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    228

    The primary disease processes that give rise to swellings

    and tumors of the oral cavity include cysts, mucousextravasation and retention in the minor salivaryglands, foci of granulation tissue and inflammation,abscesses and connective-tissue proliferations that arewell defined or encapsulated, as well as infiltrative sar-comas. Figure 231is a representation of the processesthat cause soft-tissue tumefactions in the mouth. Bothepithelial and connective-tissue disease processes canpresent as masses. Benign and malignant surface epithe-lial tumors are discussed in the Chapters 15 and 20,respectively. From a clinical perspective the three mostimportant defining characteristics of any soft-tissueswelling are location, coloration, and palpable nature.

    As for location, certain diseases tend to occur in spe-cific sites to the exclusion of others. Table 231lists themost common lesions according to site. This is not tosay that these sites are exclusive, since many lesions canin fact occur anywhere in the mouth; rather, this tabu-lation catalogues the most likely lesions for that site interms of overall prevalence. Coloration is dependentupon the tissues present in the mass and the depth of thelesion. Table 232lists the most frequently encounteredcolorations observed with soft-tissue masses and indi-

    cates the lesions that most often present with a given

    coloration. In general, yellow-appearing lesions arecomprised of lymphoid tissue or adipose tissue, red

    Cyst

    Abscess

    Sarcoma

    Tumor

    Granuloma

    Carcinoma

    Figure 231 Schematic diagram showing the various pathologic

    processes that can manifest as a submucosal or subcutaneous mass.

    Molecular and pathologic

    correlates of disease, 229

    Clinical features of oral

    swellings, 231

    Traumatic fibroma, 231

    Inflammatory fibrous

    (denture) hyperplasia, 232

    Mucous extravasation

    phenomenon (mucocele), 232

    Mucous retention cyst, 232

    Reactive gingival

    tumefactions, 233

    Peripheral odontogenic cysts

    and tumors, 234

    Diffuse gingival

    enlargements, 234

    Varix, 234

    Pulsatile labial artery, 235

    Parulis, 236

    Specific granulomas, 236

    Ectopic lymphoid tissue and

    benign lymphoepithelial

    cysts, 237

    Amyloidosis, 237

    Mesenchymal neoplasms, 238

    Aggressive proliferations, 240

    Squamous cell carcinoma, 240

    Salivary gland tumors, 240

    Sarcomas and lymphomas,

    241

    Clinical features of facial

    tumors and swelling, 241

    Odontogenic infections, 242

    Soft-tissue emphysema, 242

    Seborrheic keratosis, 242

    Melanocytic lesions, 242

    Mesenchymal neoplasms,

    243

    Basal cell carcinoma, 243

    Squamous cell carcinoma,

    244

    Suggested reading, 244

    23Swellings and Tumors ofthe Oral Cavity and Face

    L. Roy Eversole, DDS, MSD, MA, and Sol Silverman, Jr, MA, DDS

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    S W E L L I N G S A N D T U M O R S O F T H E O R A L C A V I T Y A N D F A C E 229

    swellings are vascular, blue swellings are mucinous orvenous, and brown swellings contain melanin or bloodpigments. Lesions with normal mucosal pink colorationare generally composed of fibrous tissues or some othertissues lying deeper in the connective tissues.

    Table 233groups swellings according to their pal-pation characteristics. Firm movable masses are usuallyneoplasms or granulomas; soft movable masses are fattyor myxoid tumors; fluctuant masses are cysts, mucoce-les or mucous-duct retention cysts and abscesses; andindurated fixed masses are probably malignant and may

    represent carcinomas, salivary adenocarcinomas, lym-phomas, and sarcomas.

    In terms of frequency, the majority of oral mucosalmasses are reactive proliferations, such as fibroushyperplasias, pyogenic granulomas, and mucousextravasation reactions. Mesenchymal and salivary neo-plasms are uncommon, and lymphomas and sarcomasare rare causes of oral swelling. Indeed, the probabilitythat a mucosal mass is a reactive or hyperplastic processis probably 50-fold compared to a true neoplasticprocess. In most instances, biopsy is necessary to arriveat a definitive diagnosis. Aspiration or incision and

    drainage may be performed as a diagnostic procedurewhen the mass is consistant with an abscess.

    Molecular and pathologic correlates

    of disease

    The molecular aspects or oral soft-tissue swellings arepoorly understood and have not received much attentionin the experimental literature. Conversely, the underlyingpathologic processes associated with the various lesions

    that produce tumefaction in the oral cavity are welldefined in the oral and maxillofacial pathology literature.

    As an overview of pathologic mechanisms, basic con-cepts are briefly presented here. The common masses thatrepresent hyperplasias evolve as a consequence of irrita-tion to the mucosal tissues by a dental appliance or bytrauma, often the consquence of biting. The injured tis-sues respond to chronic and sometimes acute injury byproliferation of cells. The most commonly encounteredhyperplasias are those involving fibroblasts. Injury toconnective tissue results in fibroblastic proliferation of a

    benign nature, followed by collagen fibrillogenesis. Manyfibrous hyperplasias are comprised of loose collagen andare soft to palpation, such as denture-induced fibroushyperplasia and the common traumatic fibromas of thetongue and labial and buccal mucosae. In the gingiva, theperiodontal tissues may be the targets of injury, particu-larly from irritants that may become entrapped in the gin-gival sulcus. Calculus, food particles, and foreign objectsmay be introduced into the sulcus, where they irritate the

    Table 231 Orofacial Soft-Tissue Swellings according to Site

    Site Type of Lesion

    Intraoral

    Lips and buccal mucosa Fibroma, mucocele, mesenchymal tumor, salivary tumor, squamous cell carcinoma

