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 le-
sions into a thoroughbut comprehensibleformat, the prin-
ciples of differential diagnosis must be used. All oral en-
largementsare broadly classified as soft tissue or bony
abnormalities.Determinationof the specific lesion category
is based primarily on a prominent feature that demon-
strates the nature of the lesion, followed by the secondary
clinical features andany contributorypatient information.
Classificationof exophyticsoft tissue entities includes:pap-
illary surface enlargements, acute inflammatoryenlarge-
ments, 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 repre-
sent a wide range of entities such as anatomic
variations, developmental anomalies, inflam-
matory 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).
* Figs1 through6 weremodified
withpermission
fromChapter
18,Differentialdiagnosis
In: Principlesof OralDiagnosis,
Coleman
GC,NelsonJF, Eds,St Louis:Mosby-Year
294American
Academy
of PediatricDentistry
Oncea specific category has been selected, the char-
acteristics of the lesion can be compared with other
diseases that share commonclinical features and be-
havioral patterns.
Soft tissuelesions
Papillary enlargementsof the soft tissues are a dis-
tinct group of lesions that are easy to recognize because
of their commonclinical appearance. Most of these
lesions represent a viral-induced epithelial prolifera-
tion 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 appro-
priate management of the pediatric patient (Fig 2). The
behavior of these lesions is variable, ranging from spon-
taneous resolution to a recurrent, protracted course.
Acute inflammatory enlargements are characterized
by sudden onset, rapid progression, and compressible
tissue distention. These fluid-filled or edematousle-
sions 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 nonin-
fectious processes that present with either localized or
diffuse tissue involvement. In most instances, identify-
ing 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 reac-
tive 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 lim-
ited growth potential. The degree of vascularity and
edemaassociated with the soft tissue enlargement de-
termines 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-
of oral soft tissueenlargements.
Book,Inc. 1993,pp352-88.
PediatricDentistry-17:4,1995
 CHARACTERISTICS OF INTRAORAL SOFT
TISSUE ENLARGEMENTS IN CHILDREN

Smooth,bosselated, Dome-shaped enlargement Asymmetric enlargement

fissured sudace Superficial mucosa unaffected
Paleto redin color Widevariability in color
Maybe ulcerated Solitarylesionwithwell
Nodularor polypoldin shape definedmargins
Solitaryor multifocal Freely movable
Moderate growthrate Compressible to firm
(months) Stowgrowthrate
Painlessuntesssecondarily (monthsto years)
traumatized Asymptomatic unless
Softor firm incidentallytraumatized or
Limitedgrowthpotential interferewithfunction
Cause is often apparent Unlimitedgrowthpotential
Nosystemicfeatures Noapparentcause
Recur or persistif cause
is Nosystemicfeatures
not eliminated Characterized by distortion of
Very common anatomiccontours
Remains localized
Uncommon
=
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

~’
Papillary Surface Acute Reactive Benign Aggressive
Enlargements Inflammatory Hyperplaslas Submucosal and
Enlargements Cysts and Malignant
Neoplasms Neoplasms

Fig 1. Differential diagnosis of intraoral soft tissue enlargements in children.

ORAL PAPILLARY SURFACE

ENLARGEMENTS

I
I

Cauliflower II
or finger-like Nodular,sessilelesion
I Plaque-like
lesions
I
Red,papularlesions
Rough, pale surface Papillary,sessilelesion
appearance II Rough, stippledsurface Sessile base Softto palpation Pale,granular Superficialcandidiasis
Narrow,stalk-like baseI I Paleto normalin color Perioralskin,lips and Clustereddistribution surface Clustered
distribution
Pink or whitein color I I Gingiva,tongue palate Sexualcontactwith Welldefinedborders Hardpalate
FiKn, rough,nontender I I andpalate Additionallesionson similargenitallesions Widespreadoral Reactivehyperplasla
to palaption I I Reactivehyperplasia hands,fingers Recurrenceis common involvement Associatedwith full
Palateandtongue I I Recurrenceis rare Autoinoculation Maybe a signof Spontaneous palatal coverage
Recurrenceis rare I I Common oral lesion Common skin lesion sexualabuse regressionmay applianceor na~Tow
Common oral lesion ! Rareoral lesion occur palatalvault
Rare Uncommon

