1.4 Benign Oral and Odontogenic Disorders
Key Features
Pathology may arise from any of the tissue types within the oral cavity—mucosal, glandular, nervous, vascular, immunologic, osseous, and dental.
Lesions may present symptomatically or be noted on routine screening.
Squamous papilloma is the most common oral mucosal papillary lesion (2.5% of all oral lesions).
Benign lesions should be differentiated from malignancy, which when indicated requires biopsy.
Benign oral lesions are common and may be manifestations of local or systemic disorders. The appearance of the lesion, associated symptoms, temporal relationship to other illnesses, and, when necessary, biopsy will enable the appropriate therapy to be determined. Differentiation of benign and malignant lesions is important for proper and expedient care.
Etiology
Lesions may be infectious, inflammatory, neoplastic, traumatic, vascular, or congenital/developmental. They may be isolated phenomena or be related to underlying medical disease or systemic disorder. The pathophysiology varies widely and is mentioned in connection to specific lesions in the Clinical section, below.
Clinical
Signs and Symptoms
Lesions of the oral cavity may present asymptomatically or may be noted by the patient or dental provider. Associated symptoms may include pain, bleeding, recurrent trauma, dental pain, malocclusion, or loose dentition. Benign lesions of varied etiology may share morphologic features. Many lesions appear as white plaques (i.e., leukoplakia) or ulcerations. Epithelial changes involving alteration in maturation (e.g., hyperplasia, dysplasia, carcinoma) often appear white in the moist environment of the oral cavity. Time course of the lesion and associated symptoms may guide the clinician as to the nature of the pathology.
Differential Diagnosis
For patients with oral cavity lesions or periodontal findings, several considerations must be taken into account in generating the differential diagnosis: color of the lesion (e.g., white, red, normal), thickness (e.g., exophytic, plaque, erosive), presence of pain, subsite within the oral cavity/oropharynx (e.g., hard palate, soft palate, gingiva, buccal mucosa, lips), type of apparent tissue involved (e.g., mucosa alone, bony, salivary), and underlying induration or fluctuance. Lesions may involve local factors or may be related to systemic illnesses. Systemic lupus erythematosus, sarcoidosis, Sjögren′s disease, Kawasaki′s disease, drug reaction, amyloidosis, viral infections, immune deficiencies, Crohn′s disease, HIV, and nutritional and metabolic deficiencies are among the possibilities.
Exophytic Mucosal Lesions
Squamous Papilloma
Squamous papilloma is a common benign epithelial growth caused by human papillomavirus (HPV). The lesion is usually pink to red with typical verrucous appearance. These may be singular or multiple (more often in immunocompromised patients). Excision to include the base of the lesion is typically curative, but lesions can recur from incomplete resection or other cells infected with HPV.
Fibromas
Fibromas are nodular swellings with fibrotic submucosal reaction related to trauma or chronic irritation. These may occur anywhere but are more common on the buccal, labial, and lingual mucosa. Excision may be carried out for diagnosis or if repeated trauma is occurring because of the lesion size.
Congenital Epulis
Congenital epulis is a benign lesion occurring along the alveolar region in infants, with a female predominance. Simple excision may be done for comfort or diagnosis.
Lobular Capillary Hemangioma (Pyogenic Granuloma)
Lobular capillary hemangioma (pyogenic granuloma) was long thought to be an inflammatory lesion but has been reclassified as a benign vascular neoplasm. It may be found on any mucosal surface in all demographics, but there is some association with pregnancy. Although vascular in nature, it may become increasingly fibrotic with time. Simple excision is the treatment of choice, but recurrence is not unusual.
Granular Cell Tumor
Granular cell tumor is a benign neoplasm originating with Schwann cells. They most often form on the lingual dorsum and may have some mild surrounding induration. Simple excision is typically curative.
Oral Hairy Leukoplakia
Oral hairy leukoplakia occurs on the tongue, often along the lateral border, and appears as rough white plaques. It is caused by Epstein-Barr virus (EBV) and occurs most often in immunocompromised patients, such as HIV-positive individuals. The appearance can fluctuate. Typically this is asymptomatic, but occasionally some mild discomfort or taste aberration may be present. No specific treatment is required.
Hairy Tongue
In contrast to the preceding, hairy tongue occurs along the tongue dorsum and may be darkly pigmented, pink, or even colored by other agents, such as coffee or mouthwash. It is associated with smoking, poor oral hygiene, local radiation, and antibiotic use. The filiform papillae of the tongue fail to desquamate normally and hence become elongated (or “hairy”). The condition is usually asymptomatic, but some patients relate a tickling sensation or find it unsightly. Treatment involves limiting the potential offending agents, along with tongue brushing or use of a commercially available tongue scraper.
Mucoceles
Mucoceles are cystic, ballottable swellings related to salivary gland trauma, often occurring on the lips or buccal mucosa. They may be clear, pink or even bluish in color. They may spontaneously resolve or may be excised to avoid repeated trauma or for diagnosis.
Gingival Hyperplasia
Gingival hyperplasia involves excessive growth of the gingival (gum) tissue. This may occur in response to inflammatory conditions, but when more pronounced, it is more often related to side effects of medications, including phenytoin, cyclosporin, and some calcium channel blockers.
Mesenchymal Tumors
Mesenchymal tumors may arise in the oral cavity. These include hemangioma, leiomyoma, rhabdomyoma, schwannoma, and neurofibroma. Local excision is usually adequate in these lesions, except hemangioma which, in pediatric patients will often regress.
Salivary Gland Adenomas
Salivary gland adenomas may occur in the mucosa of the oral cavity. Pleomorphic and monomorphic lesions may occur. These should be distinguished from minor salivary gland malignant lesions, which are more common.
Surface Mucosal Lesions
Leukoplakia
“Leukoplakia” is a term that may be used to describe any white plaque in the oral mucosa. It typically is related to some epithelial maturation issue, ranging from hyperkeratosis to dysplasia to carcinoma. Leukoplakias may occur as a result of chronic irritation, such as trauma (e.g., dentures, chewing on edentulous alveolus) or tobacco use (e.g., chew/“dip,” smoking). Excisional or incisional biopsy may be indicated for diagnostic purposes to rule out early carcinoma.
Nicotine Stomatitis
Nicotine stomatitis is a leukoplakic lesion, located along the hard and soft palate and caused by the heat from cigar, pipe, or, less commonly, cigarette smoking. Often it is diffuse in nature with white irregular patches mixed with red spots. If consistent historically, it does not require biopsy unless clinical concerns are present.
Fordyce Granules
Fordyce granules are flat to slightly raised yellow clustered lesions occurring on the buccal mucosa and lip. They represent sebaceous glands within the mucosa and require no treatment beyond patient reassurance.
Lichen Planus
Lichen planus is a dermatologic condition that may also involve the oral mucosa. Classically it appears as pink to purple patches with surrounding white “lacy” lines. Often this is asymptomatic, but it may be painful in the erosive subtype. Biopsy is necessary for definitive diagnosis. Treatment is not often necessary for the asymptomatic lesions, but topical or systemic steroids may be necessary in the painful erosive circumstances. A slightly elevated risk of oral squamous cell carcinoma is associated with lichen planus, particularly the erosive subtype. Lichen planus should be monitored during regular semiannual dental visits.
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