    Gingiva Parulis, pyogenic granuloma, peripheral fibroma, peripheral giant cell granuloma, peripheral ossifying

    fibroma, gingival cyst, peripheral odontogenic tumors, squamous cell carcinoma

    Palate Abscess, torus, salivary gland tumor

    Dorsolateral tongue Fibroma, granular cell tumor, pyogenic granuloma, squamous cell carcinoma

    Ventral tongue and oral floor Mucocele, ranula, lymphoid aggregates, lymphoepithelial cyst, osteocartilagenous choristoma, squamous

    cell carcinoma

    Face and neck swellings

    Masseteric region Cellulitis, space infection, jaw cysts and tumors, masseteric hypertrophy

    Parotid region Sialadenitis, sialolithiasis, salivary neoplasm

    Submandibular region Lymphadenopathy, sialolithiasis, salivary neoplasm

    Lateral neck Lymphadenopathy, mesenchymal neoplasm, branchial cleft cyst, metastatic carcinoma, lymphoma, carotid

    body tumor

    Anterior neck Goiter, thyroid neoplasm, thyroglossal cyst

    Face Seborrheic keratosis, basal cell carcinoma, adnexal skin tumors, squamous cell carcinoma, melanoma

    Table 232 Masses with Coloration or Pigmentation

    Color Soft-Tissue Mass

    Bluepurple Hemangioma, varix, hematoma, peripheral

    giant cell granuloma, mucocele, Kaposi sarcoma

    Red Hemangioma, pyogenic granuloma,

    Kaposi sarcoma

    Brown Nevus, hematoma, seborrheic keratosis,

    Kaposi sarcoma, melanoma

    Black Melanoma

    Yelloworange Lymphoid aggregates, lymphoepithelial cyst,

    lipoma, granular cell tumor

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    230 C H A P T E R 2 3

    fibrovascular connective tissues, periosteum, and perio-dontal ligament fibrous tissues. Proliferation of thefibrovascular connective tissue, along with inflammation,gives rise to pyogenic granulomas, whereas proliferationof the periosteal tissues, which contain osteoblasts and

    osteoclasts, gives rise to peripheral giant cell granulomas.When periodontal ligament fibroblasts proliferate, theyretain the potential to elaborate bone and cementum,thereby giving rise to peripheral ossifying fibromas.

    Minor salivary glands are located everywhere in theoral cavity except on the anterior dorsal tongue and theattached gingiva. They are most easily damaged fromaccidental biting in the lower lip and sometimes in thebuccal mucosa, whereas injuries to the palatal andupper lip glands are rare. Therefore, severence of theminor gland ducts after an acute biting episode fre-quently leads to mucous extravasation into the connec-tive tissues of the lips and buccal mucosa. In thesemucoceles, the extravasated mucus becomes encapsu-lated, or walled-off, by fibrous and granulation tissues,giving the appearance of a cyst. Less commonly, mucousplugs form in the ducts of minor glands and cause reten-tion of mucus. The ducts undergo cystic dilation and areepithelial lined; such lesions are referred to as mucousretention cysts or sialocysts. Although rare, true salivarystones may arise in minor salivary ducts, and as theygrow, they result in an enlargement within the sub-mucosa that is movable and hard.

    Acute infections of the soft tissues are uncommon;however, occasionally a foreign body, such as a small fishbone or material from a dental procedure may beimplanted into the soft tissues and cause an acute reac-tion. These submucosal fluctuant abscesses are moreoften seen on the tongue. Of course the most common

    location for abscess in the oral cavity is the gingiva andvestibule. In such instances the abscess is a parulis fromodontogenic infection or a periodontal abscess arising ina periodontal pocket. Pulp vitality testing of adjacentteeth, periapical radiographs, periodontal probing, andaspiration are all important procedures when attemptingto establish a definitive diagnosis. For accurate culturesprocured for identifying causative microorganisms, apure suppurate is essential; this is to avoid contaminants.

    Chronic foci of inflammation may also account forsubmucosal masses. Lymph nodes are located in the buc-cal mucosa and in health are not palpable. Sometimesthey become irritated or drain a local viral or bacterial

    infection and become enlarged. This enlargement isreferred to as reactive lymphoid hyperplasia in whichboth T cells and germinal-center B cells undergo immune-mediated proliferation. Foreign bodies, in addition toacute infections, may induce granuloma formation.Recall that many foreign bodies can cause a giant cellreaction with accompanying chronically inflamed granu-lation tissue. Oral mucosal foreign body granulomas areseen with many dental materials, including amalgam anddental cements, handpiece oil (oil granulomas), and veg-etable particles (legume or pulse granulomas).

    A group of idiopathic diseases, collectively known asorofacial granulomatosis, is histologically characterized

    by multiple, often confluent foci of granulation tissuewith giant cell formation in the absence of foreign ma-terial or a specific infectious agent. These are termednoncaseating granulomas, because unlike the granulo-mas of tuberculosis, there is no focus of caseous necro-sis. Included in the orofacial granulomatosis group oflesions are Crohn disease, sarcoidosis, Melkersson-Rosenthal syndrome, and cheilitis granulomatosa (seeChapter 24). Submucosal masses comprised of granulo-mas also occur in response to infectious agents and areknown as specific granulomatous inflammatory lesions.Included here are such specific infections as tuberculosisand deep fungal infections, the most common of whichis histoplasmosis. The specific infectious granulomasare typically multinodular with an erythematous granu-lar surface. Wegener granulomatosis is a systemic dis-ease with multiple organ involvement that also mani-fests as a red granular swelling, usually confined to thefixed gingiva, so-called strawberry gums.