Squamous Giant Verruca Condyloma Focal Epithelial Papillary

Papilloma Fibroma Vulgaris Acumlnatum Hyperplasia Hyperplasla

Fig 2. Differential diagnosis of papillary surface 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 un-
commongroup of lesions that are nodular, well delin-
eated, and freely movable enlargements with normal-
appearing, intact mucosal surfaces. The slow and
persistent growthpattern results in alteration or dis-
tortion 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 sali-
vary gland neoplasmsas illustrated in Fig 5. In addi-
tion, this group is subdivided by site predilection and
palpation characteristics. Definitive diagnosis of this
disease category is based on histopathologic examina-
tion 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 ir-
regular surface changes with areas of erythema and
ulceration. Although early lesions are asymptomatic,

Pediatric Dentistry - 17:4, 1995 American Academy of Pediatric Dentistry 295

 ACUTE INFLAMMATORY ENLARGEMENTS

Fo ninfectiousProcess
I

Translucentblue
Swellingusually Swellingassociated Fluctuatesin size
associatedwith a with an unerupted Mucuscontents
periapicalor mand~ularmolar Historyof injury
periodontallesion Pain, trismus Mandibular lip
Redor yellowin color Usuallycontains Frequentlyrecurs
Purulentexudate semisolidmatedal Common
Very common Very common

Mucus Retention Phenomenon

Soft Tissue Pericoronitis
Abscess
I
Fluctuatesin size Pruritic planes
I I Blockageof Suddenonset Introducedby air
Extensiveswelling ~ ~ Majorglandinvolvement Wharton’sduct Smoothsurface syringe or handpiece

I
Suddenonset | ~ Unilateralor bilateral Floorof mouth Allergicreactionor Immediateonset
Obviouscause | Ii Viral,bacterialor Unilateralor hereditary Crepit~tionon
Fever,pain, tdsmus| | obstructive bilateral pattern palpation
Life threatening | | Maybe recurrent Mayherniate Lips Mayresult in
complicationsmay| | Painful wheneating throughfascial ng if..
Life threaten pneumomediastinum
develop | | or drinldng planes larynxis invoived Rare~atmgen~c
Common I i Commonwmmumps Uncommon Uncommon complication

+
Cellulitis Acute Sialadenitis Ranula Angioedema Emphysema

Fig 3. Differential diagnosisof acuteinflammatory

soft tissue enlargements
in children.

SOFT TISSUE REACTIVE HYPERPLASIAS

I
I I
PrimaryCauseIs RecurringInju~ or I Multifactorial Causes
PlusLocalIrritation
ChronicLocal Irritation I Gingiva Affected
I I
L Hormoneor Drug-Related I

Red,ulcerated
Surface Nontender Surface Smoothsurface I Smooth,pebbly Soft
ulceration Maybe ulceration Nontender I Firm Hemorrhagic
Bleedswith ulcerated Hemorrhagic Generalized I Generalized Hormonal
probing Displacesteeth Nontender enlargement I enlargeme~ fluctuations
Nontender Alveolarcuffing Mayoccurat Familymembers I Nontender Nontender
Alveolarcuffing of bone othersites affected I Common with Females
of bone Uncommon Common Uncommon Common
I certain drugs

I
Gingival Drug-induced
Peripheral Peripheral Pyogenic Fibromatosls Ginglval
Giant Cell Ossifying Granuloma Hyperplasia

I Nontender II Maybemultiple
Normatcolor I! Red,ulcerated
Tenderwhen II fissured surface
Sites of II Spongytofirm palpated
andlips II
I
I frequent II MitdlytenderTongue II Lobulated
Rrm
Frequently II Mucobuccalfold
I frauma II Surf’ace associated II RelatedtO Hormonal Pregnancy
II vacularity
IL...._.,.~_...J
c6mmon IITongue. withscarII over~ened Tumor Gingivitis
floor of mouth Uncommon acrylic appliances
I
~ ~ IVery IIUnc°mm°n
*
;I C°mmon t ;
Pulp Epulis Traumatic Reactive Traumatic Inflammatory
Polyp Granulomatosum Fibroma Lymphoid Neuroma Fibrous
Hyperplasia 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 Gingiva
Not Limited In Location To

