Other dental and oral problems

The range of possible oral pathology is large, so that we can only describe a few of the conditions you might might see. Some of the more important ones are tumours. Cysts of the jaw have been described in a previous section. An epulis is a mass arising from the gum. If you take a biopsy, be sure to take samples from different parts of the lesion.

OTHER DENTAL AND ORAL PROBLEMS ULCERS [s7]OF THE MOUTH If a patient has a recent, shallow, painful ULCER in his mouth, it is likely to be an APTHOUS ULCER, or a recurrent HERPETIC ULCER (both very common). The distinction between them is not important, since there is little you can do about either of them, and they will resolve spontaneously. Advise mouth washes, and try folic acid 5 mg weekly, both as prevention and treatment. These ulcers are more common in people taking proguanil (''Paludrine')

If he has a RAGGED ULCER of his gums, cheek or the floor of his mouth, suspect that he has a CARCINOMA (uncommon), especially if it has a raised edge. Send tissue for histology and refer him for deep radiotherapy, or radical surgery. See also Section 32.22.

LUMPS [s7]ARISING FROM THE ALVEOLUS Consider also carcinoma of the mouth (32.22).

If he has a FIRM LUMP ON HIS GUM, it is probably a FIBROUS EPULIS (common). Some of these lesions are fast-growing, and if a lump is soft, bluish, and grows rapidly it may be a sarcoma (very unusual). Excise it, or treat it by diathermy (if small, unusual),,, and send tissue for histology. If it is very extensive, try to refer him to an expert periodontologist (if you can find one!) or a maxillofacial surgeon. It may be one of a wide range of obscure, rare, fibro-osseous lesions.

If a patient has a SOFT SWELLING ON HIS (or her) GUM, between two teeth, or on the palate, and associated with chronic infection, it is probably a PYOGENIC GRANULOMA (granulomatous epulis, 34.2, common) and is particularly likely to occur during pregnancy (B, 26-12, pregnancy epulis), when it is often very vascular, and may simulate a malignancy. Pyogenic granulomas are common inside the mouth, and can also occur on the tongue. If a patient is pregnant, leave the lesion and don't try to excise it. Otherwise, excise it, and provided the infection is eradicated, it will not return. Send any material you obtain for histology. Make sure there is no underlying osteomyelitis (7.14a); if there is, treat it.

If a CHILD IN THE ''BURKITT ZONE' has a LOOSE TOOTH, with a swollen jaw, or SWELLINGS OF HIS JAW, suspect that he has BURKITT'S LYMPHOMA (32.3). Typically, his teeth are displaced.

LUMPS [s7]ARISING ELSEWHERE IN THE MOUTH If he has a PEDUNCULATED SWELLING on his cheek (or tongue), it is probably a FIBROEPITHELIAL POLYP or a fibroma (A, 26-12). This is commonly associated with irritative trauma, particularly that from an ill-fitting denture. Excise it and it will not recur, provided the trauma is removed.

If he has a PAPILLOMA (wart) inside his mouth, it may be viral (verruca vulgaris), and he may have similar lesions on his hands. If necessary, excise his oral lesion.

If he has an EXPANDING TUMOUR OF HIS MANDIBLE, with an X-ray showing large loculi and a honeycomb appearance, suspect that he has an AMELOBLASTOMA (rare). See Section 26.7.

CYSTS [s7]OF THE MOUTH If he has a bluish, translucent, RAISED VESICLE several millimetres to a centimetre or more in diameter, it is probably a MUCOUS RETENTION CYST (C, 26-13, common). These cysts may arise from the mucous glands anywhere inside his mouth, including his tongue, but are most common inside his lower lips. They may arise in a few days, persist for months, periodically discharge their contents, and then recur. Try to excise the lesion; if you merely incise it, it is likely to recur.

If a CHILD has a circumscribed, fluctuant, often BLUISH SWELLING of his alveolar ridge, over the site of an erupting tooth (common), it is probably an eruption cyst. This is usually symptomless, and bursts spontaneously to allow the tooth under it to erupt. If it does not, give him ketamine, grasp it with toothed forceps, and excise it. A little dark blood will escape, and the underlying tooth will erupt during the next few months.

If he has a slowly enlarging painless MASS on one side of the FLOOR OF HIS MOUTH, with normal mucosa over it, it is probably a RANULA (A, 26-13, uncommon). This is a particular form of retention cyst, arising from the inferior aspect of the tongue, and caused by blockage of the submandibular duct. If you remove it entirely by careful dissection, it will not recur. If this is difficult, deroof it; it will probably not recur.

It may also be a SUBLINGUAL DERMOID CYST (B, 26-13, rare), which is a developmental cyst in the line of fusion of the first branchial arches. The epithelium lining it is thicker than that of a ranula. Although it arises in the midline, it usually displaces the tongue to one side. Dissect it out cleanly, and take care not to injure his submandibular duct.

If he has a midline swelling in the roof of his mouth, it is probably a NASOPALATINE CYST (D, 26-13, 26.7, rare), which may have become secondarily infected. More likely, it is a pleomorphic adenoma (mixed salivary tumour) in an ectopic site.

Fig. 26-13 CYSTS IN THE MOUTH. A, a ranula. B, a sublingual dermoid cyst. C, a mucocele of the lip. D, a secondarily infected nasopalatine cyst. Adapted from drawings by Frank Netter, with the kind permission of CIBA-GEIGY Ltd, Basle (Switzerland).