    Swellings that diffusely involve the gingiva are theresult of pathologic leukocytic infiltrates, such as mightbe encountered in leukemia, proliferation of granula-tion tissue in instances of nonspecific hyperplastic gin-

    Table 233 Masses according to Palpation Characteristic

    Palpation Characteristic Mass

    Soft, fluctuant Mucocele, ranula

    Developmental cysts

    Sialocysts

    Gingival cysts

    Parulis

    Space infections and abscesses

    Soft, nonfluctuant Lipoma

    Fibroma

    Organized mucocele

    Firm, movable Mesenchymal tumors

    Granulomas

    Salivary adenomas

    Adnexal skin tumors

    Firm, fixed Granular cell tumor

    Seborrheic keratosis

    Keratoacanthoma

    Fibromatosis

    Indurated, fixed Basal cell carcinoma

    Salivary adenocarcinomasSquamous cell carcinoma

    Melanoma

    Sarcomas

    Lymphomas

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    S W E L L I N G S A N D T U M O R S O F T H E O R A L C A V I T Y A N D F A C E 231

    givitis, and overproduction of collagen in cases of drug-induced gingival hyperplasia (eg, Dilantin, nifedipine,cyclosporine), or the rare hereditary condition, familialfibromatosis gingivae.

    As stated previously, true connective-tissue neoplasmsare uncommonly seen in the oral cavity as compared with

    reactive and inflammatory masses. They may derive fromany of the submucosal tissues, such as fibroblasts,lipocytes, nerve sheath, smooth muscle, skeletal muscle,vessels, osteoblasts, and chondroblasts. Sarcomas ofthese tissues are extremely rare. The proliferations con-tain cellular elements that are histogenically related to thenormal tissues from which they arise and are namedaccording to their histologic differentiation. The benignentities derived from mesenchymal or connective-tissuesare variably encapsulated or are at least well circum-scribed. A specific microscopic diagnosis is essential,since not all connective-tissue tumors behave in the sameway. Some are aggressive, such as myofibromatoses, and

    have a tendency for local recurrence. Others are benignand have no tendency for recurrence after excision.

    Minor salivary tumors also present as submucosalmasses (see Chapter 26). They are most commonlyfound in the palate and buccal mucosa, but can arise inany location where minor glands are located. Clinically,benign salivary gland tumors are nonulcerated andshow normal surface coloration, whereas the malignanttypes often exhibit surface telangiectasia, can be ulcer-ated, and are usually firm to palpation, owing to cellu-lar proliferation. As with connective-tissue tumors, thesalivary adenomas and adenocarcinomas are classifiedaccording to histologic patterns of differentiation.

    Recall that normal glands are comprised of ducts, acini,and myoepithelial cells. The various salivary-glandtumors are segregated and classified according to thepatterns of these various cell types. The common pleo-morphic adenoma is a lesion comprised of benign prolif-erations of ducts and myoepithelial cells. In the malignantcategory, adenoid cystic carcinoma and polymorphouslow-grade adenocarcinoma are composed of solid-tumor islands with additional foci of ductal formations.Mucoepidermoid carcinoma shows both acinar andductal cells with squamous (epidermoid) and mucousacinar cell differentiation. Mucoepidermoid carcinomasshow variations in cell patterns that allow for assign-ment into low- or high-grade subgroups that correlatewith good and poor prognosis, respectively.

    Masses of the facial skin can also, as in the mouth,be represented by inflammatory, infectious, develop-mental, and neoplastic processes. Diffuse swellingsoccur in edematous states and in inflammatory condi-tions, such as dental-space infections, cellulitis, andallergic reactions. Focal masses are often the conse-quence of either benign or malignant tumors that arisefrom the surface epithelium, adnexal structures (hair

    follicles, sweat glands, sebaceous glands), and the der-mal connective tissues. The most common focal cancer-ous swelling of the face is basal cell carcinoma. It hasbeen shown that these tumors, as well as those associ-ated with the basal cell nevus syndrome, harbor muta-tions in the patched gene, a membrane tumor sup-

    pressor involved in the sonic hedgehog morphogenpathway. Jaw keratocysts harbor these same mutations.

    Clinical features of oral swellings

    The clinical features for the more common mucosalswellings vary according to each specific entity. As hasalready been emphasized, it is crucial that the cliniciantake note of the location, coloration, surface texture, andpalpable nature of the mass before attempting to secure adefinitive diagnosis. If the lesion shows the features of anabscess, then diagnostic testing for odontogenic or perio-

    dontal origin must be performed by obtaining radio-graphs, pocket probing, pulp vitality testing, and identi-fying pyogenic suppuration. If no apparent infectioussource is uncovered, then biopsy may be the chief methodfor procurement of a definitive diagnosis. In the case ofdiffuse gingival enlargement, interrogation with regardto drug use is imperative. As in all cases of oral lesions,the clinician must obtain a thorough medical history,knowing that some swellings may be associated withsystemic diseases. When biopsy is to be undertaken, adecision must be made as to whether the biopsy will beincisional or excisional, a consideration based on boththe size of the lesion and the possibility of malignancy.

    If malignancy has a high priority in the differential diag-nosis, then incisional biopsy is indicated (see Chapter20). The lesional and diagnostic tissue lies deep in thesubmucosa, and therefore, an incisional biopsy must betaken to a significant depth within the tumefaction. Awedge or pie-shaped incisional biopsy is advisable inthese situations, to get an adequate specimen.

    Traumatic fibroma

    Focal fibrous hyperplasia as a consequence of traumaunderlies the pathogenesis of this common benign oraltumor. It is pink in color yet may have a white keratoticsurface if it is repeatedly irritated. Most fibromas areround, dome shaped sessile, soft masses (Figure 232).They vary greatly in size and are usually asymptomatic.The most common sites are the lips, commissures, buc-cal mucosa, and tongue. When traumatic fibromasoccur on the gingiva they are commonly referred to asperipheral fibromas. Some show unique histologic fea-tures and are designated gingival fibromas. Anothervariant that can occur anywhere in the mouth is the

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    232 C H A P T E R 2 3

    giant cell fibroma, not to be confused with giant cellgranuloma, an aggressive lesion of the gingiva. Fibro-mas are treated by simple excision as well as trying toidentify and remove a possible causative irritant, whichis not often apparent.

