Foliate papillae
Description: Foliate papillae appear as an area of vertical folds and grooves located on the extreme
posterior-lateral surface of the tongue. They are occasionally mistaken for tumors or inflammatory
disease. The grooves are best seen when air from an air syringe is directed at them. Their long axis is “up
and down”, that is they are at right angles to the long axis of the tongue. Our experience has been that
they are usually bilaterally symmetrical. In most people, the papillae are small and inconspicuous,
whereas in others they are prominent. Lingual tonsils are found immediately beneath the foliate papillae
and, when hyperplastic, cause a prominence of the papillae. Those familiar with the basic fold and groove
structure of the foliate papillae are not apt to confuse these normal structures with an abnormality.
ETIOLOGY: They are normal anatomical structures.
TREATMENT: None required.
PROGNOSIS: Good
DIFFERENTIAL DIAGNOSIS: Hyperplastic lingual tonsils, squamous carcinoma, soft tissue tumors
Lymphoid aggregates
DESCRIPTION: Lymphoid aggregates appear as small, slightly elevated nodules that may be normal
colored or have a slight yellow-orange hue. Those illustrated here are in the soft palate. They may be
found anywhere in the mucosa but are especially common where the mouth meets the throat, including
the base of the tongue. This lymphoid rich area has been called Waldeyer’s ring. When they occupy the
same area as the foliate papillae, the papillae may take on a more nodular appearance. In the tongue they
have been referred to as “lingual tonsils.”
ETIOLOGY: They are normal structures, components of Waldeyer’s ring.
TREATMENT: None required.
PROGNOSIS: Good. They may enlarge or regress in relationship to oral or upper respiratory infections.
DIFFERENTIAL DIAGNOSIS: Although foliate papillae and lymphoid aggregates of lingual tonsils may
occupy the same area, they are different entities.
Mucocele
DESCRIPTION: A mucocele is a collection of saliva in the oral mucosa. They are soft elevations whose
color ranges from that of normal mucosa to light blue or even white. Patients with mucoceles regularly
state that the lesion “gets larger, then smaller, then larger again.” This has become an important
diagnostic sign. The mucosa of the lower lip and buccal mucosa are the most common sites, but any
area that contains intraoral salivary glands is a potential site.
ETIOLOGY: Traumatic severance of salivary ducts permitting salivary escape into mucosa is the accepted
etiology.
TREATMENT: Surgical excision deep enough to include the underlying gland that feeds it.
PROGNOSIS: Good
DIFFERENTIAL DIAGNOSIS: Salivary gland neoplasms (especially mucoepidermoid carcinoma), varix,
and hemangioma.
Irritation fibroma (traumatic fibroma)
DESCRIPTION: Traumatic fibroma is a dome-shaped soft tissue mass usually found on buccal mucosa
along the line of occlusion. Less frequently they may be found on lips and tongue. They are among the
most common oral soft tissue lesions. The color is usually the same as the surrounding mucosa and the
consistency is surprisingly soft. Patients are generally aware of the lesion being present months to years
with little change. Histologically, they exhibit fibrous hyperplasia that is collagenous and acellular.
ETIOLOGY: The presumed etiology is trauma to the affected mucosa. Accidental biting probably accounts
for most of these lesions.
TREATMENT: Excision
PROGNOSIS: Good
DIFFERENTIAL DIAGNOSIS: Salivary gland tumors and other soft tissue tumors may have a similar
appearance but are usually more firm. Other lesions such as mucocele may also resemble traumatic
fibroma.
Leukoedema
DESCRIPTION: Leukoedema appears as a filmy, opaque, white to slate gray discoloration of mucosa,
chiefly buccal mucosa. Redundancy of the mucosa may impart a folded or wrinkled appearance to the
relaxed mucous membrane. It partially disappears when the mucosa is stretched. It is stated to be seen
in 90% of Blacks and 10–90% in Whites. This variation may be due to the difficulty in observation of
leukoedema in non-pigmented mucosa. Leukoedema is accentuated in smokers.
ETIOLOGY: Leukoedema is a variation of normal that should not be confused with something ominous.
Intracellular edema of the superficial epithelial cells coupled with retention of superficial parakeratin is
thought to account for the white appearance. Microscopic examination reveals superficial squamous cells
have a clear, seemingly empty cytoplasm but it has not been shown that there is an increase in
intracellular water. Thus, the term edema is questionable.
TREATMENT: None required.