~tS~L"~c~n d~:a nt

Infant Infant [ Connectivetissue origin

Female Bluish, cystic
predileciton
Anterior Posterioralveolar Usuallynot site specific Uncommon to rare lesions
maxillary Vascularlesions are Anyintraoral site possibleexcluding
mucosa
Multiple,bilateral common,others are gingivaandantedorhard palate.
mucosa
Pink, red nOdule Black ma~e rare in children Posterior palate is mostcommon oral
predilectlon location. Parotldis the majorgland
Epstein’s Thyroglossa! Cyst mostoften affected.
,| Uncommon Pearls Neck Moderaterecurrence rata
Dermoid Cyst
Floor of mouth !
Congenital Neonatal Nasolabial Cyst
Soft,
compressibleI
Gingival Alveolar Maxillarylip
Granular Cell Lymphangloma Lymphoepithellal Cyst I
Tumor Floor of mouth, tongue c°miressib!~
~ I ’--
Pleomorphlc
Lipoma Neuroflbroma Adenoma
I . I (most common)
Yellow Tongue, palate
Infants II Unerupted II Incisive Buccal mucosa Myoepithelioma
super~ialgingiva
II tooth II ~a Schwannoma
Basal Cell Adenoma
Hemangloma Encapsulated
Multiple
SpontaneoosII Bluish II Uncommon Red, blue, blanches Tongue, palate
regression II ~ I~
II regresses I~ Parotid, tongue,lips Rhabdomyoma
Lymphangloma Parotid, tongue, Cystadenoma
I ve~commo~
II commo~
~ Pink, red, pebbly surface soft palate Warthln’s Tumor
Tongue,lips, (Cystic Leiomyoma
Hygroma in neck) Occasionally red
Dental Eruption Cyst of the Plexlform Lips, tongue, palate
Lamina Cyst Incisive Neurofibroma Granular Cell Tumor
Cyst Papilla Feature of White, rough surface
neurofibromatosis 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 Surface Epithelial Mal~nancios]
I
[ ’ I I
Maybe congenital Youngmalss White, thickenedor Cutaneous lesion
Infiltrative Nasalobstruction red granular Flesh-coloredor
Rapid growth Epistaxis surface p/gmented
Surface Facial palatal Nonhealingulcer Nodulewith
ulceration expansion depressedcenter
Posterior tongue
High recurrence Ulcerated, vascular Cofactors(alcohol, Associatedwith
rate Intracranial navoidbasalcell
tobacco,UVlight,
extension common viruses and immune carcinoma
systemdeficiency) syndmme
Rhabdom osarcoma Leukemi= Veryrare in children Veryrare in children
Tongue,soft palate and Generalizedgingival
Aggressive Nasopharyngeal tonsillar pillar region enlargement
FIbromatosis Angiofibroma Flbrosar¢oma Petechiee and ecchymoses
Mandibular alveolar mucosa, Oral ulcers Squamous Cell Basal Cell
chin and angle of the Mobility of teeth Carcinoma Carcinoma
Hodgkln’s Lymphoma
Other Sarcomas Painless lymphedenopathy
Site depends on neoplasm Cervical lymph node chain
Malignant Salivary Weightless, fever, night sweats
Gland Neoplasms Non-Hodgkln’s Lymphoma
Most common: Painless lymphadenopathy
Mucoepidermoid carck’~ma Asymmetric enlargement of
Early lesions mimic pha~ngealtonsils, palatal
benign neoptasm mucusa, buccai muceaa,giegiva
Paro~dand posterior Metastatic disease
hard palate Gingiva most common soft tissue site
Malignancies of Bone Tumorextrusion from exl~action sits
with Soft Tissue
Extension
See Figure 10

Fig 6. Differentialdiagnosis
of aggressive
andmalignant
soft tissueenlargements
in children.