    Inflammatory fibrous (denture) hyperplasia

    The irritation from an overextended denture flange canirritate the submucosal connective tissue. This tends tooccur under dentures when alveolar ridge resorption hascaused the denture to overseat. The irritating flangesinduce multinodular flabby masses along the maxillaryor mandibular vestibule (Figure 233). This so-calledepulis fissuratum, an older term for fibrous hyperplasiaassociated with denture irritation, was used in a descrip-tive sense because so many of these common lesions arelobulated, with intervening fissural depressions. Themost common locations are the anterior maxillary andmandibular vestibules, but they can be located anywhere

    along the sites of denture compression and irritation.Recall that in the palatal vault denture hyperplasias arediffuse and papillary, a lesion termed inflammatory pap-illary hyperplasia.

    Mucous extravasation phenomenon (mucocele)

    Mucoceles are the result of minor salivary gland ductseverage with resultant escape of mucus into the sub-mucosal connective tissues. With no conduit for excre-tion, the mucus collects in the connective tissues, creat-ing a pseudocyst (they lack an epithelial lining) whichbecomes walled-off with granulation tissue and if notremoved, the wall becomes fibrotic. The duct severageis the consequence of biting, usually in the lower lip.Mucoceles rarely involve the upper lip yet may occur atany site where minor salivary glands are located.

    The clinical presentation is that of a soft-tissue cyst

    that is soft and fluctuant (Figure 234).When superficialthey are faintly blue; if walled-off or fibrosed they mayfeel more solid and have normal mucosal coloration.Occasionally, the patient pops the lesion (with a pin or bybiting) and it resolves; however, it usually recurs. Moreoften, is the tendency to remain or even enlarge. Surgicalexcision of the cystic tissue should be accompanied byremoval of the underlying feederminor glands. Largemucoceles in the floor of the mouth arise from severageof the sublingual or even the major submandibular ductand are referred to as ranulas. Some of these mucousextravasations extend deeply into the intrinsic muscles ofthe tongue and mylohyoid, so-called plunging ranulas.

    Mucous retention cyst

    True cysts of the minor salivary ducts are referred to asmucous retention cysts or sialocysts. These lesions mani-

    Figure 233 Inflammatory fibrous hyperplasia under a mandibular

    denture.

    Figure 232 A, Clinical appearance of traumatic (irritation) fibroma;

    B, microscopic appearance of fibroma.

    A

    B

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    S W E L L I N G S A N D T U M O R S O F T H E O R A L C A V I T Y A N D F A C E 233

    fest the same clinical characteristics as the mucocele, beingsoft fluctuant bluish masses. Whereas some are probablytrue blind cysts lined by salivary ductal epithelium, othersare ductal dilatations that develop as a consequence ofductal obstruction or occlusion by mucous plugs. Theselatter retentive cysts tend to occur in the buccal mucosa

    of older adults. Treatment is complete excision.

    Reactive gingival tumefactions

    Four pathologically related proliferations are encoun-tered on the gingiva, usually arising in the interdental orgingival papilla region. All are reactions to irritationfrom calculus or particles that become wedged into thegingival sulcus (toothpick fragments, popcorn kernels,

    etc.). The host reacts to the irritant by hyperplasia of theendogenous tissues in the site, which include fibrovascu-lar connective tissues, periodontal ligament fibroblasts,and periosteal tissues. Proliferation of granulation tissuegives rise topyogenic granulomas, which may fibrose toperipheral fibroma; periodontal ligament cells give riseto cells capable of osteogenesis and cementogenesis,causing the ossifying fibroma; periosteal progenitor cells,including osteoblasts and osteoclasts, proliferate, pro-ducing a lesion termed peripheral giant cell granuloma(Figure 235).The term peripheral is employed to dis-tinguish these common lesions from their less commoncounterparts that arise within the jaw bones. Pyogenicgranulomas and peripheral ossifying fibromas are com-mon in pregnancy.

    Clinically either facial-buccal or lingual gingiva maybe involved and there may be a history of rapid growth.The pyogenic granuloma is usually red; fibromas andossifying fibromas are pale pink; and giant cell granulo-mas are bluish; and all can become ulcerated with a whitepseudomembranous surface (Figure 236, 237, and238).The peripheral giant cell granuloma is the moreaggressive of these lesions, often eroding underlying alve-olar bone and even causing root resorption (Figure 239).

    Figure 234 A, Mucocele of the lower lip; B, photomicrograph show-

    ing pooling of mucin under the surface epithelium with minor gland lob-

    ules in the deeper connective tissue; C, ranula in the floor of the mouth.

    B

    A

    C

    Fibrovascular

    connective

    tissues

    Pyogenic

    granuloma

    Peripheral

    fibroma

    Peripheral

    ossifying

    fibroma

    Peripheral

    giant cell

    granuloma

    Periodontal

    ligament

    Periosteum

    Figure 235 Diagram depicting the various reactive lesions of the

    gingiva.

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    Figure 236 A, Pyogenic granuloma with red coloration; B, photo-

    micrograph of pyogenic granuloma showing fibrovascular tissues.

    A

    B

    234 C H A P T E R 2 3

    eral odontogenic fibroma being the most common (Fig-ure 2311). Rare peripheral odontogenic tumors thatappear as gingival masses include ameloblastoma,dentinogenic ghost-cell tumor, and calcifying epithelialodontogenic tumor.

    Diffuse gingival enlargements

    Gingival hyperplasias can be nonspecific, drug-induced,hormonally-related, granulomatous, or even neoplastic.Nonspecific gingival hyperplasias often have theappearance of multifocal pyogenic granulomas, beingsoft, hemorrhagic, and fiery red. There is a systemicunderlying hormonal influence in the pathogenesis ofhyperplastic gingivitis when the patient is a femaleentering puberty or gravid (Figure 2312). Suchinstances are often referred to as puberty and pregnancygingivitis, respectively. The gingival lesions are typicallyassociated with formation of pseudopockets.

