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Lumps and Swellings Clinical Oral medicine for the general practitioner: lumps and swellings Crispian Scully 1 his series of five papers summarises some of the most important oral medicine problems likely to be Tencountered by practitioners. Some are common, others rare. The practitioner cannot be expected to diagnose all, but has been trained to recognise oral health and disease, and should be competent to recognise normal variants, and common orofacial disorders. In any case of doubt, the practitioner is advised to seek a second opinion from a colleague. The series is not intended to be comprehensive in coverage either of the conditions encountered, or all aspects of Figure 1: Torus mandibularis. diagnosis or treatment: further details are available in standard texts, in the further reading section, or from the internet. The present article discusses aspects of lumps through fear, perhaps after hearing of someone with and swellings. ‘mouth cancer’. Thus some individuals discover and worry about normal anatomical features such as tori, the parotid Lumps and swellings papilla, foliate papillae on the tongue, or the pterygoid Lumps and swellings in the mouth are common, but of hamulus. The tongue often detects even a very small diverse aetiologies (Table 1), and some represent swelling, or the patient may first notice it because it is sore malignant neoplasms. Therefore, this article will discuss (Figure 1). In contrast, many oral cancers are diagnosed far lumps and swellings in general terms, but later focus on too late, often after being present several months, usually the particular problems of oral cancer and of orofacial because the patient ignores the swelling. granulomatosis, presentations of which can also include Many different conditions, from benign to malignant, oral ulceration. may present as oral lumps or swellings (see Tables 1 to 5) Most patients have only a passing interest in their mouths including: but some examine their mouths out of idle curiosity, some Developmental Unerupted teeth, and tori are common causes of swellings related to the jaws Inflammatory Dental abscess is one of the most common causes of oral swelling. However, there are a group of 1 Professor Crispian Scully CBE, MD, PhD, MDS, MRCS, BDS, BSc, conditions characterised by chronic inflammation and MB.BS, FDSRCS, FDSRCSE, FDSRCPS, FFDRCSI, FRCPath, FMedSci, granulomas, which can present with lumps or swellings. FHEA, FUCL, DSc, DChD, DMed (HC), Dr HC. Emeritus Professor, University College London (UCL); Professor of Oral Medicine, These, which include Crohn’s disease, orofacial University of Bristol; Visiting Professor at Universities of Athens, granulomatosis, and sarcoidosis, are discussed below Edinburgh, Granada, Helsinki and Peninsula Neoplasms Oral squamous cell carcinoma (OSCC), 72 INTERNATIONAL DENTISTRY SA VOL. 13, NO. 2 Clinical Table 1: Main conditions which may present as lumps or swellings in the mouth Kaposi’s sarcoma, lymphomas and other neoplasms may Normal anatomy Pterygoid hamulus present as swellings, as discussed below. Occasionally Parotid papillae metastatic malignant disease may present as a lump in the Lingual papillae mouth or jaw Developmental Unerupted teeth Traumatic Haematoma may cause a swelling at the site Odontogenic cysts of trauma. The flange of a denture impinging on the Eruption cysts vestibular mucosa may stimulate a reactive irregular Developmental cysts (e.g. hyperplasia (denture-induced hyperplasia) thyroglossal, dermoid) Hormonal Pregnancy may result in a gingival swelling Haemangioma (pregnancy epulis) Lymphangioma Drug-induced A range of drugs can produce gingival Maxillary and mandibular tori swelling - most common are phenytoin, ciclosporin and Hereditary gingival fibromatosis calcium channel blockers (Table 2) Lingual thyroid Viral lesions Papillomas, common warts (verruca Inflammatory Abscess vulgaris), genital warts (condyloma acuminatum) and Cellulitis focal epithelial hyperplasia (Heck’s disease) are all lumps Crohn’s disease caused by human papillomaviruses Cysts Human papillomavirus-induced Fibro-osseous lesions Fibrous dysplasia and Paget’s lesions (warts etc) disease can result in hard jaw swellings. Insect bites Orofacial granulomatosis Diagnosis Pyogenic granuloma Important features to consider when making the Sarcoidosis provisional diagnosis of the cause of a lump or swelling Sialadenitis include: Traumatic Denture granulomata Position The anatomical position should be defined and Epulis the proximity to other structures (e.g. teeth) noted Fibroepithelial polyp • Midline lesions tend to be developmental in origin Haematoma (e.g. torus palatinus) Mucocele • Bilateral lesions tend to be benign (e.g. sialosis - salivary Surgical emphysema swelling in alcoholism, diabetes or other