Pediatric Dentistry - 17:4, 1995 American Academy of Pediatric Dentistry 297

 CHARACTERISTICS OF JAW ENLARGEMENTS IN CHILDREN

Clinical Radiographic Clinical Radiographic Clinical Radiographic

Features: Features: Features: Features: Features: Features:
Tender or painful to Widenedperiodontal Nontender to palpation Intact periodontal Maybe tenderor painful Lossof the laminadura
palpation ligament space, Slowgrowth I~jament space Moderategrowthrate anddental crypt
Rapid entargement especiallyapica~113 (monthsto years) Laminadura anddental (weeksto months) Roaringtooth
(days to weeks) or furca Localized expansion crypt present Diffuse enlargement appearance
Diffuseor localized Loss of lamina dura Normalsurrounding Occursin alveolus and Mayhavea multitocal Bodyof Jaws, may
enlargement anddental crypt mucosa bedyof the jaws distribution extepdto the
Red,fender swoilan Irregularinternal or Progressesin size Interior or lateral tooth Mucosa is red, ulcerated, alveolus
mucosa external resorption Usually no apparent displacement firm andftxed Symmetricwidening of
Fluctuatesin size Locatedin alveolar cause Displacementof Vital, mobileteeth the periodontal
Drainage,sinustract bone,mayextendto No systemicfeatures anatomicstructures Extrusionof teeth ligament space
foRnation body of bone Maydelay tooth Blunt root resorptionwith Progressiveincrease in Irregular root
Causeis often apparent Usuallyradiolucent, eruption large lesions size resorption
Mobile,nonvital tooth mayappear mixad Subtlefacial Radiolucent,mixedor No apparent cause Irregular wideningof
Systemicfeatures such Poorly defined margins asymmetry radiopaque Systemicfeatures maybe maedibularcana~
as fever, Indistinct trabecular Uncommon Unilocularor muitilocular present Radiolucentor mixed
lymphadenopathy ff pattern shape Frequentparesthesle, lesion
advanced Proliferativeperiostitis Well delineated margins anesthesia Poorly defined margins
Trismus,occasional is common Cortical expansion Trlsmuswith advanced Lossof trebecular
pere~hesle disease pattern
Regression(healing) Uncommon or rare Occasional
Common proliferative
periostitis
Cortica~destn~ction

Inflammatory Benign Cystic and Aggressive and

Lesions of the Neoplastic Lesions Malignant Lesions
Jaws of the Jaws of the Jaws

Fig 7. Differential diagnosis of intraoral lesions characterized by bony enlargement in children.

INFLAMMATORY LESIONS OF THE JAWS IN CHILDREN

I I

I Localized Lesions I I Diffuse Lesions I

, I
I i I I
I Periapical Location I ! Nonperiapical Location I
[ IRnfead~t(~loUu(:nt’ Idiopathic I
I I
I I
I nadiopaque I I Peripheral Codex Pain, trismus
Cedes,trauma,
Inherited disease
Occurspdor to six months
I I idiopathic of age
Chronicpulpal Radiolucent Swelling, purulence Tender,soft tissue
disease Associatedwith Facial trauma Febrile, swelling
Nonexpansile erupting mandibular Inferior borderof lymphadenopa~y Febdle, lymphedenopathy
Posterior mandible molars mandible Posterior mand~le Bilateral mand~ular
Sharp margins History of pericoronitis Maybe associated involvement
Static with time Buccal expansion with jaw fracture "Onion-skin" appaarence
Deepperiodontal Irregular or sunburst Spontaneousresolution
pocket pattem Acute
Proliferativeperlostitis Osteomyelitis
Focal Scleroslng
Osteomyelltla Infantile Cortical
Hyperostosis
Inflammatory
Paradental Cyst
Traumatic
Osteoma I
Chronic dental
lnfestion
II Chronic
dentalinfection

Indistinct margins Di"use’

lesion
II expansi’e
Tender,painful Chmnic Maybe tender Mottled bonypattern i IndiStinct margins
History of infection Distinct hyperostotlc SequestnJm Is : Mottled bonepattern
caries, trauma Periodsof acute borders =
common "Onion.skin
Untlocular, exacerbation Nonvital tooth Ankylosis mayoccur appearance
indistinct Unlfocular, Expensile Posterior mandible Posterior mandible
man:J~ns distinct margins Displacementof
Nonvital tooth Nonvital tooth developingtooth

Chronic Diffuse Chronic

Scleroslng Osteomyelitls
Perlaplcal Perlaplcal Perlaplcal Osteomyelltis wlth Proliferative
Abscess Granuloma Cyst Periostltls

RURO= mixed radiolucent 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 Mixed Radi°lucent-Radi°paque I
I ,
i Radi°paque
2 I
I

