ThemeSection
Differential diagnosisof oral enlargements
in children
Catherine M. Flaitz,
DDS,MSGary C. Coleman,DDS,MS
Abstract
The purposeof this article is to review soft tissue and
bony enlargements that typically occur in the oral and
perioral region of children. In order to organizethese lesions into a thoroughbut comprehensibleformat, the principles of differential diagnosis must be used. All oral enlargementsare broadly classified as soft tissue or bony
abnormalities.Determinationof the specific lesion category
is based primarily on a prominent feature that demonstrates the nature of the lesion, followed by the secondary
clinical features andany contributorypatient information.
Classificationof exophyticsoft tissue entities includes:papillary surface enlargements, acute inflammatoryenlargements, reactive hyperplasias, benign submucosalcysts and
neoplasms, and aggressive and malignant neoplasms. Bony
enlargementsof the maxilla and mandibleare divided into
three categories: inflammatorylesions, benign cystic and
neoplastic lesions, and aggressive and malignantlesions.
This extensive topic is summarizedon flow charts for easy
reference with emphasison groupingtogether lesions with
common
characteristics. ( P ediatr Dent 17:294-300,1995)
A
n enlargement of the oral cavity may represent a wide range of entities such as anatomic
variations, developmental anomalies, inflammatory and reactive diseases, cysts, and neoplasms.
The goal of differential diagnosis is to determine the
nature of the enlargement as a basis for formulating a
rational treatment approach. The symptoms, growth
rate, palpation characteristics, surface morphology,and
lesion site allow for categorization of the soft tissue
lesions into one of the five lesion groups as outlined in
Fig 1". These descriptive categories consist of:
1. Papillary surface enlargements (Fig 2)
2. Acute inflammatory enlargements (Fig 3)
3. Reactive hyperplasias (Fig 4)
4. Benign submucosal cysts and neoplasms (Fig 5)
5. Aggressive and malignant neoplasms (Fig 6).
Oncea specific category has been selected, the characteristics of the lesion can be compared with other
diseases that share commonclinical features and behavioral patterns.
Soft tissuelesions
Papillary enlargementsof the soft tissues are a distinct group of lesions that are easy to recognize because
of their commonclinical appearance. Most of these
lesions represent a viral-induced epithelial proliferation resulting in pale, spongy-to-firm enlargementswith
a pebbly or papillary, rough surface texture. These
slow-growinglesions are painless with a limited growth
potential. Broadly this group is divided into isolated
or multiple lesions to assist in the diagnosis and appropriate management
of the pediatric patient (Fig 2). The
behavior of these lesions is variable, ranging from spontaneous resolution to a recurrent, protracted course.
Acute inflammatory enlargements are characterized
by sudden onset, rapid progression, and compressible
tissue distention. These fluid-filled or edematouslesions are frequently tender or painful to palpation and
mayfluctuate in size. Systemic manifestations such as
fever, malaise, and lymphadenopathy may develop
with lesion progression. As described in Fig 3, this
disease category is divided into infectious and noninfectious processes that present with either localized or
diffuse tissue involvement. In most instances, identifying and eliminating the source of the inflammation
produces rapid resolution of the lesion.
Reactive hyperplasias are a benign group of lesions
that frequently mimic neoplastic disease. Most reactive hyperplasias develop in response to a chronic,
recurring injury that stimulates an exuberant tissue
repair. These inflammatory enlargements are defined
by a moderate growth rate, absence of pain, and limited growth potential. The degree of vascularity and
edemaassociated with the soft tissue enlargement determines the color and palpation characteristics.
As
illustrated in Fig 4, this disease group is divided into
either a primary or multifactorial cause for lesion ini-
* Figs1 through
6 weremodified
withpermission
fromChapter
18,Differentialdiagnosis
of oral soft tissueenlargements.
In: Principlesof OralDiagnosis,
Coleman
GC,Nelson
JF, Eds,St Louis:Mosby-Year
Book,Inc. 1993,pp352-88.
