Diagnosis and Management of Intra-Oral Swellings PDF

Diagnosis and Management of Intra-Oral Swellings Dr Alistair Reid BDS MBBS FRACDS(OMS) Senior Lecturer: UQ Private Practice: Brisbane OMS Objective Overview of intra-oral swellings Diagnostic approach Important swellings in dental practice Management Cysts will be covered separately Intra-Oral Swell...

Diagnosis and Management of Intra-Oral Swellings Dr Alistair Reid BDS MBBS FRACDS(OMS) Senior Lecturer: UQ Private Practice: Brisbane OMS Objective Overview of intra-oral swellings Diagnostic approach Important swellings in dental practice Management Cysts will be covered separately Intra-Oral Swellings Normal anatomy Developmental Inflammatory Traumatic Cystic Fibro-osseous Hormonal Drugs Blood dyscrasia Neoplasia Other Intra-Oral Swellings Normal anatomy Pterygoid hamulus Parotid papilla Sublingual papilla Unerupted teeth Developmental Haemangiomas Lymphangiomas Tori Hereditary gingival fibromatosis Von Recklinghausen neurofibromatosis Intra-Oral Swellings Inflammatory Abscess Pyogenic granuloma Crohns Disease Orofacial granulomatosis Sarcoidosis Wegeners granulomatosis Traumatic Fibroepithelial polyp Denture hyperplasia Cystic Eruption cysts Developmental cysts Infective cysts Intra-Oral Swellings Fibro-osseous Fibrous dysplasia Paget’s Disease Hormonal Pregnancy epulis, gingivitis Drugs Phenytoin, cyclosporin, calcium channel blockers Blood dyscrasia Leukaemia, lymphoma Neoplasms Benign Malignant Other Angioedema Amyloidosis Approach to Patient History Examination Provisional / Differential Diagnosis Investigation Imaging M/C/S Bloods Biopsy Diagnosis Definitive management History History of presenting complaint Onset, duration of symptoms Pain (dental or otherwise) Altered sensation Recent dental work Swelling, deformity Infection Past Medical History Examination General appearance Asymmetry Deformity Dentition Dentate vs endentulous Displaced or mobile teeth Caries, restorations, implants Oral mucosa Soft tissue swellings (location) Draining sinus Bony deformity Expansion Loss of cortex Neurosensory function Including pulp vitality testing Anaesthesia, paraesthesia & dysaesthesia of major sensory nerves Examination Palpation Examination by feeling Can be bimanual (floor of mouth, lips, cheeks) Fluctuance: consistency of being fluid filled Tethering: attached to deeper structures Consistency: hard, rubbery, soft, friable Deep or superficial compressibility: does it blanch Observation Colour, size, ulceration, regularity Sessile: broad based Pedunculated: having a stalk Location Description of intra-oral swellings Site Size Colour Shape Feel Importance of Site Spread of infection Primary and secondary spaces Nodes Risk to surrounding structure Danger area Airway Orbit Mediastinal spread via deep neck spaces Metastasis Lymphatic system and draining lymph nodes Nerves Importance of Site Junction of Hard & Soft Palate Common site for minor salivary gland neoplasms Close to base of skull Posterior mandible Important site to be wary of infection 2nd and 3rd molar apices below mylohyoid Drainage into submandibular space Spread to Pterygmandibular space Parapharyngeal space Retropharyngeal space mediastinuam Importance of Site Retromolar trigone Common site for SCC or dysplasia Floor of mouth Also common site for SCC or dysplasia Salivary stones Major salivary glands and ducts Establishing Differential Diagnoses Surgical Sieve (VITAMIN CDEF) Vascular Infective or Inflammatory Traumatic Autoimmune Metabolic Iatrogenic or Idiopathic Neoplasia Congenital Degenerative or Developmental Endocrine or Environmental Functional Establishing Differential Diagnoses Anatomical Sieve (may be easier to use clinically) Site What tissues are present (deep or superficial) What pathology can arise from these tissues More focused DDx relevant to site Investigations Imaging Plain film CBCT Multi-slice helical CT MRI Histopathology Incisional vs excisional biopsy FNA, aspiration Odontogenic Infection Odontogenic Infection 80% of swellings in head and neck are odontogenic in origin The majority of these are infective in origin Most common cause of intra-oral swelling is dental abscess Pus follows path of least resistance – anatomy important in diagnosis Odontogenic Infection Symptoms Pain (current and also preceding dental pain) Swelling, redness Systemically unwell, fevers, chills Foul taste if purulent