I PericoronalLocation ’ , I ’ L~ I~entrat Location I IC~=Location

I I
Un"ocu’ar
I Unilocular when smatl’ I-~I--- I
Eruption Cyst
Bluealveolarmucesa(S~ple Bo~ C~t) Un~
Dentigerous Cyst Mandibutarpremolar-molar
area Mostcernmon in maxiila I Odontoma Torus/Exostosls
Thirdmolarandcanine Maycrossmidline Adenomatoid I Mayocc~in Nonneoplaaticprocess
Unicysti¢ Usuallynonexpansile Odontogenic Tumor periapical
area Obvious
clinically
I
Ameloblastoma Scalloped inttaradicularmargins Unilocular I cou~oued: Osteoma
Mandibular
sece~dand Oftenextendsbetween tooth Mostcommooin anterior maxilla tooth-l~e Maybe centTal
I
th~’dmolarregio~ roots without tooth movement Ameloblastic Fibro-odontoma I cak~cations
10%recurrencerate Mulfilocular Complex: Associatedw~h
/ amorphous Gardner’s syndrome
Mostcommon in posterior mandible~
calcifica~on
Central Giant Cell Granuloma Central Ossifying Fibroma Fibrous Dysplasla
Mandibular canine-premolar region Maybeunilocular o¢ multilccular Nonneoplastic condition
Maycrossmidline Progresses fromRL*to Maybe multifocal
Odontogenic Keratocyet Moderate recurrence rate mixed to RO**with time Maxillarypremolar-moist region
Posteriormandible Aneurysmal Bone Cyst Mandibular premotarhnolar region Progresses f~emRLto
Maycrossmidline Eccentricballooning of mandible Juvenile Ossifying Fibroma mixedtoROwi~ time
50%causepain Multilocularlesion Poorlydefinedmargins
Maybe associatedwith nevoid Associatedwith concurrent lesion Maxima Elliptical expansion
basalcell carcinoma syndrome Central Hemangloma Aggressive lesion Stabilizeswithtime
Ameloblastic Fibroma Vaguemargins Cementoblastoma
Mand~ulsr
first, second Gingivalbleeding, bruit, pulsation Postario~ mandible
molarregiee Toothmobility Progresses fi’om RLto
Recurrencesuncommon Life threateninglesion mixed to ROwith t~ne
Odontogenl¢ Myxoma Interrn~ent mildpain,vital tooth
Faint radiopaque stri~ons Attached to toothroot
Posterio~ mandible Osteoblastoma
Moderate recurrencerate Posteriormandible
Cherublsm Progresses ~’omRLto
Inherited
disordar, bilateral * RL= radioluceot mixedto ROwi~ ~me
Regresses with time °" RO= radiopaque Severe pain,vital tooth
Radiating,"sunburst"pa~em

Fig9. Differentialdiagnosis
of benign
cystsandneoplastic
lesions
of thejawsin children.

AGGRESSIVE AND MALIGNANT NEOPLASMS OF THE JAWS

I
Unifocal and
Radiolucent
I
I Unifocal and Mixed
Radiolucent-Radiopaque
Multifocal and
Radiolucent

Posterior Posteriormandible Mandibleor

I mandibleand Early symme~ic Palnf%li~aswelling
I
ramus widening of
Anterior
maxilla Maybe multifocal Painfulexpansion periodontal
Poorlydelineated "Punched-out" ligament tad o ucent
Expansile radiolucancy Febrile,
"Floating Usuallynonexpansile leukccytosls Occasional
toothbuds" "Floatingtooth" "Moth-eaten" periosteat
Pigmentedor red appearance pattem proliferation
surface Occasional Periosteal Sunburstpatternis
proliferative
perioatitls proliferation uncomrnon

Maybemultilocular Ewing’s SarcomaOsteosarcoma Mesenchymal

I
Poorlydelineated Chondrosar¢oma
Localized
Expaesile Idiopathic I I
"Floatingtoothbuds" Hlstiocytosls Multiplehone, Postariormaxilla widespread Pceterior I
Softtissueexqension (Eosinophilic argan andmandible involvement mandible
Highrecurrencerate Granuloma) involvement Oneto four Occasional Poorlydefined
Pain, quadrants gingival radiolucescy
i