294American
Academy
of PediatricDentistry
PediatricDentistry-17:4,1995
CHARACTERISTICS
OF INTRAORAL
SOFT
TISSUE
ENLARGEMENTS
IN CHILDREN
Smooth,bosselated,
fissured sudace
Paleto redin color
Maybe ulcerated
Nodularor polypoldin shape
Solitaryor multifocal
Moderate
growthrate
(months)
Painlessuntesssecondarily
traumatized
Softor firm
Limitedgrowthpotential
Cause
is often apparent
Nosystemicfeatures
Recur
or persistif cause
is
not eliminated
Very common
Dome-shaped
enlargement
Superficial mucosa
unaffected
Widevariability in color
Solitarylesionwithwell
definedmargins
Freely movable
Compressible
to firm
Stowgrowthrate
(monthsto years)
Asymptomatic
unless
incidentallytraumatized
or
interferewithfunction
Unlimitedgrowthpotential
Noapparentcause
Nosystemicfeatures
Characterized
by distortion of
anatomiccontours
Remains
localized
Uncommon
=
~
Papillary Surface
Enlargements
Fig 1. Differential
Acute
Inflammatory
Enlargements
diagnosis
of intraoral
Reactive
Hyperplaslas
soft tissue
Asymmetric
enlargement
Fusiformor pelypoidin shape
Alteredappearance
of
superftcial mucosa
Ulcerated,red surface
Rapidgrowth(weeksor months)
Asymptornatic
(early lesions)
Pain,paresthesia,
lymphadenopathy
(advanced
lesions)
Firmto induretod
Fixedto underlyingtissues
Infiltrative margins
Invasionof alveolarbone
Characterized
by tissue
destruction
Naso-oropharyngeal
obstruction
Dissemination
and metastasis
often develop
Rare
Benign
Submucosal
Cysts and
Neoplasms
~’
Aggressive
and
Malignant
Neoplasms
enlargements in children.
ORAL PAPILLARY
SURFACE
ENLARGEMENTS
I
I
II
Cauliflower
or finger-like Nodular,sessilelesion
appearance
II Rough,
stippledsurface
Narrow,
stalk-like baseI I Paleto normalin color
Pink or whitein color I I Gingiva,tongue
FiKn, rough,nontender
I I andpalate
to palaption
I I Reactivehyperplasia
Palateandtongue
I I Recurrence
is rare
Recurrence
is rare
I I Common
oral lesion
!
Common
oral lesion
Squamous
Papilloma
Fig 2. Differential
I
Rough,
pale surface
Sessile base
Perioralskin,lips and
palate
Additionallesionson
hands,fingers
Autoinoculation
Common
skin lesion
Papillary,sessilelesion
Softto palpation
Clustered
distribution
Sexualcontactwith
similargenitallesions
Recurrenceis common
Maybe a signof
sexualabuse
Rareoral lesion
Verruca
Vulgaris
Condyloma
Acumlnatum
Giant
Fibroma
diagnosis
of papillary
surface
Focal Epithelial
Hyperplasia
I
Red,papularlesions
Superficialcandidiasis
Clustered
distribution
Hardpalate
Reactivehyperplasla
Associated
with full
palatal coverage
applianceor na~Tow
palatalvault
Uncommon
Papillary
Hyperplasla
enlargements in children.
tiation and growth. Partial regression of the lesion may
occur if the source of the soft tissue injury is removed.
Benign submucosal cysts and neoplasms are an uncommongroup of lesions that are nodular, well delineated, and freely movable enlargements with normalappearing, intact mucosal surfaces. The slow and
persistent growthpattern results in alteration or distortion of the tissues. Most of these lesions are
asymptomatic unless they are traumatized or impinge
on vital structures. Theselesions are divided into soft
tissue cysts, benign connective tissue tumors, and salivary gland neoplasmsas illustrated in Fig 5. In addiPediatric Dentistry - 17:4, 1995
Plaque-like
lesions
Pale,granular
surface
Welldefinedborders
Widespread
oral
involvement
Spontaneous
regressionmay
occur
Rare
tion, this group is subdivided by site predilection and
palpation characteristics. Definitive diagnosis of this
disease category is based on histopathologic examination of the surgical specimen.
