Sign In Soft tissue swellings can have a number of manifestations in the mouth. It is vital that you can identify them from one another as well as being able to describe them accurately.
Features of a lump/swelling in the mouth which are paramount for a correct diagnosis are:
- Number/anatomy of lesions e.g. bilateral, unilateral, symmetrical
- Alteration in size
- Any discharge from the lesion
- When the patients first noticed the lesion (if the patient is the one that noticed it first)
Important factors to consider when making a provisional diagnosis are the following:
- Position – anatomical position should be reported and it’s proximity to vital structures noted:
– Midline lesions – lesion in the midline tend to be developmental
– Bilateral lesions – these lesions are generally benign e.g. sialosis
– Unilateral lesion – these are often malignant in nature
Other features that help with the diagnosis that need to be noted are:
| Size | Size should always be measured and monitored. Photographs are a good way to do this. |
| Shape | Pedunculated= Attached to a surface via narrow elongated stalk. Sessile= If no stalk present. Same diameter at the top as bottom. |
| Colour | Purple/red lesions often indicate haemangioma or kaposi sarcoma. |
| Temperature | Skin overlying an abscess or haemangioma is often warm. |
| Tenderness | Tenderness is a common trait of an abscess and other inflammatory swellings. |
| Discharge | Note any discharge as this often indicates an abscess. |
| Movement | Should be checked to determine if the lesion is attached to adjacent structures or the overlying mucosa which is common with neoplasms. |
| Consistency | Firm texture is common with carcinomas. Palpation may cause pus to be released indicating an abscess whilst blanching would indicate a vascular origin. A blister may appear on palpation which is a nikolsky sign (see ulcers). Pain on palpation would suggest an inflammatory origin. Swelling overlying a bony cyst would often crackle like an egg-shell upon palpation. |
| Surface texture | Squamous cell carcinoma are often nodular and ulcerated. |
| Ulceration | Common with malignant lesions. |
| Margins | well defined margins indicate a benign lesion whereas poorly defined margins often indicate malignancy. |
| Number of lesions | Multiple lesions often indicate infective origin. |
Epulis
An epulis is a soft tissue swelling of the gingival margin. Most commonly found in females as normally found in the anterior region of the mouth.
Management of most types of epulis follow the follwing theme:
- Excised (sometimes sent for biopsy) – if complete excision is not performed recurrence can occur
- Curettage of the underlying bone defect
- Remove cause e.g. calculus, overhang
The most common ones you need to know are:
This is an epulis that is due to a hyperplastic response to chronic irritation.
It leads to swelling of the gingiva, consisting of heavily fibrosed interlacing granulation tissue.
It has a firm rubbery texture and it’s colour is pale pink. Early on it may be soft in texture and in the later stages bone formation may be present.
This is also known as Peripheral giant cell granuloma. These are osteogenic in nature and often occur after an extraction or local irritation.
Overtime they become less vascular and more fibrosed, bone formation may also result.
Clinically in the early stages they are deep red maroon or blue in appearance. This provides a preliminary distinguishing feature from pyogenic granuloma or fibrous epulis.
Histological findings are used to determine the diagnosis.
It can be one of the early signs of hyperparathyroidism thus para thyroid hormone levels should be assessed.
Present as reddish, purple, vascular, swelling that is commonly found on the gingiva but can be found on any part of the mouth. They are also vascular in nature.
They can mature and become and fibroepithelial polyp.
They are redder in colour than the fibrous epulis and they have a tendency to bleed because of its vascular content.
They are the exact same as the pyogenic granuloma except that they occur exclusively in pregnant women, most commonly in the third trimester. It is often accompanied with pregnancy gingivitis as well.
It is understood the hormonal changes that occur during pregnancy lead to an exaggerated response to any irritant leading to an epulis formation.
If left, they often disappear after pregnancy.
This is essentially a fibrous epilus, but found on the labial or buccal mucosa. Normally caused by chronic trauma such as biting. They are often pink in colour and rubbery in texture.
This is also known as denture granuloma. It is similar to a fibroepithelial polyp but is found on the flange or sulcus due to chronic irritation from a poorly-fitting denture. Clinically, it can appear as erythematous mucosa or more dense connective tissue that is pale and rubbery.
A mucocele is essentially a mucus filled cyst that is commonly found on the lip, but can be found anywhere in the mouth.
They occur when the salivary glands get blocked by mucus.
They are painless but can become permanent if not treated.
Treatment can be cryotherapy, laser therapy, or in more severe cases, surgical removal is performed.
This is a fluid collection or cyst that forms in the mouth under the tongue. It is filled with saliva that has leaked out of a damaged salivary gland.
The most common cause is minor trauma to the floor of the mouth which can damage the ducts that drain saliva from the sublingual glands.
They are soft, fluctuant, bluish and are typically painless but can interfere with speech or mastication.
Clinically they look like a mucocele found sublingually.
Treatment involves incision and drainage, but in most cases they go away spontaneously.
- Inflammation of the orofacial region.
- Lips are commonly affected.
- Often associated with systemic condition such as Sarcoidosis and Crohn’s disease.
Causes:
- Not known
- Although can be a result of bacterial or hypersensitivity reaction
Diagnosis:
- Clinical observation
- Biopsy
Treatment:
- Identify and remove any factors causing the disease
- Intralesional steroids is an option
Onset is usually 1-3 months after the usage of particular drug.
Clinically it manifests as pink and firm gingiva that covers the crown of the tooth.
It’s caused by an abnormal response of the gingiva to a certain systemic drug. Examples are:
- Phenytoin – anti-seizure
- Cyclosporin – immunosuppresant
- Nifidipine – calcium ion channel blocker
Histology:
- Stratified squamous epithelium
- Elongated rete ridges
- Increased collagen
- Lymphocyte infiltration
Treatment focuses on altering the medication. In more severe cases, gingivectomy is a good option.
Scully, C. (1999). Handbook of oral disease. London: Martin Dunitz.
Jordan, R. and Lewis, M. (2004). A color handbook of oral medicine. New York: Thieme
Dental Updates: Oral medicine – Lumps And Swellings:
https://www.dental-update.co.uk/issuesSingleIssueArticle.asp?aKey=1182
See also Ulcers