~
lymphadenopathy involved enlargement Softtissue
Well to poody Gingival Painfulswelling Lossof lamina
Neuroectodermal Paresthesia definedmargins enlargement First sign:tooth dura
Tumorof Infancy Paresthesia
Unilccularor "Cupped-out" Premature mobility Toothmobility
mutlilocular appearance exfoliafion
of "Moth-eaten" or Diffuse,poorly
Desmoplastic I Cortical
Bodyof mandible Fine"ground teeth multilocular defined
Fibroma of Bone pedocation glass" berdars "Floatingtooth" radiolucency radiolucency
appearance Periostealbone Occasionat
+
Central SarcomasPrimary Soft
formation periosteaJ
forrnafion
bone

of Bone Tissue ~
Malignancies ~--I
Adjacent to Bone Disseminated Burkltt’s Leukemia Metastatic
Idiopathic Lymphoma Disease
Histiocytosls

Fig 10. Differential diagnosis of aggressive and malignant neoplasms of the jaws in children.

Pediatric Dentistry - 17:4, 1995 American Academy of Pediatric Dentistry 299

pain, paresthesia, lymphadenopathy,and naso-oropha-
ryngeal obstruction develop with tumor progression.
These diseases have been divided into: benign, aggres-
sive 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
Bony enlargements of the maxilla and mandible in
children rely on both clinical features and radiographic
interpretation in order to develop a differential diag-
nosis. To managethis comprehensive topic, there are
three distinct categories of bony enlargements: 1) in-
flammatorylesions 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 clini-
cal findings as those described for the soft tissue coun-
terpart. Rapid enlargement, pain, erythema, and drain-
age are characteristic. An apparent cause, in particular
a mobile, nonvital tooth, frequently is observed. Im-
portant radiographic features include a poorly defined
radiolucent or mixed radiolucent-radiopaque lesions
of the alveolar bone. Additional findings maydemon- professor, Division of Oral Diagnosis, Baylor College of Dentistry,
strate a widened periodontal ligament space, loss of
the lamina dura or dental crypt, and internal or exter-
nal root resorption. Proliferative periostitis is common
in this age group.
Broadly, inflammatory lesions of the jaws are
classified as localized or diffuse entities with a radio-
lucent, radiopaque, or mixed radiolucent-radiopaque
appearance (Fig 8).
Benigncystic and neoplastic lesions of the jaws are
defined as locally expansile lesions with a slow but
progressive growth pattern, Delayed tooth eruption and
subtle facial asymmetryare associated with this group
of lesions. The pertinent radiographic features include
a well-delineated unilocular or multilocular lesion with
cortical expansion. These bony lesions may appear
radiolucent, radiopaque, or mixed. Inferior or lateral
movementof teeth, blunt apical root resorption, and
displacement of anatomic structures are detected when
large lesions are present. As outlined in Fig 9, benign
cystic and neoplastic lesions of the jaws are classified
according to radiographic appearance and lesion site.
Aggressive and malignant neoplasms of the jaws
are characterized by a diffuse enlargement with a mod-
erate growth rate. Pain, mucosal ulceration, extrusion
of teeth, and paresthesia are commoncomplaints.
Important radiographic features include a poorly de-
fined radiolucent or mixedradiolucent-radiopaque le-
sion with cortical destruction. Irregular root resorp-
tion, loss of the lamina dura and dental crypt,
symmetrical widening of the periodontal ligament
300 American Academyof Pediatric Dentistry
space, and a floating tooth appearance frequently are
observed. Aggressive and malignant neoplasms of bone
are categorized as radiolucent or mixed radiolucent-
radiopaque lesions demonstrating unifocal or multifo-
cal presentation (Fig 10).
Conclusion
In summary,this review article arranges exophytic
oral lesions according to common,pertinent character-
istics to allow differential diagnosis in the pediatric age
group. Flow charts for both soft tissue and bony en-
largements of the oral cavity have been designed to
assist the pediatric dentist in this important decision-
makingprocess. Although the outline of this material
is fairly comprehensive,its utility is as a supplementto
more comprehensiveoral pathology and diagnosis text-
books. In addition, it is not the goal of this material to
allow the practitioner to arrive at a definitive diagno-
sis, 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 sig-
nificant impact on the treatment regimen, surgical re-
sults, and overall prognosis.
Dr. Flaitz is associate professor and director, Surgical Oral
PathologyService, Divisionof Oral Pathologyand Divisionof
Pediatric Dentistry, TheUniversityof Texas---Houston Health
Science Center Dental Branch, Houston. Dr. Colemanis associate
Dallas,Texas.
1. Coleman GC:Differential diagnosisof radiographicabnor-
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