PROGNOSIS: Good
DIFFERENTIAL DIAGNOSIS: White sponge nevus, hereditary benign intraepithelial dyskeratosis, and
dyskeratosis congenital. All are extremely rare
.
Pyogenic granuloma
DESCRIPTION: Pyogenic granuloma is a red, nodular overgrowth of granulation tissue that arises from
the mucosal or skin surface. Approximately two-thirds of oral lesions are found on the gingival followed
in descending order by the lips, tongue, buccal mucosa, palate, vestibule and edentulous areas. The
interdental papilla of the maxillary facial gingival is the single most common site. A review of more than
800 cases disclosed the mean size to be approximately 1.0 cm with a range of 3 mm to 4 cm. Females
were more often affected (72%). Duration varied widely with a mean of 5.5 months. Because of the
vascular nature of pyogenic granuloma, they bleed easily and some cause mild pain. They commonly
develop during pregnancy. The association with pregnancy is so common that the lesion has also been
called granuloma gravidarum or pregnancy tumor. Because pus is infrequently found in this lesion, the
term pyogenic granuloma is a misnomer but remains the preferred term.
ETIOLOGY: The stimulus that provokes this overgrowth of granulation tissue is unknown although mild
trauma and infection are prominently mentioned.
TREATMENT: Conservative excision. They may recur.
PROGNOSIS: Good.
DIFFERENTIAL DIAGNOSIS: Peripheral giant cell granuloma and peripheral ossifying fibroma.
Torus palatinus and torus mandibularis
DESCRIPTION: Bony exostoses in the midline of the hard palate and on the lingual aspect of the mandible
are referred to as torus palatinus and torus mandibularis respectively. Some studies suggest they are
inherited whereas others suggest environmental factors. They start in childhood and reach peak incidence
in young adults. Once they have reached “programmed size”, their growth stops. Some are so subtle they
hardly constitute an abnormality, whereas others are so large they frighten the uninitiated observer. In
the mandible, they may form a row of nodules as illustrated. In most individuals they occur bilaterally.
Those in the palate may be divided by deep grooves to form a cluster of nodules. Exostoses entirely
similar to tori occur elsewhere on the alveolar bone, but there is no specific name for them. It has been
estimated that palatal tori occur in 20-35% of the population. Mandibular tori are less common, about
10% of the population are affected.
ETIOLOGY: Tori are developmental over-growths of normal bone and as previously stated they may be
inherited.
TREATMENT: Tori and other exostoses seldom cause symptoms. Because they extend above the level of
surrounding normal mucosa, they invite trauma. Small traumatic ulcers are therefore commonly seen on
the mucosa that covers tori, more commonly palatal tori. Tori may interfere with prosthetic appliances
and, for that reason, may require removal.
PROGNOSIS: Good
DIFFERENTIAL DIAGNOSIS: Tori have such a characteristic clinical appearance and history that
differential diagnosis is seldom a problem.
Varix (plural: varices)
DESCRIPTION: Varices appear as red, blue, or deep purple broad-based elevations in oral mucosa. The
size is usually less than 5 mm. The buccal mucosa is a common place to find them, however, they are
also found in lip mucosa and ventral and lateral mucosa of the tongue and floor of the mouth. On ventral
tongue they are apt to be multiple and the term “caviar tongue” has been commonly used to describe
them. They are seen more commonly in the elderly.
ETIOLOGY: A varix is a distended vein that elevates the overlying mucosa. The reason for venous
distention is unclear but may be related to weakening of the vessel wall secondary to aging.
TREATMENT: None usually required. They often thrombose but this is of little clinical consequence.
PROGNOSIS: Good
DIFFERENTIAL DIAGNOSIS: Mucocele, hemangioma and angina bullosa hemorragica.
Osteoporotic bone marrow defect
DESCRIPTION: As the name implies, this is a localized increase of hematopoietic bone marrow that
creates a radiolucent radiographic defect. They occur more commonly in women in the midyears and
show a predilection for the molar region of the mandible. They are especially common in extraction sites.
Scattered trabeculae may extend short distances into the defect or, in some instances, through it giving
the defect a fairly characteristic appearance. Naturally there are no clinical symptoms.
ETIOLOGY: The etiology remains unknown. No connection has been found linking the osteoporotic bone
marrow defect with anemia or systemic need for increased erythrocytes.
TREATMENT: Once the diagnosis is established, no treatment is required.
PROGNOSIS: Good
DIFFERENTIAL DIAGNOSIS: This defect may easily be mistaken for a cyst or tumor. In those cases where
there is doubt about the diagnosis, biopsy should be done.
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