Aggressive and malignant soft tissue enlargements
of the oral cavity are the rarest but most important
group to identify in the pediatric population. Rapid,
progressive growth of an asymmetric enlargement with
infiltrative margins are defining features of this group
of lesions. These firm, fixed tumors demonstrate irregular surface changes with areas of erythema and
ulceration. Although early lesions are asymptomatic,
American Academy of Pediatric
Dentistry
295
ACUTE INFLAMMATORY ENLARGEMENTS
Fo
ninfectiousProcess
Swellingusually
associatedwith a
periapicalor
periodontal
lesion
Redor yellowin color
Purulentexudate
Very common
Swellingassociated
with an unerupted
mand~ularmolar
Pain, trismus
Usuallycontains
semisolidmatedal
Very common
Soft Tissue
Abscess
Pericoronitis
I
Translucentblue
Fluctuatesin size
Mucuscontents
Historyof injury
Mandibular
lip
Frequentlyrecurs
Common
Mucus Retention
Phenomenon
I
I
I
Extensiveswelling ~ ~ Majorglandinvolvement
Suddenonset
| ~ Unilateralor bilateral
Obviouscause
| Ii Viral,bacterialor
Fever,pain, tdsmus| | obstructive
Life threatening | | Maybe recurrent
complicationsmay| | Painful wheneating
develop
| | or drinldng
Common
I i Commonwmmumps
I
Fluctuatesin size
Blockageof
Wharton’sduct
Floorof mouth
Unilateralor
bilateral
Mayherniate
throughfascial
planes
Uncommon
Pruritic
Suddenonset
Smoothsurface
Allergicreactionor
hereditary
pattern
Lips
Life threaten
ng if..
larynxis invoived
Uncommon
planes
Introducedby air
syringe or handpiece
Immediateonset
Crepit~tionon
palpation
Mayresult in
pneumomediastinum
Rare~atmgen~c
complication
Angioedema
Emphysema
+
Cellulitis
Acute Sialadenitis
Ranula
Fig 3. Differential diagnosisof acuteinflammatory
soft tissue enlargements
in children.
SOFT TISSUE REACTIVE HYPERPLASIAS
I
I
I
PrimaryCauseIs RecurringInju~ or I
ChronicLocal Irritation
I
Multifactorial Causes
PlusLocalIrritation
Gingiva Affected
I
I
L Hormoneor Drug-Related I
Surface
ulceration
Bleedswith
probing
Nontender
Alveolarcuffing
of bone
Peripheral
Giant Cell
Nontender
Maybe
ulcerated
Displacesteeth
Alveolarcuffing
of bone
Uncommon
Surface
ulceration
Hemorrhagic
Nontender
Mayoccurat
othersites
Common
Peripheral
Ossifying
Pyogenic
Granuloma
I
Epulis
Granulomatosum
Drug-induced
Ginglval
Hyperplasia
withscarII over~ened
Uncommon
acrylic appliances
Red,ulcerated
Soft
Hemorrhagic
Hormonal
fluctuations
Nontender
Females
Common
C°mmon t
Traumatic
Fibroma
Hormonal
Tumor
I
Pregnancy
Gingivitis
IIUnc°mm°n
*
IVery
;I
Pulp
Polyp
Gingival
Fibromatosls
Smooth,pebbly
Firm
Generalized
enlargeme~
Nontender
Common
with
certain drugs
I!
IITongue.
IL...._.,.~_...J
c6mmon
floor of mouth
~
I
I
I
I
I
I
I
Normatcolor
Red,ulcerated
Tenderwhen II fissured surface
Nontender
II Maybemultiple
palpated
Sites of II Spongytofirm
andlips II
II Lobulated
Rrm
frequent II MitdlytenderTongue
Frequently
II
Mucobuccal
fold
frauma II Surf’ace
associated II RelatedtO
II vacularity
I
I
I
I
~
Smoothsurface
Nontender
Generalized
enlargement
Familymembers
affected
Uncommon
Reactive
Lymphoid
Hyperplasia
;
Traumatic
Neuroma
Inflammatory
Fibrous
Hyperplasia
Fig 4. Differential diagnosis
of soft tissuereactivehyperplasias
in children.
296 AmericanAcademyof Pediatric Dentistry
Pediatric Dentistry - 17:4,1995
BENIGN
SUBMUCOSAL
CYSTS
AND
NEOPLASMS
I
Gingival
Site
Not Limited
~tS~L"~c~n
Infant
Female
predileciton
Anterior
maxillary
mucosa
Pink, red nOdule
d~:a
In Location
To
nt
Infant
Bluish, cystic
[ Connectivetissue origin
Posterioralveolar
mucosa
Multiple,bilateral
Black ma~e
predilectlon
,| Uncommon
Congenital
Gingival
Granular
Cell
Tumor
Usuallynot site specific
Vascularlesions are
common,others are
rare in children
Epstein’s
Pearls
Neonatal
Alveolar
Lymphangloma
I
Thyroglossa!
