P A LA TA L S WELLING S

1. Anatomy of the palate

1.1. Hard palate
⚫ Anterior bony part is formed by palatine process of the maxillae & the horizontal plates of the palatine bones
⚫ Anteriorly & laterally bounded by alveolar processes & the gingivae
⚫ Posteriorly continuous with the soft palate
⚫ Incisive foramen: Entrance of the incisive canal
o Common opening for the right & left incisive canals
o Transmit the greater palatine artery (supplies the hard palate) that terminates & anastomose with the
sphenopalatine artery (supplies the nasal septum)
o Transmit also the nasopalatine nerve (supplies the palatal structures overlying incisors & canines; supplies the
mucosa of nasal septum) which communicates with the greater palatine nerve of the corresponding side
⚫ Greater palatine foramen: Medial to the third molar tooth
o Pierces the lateral border of the bony palate
o Where the greater palatine AN emerge from & run anteriorly into 2 grooves on the palate
⚫ Lesser palatine foramen
o Transmits the lesser palatine AN, which runs to soft palate & adj. structures
1.2. Soft palate
⚫ A movable, fibromuscular fold that is attached to the posterior edge of the hard palate
o With NO bony support, but contains palatine aponeurosis (layers of flat broad tendons)
⚫ Extends posteroinferiorly to a curved free margin from which hangs a conical process, the uvula
⚫ Continuous laterally with the wall of the pharynx & is joined to the tongue & pharynx by palatoglossal &
palatopharyngeal folds
⚫ The soft palate separates the nasopharynx superiorly & the oropharynx inferiorly
⚫ During swallowing, the soft palate moves posteriorly against the wall of the pharynx
→ Prevents regurgitation of food into the nasal cavity
2. Diagnosis & Management of Palatal Swellings
2.1. History taking
⚫ History of the swelling
o Onset
o Duration
o Location
o Size (& alteration in size)
o Consistency (e.g. fluctuant, firm, rubbery)
o Associated pain/ tenderness
o Associated symptoms (e.g. fever)
⚫ Medical history (e.g. systemic disease)
⚫ Dental history (e.g. denture wearing, caries, periodontal diseases)
2.2. Clinical examination
⚫ Features of the swelling

No. of lesions ⚫ Singular: Trauma/ infective/ developmental origin

⚫ Multiple: Associated with systemic diseases/ infective / occasionally developmental origin
⚫ Bilaterally symmetrical: Anatomical cause

Location Define the anatomical position & proximity to other structures (e.g. teeth)
⚫ Midline: Developmental in origin (e.g. torus palatinus)
⚫ Bilateral: Tends to be benign (e.g. sialodenosis)
⚫ Unilateral: Most are neoplastic

Size Measure & record any alteration in size (ideally with photograph)
Shape ⚫ Parotid swelling often fills the space between posterior border of the mandible & the
mastoid process
Colour ⚫ Brown/ black: Tattoo/ naevus/ melanoma
⚫ Purple/red: Haemangioma/ Kaposi’s sarcoma/ giant-cell lesion

Tenderness ⚫ Inflammatory swellings (e.g. abscess): Characteristically painful / tender

⚫ Benign lesions: Usually painless

Temperature ⚫ Skin overlying acute inflammatory lesions (e.g. abscess, haemangioma): Usually warm

Discharge ⚫ Clear fluid/ pus/ blood from orifice or sinus

Movement Whether it’s fixed to adj. structure or the overlying skin/ mucosa
Consistency By palpation
⚫ May cause fluid discharge (e.g. pus, blood), or cause blanching (vascular), or occasionally
cause a blister to appear or expand
⚫ May disclose underlying structure (e.g. tooth crown under an eruption cyst), or show that
the actual swelling is in deeper structure (e.g. submandibular calculus)

⚫ Hard/ indurated: Carcinoma

⚫ Soft/ fluctuant: Presence of fluids (e.g. abscess, cyst near the surface) or benign nature

⚫ Cracking sound on palpation: (Egg-shell like) palate bone overlying a bony cyst
 Surface texture ⚫ Anemone-like appearance: Papilloma
⚫ Nodular/ ulcerated: Possibly a carcinoma or other malignant lesions
⚫ Abnormal blood vessels: Neoplasms

Ulceration Record features of the edge of ulcer & appearance of ulcer base
⚫ May be due to trauma e.g. ill-fitting denture, deeper cysts covered by normal mucosa
⚫ May suggest malignancy e.g. squamous cell carcinoma

Margin ⚫ Well-defined margins: Benign lesions

⚫ Ill-defined margins: Frequently associated with malignancy

⚫ Statuses of teeth adj. to the swelling

o Pulp vitality
o Presence of caries/restoration
o Periodontal status
2.3. Imaging
⚫ E/O radiographs: OPG, Water’s view
⚫ I/O radiographs: Periapical, occlusal radiographs
⚫ CT & PET-CT
⚫ MRI
⚫ Ultrasound
⚫ Bone scintigraphy
2.4. Blood test
⚫ When blood dyscrasia/ endocrinopathy is suspected
2.5. Biopsy & histological examination – fine needle aspiration / incisional & excisional biopsy
⚫ Required for definitive diagnosis (& planning of optimal management)
o Esp. if lesion is single & chronic (∵ Could be neoplasm or other serious condition)

