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7. Complaints Affecting Particularly the Palate Or Gingivae

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7. Complaints Affecting Particularly the Palate Or Gingivae ORAL MEDICINE Orofacial Disease: Update for the Dental Clinical Team: 7. Complaints Affecting Particularly the Palate or Gingivae CRISPIAN SCULLY AND STEPHEN PORTER 1999; 26: 123 – 129); an example is Abstract: Certain lesions 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 Stomatitis 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 malignancy. diffuse erythema 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 torus palatinus is a common be fibrous, pyogenic granulomas, giant Denture-induced stomatitis is found only developmental abnormality and cell lesions or neoplasms. in people who wear appliances (usually erythematous candidosis may affect Desquamative gingivitis 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 lymphomas must be excluded. aged or elderly women and is usually a Denture-induced stomatitis is a manifestation of atrophic lichen planus common complaint in the palate; it is or mucous membrane pemphigoid. 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 infections, especially in deep fungal candidosis. Ulceration of the palate is infections, in dermatological disorders uncommon except in pemphigus and and with neoplasms. lupus erythematosus. The first article in this series Most generalized gingival swellings presented several general observations are due to hyperplasia related to on diagnosis and treatment which plaque and are occasionally secondary should be borne in mind in relation to to hormonal changes (puberty, this article. pregnancy) 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 lesion. 308 Dental Update – September 99 ORAL MEDICINE 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 chlorhexidine. 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 infection. 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. Dental Update – September 99 309 ORAL MEDICINE 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 ● dental abscess pointing on the immunocompromised patients. ● pregnancy epulis; 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, ● sarcoidosis; ● papillomas; bluish or purple (sometimes brown) ● papillomas; ● carcinomas; 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 ● lymphoma; salivary neoplasms; greater palatine vessels (Figure 7), but ● Wegener’s granulomatosis. ● invasive carcinoma 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
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