Cyst
Neck
Dermoid Cyst
Floor of mouth
Nasolabial Cyst
Maxillarylip
Lymphoepithellal
Cyst
Floor of mouth, tongue
super~ialgingiva
II tooth II ~a
Multiple
II Bluish II Uncommon
Spontaneoos
regression
II
~ I~
II regresses I~
I ve~commo~
II commo~
~
Dental
Lamina
Cyst
Eruption
Cyst
Cyst of the
Incisive
Papilla
Uncommon
to rare lesions
Anyintraoral site possibleexcluding
gingivaandantedorhard palate.
Posterior palate is mostcommon
oral
location. Parotldis the majorgland
mostoften affected.
Moderaterecurrence rata
!
Soft,
compressibleI
I
c°miressib!~
I ’-~
Lipoma
Yellow
Buccal mucosa
Hemangloma
Red, blue, blanches
Parotid, tongue,lips
Lymphangloma
Pink, red, pebbly surface
Tongue,lips, (Cystic
Hygroma in neck)
Plexlform
Neurofibroma
Feature of
neurofibromatosis
.
I
II Unerupted II Incisive
Infants
Gingiva
Pleomorphlc
Adenoma
Neuroflbroma
(most common)
Tongue, palate
Myoepithelioma
Schwannoma
Basal Cell Adenoma
Encapsulated
Tongue, palate
Rhabdomyoma
Parotid, tongue,
Cystadenoma
Warthln’s
Tumor
soft palate
Leiomyoma
Occasionally red
Lips, tongue, palate
Granular Cell Tumor
White, rough surface
Tongue
Mucosal Neuroma
Feature of multiple endo~ine
neoplasia syndrome
Fig5. Differentialdiagnosis
of benign
submucosal
cystsandneoplasms
in children.
AGGRESSIVE
AND
MALIGNANT
SOFT
TISSUE
ENLARGEMENTS
I
Submucosal Malignancies I
I Benign, Aggressive Conditions I
[
’
I
Maybe congenital
Infiltrative
Rapid growth
Surface
ulceration
High recurrence
rate
Youngmalss
Nasalobstruction
Epistaxis
Facial palatal
expansion
Ulcerated, vascular
Intracranial
extension common
Aggressive
FIbromatosis
Nasopharyngeal
Angiofibroma
I Surface Epithelial
Mal~nancios]
I
Rhabdom osarcoma
Tongue,soft palate and
tonsillar pillar region
Flbrosar¢oma
Mandibular alveolar mucosa,
chin and angle of the
Other Sarcomas
Site depends on neoplasm
Malignant Salivary
Gland Neoplasms
Most common:
Mucoepidermoid carck’~ma
Early lesions mimic
benign neoptasm
Paro~dand posterior
hard palate
Malignancies
of Bone
with Soft Tissue
Extension
See Figure 10
I
White, thickenedor
red granular
surface
Nonhealingulcer
Posterior tongue
Cofactors(alcohol,
tobacco,UVlight,
viruses and immune
systemdeficiency)
Veryrare in children
Leukemi=
Generalizedgingival
enlargement
Petechiee and ecchymoses
Squamous Cell
Oral ulcers
Carcinoma
Mobility of teeth
Hodgkln’s
Lymphoma
Painless lymphedenopathy
Cervical lymph node chain
Weightless, fever, night sweats
Non-Hodgkln’s
Lymphoma
Painless lymphadenopathy
Asymmetric enlargement of
pha~ngealtonsils, palatal
mucusa, buccai muceaa,giegiva
Metastatic
disease
Gingiva most common
soft tissue site
Tumorextrusion from exl~action sits
Cutaneous
lesion
Flesh-coloredor
p/gmented
Nodulewith
depressedcenter
Associatedwith
navoidbasalcell
carcinoma
syndmme
Veryrare in children
Basal Cell
Carcinoma
Fig 6. Differentialdiagnosis
of aggressive
andmalignant
soft tissueenlargements
in children.
Pediatric
Dentistry
- 17:4,
1995
American
Academy
of
Pediatric
Dentistry
297
CHARACTERISTICS
Clinical
Features:
Tender
or painful to
palpation
Rapid entargement
(days to weeks)
Diffuseor localized
enlargement
Red,fender swoilan
mucosa
Fluctuatesin size
Drainage,sinustract
foRnation
Causeis often apparent
Mobile,nonvital tooth
Systemicfeatures such
as fever,
lymphadenopathy
ff
advanced
Trismus,occasional
pere~hesle
Regression(healing)
Common
OF
7.