conditions) Neoplasms Carcinoma • Most neoplastic lumps are unilateral Leukaemia Other similar or relevant changes elsewhere in the oral Lymphoma cavity should be noted Myeloma Size The size should always be measured and recorded. A Odontogenic tumours diagram and photograph may be helpful Others Shape Some swellings have a characteristic shape that Fibro-osseous Cherubism may suggest the diagnosis: thus a parotid swelling often Fibrous dysplasia fills the space between the posterior border of the Paget’s disease Hormonal Pregnancy epulis/gingivitis mandible and the mastoid process Oral contraceptive pill gingivitis Colour Brown or black pigmentation may be due to a Sialosis variety of causes such as a tattoo, naevus or melanoma. Metabolic Amyloidosis Purple or red may be due to a haemangioma, Kaposi’s Other deposits sarcoma or giant-cell lesion Drugs Phenytoin Temperature The skin overlying acute inflammatory Ciclosporin lesions, such as an abscess, or over a haemangioma, is Calcium channel blockers frequently warm Allergic Angioedema Tenderness Inflammatory swellings such as an abscess INTERNATIONAL DENTISTRY SA VOL. 13, NO. 2 73 Scully Table 2: Oral malignant neoplasms Common Squamous cell carcinoma Less common Salivary gland tumours Malignant melanoma Lymphomas Neoplasms of bone and connective tissue Some odontogenic tumours Maxillary antral carcinoma (or other neoplasms) Metastatic neoplasms (breast, lung, kidney, stomach, liver) Langerhans cell histiocytoses Kaposi’s sarcoma are characteristically tender, although clearly palpation Ulceration Some swellings may develop superficial must be gentle to avoid excessive discomfort to the ulceration such as squamous cell carcinoma. The character patient of the edge of the ulcer and the appearance of the ulcer Discharge Note any discharge from the lesion (e.g. clear base should also be recorded fluid, pus, or blood), orifice, or sinus Margins Ill-defined margins are frequently associated Movement The swelling should be tested to determine if with malignancy, whereas clearly defined margins are it is fixed to adjacent structures or the overlying suggestive of a benign lesion skin/mucosa such as may be seen with a neoplasm Number of swellings Multiple lesions suggest an Consistency Palpation showing a hard (indurated) infective or occasionally developmental, origin. Some consistency may suggest a carcinoma. Palpation may conditions are associated with multiple swellings of a cause the release of fluid (e.g. pus from an abscess) or similar nature, e.g. neurofibromatosis. cause the lesion to blanch (vascular) or occasionally cause a blister to appear (Nikolsky sign) or to expand. Investigations Sometimes palpation causes the patient pain (suggesting The medical history should be fully reviewed, since an inflammatory lesion). The swelling overlying a bony some systemic disorders may be associated with intra- cyst may crackle (like an eggshell) when palpated or oral or facial swellings (Table 1). The nature of many fluctuation may be elicited by detecting movement of lumps cannot be established without further fluid when the swelling is compressed. Palpation may investigation: disclose an underlying structure (e.g. the crown of a tooth • Any teeth adjacent to a lump involving the jaw should under an eruption cyst) or show that the actual swelling is be tested for vitality, and any caries or suspect in deeper structures (e.g. submandibular calculus) restorations investigated. Surface texture The surface characteristics should be • The periodontal status of any involved teeth should also noted: papillomas have an obvious anemone-like be determined. appearance; carcinomas and other malignant lesions and • Imaging of the full extent of the lesion and possibly deep fungal and other chromic infections tend to have a other areas is required whenever lumps involve the nodular surface and may ulcerate. Abnormal blood vessels jaws. OPT and special radiographs (e.g. of the skull, suggest a neoplasm sinuses, salivary gland function), computerised 74 INTERNATIONAL DENTISTRY SA VOL. 13, NO. 2 Scully Figure 2: Gingival swelling caused by nifedipine. Figure 3: Oral squamous cell carcinoma. Figure 4: OFG (orofacial granulomatosis). tomography (CT scans) or magnetic resonance imaging Oral cancer (MRI), or ultrasound may, on occasions, be indicated. Oral cancer is the most common malignant epithelial Photographs may be useful for future comparison. neoplasm affecting the mouth. More than 90% is oral • Blood tests may be needed, particularly if there is squamous cell carcinoma (OSCC). Cancers of the oral suspicion that a blood dyscrasia or endocrinopathy may cavity are classified according to site: underlie the development of the lump. • Lip (International Classification of Diseases (ICD) 140) • Tongue
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