingivostomatitis Millard HD, Mason DK, eds. Perspectives on 1993 Scully C. The pathology of orofacial disease. In: ● Kaposi’s sarcoma World Workshop on Oral Medicine. Chicago: Barnes IE, Walls AWG, eds. Gerodontology. University of Michigan. Oxford: Wright, 1994; pp.29-41. Table 2. Gingival red lesions. Porter SR, Scully C. Periodontal aspects of systemic Wray D, Lowe G, Bagg J, Felix D, Scully C. disease. A system of classification. In: Lang N, ed. Textbook of General and Oral Medicine. corticosteroids, may be required. The European Workshop of . Chicago: Edingburgh: Livingstone, 1999. desquamative gingivitis can be Quintessence, 1994; pp.374-419. improved if oral hygiene is increased Porter SR, Scully C. Periodontal aspects of systemic and topical corticosteroids given as disease. Some therapeutic concepts. In: Lang N, appropriate (Table 3). Corticosteroid ed. European Workshop of Periodontology. ABSTRACTS creams used overnight in a polythene Chicago: Quintessence, 1994; pp.415-438. splint may help. Other available Scully C, Handbook of Oral Diseases. London: Martin HOW BRIGHT IS YOUR LIGHT? therapies include cyclosporin, dapsone Dunitz, 1999. A Survey of Output Intensity and Scully C, Cawson RA. Medical Problems in Dentistry, Potential for Depth of Cure among Light- and . 4th ed. Oxford: Butterworth-Heinemann, 1998. Scully C, Flint S, Porter S. Oral Diseases. London: curing Units in Clinical Use. R Pilo, D Martin Dunitz, 1996. Oelgiesser and H Cardash. Journal of GINGIVAL BLEEDING Scully C, Welbury R. Colour Atlas of Oral Disease in Dentistry 1999; 27: 235-241. Children and Adolescents. London: Mosby-Wolfe, The depth of cure of VLC composites Most gingival bleeding is due to 1994. is dependant on both the properties of the inflammatory , Scully C, Porter SR, Mutlu S. Markers of disease material, and the intensity and duration of sometimes exaggerated by hormonal susceptibility and activity for periodontal exposure to the visible light source. The changes such as occur during diseases: changing subject-based risk factors. In: presence of poorly polymerized pregnancy, but haemorrhagic disease Johnson NW, ed. Risk Markers for Oral Disease: composite beneath a restoration is of (including leukaemia) and drugs are 3. Periodontal Diseases. Cambridge: Cambridge considerable concern. Not only are the occasionally responsible. University Press, 1991; pp.139-178. Scully C, Porter SR. Oral mucosal disease: a decade mechanical properties and long-term of new entities, aetiologies and associations. Int retention compromised, but there are also Dent J 1994; 44: 33-43. residual monomers which may lead to FURTHER READING Scully C. Diagnosis and diagnostic procedures: staining, secondary caries, pulpal Burton J, Scully C. The . In: Champion RH, general and soft tissue diagnosis. In: Pathways in irritation and even systemic effects. A Burton J, Burns DA, Breathnach SM, eds. Practice. Faculty of General Dental Practice , decrease of only 10% in light intensity may have a significant effect on polymerization only 2 mm beneath the Dental surgeon Ancillary, Hygienist, Nurse surface of the restoration. Understand disease and management in or der Understand disease and management in or der One hundred and thirty curing lights in to extend education of, and reassure, patient to extend education of, and reassure, patient general dental practices were assessed using curing and heat radiometers. The Establish a diagnosis; biopsy if necessary. Refer Oral health education of patient light intensity should be greater than 300 to specialist if extra-oral lesions or pemphigus -2 suspected mW cm . The results revealed a range of 25 (yes 25) – 825 mW cm-2. Almost half Initiate therapy, usually with topical Help patient maintain good oral hygiene of the lights tested required repair or corticosteroids and chlorhexidine replacement, and almost a third were Be alert to any possible adverse effects of Alert Dental Surgeon to any changes, or deemed unusable according to their treatment, such as candidosis possible adverse effects of treatment manufacturer’s instructions. Other workers in this field report similar results. Oral health care; in particular to avoid When did you last check the output of infection the curing lights in your practice? Oral health education of patient Peter Carrotte, Glasgow Dental Table 3. Roles of the dental clinical team in the management of a patient with desquamative gingivitis. School

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