18: The oral medicine and oral surgery–endo interface

The oral medicine and oral surgery–endo interface

Periapical disease presents with swellings and radiographic changes (osteolytic or osteosclerotic). It is therefore, essential for dentists to be aware of any non-endodontic lesions that may mimic periapical pathosis. Although many of the lesions presented in this chapter appear to have such distinct appearance that it may seem unlikely they would be confused with apical pathosis, hospital records and journals are full of cases where just that has happened. At best, this may be embarrassing and, at worst, it could cost a life. Such confusion need not represent incompetence since all dentists are taught the features of central tendency of any condition, as the commonest presenting characteristics. Only experience and further training will enable the full spectrum of normal distribution of disease presentation to be grasped. The problem is that presentations of many diseases can have overlapping features when the full spectrum of disease presentation is taken into account; the overlap is greater for some diseases than others, particularly when the time-line or natural history is considered. There may be greater overlap at the incipient stages.

Endodontists and dentists should therefore, remain familiar with alternative diagnoses and retain a broad surgical sieve at their finger-tips. The purpose of this chapter is not to provide encyclopaedic information about alternative disease states but to provide an organized summary listing of the factors to consider. Where suspicions are aroused by a disease presentation, an appropriate referral to a specialist should be sought.

Differential diagnosis of orofacial lumps and bumps

When examining any lesion whether obviously related to a tooth or adjacent to a tooth, a standard description (Table 17.1) is undertaken in order to establish diagnosis or enable differential diagnosis.

Table 17.1

Description of lesion








Hard and soft tissue swellings are often encountered in the orofacial region and are most frequently hyperplastic, reactive proliferations of epithelium and connective tissue, due to irritation, chronic injury or infection. Self-limiting growths or benign neoplasms of connective tissue develop from fibrous tissue, endothelia, skeletal and smooth muscle, lipocytes, nerve sheaths and osteoprogenitor cells. Although usually slow growing some may be aggressive and cause local destruction. Malignant connective tissue sarcomas with their metastatic potential and rapid spread are rare but early detection is important before haematogenous spread occurs. Epithelial derived squamous cell carcinomas are however, the most common malignant neoplasm of the oral cavity.

Soft tissue swellings

Various tissue elements may give rise to soft tissue lesions that are hyperplasias or neoplasms, either benign or malignant. Connective tissue lesions presenting as swellings are shown in Table 17.2.

Other tissues involved in orofacial soft tissue swellings may be epithelial (Table 17.3) in origin or related to the salivary glands (Table 17.4), haematological (Table 17.5) tissues or cysts (Table 17.6).

Table 17.3

Soft tissue swellings derived from epithelial tissue

Benign epithelial lesions Squamous papilloma, epithelial polyp (Fig. 17.2)
Keratocanthoma, verrucous papilloma (Fig. 17.3a)
Leaflet papilloma (Fig. 17.3b,c)
Benign pigmented lesions Melanotic macule, naevi, seborrheic keratosis, actinic lentigo, Peutz–Jeghers syndrome, melasma, acanthosis nigricans
Epithelial hyperplasia Hyperkeratosis, acanthosis, nicotinic stomatitis, proliferative verrucous leukoplakia
Epithelial atrophy Oral submucous fibrosis
Epithelial dysplasia Carcinoma in situ
Malignant epithelial neoplasms Squamous cell carcinoma (Fig. 17.4), verrucous carcinoma (Fig. 17.5)

Hard tissue swellings

Hard tissue swellings in the mouth most commonly arise from bone (Table 17.7) or odontogenic (Table 17.8) origin and can be classified broadly into the categories shown in Tables 17.7 and 17.8.

Jan 2, 2015 | Posted by in Endodontics | Comments Off on 18: The oral medicine and oral surgery–endo interface
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