    Drug-induced gingival hyperplasias are diffuse, andthe lesions may be of normal coral pink coloration orred and inflamed. Phenytoin, calcium channel blockers,and cyclosporine used in the treatment of seizure dis-orders, hypertension and cardiovascular disease, andimmunosuppression for organ transplantation, respec-tively, are all responsible (Figures 2313 and 2314).The fibrosis of cyclosporine enlargement is not limitedto the gingival tissues; indeed, renal, pulmonary, andretroperitoneal fibrosis are complications of this drug.These lesions do not resolve with drug withdrawal.

    Familial fibromatosis gingivae is a rare disorder thatis inherited as an autosomal dominant trait. Theenlarged gingivae are firmly fibrotic and devoid of sig-nificant inflammatory erythema as a rule (Figure 2315).Periodic gingivectomies are often requested by thepatient for esthetic as well as functional reasons.

    Wegener granulomatosis is a multisystem immuno-pathologic disease that affects the lungs, kidneys, skin,and middle ear. The enlarged gingiva is red and granu-lar, often termed strawberry gums (Figure 2316). Ahistopathologic diagnosis of Wegener granulomatosiswarrants a systemic workup to examine for other sitesof involvement. The serologic marker antineutrophilcytoplasmic antibody (ANCA) is of diagnostic impor-

    tance, being found in over 85% of cases.

    Varix

    Focal varices are most common in the lower lip and areprobably the consequence of trauma, such as lip biting,to the submucosal vessels. Venous channels proliferateand become dilatated. These lesions may be flat or, moreoften, raised blue or purple masses (Figure 2317).Somewill blanch on diascopy (exerting direct pressure on the

    Wide surgical excision is the treatment. Recurrenceoccurs in over 20% of the cases, which can be minimizedby adequate surgical excision coupled with root planing.

    Peripheral odontogenic cysts and tumors

    Although odontogenic tumors are encounted central inthe jaws, recall that the dental lamina arises from thealveolar mucosa, and odontogenic rests, which can giverise to neoplasms and cysts, are located in the gingiva.The most common entity is the gingival cyst of the adult,a lesion that appears as a nodule on the attached gingivaand may erode the underlying cortex (Figure 2310).Benign odontogenic tumors also occur here, the periph-

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    236 C H A P T E R 2 3

    mucosa should be incised and the vessel blunt dissected,followed by ligation and excision.

    Parulis

    Odontogenic infections that evolve into periapicalinflammatory lesions may perforate the cortex, withdrainage into the oral soft tissues. Focal drainage of anacute inflammatory process creates a tract that deliverssuppurative material into the gingival submucosa.These drainage tracts may occur anywhere from the freegingival margin down to the vestibule (Figure 2318).This submucosal abscess, or parulis, is associated withan endodontically involved necrotic tooth. Radiographs

    and pulp vitalometry testing disclose the incriminatingtooth. If all teeth in the region of the parulis are vital,then the lesion may represent a focal periodontalabscess, and in such cases, a deep pocket is identifiableand probing causes exudation.

    Specific granulomas

    Granulomatous inflammation is characterized by gran-ulomas with multinucleated giant cells. This type of his-tologic reaction is seen in foreign body reactions, orofa-cial granulomatosis, and such specific infections astuberculosis and deep fungal infections. Specific granu-lomas occur most often in the tongue, vestibule, andbuccal mucosa, where they appear as submucosal nod-ules, some being multinodular. Foreign body reactionsare commonly found to contain fruit or vegetable ma-terial (pulse granulomas), dental materials, or oil fromhandpieces, thereby representing iatrogenic lesions.Granulomas that represent specific microbial infectionsare often red with a granular strawberryappearance.

    They are generally firm to palpation. Biopsy with spe-cific microbial stains usually allows the pathologist toidentify the genus of the microorganism. Orofacialgranulomatosis includes sarcoid, sarcoid-like diseases,and Crohn disease (see Chapter 24).

    Figure 2310 Gingival cyst. Figure 2312 Nonspecific puberty-associated hyperplastic gingivitis.

    Figure 2311 Peripheral odontogenic fibroma appearing as a gingival

    mass. Figure 2313 Dilantin-induced gingival hyperplasia.

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    S W E L L I N G S A N D T U M O R S O F T H E O R A L C A V I T Y A N D F A C E 237

    Ectopic lymphoid tissue and benignlymphoepithelial cysts

    Ectopic lymphoid tissue is commonly seen in the oralcavity where it appears as a yellow nodular or multi-nodular mass (Figure 2319).The common sites are thefloor of the mouth and the soft palate. Many of theselymphoid aggregates emulate tonsilar tissue in thatepithelial lined crypts extend into the lymphoid tissueand some become impacted with keratin, exhibiting acystic appearance.

    Amyloidosis

    Amyloid is a pathologic fibrillar protein that accumu-

    lates within the connective tissues and is associated withcertain neoplasms. Chemically, there are over 15 sepa-rate varieties, yet only three are of clinical significance:amyloid light chain (AL) protein, derived from plasma-cell-generated immunoglobulin light chains; amyloid-associated (AA) protein, which is made in the liver, and

    beta-2-microglobulin. Amyloid light chain protein isassociated with primary amyloidosis and becomesdeposited in tissues in patients with B lymphocyte pro-

    liferations, multiple myeloma being the most prevalent.Amyloid-associated protein is deposited in secondaryamyloidosis, such as inflammatory lesions and tubercu-losis, and beta-2 microglobulin is associated with long-term renal dialysis. In the oral cavity, these deposits areusually encountered on the tongue as multiple or, less

    Figure 2314 Gingival enlargement associated with a calcium chan-

    nel blocker.