Differential
diagnosis
ENLARGEMENTS
Clinical
Features:
Nontender
to palpation
Slowgrowth
(monthsto years)
Localized expansion
Normalsurrounding
mucosa
Progressesin size
Usually no apparent
cause
No systemicfeatures
Maydelay tooth
eruption
Subtlefacial
asymmetry
Uncommon
Radiographic
Features:
Widenedperiodontal
ligament space,
especiallyapica~113
or furca
Loss of lamina dura
anddental crypt
Irregularinternal or
external resorption
Locatedin alveolar
bone,mayextendto
body of bone
Usuallyradiolucent,
mayappear mixad
Poorly defined margins
Indistinct trabecular
pattern
Proliferativeperiostitis
is common
Inflammatory
Lesions of the
Jaws
Fig
JAW
IN
Radiographic
Features:
Intact periodontal
I~jament space
Laminadura anddental
crypt present
Occursin alveolus and
bedyof the jaws
Interior or lateral tooth
displacement
Displacementof
anatomicstructures
Blunt root resorptionwith
large lesions
Radiolucent,mixedor
radiopaque
Unilocularor muitilocular
shape
Well delineated margins
Cortical expansion
CHILDREN
Clinical
Features:
Maybe tenderor painful
Moderategrowthrate
(weeksto months)
Diffuse enlargement
Mayhavea multitocal
distribution
Mucosa
is red, ulcerated,
firm andftxed
Vital, mobileteeth
Extrusionof teeth
Progressiveincrease in
size
No apparent cause
Systemicfeatures maybe
present
Frequentparesthesle,
anesthesia
Trlsmuswith advanced
disease
Uncommon
or rare
Benign Cystic and
Neoplastic
Lesions
of the Jaws
of
intraoral
lesions
INFLAMMATORY
characterized
LESIONS
OF
Aggressive
and
Malignant Lesions
of the Jaws
by bony
THE
JAWS
enlargement
IN
in
children.
CHILDREN
I
I Localized
,
I
Lesions
I
I
I Periapical Location I
I
I Diffuse
i
I
! Nonperiapical Location I
I
I
I nadiopaque I
I
Chronicpulpal
disease
Nonexpansile
Posterior mandible
Sharp margins
Static with time
Radiolucent
Associatedwith
erupting mandibular
molars
History of pericoronitis
Buccal expansion
Deepperiodontal
pocket
Proliferativeperlostitis
I
Peripheral
Inflammatory
Paradental
Cyst
Tender,painful
Chmnic
Maybe tender
History of
infection
Distinct hyperostotlc
borders
caries, trauma Periodsof acute
exacerbation
Nonvital tooth
Untlocular,
indistinct
Unlfocular,
Expensile
man:J~ns
distinct margins Displacementof
Nonvital tooth
Nonvital tooth
developingtooth
Perlaplcal
Granuloma
RURO= mixed radiolucent
Perlaplcal
Cyst
Lesions
I
I
I
Idiopathic
[ IRnfead~t(~loUu(:nt’
Codex
I
Facial trauma
Inferior borderof
mandible
Maybe associated
with jaw fracture
Irregular or sunburst
pattem
Focal Scleroslng
Osteomyelltla
Perlaplcal
Abscess
Radiographic
Features:
Lossof the laminadura
anddental crypt
Roaringtooth
appearance
Bodyof Jaws, may
extepdto the
alveolus
Symmetricwidening of
the periodontal
ligament space
Irregular root
resorption
Irregular wideningof
maedibularcana~
Radiolucentor mixed
lesion
Poorly defined margins
Lossof trebecular
pattern
Occasional
proliferative
periostitis
Cortica~destn~ction
Traumatic
Osteoma
I
I
Pain, trismus
Cedes,trauma,
idiopathic
Swelling, purulence
Febrile,
lymphadenopa~y
Posterior mand~le
Inherited disease
Occurspdor to six months
of age
Tender,soft tissue
swelling
Febdle, lymphedenopathy
Bilateral mand~ular
involvement
"Onion-skin" appaarence
Spontaneousresolution
Acute
Osteomyelitis
I
Infantile Cortical
Hyperostosis
II Chronic
Chronic dental
dentalinfection
lnfestion
Indistinct margins
Mottled bonypattern i IndiStinct margins
SequestnJm
Is
: Mottled bonepattern
=
"Onion.skin
common
Ankylosis mayoccur
appearance
Posterior mandible
Posterior mandible
Di"use’
expansi’e
lesion
II
Chronic Diffuse
Scleroslng
Osteomyelltis
Chronic
Osteomyelitls
wlth Proliferative
Periostltls
and radiopaque lesion
Fig 8. Differential diagnosisof inflammatory
lesionsof the jawsin children.
