8: Oral lesions: differential diagnosis and biopsy techniques

8 Oral lesions: differential diagnosis and biopsy techniques



Colour will distinguish between fibroepithelial polyps (pink) (Fig. 8.1) and the white rough cauliflower presentation of viral papillomas (warts) (Fig. 8.2). Mucous cysts tend to be translucent with a bluish colour (see Figs 14.7, 14.8) and haemangiomas and ‘venous lakes’ (Fig. 8.3) dark blue. Pyogenic granulomas (Fig. 8.4) and giant-cell epulides (Fig. 8.5) normally present as maroon/red.

Modifying influences

The intraoral environment having given rise to lesions may in turn alter their morphology, depending on site. For example, fibroepithelial polyps can vary in presentation from ‘leaf fibromas’ in the palate to denture-induced hyperplasia at the periphery of a denture (see Figs 11.5, 11.6). Immature or developing polyps, particularly when arising from the gingivae, are described as pyogenic granulomas and the pregnancy epulis is a variant. They present as red, acutely inflamed lesions that are soft and bleed readily. Similar in presentation is the peripheral giant-cell granuloma although this may be more purple.


Fibroepithelial polyps, squamous papillomas and epulides

Surgical excision is the most common treatment for small lesions (fibroepithelial polyps, squamous papillomas and epulides) and is often completed as part of the biopsy (see below). It must, however, be combined with appropriate management of precipitating or causative factors. These include the elimination of chronic trauma for polyps or the removal of localized deposits of calculus for pyogenic granulomas. Peripheral giant-cell lesions will require a similar approach including curettage of the underlying bone. Epulides related to pregnancy are, unless they are large and causing distress, best left alone and removed if they persist postpartum, usually with an appropriate adjunctive periodontal therapy. Scaling and improved oral hygiene during pregnancy may reduce further growth and lessen the likelihood of surgery.

Surgical management of denture-induced hyperplasia must be combined with appropriate modification to the prosthesis such as temporary relining (Ch. 11). This is essential to retain sulcus form and prevent recurrence and is similarly so for ‘leaf-fibroma’ in the palate. Denture-induced hyperplasia can be extensive and, when affecting the lower jaw, is often related to other significant anatomical structures. This is particularly so in the anterior region where the main trunk of the mental nerve can be superficial due to resorption of the alveolus. The lingual nerve can also be at risk when the lingual side is operated on. In these circumstances it is important to carefully identify the edge of the hyperplastic tissue, to keep the excision superficial and to use blunt dissection to free the tissue from underlying structures (see section on biopsy).

Vascular lesions

Vascular lesions are best considered as two groups: the rare haemangiomas, which can be extensive and multiple, and the common smaller degenerative malformations (varicosities) often seen on the lip in older patients (Fig. 8.3). For the former it is essential that the type, site and extent are fully evaluated, which normally requires referral to a specialist centre. For extensive and deep lesions or where there is any possibility that the haemangioma extends into bone, extractions or other surgery must be avoided until the type and extent of the vascular abnormality have been established. Conversely, discrete small lesions are easily dealt with either by excision with appropriate management of the vascular source or by cryotherapy. Indications for surgery are cosmetic or lesions that are repeatedly traumatized and bleed.



Hard-tissue lesions can arise from odontogenic tissue or from bone. They present a range of diagnoses from developmental lesions such as palatal or mandibular tori or odontomas (see Figs 8.6, 11.13, 11.14) and bony exostoses, to the rarer benign and locally invasive lesions such as ossifying fibroma, ameloblastoma and cementoblastoma.

This is a complex group of lesions and conditions. Readers are referred to relevant pathology and radiology texts for more detailed descriptions of the various types and their histological and radiological findings. From the clinical standpoint they can be considered according to presentation: the common single discrete lesions (odontomes, odontogenic tumours and osteomata); the rare, large and diffuse lesions (fibrous dysplasia and Paget’s disease); and rare conditions with multiple lesions (Gardner’s syndrome and cemento-ossifying lesions).

Often they first come to attention as a bone-hard swelling beneath the overlying mucosa, but in many cases presentation is an incidental finding on routine radiography. As the symptoms and signs have so much overlap, diagnosis is largely dependent on radiological findings and, more importantly, histology. As described below, site can be an important sign in establishing the diagnosis: not only are the lesions within this group difficult to separate, they are often clinically and radiographically similar to cysts (see Ch. 9). As with soft-tissue lesions, there will be malignant counterparts, e.g. osteos/>

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Jan 14, 2015 | Posted by in Oral and Maxillofacial Surgery | Comments Off on 8: Oral lesions: differential diagnosis and biopsy techniques

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