    Figure 2315 Familial gingival hyperplasia.

    Figure 2316 The strawberry gumsof Wegener granulomatosis.

    Figure 2317 A, Varix of the lip; B, photomicrograph of varix with an

    organizing thrombus.

    A

    B

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    238 C H A P T E R 2 3

    Figure 2321 A, Nerve sheath tumor of the tongue; B, photomicro-

    graph of a neurilemoma showing nuclear palisading (Antoni type A

    tissue).

    A

    B

    often, single nodules (Figure 2320).The presence ofamyloid in oral biopsies is determined by Congo redstaining with subsequent demonstration of green bi-refringence under polarized light. The fluorochrome

    thioflavin T also stains amyloid, yet is not specific.

    Mesenchymal neoplasms

    A variety of neoplasms arise from the submucosal con-nective tissues, and such tumors appear as nodularswellings. They may show distinct clinical features, suchas hemangioma and lymphangioma, or they may benondescript, simply presenting as pink, smooth-surfaced tumefactions. Hemangiomas and lymphan-giomas are considered to be developmental lesions,since these lesions often proliferate in infancy or child-

    hood, and may spontaneously resolve during teenageyears (see Chapter 25). Most mesenchymal tumors arefound in the tongue or buccal mucosa, but they canoccur anywhere in the mouth. The more common arenerve sheath tumors, including neurilemoma (shwan-noma) and neurofibroma (Figure 2321).The granularcell tumor is generally considered to be a nerve sheathtumor as well (Schwann cell origin) and is most com-

    monly found in the tongue, where it appears as a yellow,smooth-surfaced, firm plaque or nodule (Figure 2322).

    Lipomas are typically located in the buccal mucosa,

    appearing as soft, yellow, single or multinodular masses(Figure 2223).Choristomas are benign growths thataberrantly arise in locations that do not harbor theprogenitor cells from which they arise. In the oral cav-

    Figure 2318 Parulis associated with periapical infection.

    Figure 2319 Ectopic lymphoid tissue in the oral floor.

    Figure 2320 Amyloidosis presenting as multiple tongue nodules.

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    ity, chondroid (cartilaginous) choristomas are typicallyencountered as hard nodules in the submucosa of thetongue. Other benign mesenchymal neoplasms that areoccasionally encountered in the oral cavity are rhab-domyoma, leiomyoma, nodular fasciitis, solitaryfibrous tumor, and fibrous histiocytoma, to mention but

    a few (Figures 2324and 2325).These specific entitiesare all treated by surgical excision, and have variabletendencies for recurrence.

    A

    B

    Figure 2322 A, Granular cell tumor of the tongue; B, photomicrograph

    of granular cell tumor with overlying pseudoepitheliomatous hyperplasia.

    Figure 2323 Lipoma with yellow coloration of the buccal mucosa.

    Figure 2324 Submucosal tumor of the lip.

    Figure 2325 Photomicrograph of a well-defined mesenchymal neo-

    plasms, in this case a leiomyoma.

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    Figure 2327 A, Adenocarinoma of the minor salivary glands of the

    palate, the most common site for oral salivary gland tumors. B, Retro-

    molar adenocarcinoma.

    Aggressive proliferations

    Certain mesenchymal proliferations are characterized byrapid growth and can reach large proportions; someactually invade adjacent soft and hard tissues despitetheir inability to metastasize. All are defined by their

    microscopic appearance. These aggressive mesenchymaltumors often lie deep within the facial tissues, floor ofthe mouth, tongue, or neck, and are firm to palpation. Ifthere is any invasion of contiguous tissues, they are par-tially fixed, as assessed by palpation. Included in thisgroup are fibrous histiocytoma, aggressive juvenile fibro-matosis, hemangiopericytoma (some of which showmalignant behavior), and hemangioendothelioma. Openbiopsy or needle aspiration cytology are acceptable diag-nostic procedures. Wide excision is generally required.

    Squamous cell carcinoma

    Chapter 20 discusses oral malignant epithelial neo-plasms in detail. Late-stage tumors often present asindurated ulcerated masses, although some are non-ulcerated. Most squamous cell carcinomas are locatedin the tongue and lips and in the floor of the mouth (Fig-ure 2326).For oral cancers in general, the more ante-rior the carcinoma is located in the mouth, the betterthe prognosis; the more posterior, the worse the prog-nosis. This may be attributable to delayed diagnosis(advanced stages), intrinsic cell proliferation differ-ences, or greater lymphatic drainage in those areas. Inci-sional biopsy is recommended for diagnosing these

    tumefactive indurated lesions. Treatment planning iscomplex, with the more advanced-stage lesions requir-ing more aggressive treatment. Overall prognosis ispoor, with only about 50% surviving.

    Salivary gland tumors

    Chapter 26 discusses each of the histologic types of sali-vary gland tumors. Some types that are commonly foundin the major glands are rare or may never be found in theminor glands of the mouth, conversely, there are minor

    salivary gland tumors that rarely arise in the majorglands. Intraoral minor gland tumors present as sub-mucosal masses and are as apt to be malignant as they areto be benign. The most common site is the palate, wherethe mass is off the midline, arising in the posterior aspectof the hard palate or at the hardsoft palate junction (Fig-ure 2327).The buccal mucosa, upper lip, and ventraltongue are also common sites for these neoplasms. Thebenign tumors that occur in minor glands include thepleomorphic adenoma, monomorphic adenoma, andcanalicular adenoma, the latter arising almost exclusivelyin the upper lip, where it may be multifocal. Polymor-phous low-grade adenocarcinoma is a common malig-

    nant minor salivary gland tumor that almost never arisesin the major glands. Other adenocarcinomas arising inthe oral mucosa are mucoepidermoid carcinoma, adenoidcystic carcinoma, and adenocarcinoma not otherwisespecified. There are many other rare histologic types thatcan arise in either major or minor glands. Clinically, thebenign adenomas are typically smooth surfaced, nonul-

    Figure 2326 Squamous cell carcinoma of the lip.