298American
Academy
of PediatricDentistry
PediatricDentistry-17:4,1995
BENIGN CYSTIC
AND NEOPLASTIC
LESIONS
OF THE JAWS
I
t
Radiolucent
I
I PericoronalLocation
’
,
’
Un"ocu’ar
I
Odontogenic Keratocyet
Posteriormandible
Maycrossmidline
Maybe associated
with nevoid
basalcell carcinoma
syndrome
Ameloblastic Fibroma
Mand~ulsr
first, second
molarregiee
Recurrencesuncommon
I
I
I IC~=Location
I
Eruption Cyst
Un~
Bluealveolarmucesa(S~ple Bo~ C~t)
Mostcernmon
in maxiila
Dentigerous Cyst
Mandibutar
premolar-molar
area
I
Adenomatoid
Thirdmolarandcanine Maycrossmidline
I
Odontogenic Tumor
Unicysti¢
Usuallynonexpansile
I
Unilocular
Ameloblastoma Scalloped
inttaradicularmargins
I
Most
commoo
in
anterior
maxilla
Mandibular
sece~dand Oftenextendsbetween
tooth
I
Ameloblastic
Fibro-odontoma
roots
without
tooth
movement
th~’dmolarregio~
I
Mulfilocular
10%recurrence
rate
/
Mostcommon
in posterior mandible~
Radi°paque
2
L~ I~entrat Location
I
I
Unilocular when smatl’ I-~I---
I
i
I Mixed Radi°lucent-Radi°paque I
I
,
,
Odontoma
Mayocc~in
periapical
area
cou~oued:
Torus/Exostosls
Nonneoplaatic
process
Obvious
clinically
Osteoma
Maybe centTal
tooth-l~e
cak~cations
Complex:
Associatedw~h
amorphous
Gardner’s
syndrome
calcifica~on
Central Ossifying Fibroma
Fibrous Dysplasla
Maybeunilocular
o¢ multilccular
Nonneoplastic
condition
Progresses
fromRL*to
Maybe multifocal
mixed
to RO**with time
Maxillarypremolar-moist
region
Mandibular
premotarhnolar
region Progresses
f~emRLto
Juvenile Ossifying Fibroma
mixedtoROwi~ time
Multilocularlesion
Poorlydefinedmargins
Maxima
Elliptical expansion
Aggressive
lesion
Stabilizes
withtime
Cementoblastoma
Postario~
mandible
Progresses
fi’om RLto
mixed
to ROwith t~ne
Interrn~ent
mildpain,vital tooth
Attached
to toothroot
Osteoblastoma
Posteriormandible
Progresses
~’omRLto
* RL= radioluceot
mixedto ROwi~ ~me
°" RO= radiopaque
Severe
pain,vital tooth
Radiating,"sunburst"pa~em
Central Giant Cell Granuloma
Mandibular
canine-premolar
region
Maycrossmidline
Moderate
recurrence
rate
Aneurysmal Bone Cyst
Eccentricballooning
of mandible
50%causepain
Associated
with concurrent
lesion
Central Hemangloma
Vaguemargins
Gingivalbleeding,
bruit, pulsation
Toothmobility
Life threatening
lesion
Odontogenl¢ Myxoma
Faint radiopaque
stri~ons
Posterio~
mandible
Moderate
recurrencerate
Cherublsm
Inherited
disordar,
bilateral
Regresses
with time
Fig9. Differentialdiagnosis
of benign
cystsandneoplastic
lesions
of thejawsin children.