3. Classification
ORIGIN OF SWELLING EXAMPLES
DEVELOPMENTAL ⚫ Torus
⚫ Unerupted teeth (e.g. permanent canine, 2nd premolar)
⚫ Developmental odontogenic cysts

INFLAMMATORY ⚫ Abscess
⚫ Pyogenic granuloma
⚫ Inflammatory odontogenic cysts (e.g. Radicular cysts)
⚫ Mononucleosis (caused by Epstein-Barr virus)
⚫ Osteonecrosis

TRAUMATIC ⚫ Denture granuloma

⚫ Denture stomatitis
⚫ Epulis
⚫ Fibroepithelial polyp
⚫ Haematoma

FIBRO-OSSESOUS ⚫ Ossifying fibroma

 ⚫ Fibrous dysplasia
⚫ Paget’s disease of bone

NEOPLASMS Odontogenic tumours

⚫ KCOT, CCOT, CEOT, ameloblastoma
Non-odontogenic tumour – salivary gland neoplasm
⚫ Epithelial salivary adenomas (pleomorphic & monomorphic)
⚫ Mucoepidermoid carcinoma, acinar cell carcinoma, non-epithelial like lymphomas
Epithelial & connective tissue neoplasms
⚫ Papilloma, brown tumour

4. Common differential diagnoses

4.1. Torus palatinus
⚫ Developmental bony protrusion that presents on the midline of the hard palate
⚫ More common in female (not evidence-based though)
⚫ Clinical manifestation
o Asymptomatic
❖ But may interfere with eating, denture wearing & is easily subject to trauma
⚫ Management
o No treatment
o Surgical removal
❖ Midline incision → Flap raised → Torus divided using bur → Fragments elevated from the palate with a chisel
→ Bone smoothened with bur → Flap closed

4.2. Odontogenic cysts

⚫ Commonly include:
o Inflammatory: Radicular, paradental, residual radicular
o Developmental: Dentigerous, eruption, glandular odontogenic, lateral periodontal, odontogenic keratocyst
⚫ Management
o Non-surgical
❖ Root canal treatment: With CHX & AB (if cyst is infected) as intracanal medicament
o Surgical
❖ Enucleation: Removal of the whole cyst (incl. epithelial & capsular layers) without rupture
❖ Marsupialisation: Evacuation of the cyst content without removing the whole cyst
▪ Surgical window created through soft tissue/bone to expose the cyst
→ Cyst lining sutured to the oral mucosa to keep the cavity open
→ The cavity is dressed with BIPP & very good OH must be kept to prevent food debris trapping
→ Healing occurs after months with shrinkage of cyst promoted by space being filled with bone (due to
decreased intracystic pressure)
❖ Combination of enucleation & marsupialization
❖ Enucleation with curettage
4.3. Pyogenic granuloma
⚫ Inflammatory hyperplasia, unrelated to infection
o Response to low-grade local irritation, traumatic injury or hormonal
factors (∴ More common in young females & pregnant women)
⚫ Clinical manifestation
o Non-tender
o Smooth surface
⚫ Management
o Excision

4.4. Osteonecrosis
⚫ Bone disease that occurs when bone is exposed & dies due to lack of blood supply
⚫ Often happens following dental extraction & is associated with
bisphosphonate therapy
⚫ Clinical manifestation
o Exposure of bone through gingiva
❖ Non-healing
❖ May be asymptomatic, painful or infected
⚫ Management
o Surgical removal of the necrotic bone

4.5. Denture granuloma (/ Epulis fissuratum / inflammatory fibrous hyperplasia)

⚫ Benign hyperplasia of fibrous connective tissue
o Develops as a reaction lesion to chronic mechanical irritation produced by flange of a poorly fitting denture
⚫ Management
o Surgical excision
o Correction of denture faults (Reline / rebase / remake)

4.6. Denture stomatitis

⚫ Candida-associated infection of the denture covering mucosa with inflammation
& redness

4.7. Peripheral ossifying fibroma (/ fibrouos epulis)

⚫ Gingival nodule made of cellular fibroblastic connective tissue, associated with calcified products (bone, cementum-
like products)
⚫ Could be due to a maturation of a pre-existing pyogenic granuloma, or
peripheral giant cell granuloma that undergoes calcification
o Due to trauma or irritation
⚫ NOT the same as ossifying fibroma of bone
⚫ Management
o Surgical removal
4.8. Peripheral giant cell granuloma
⚫ Reaction lesion due to local irritation or trauma with many multinucleated giant cells
⚫ Clinical manifestation:
o Peripheral giant cell granuloma, peripheral ossifying fibroma & pyogenic granuloma all resemble each other
⚫ Management
o Surgical excision

4.9. Odontogenic tumours

⚫ Benign
o Odontogenic fibroma
o Odontogenic myoma/ myxofibroma
o Cementoblastoma
⚫ Malignant
o Odontogenic carcinoma (e.g. ameloblastic carcinoma)
o Odontogenic sarcoma (e.g. osteosarcoma)

4.10. Salivary gland tumours

⚫ Benign
o Pleomorphic adenoma
o Warthin’s tumour
⚫ Malignant
o Adenoid cystic carcinoma
o Mucoepidermoid carcinoma
o Acinar cell carcinoma