    A

    B

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    cerated nodules that are movable, unless located in thepalate, where the tumor is trapped between the palatalbone and mucosa. Malignant salivary gland tumors areindurated (low-grade mucoepidermoid carcinoma beingthe exception) and may show surface ulceration andtelangiectasia. Incisional biopsy is the diagnositic proce-

    dure of choice; fine-needle aspiration is also useful fordiagnosis. Primary treatment is surgical removal. Basedon the histologic type and surgical margins, postsurgicalradiation therapy can be used. Adenomatous hyperplasiais seen in the soft palate and floor of the mouth and rep-resents a benign nonneoplastic growth of normal salivarytissue (Figure 2328).

    Sarcomas and lymphomas

    Malignant mesenchymal neoplasms are rarely encoun-tered in the oral soft tissues, being much more prevalent

    in the neck. Sarcomas can arise anywhere, and caseshave been reported in the tongue, buccal mucosa, andoral floor, being extremely rare in other locations (Fig-ure 2329). Rhabdomyosarcoma, fibrosarcoma, andmalignant fibrous histiocytoma have been the more fre-quent sarcomas reported to arise in the oral cavity (Fig-ure 2330).These malignancies account for less than5% of all oral cancers.

    Whereas lymphomas are usually seen in the cervicallymph node chain, extranodal non-Hodgkin lym-phomas are encountered in the oral cavity. They are farmore common in the human immunodeficiency virus(HIV)-infected patient, where they tend to occur on the

    buccal and palatal gingiva. The masses are firm, rapidlygrowing, often multinodular, and may show surfaceulceration. Microscopically they are usually high-gradelesions populated by monoclonal B lymphoblasts with adiffuse medium or large cell morphology. Patients withacquired immunodeficiency syndrome (AIDS) present-

    ing with lymphoma generally succumb within 6 monthsof diagnosis. In the United States, HIV-associated lym-

    phomas account for approximately 25% of all lym-phomas reported each year (see Chapters 8 and 14).

    Atypical lymphoproliferative lesions represent alymphoid infiltrative disease of the palate that invadesminor salivary tissue while leaving the extralobularducts relatively well preserved. These lesions appear asunilateral, soft, boggy, diffuse swellings at the hardsoftpalate junction. Some are polyclonal B-cell lesions thatare probably reactive; others are monoclonal and likelyrepresent low-grade mucosa-associated lymphoid tissue(MALT) lymphomas. These lesions are responsive tolow-dose radiation therapy.

    Clinical features of facial tumors

    and swellings

    The swellings that are seen on the face can be clinicallydivided into two major types: those that are diffuse

    Figure 2328 Adenomatous hyperplasia of salivary glands in the lat-

    eral oral floor.

    Figure 2329 Rhabdomyosarcoma of the tongue is a massive, aggres-

    sive malignancy that is rare in the oral cavity.

    Figure 2330 Photomicrograph of a sarcoma showing a spindle cell

    lesion (fibrosarcoma) with marked nuclear pleomorphism.

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    Figure 2332 Red nodular hemangioma (a nevus is also present as a

    brown macule).

    and those that are focal nodules. As alluded to previ-ously, diffuse swellings are usually inflammatorylesions, such as edema, emphysema, space infection, orcellulites. Facial asymmetry also may be seen whenthere is an underlying central lesion of the maxillary ormandibular bone and, of course, such lesions are bony

    hard. Radiographs are necessary diagnostic and evalu-ative tools.Focal nodules of the face may be covered by normal

    skin or they may be verrucous, ulcerated, or pigmented.Most small facial nodules are sebaceous cysts, basal cellcarcinomas, nevi, and seborrheic keratoses, the lattertwo being pigmented. Less common are squamous can-cers, melanomas, and mesenchymal neoplasms.

    Odontogenic infections

    Buccal drainage from a periapical abscess can result in sig-

    nificant facial swelling, which may localize over themandible or, less frequently, below the zygoma. As theinfection progresses through the buccal plate, bacteria andthe host response to it result in purulent exudates. If thissuppurative process is confined to spaces bordered bymuscle and fascia, the diffuse swelling is soft or fluctuantand tender to palpation. Alternatively, if the infectiousprocess infiltrates into muscle and leukocytic infiltratesare interposed within the substance of the muscle itself,then the lesion becomes indurated, a process termed cel-lulitis. The clinical distinction between cellulitis and spaceinfection is germane to treatment, since the former cannotbe incised and drained, whereas the latter is amenable to

    such intervention. Of course, the incriminated tooth mustbe treated as well. Depending upon the status of the tooth,endodontic therapy or extraction must be performed, andantibiotic therapy is indicated in these examples of moreextensive spread of infection. In some instances, the

    periosteum reacts to underlying odontogenic infection,giving rise to proliferative periostitis (Figure 2331).

    Soft-tissue emphysema

    On rare occasion, air may be forcefully introduced

    between tissue planes. This may occur during maxillaryendodontic, periodontal, and oral surgery procedures inwhich compressed air is applied and separates the tissueplanes. The entrapped air causes a diffuse facial swellingthat is crepitant to palpation. A potentially lethal com-pliction is vascular air embolism, an event that usuallyoccurs shortly after the introduction of compressed airinto the tissues. Aspiration of the swollen area may beattempted with caution, making sure not to puncture amajor vessel in the process. Eventually, the trapped airis absorbed by the tissues.