AGGRESSIVE
AND MALIGNANT
NEOPLASMS OF THE JAWS
I
I
Unifocal and Mixed
Radiolucent-Radiopaque
Unifocal and
Radiolucent
I
I
Anterior
maxilla
Poorlydelineated
Expansile
"Floating
toothbuds"
Pigmented
or red
surface
Maybe multifocal
"Punched-out"
radiolucancy
Usuallynonexpansile
"Floatingtooth"
appearance
Occasional
proliferative
perioatitls
Maybemultilocular
Poorlydelineated
I
Localized
Expaesile
Idiopathic
"Floatingtoothbuds" Hlstiocytosls
Softtissueexqension (Eosinophilic
Highrecurrence
rate
Granuloma)
Multifocal and
Radiolucent
or
Posterior
Posteriormandible Mandible
Early symme~ic Palnf%li~aswelling
mandibleand
I
widening
of
ramus
Painfulexpansion periodontal
ligament
tad o ucent
Febrile,
leukccytosls Occasional
periosteat
"Moth-eaten"
pattem
proliferation
Periosteal
Sunburst
patternis
proliferation
uncomrnon
Ewing’s SarcomaOsteosarcoma Mesenchymal
Chondrosar¢oma
I
Multiplehone,
Postarior
maxilla
argan
andmandible
involvement
Oneto four
Pain,
quadrants
i
lymphadenopathy involved
Well to poody
Gingival
Painfulswelling
Neuroectodermal
Paresthesia
definedmargins enlargement
First sign:tooth
Tumorof Infancy
Unilccularor
"Cupped-out"
Premature
mobility
mutlilocular
appearance
exfoliafion
of
"Moth-eaten"
or
I Cortical
Bodyof mandible Fine"ground
multilocular
teeth
Desmoplastic
pedocation
glass"
berdars
"Floatingtooth"
radiolucency
Fibroma of Bone
appearance
Periostealbone
formation
Central SarcomasPrimary Soft
of Bone
Tissue
~
~--I
Malignancies
Adjacent to Bone Disseminated
Burkltt’s
Idiopathic
Lymphoma
Histiocytosls
~
+
Fig 10. Differential
diagnosis
Pediatric Dentistry - 17:4, 1995
of aggressive
and malignant
I
widespread
involvement
Occasional
gingival
enlargement
Lossof lamina
dura
Toothmobility
Diffuse,poorly
defined
radiolucency
Occasionat
periosteaJ
bone
forrnafion
Pceterior
I
mandible
Poorlydefined
radiolucescy
Softtissue
Leukemia
Metastatic
Disease
Paresthesia
neoplasms of the jaws in children.
American Academy of Pediatric
Dentistry
299
pain, paresthesia, lymphadenopathy,and naso-oropharyngeal obstruction develop with tumor progression.
These diseases have been divided into: benign, aggressive conditions; submucosal malignancies; and surface
epithelial malignancies to compare commonclinical
features (Fig 6). In general, prognosis of this category
of lesions dependson the size of the lesion, proximity
to vital structures, and evidence of metastasis.
Bonyenlargements
space, and a floating tooth appearance frequently are
observed. Aggressive and malignant neoplasms of bone
are categorized as radiolucent or mixed radiolucentradiopaque lesions demonstrating unifocal or multifocal presentation (Fig 10).
Conclusion
In summary,this review article arranges exophytic
oral lesions according to common,pertinent characteristics to allow differential diagnosis in the pediatric age
group. Flow charts for both soft tissue and bony enlargements of the oral cavity have been designed to
assist the pediatric dentist in this important decisionmakingprocess. Although the outline of this material
is fairly comprehensive,its utility is as a supplementto
more comprehensiveoral pathology and diagnosis textbooks. In addition, it is not the goal of this material to
allow the practitioner to arrive at a definitive diagnosis, but rather, to determineappropriate treatment based
on the most likely cause for the soft tissue or bony
enlargement. Although neoplastic diseases in children
are uncommon,early detection frequently has a significant impact on the treatment regimen, surgical results, and overall prognosis.
Bony enlargements of the maxilla and mandible in
children rely on both clinical features and radiographic
interpretation in order to develop a differential diagnosis. To managethis comprehensive topic, there are
three distinct categories of bony enlargements: 1) inflammatorylesions of the jaws (Fig 8), 2) benign cystic
and neoplastic lesions (Fig 9), and 3) aggressive
malignant lesions (Fig 10). The pertinent clinical and
radiographic characteristics of jaw lesions in children
are summarizedin Fig 7.