discharge, smell Difficulty opening mouth (trismus) Difficulty swallowing (dysphagia, odynophagia) Difficulty breathing Signs Dental disease Swelling consistent with anatomical drainage of teeth Radiological evidence Treatment of Odontogenic Infection Treat cause (extraction or endodontic therapy) DRAIN PUS (endodontic, extraction, incision) M/C/S Post-operative antibiotics Analgesia Refer if systemically unwell, airway compromise or secondary spaces involved Primary Spread of Odontogenic Infection Maxillary sinus Nasal cavity Palate Sublingual space Submandibular space Vestibular space Buccal space Secondary Spread of Odontogenic Infection Pterygomandibular Masseteric Superficial temporal Deep temporal Infratemporal Parapharyngeal Retropharyngeal Prevertebral Mucoceles Mucoceles Often history of trauma – rupture of minor salivary gland duct Bluish swelling Rarely regress spontaneously Often burst and re-form Typically enlarge over several weeks Common in children Excise with dissection of feeding minor salivary gland Mucoceles Ranula Ranula Intra-oral ranula Mucous retention involving the sublingual gland (major v minor gland) Large bluish swelling in floor of mouth, unilateral Painless, interferes with speech and swallowing Above mylohyoid muscle Treatment Marsupialisation Removal of sublingual gland Botox Plunging ranula Pierces mylohyoid and descends in neck Requires surgical removal via neck if large enough Neoplasms Benign Lipoma Pleomorphic adenoma Osteoma Ameloblastoma Keratocyst (KCOT) Malignant SCC Salivary gland Mucoepidermoid ca Adenoid cystic ca Osteosarcoma Lipoma Soft, smooth swelling Buccal space common Painless Can be large Surgical excision Pleomorphic Adenoma Benign Posterior hard palate common Rubbery Normal mucosa May have punctum Surgical excision Adenoid Cystic Carcinoma Posterior hard palate common Firm Ulceration common High metastatic potential Perineural spread Wide margin (maxillectomy possibly) Post-op XRT 75% 5 year survival Lymphoma Great impersonator Usually B cell lesions Anywhere in mouth Chemotherapy and XRT Occasional surgery Lymphoma Lymphoma Congenital Lesions Haemangioma Usually regress with age, some persist Can bleed significantly if traumatized Surgery, interventional radiology Lymphangioma Lymphatic equivalent of haemangioma Can be very large and interfere with function Fibrous Dysplasia Cherubism Haemangioma Fibrous Dysplasia Fibrous Dysplasia Normal bone replaced with proliferation of cellular fibrous connective tissue and irregular bony trabeculae Sporadic post-zygotic gene mutation (GNAS1) Late mutations lead to more localized disease Monostotic, polyostotic, craniofacial Average age of onset 10 Bony expansion Ground glass on xray/CT Can impinge on foramina Can be very deforming Fibrous Dysplasia Cherubism Cherubism Autosomal dominant Bilateral and symmetrical expansion of posterior maxilla and mandible “eyes looking heavenward” Usually completely reverses post-puberty Developmental Tori and bony exostoses Common No gender predilection Probably genetic basis but may have functional element Slow growth over may years Dense cortical bone Surgical removal if symptomatic Trauma, ulceration Antiresorptives important Dentures problematic Lingual Tori Lingual Tori Palatal Torus Endocrine or Environmental Pyogenic granuloma Peripheral giant cell granuloma Pyogenic Granuloma Florid gingival reaction Bleeds easily Usually pedunculated Can be small or up to several cm Excise completely to base Treat cause (hygiene, restorative margin etc) Peripheral Giant Cell Granuloma Similar in appearance to pyogenic granuloma Will resorb alveolar bone Giant cells seem to be osteoclasts Treat by excision May recur Peripheral Giant Cell Granuloma Idiopathic Pagets disease 1% over 45yo, 10% over 90yo Subclinical disease common Usually multiple bones Lumbar vertebrae, pelvis, femur, calvarium 17% involve jaws Can have severe bone pain Reduced radiodensity then progresses to sclerosis (cotton wool) Expansion of bone Obstruction or compression of adjacent structures Paget’s Disease Conclusion Many conditions can present as intra-oral swellings A systematic approach is safe and will result in appropriate management Refer to a surgeon if you are unsure of what you are dealing with or patient safety is a concern Infectious and neoplastic conditions can be fatal Case Study Case Study Osteosarcoma Reconstruction