    Seborrheic keratosis

    Sun exposure to the facial skin damages DNA and mayinduce proliferative responses in the surface epithelium.This exposure may result in the formation of seborrheickeratosis, a benign entity. This common lesion is usuallyseen on the forehead, temples, or malar regions of theface. The lesions are slightly tumefactive, brown incolor, and have an oily texture. They vary considerablyin size and are typically symmetrical, with smooth well-delineated borders. The differential diagnosis includesnevus and basal cell carcinoma. Most seb Kscan beremoved by shave biopsy or laser ablation.

    Melanocytic lesions

    The common nevi are discussed in more detail in Chap-ter 22 on pigmentations; not all nevi, however, are pig-

    Figure 2331 Cellulitis of the masseteric region from an abscessed

    mandibular molar.

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    S W E L L I N G S A N D T U M O R S O F T H E O R A L C A V I T Y A N D F A C E 243

    mented. They can occur anywhere on the facial skin andare present from early childhood, with no history of any

    change or increase in size. In adults, they all representintradermal nevi. The pigmented nevi are symmetrical,round and nodular. The nonpigmented nevi simplyappear as nonproliferative nodules of normal skin col-oration. Treatment is deferred unless the patient wantsthem removed for esthetic reasons, or if they are near thehairline and become easily irritated. Should any long-standing nevus begin to increase in size, ulcerate, ordeepen in color, biopsy is recommended to rule out dys-plastic change in a preexisting nevus. Melanomas arealso discussed in Chapter 22.

    Mesenchymal neoplasms

    A variety of mesenchymal tumors can arise from the sub-cutaneous tissues of the facial skin. Hemangiomas appearred or purple when superficial (Figure 2332), or theymay not be discolored when they are deep and intramus-cular (Figure 2333).Neurilemomas, neurofibromas, andlipomas are relatively common connective-tissue tumorsthat appear as subcutanous masses (Figure 2334).

    Basal cell carcinoma

    Basal cell carcinomas (BCC) are the most frequentlyoccurring malignancy in the United States, accountingfor more than one million new cases each year. Sunexposure is also a factor in the etiology of BCC, whichexplains why those with fair skin and less melanocyticprotection are more prone to the development of theseskin cancers. They may appear as pearly nodules withsurface telangiectasia, or they may present as nonheal-ing ulcers (Figure 2335).The ulcerated basal cell carci-nomas usually develop rolled borders. It is common for

    these skin cancers to be multifocal. They are more oftenseen on the upper face, helix of the ear, and scalp thanon the lower face and lips. Wide local excision isrequired for cure, and despite adequate surgery, somerecur, presumably owing to a field effect of dysplasticchange that many occur in many areas of the facial skin.Radiation therapy is also effective in controlling BCC.

    Prognosis is good, since few BCCs metastasize. How-ever, they spread locally and insidiously, so if not diag-nosed and treated early, the treatment defect can be dis-figuring. Basal cell carcinoma does not arise in themucosal tissues of the mouth. Some interesting cases have

    been reported of BCC occurring in skin grafts that havebeen placed in the mouth for repair or closure purposes.

    Variant benign tumors of skin appendages areknown as adnexal skin tumors. These lesions present as

    Figure 2333 Intramuscular hemangioma is not discolored.

    Figure 2334 Supraorbital subcutaneous lipoma.

    Figure 2335 Basal cell carcinoma of the facial skin.

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    244 C H A P T E R 2 3

    smooth-surfaced nodules, because the cells of origin liewithin the dermis. Most are benign and are treated bysimple excision.

    Squamous cell carcinoma

    Arising de novo or from preexisting actinic keratoses,squamous cancers of the facial skin have potential forboth regional node and distant metastases. The actinickeratoses are reddish-brown macules with a superficialscaley keratotic crust. They are typically found on theforehead, nose, cheeks, and lower lip. When carcino-matous change arises from these precancerous dys-plasias, the lesions become tumefactive, indurated, andulcerated (Figure 2336).Ulcerated growths on the eye-lids, particular the lower lid, tend to arise from malig-

    nant transformation of the dermally situated sebaceousglands (sebaceous carcinoma). Regional nodes become

    palpably enlarged when metastases evolve. Treatmentconsists of wide local excision and/or radiation therapy;management of the neck is contingent upon clinical orimaging findings of nodal disease. On the lips, squa-mous cell carcinoma is common, and BCC is rare (seeChapter 20).

    Suggested reading

    Desai P, Silver JG. Drug-induced gingival enlargements. J Can

    Dent Assoc 1998;64:2638.

    Eversole LR, Rovin S. Diagnosis of gingival tumefactions. J

    Periodontol 1973;44:42935.

    Katz AD, McAlpin C. Face and neck neurogenic neoplasms.

    Am J Surg 1993;166:4213.

    Manor Y, Merdinger O, Katz J, Taicher S. Unusual peripheral

    odontogenic tumors in the differential diagnosis of gingi-

    val swellings. J Clin Periodontol 1999;26:8069.

    Rees SR, Gibson J. Angioedema and swellings of the orofacialregion. Oral Dis 1997;3:3942.

    Rossiter JL, Hendrix RA, Tom LW, Potsic WP. Intramuscular

    hemangioma of the head and neck. Otolaryngol Head

    Neck Surg 1993;108:1826.

    Som PM, Norton KI. Lesions that manifest as medial cheek

    and nasolabial fold masses. Radiology 1991;178:8315.

    Stewart CM, Watson RE, Eversole LR, et al. Oral granular cell

    tumors: a clinicopathologic and immunocytochemical

    study. Oral Surg Oral Med Oral Pathol 1988;65:42735.

    Tunkel DE, Baroody FM, Sherman ME. Fine-needle aspira-

    tion biopsy of cervicofacial masses in children. Arch Oto-

    laryngol Head Neck Surg 1995;121:5336.

    Van Dis ML. Swellings of the oral cavity. Dermatol Clin1996;14:35570.

    Figure 2336 Squamous cell carcinoma.


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