Inflammatorylesions of the jaws have similar clinical findings as those described for the soft tissue counterpart. Rapid enlargement, pain, erythema, and drainage are characteristic. An apparent cause, in particular
Dr. Flaitz is associate professor and director, Surgical Oral
a mobile, nonvital tooth, frequently is observed. ImPathologyService, Divisionof Oral Pathologyand Divisionof
portant radiographic features include a poorly defined
Pediatric Dentistry, TheUniversityof Texas---Houston
Health
radiolucent or mixed radiolucent-radiopaque lesions
Science Center Dental Branch, Houston. Dr. Colemanis associate
of the alveolar bone. Additional findings maydemon- professor, Division of Oral Diagnosis, Baylor College of Dentistry,
strate a widened periodontal ligament space, loss of
Dallas,Texas.
the lamina dura or dental crypt, and internal or exter1. Coleman
GC:Differential diagnosisof radiographicabnormalities. In: Principles of Oral Diagnosis.Coleman
GC,
nal root resorption. Proliferative periostitis is common
Nelson
JF,
Eds.
St
Louis:
Mosby-Year
Book
Inc,
1992,
pp
in this age group.
389-449.
Broadly, inflammatory lesions of the jaws are
2. Cunningham
MJ,MeyersEN,BluestoneCD:Malignanttuclassified as localized or diffuse entities with a radiomorsof the head and neck in children: a twenty-year review.Int J PediatrOtorhinolaryngol
13:279-92,1987.
lucent, radiopaque, or mixed radiolucent-radiopaque
3. DasS, DasAK:A reviewof pediatric oral biopsiesfroma
appearance (Fig 8).
surgical pathologyservicein a dental school.Pediatr Dent
Benigncystic and neoplastic lesions of the jaws are
15:208-11,1993.
defined as locally expansile lesions with a slow but
4. Flaitz CM:
Differentialdiagnosisof oral soft tissue enlargeprogressive growth pattern, Delayed tooth eruption and
ments.In: Principlesof OralDiagnosis.Coleman
GC,Nelson
JF, Eds. St Louis: Mosby-Year
BookInc, 1992,pp 352-88.
subtle facial asymmetryare associated with this group
5. Flaitz CM:Oralpathologicconditionsandsoft tissue anomaof lesions. The pertinent radiographic features include
lies. In: Pediatric DentistryInfancythroughAdolescence,
a well-delineated unilocular or multilocular lesion with
2nd Ed. PinkhamJR, Casamassimo
PS, Fields HW,McTigue
cortical expansion. These bony lesions may appear
DJ, Nowak
A, Eds. Philadelphia:WB
SaundersCo, 1993, pp
radiolucent, radiopaque, or mixed. Inferior or lateral
29-56.
6. Greer RO,MierauGW,FavareBE: Tumorsof the Headand
movementof teeth, blunt apical root resorption, and
Neck in Children. New York: Greenwood, 1983.
displacement of anatomic structures are detected when
7. Neville BW, DammDD, Allen CM, Bouquot JE: Oral &
large lesions are present. As outlined in Fig 9, benign
Maxillofacial Pathology. Philadelphia: WBSaunders Co,
cystic and neoplastic lesions of the jaws are classified
1995.
according to radiographic appearance and lesion site.
8. Neville BW, DammDD, White DK, Waldron CA: Color
Atlas of Clinical Oral Pathology. Philadelphia: Lea &Febiger,
Aggressive and malignant neoplasms of the jaws
1991.
are characterized by a diffuse enlargement with a mod9. Regezi JA, Sciubba JJ: Oral Pathology, Clinical-Pathologic
erate growth rate. Pain, mucosal ulceration, extrusion
Correlations. 2nd Ed. Philadelphia: WBSaunders Co, 1993.
of teeth, and paresthesia are commoncomplaints.
10. Scully C, Welbury R: Color Atlas of Oral Diseases in ChilImportant radiographic features include a poorly dedren and Adolescents. London: Wolfe Publishing, 1994.
11. Skinner RL, Davenport WDJr, Weir JC, Carr RF: A survey
fined radiolucent or mixedradiolucent-radiopaque leof biopsied oral lesions in pediatric dental patients. Pediatr
sion with cortical destruction. Irregular root resorpDent 8:163-67, 1986.
tion, loss of the lamina dura and dental crypt,
12. WoodNK,GoazPW:Differential Diagnosis of Oral Lesymmetrical widening of the periodontal ligament
sions. 4th Ed. St Louis: CVMosbyCo, 1991.
300 American Academyof Pediatric Dentistry
Pediatric Dentistry-17:4,1995