Soft tissue lesions

Epulis granulomatosa

A list of a few of the less common dental soft tissue lesions

Dental soft tissue lesions that I think are interesting.

Epulis granulomatosa

Epulis granulomatosa is found in poorly healing post extraction sites. The lesion just needs excision.

Picture of an epulis granulomatosa after a tooth extraction.

Epulis fissuratum

Epulis fissuratum is excess tissue grow from a poorly fitting denture. It is not uncommon, although does require long term wearing of ill fitting denture or partial denture.

Epulis fissuratum

Epulis fissuratum from a denture

Mucous Membrane Pemphigoid (MMP)

MMP is one of several auto-immune conditions that are both difficult to accurately diagnosis and difficult to effectively treat. Treatments are simply managing the symptoms. Differentials include erythema multiforme, Stevens Johnson syndrome, and other autoimmune blistering diseases such as pemphigus vulgaris, bullous pemphigoid, epidermolysis bullosa acquisita, and linear IgA bullous dermatosis. A few others from Gwen Brown are erosive lichen planus and dermatitis herpetiformis. Dermatitis herpetiformis is associated with true celiacs disease. Another similar condition is GPA or Wegener granulomatosis with strawberry gingivitis. PCG is a similar inflammatory condition with very bright erythematous of attached gingiva.

A patient with Mucous membrane pemphigoid gets topical steroids as needed. This diagnosis requires an eye exam to rule out symblepheron and the potential for the patient losing sight in the affected eye. A really nice post comparing MMP and pemphigus.

Mucous Membrane Pemphigoid of the upper and lower attached gingivaPhoto of a case of Mucous Membrane Pemphigoid or MMP

Herpetic Gingivostomatitis

The differential between erythema multiforme with ANUG and herpetic gingivostomatitis with ANUG is tricky. If you see vesicles or honey crusted lips then think herpetic. Punched out papilla is a sign of ANUG. This is a tricky case and diagnosis.  There are several other cheilitis lesions that are similar as well.

Case of herpetic gingivostomatitis with ANUG

One tell may be if they have a herpes outbreak on a finger.

Primary gingivostomatitis and herpetic whitlow diagnosis
Primary gingivostomatitis diagnosis made easier due to the fact that the patient has herpetic whitlow.

Is this case erythema multiforme or herpetic gingivostomatitis? If there are no lesions on the gingiva then it is not primary herpetic outbreak and secondary does not look like this. So must rule out erythema multiforme.

Erythema mutliforme or herpetic gingivostomatitis?
Erythema mutliforme or herpetic gingivostomatitis?

Erythema multiforme

This is an immune-mediated reaction with bullous and ulcerative mucocutanous lesions. Patients will present with painful ulcers, plaques, and hemorrhagic crusts on the lips, tongue, and buccal mucosa. Oral is the most common site but eyes, genitourinary, and respiratory mucosa can also be impacted. Infections cause about 90% of cases, especially HPV. Drugs cause the other 10%.

Again hard to tell if erythema multiforme or herpetic gingivostomatitis. This one came up after a new medication. Erythema multiforme is a mild version of Stevens-Johnson syndrome. Erythema multiforme is self limiting but painful. Some will get treatments of anti-virals, systemic corticosteriods and rarely antibiotics.

Erythema multiforme lesions on the lip

Stevens-Johnson syndrome

Very serious condition that needs medical attention immediately. Has a 5% mortality rate and a 30% Lyell disease rate. Questions for a patient that has a lip lesion that you are unsure of are

  • Do you have lesion on your eyes, skin, or genitals?
  • Have you had a cold sore recently?
  • Are you taking any new medications?

Typically SJS comes from a new medication but a virus like a cold sore can cause as well.

Stevens-Johnson syndrome on the lips

Staphylococcal scalded skin syndrome

This is a serious skin infection in children that typically presents around the mouth first. Dentist’s son who had it can be found here with a lot of photos.

Adverse drug reaction – Mouth sore from Tylenol (acetaminophen)

Many medications can result in mouth sores in some people. These adverse drug reactions are rare and go away once the medication is no longer taken. Lewis BDJ 2023 – Oral lesions drug adverse reaction

A rare side effect from acetaminophen is mouth sores. Whenever you see mouth sores it is a good idea to see if anything is new or has changed with diet, medication, or oral products. These lesions were from recent heavy acetaminophen use. The lesions will heal find after stopping the acetaminophen.

Mouth sores from Tylenol (acetaminophen).

Peripheral ossifying fibroma vs Peripheral Odontogenic Fibroma vs Peripheral cemento-ossifying fibroma

Not sure the difference can be made without a biopsy. The peripheral cemento-ossifying fibroma may be the same as the peripheral odontogenic fibroma. The case report here is very similar clinically to the lesion below. This could also be a peripheral giant cell granuloma but the color isn’t consistent with that. Ossifying fibroma are usually 1.5cm or less and occur on patients from 25-25 years old. Another case that is a peripheral cemento-ossifying fibroma.

Determining if this a peripheral ossifying fibroma or Peripheral Odontogenic Fibroma without a biopsy is impossible.
Peripheral ossifying fibroma vs Peripheral Odontogenic Fibroma?

Peripheral ossifying fibroma on a 25 year old

Oral chronic graft-versus-host disease

There are many soft tissue issues with this disease. The disease happens to bone marrow transplant patients.

Leukoplakia in the mouth

Leukoplakia in the mouth is typically a gray or white line or patch of tissue on the side of the tongue or along the check. Typically it forms in response to some sort of irritation like smoking and cheek chewing and is also often seen in clenches and grinders. It is not uncommon and the severity varies from patient to patient.

Usually dentist just monitor the area and look for changes that lead us to believe cancer may exist. The area does have a higher risk for developing cancer, but not significantly. As far as preventing cancer from forming there is no evidence that any treatment is more effective than placebo. The primary test is will the leukoplakia scrape off? If so it is likely candidiasis and not leukoplakia.

Leukoplakia lesion on side of tongue

Proliferative verrucous leukoplakia

Proliferative verrucous leukoplakia (PVL) is a form of oral leukoplakia with a high rate of transformation into oral squamous cell carcinoma according to Gupta.

Proliferative verrucous leukoplakia (PVL) is a distinct form of oral leukoplakia.

Sublingual varicosity

A benign condition of dilated blood vessels on the ventral surface. More prominent appearance may be indicative of a medical issue like smoking or high blood pressure. Baharvand Gen Dent 2022

Medication induced pigmentation

Many medications can cause pigmentation. Solodyn can cause brown lesions. Antimalarial medications are the class of drugs that cause the most issues. This is reversible though. Quinacrine, chloroquine and hydroxychloroquine, which has a use for autoimmune conditions, can all cause brown pigmentation.

Unknown soft tissue lesions

This one is most likely an ischemic event brought on from the injection, trauma from surgery, or the healing process. It is possible that is is a chemical burn but seems unlikely with the clear delineation of the lesion along the mucogingival junction. This cologne burn does look similar and appears to stay on the keratinized tissue.

Photo of an ischemic keratinized gingiva.