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PART II
Soft Tissue Lesions
LESIONS
• • • • •
Hemangioma Metastatic tumor Primary malignant tumor Kaposi's sarcoma (Chapters 12,36) Papilloma/condyloma/verruca
Differential Diagnosis The early IH lesion must be differentiated from other raised lesions listed in the box above. In the case of most IH lesions in their early stages of development, a precipitating irritant is usually identifiable. This strengthens the impression and supports a working diagnosis of IH. However, if an irritant is not apparent, the possibility the lesion is either a primary (probably not squamous cell carcinoma [SCC]) or secondary malignant tumor beginning beneath a normal surface epithelium is given more consideration in the differential diagnosis. In turn, a history of treatment or symptoms of a primary tumor elsewhere prompts the ordering of these possibilities in favor of a metastatic tumor (see Fig. 5-21). Excluding SCC and salivary gland tumors, primary malignant tumors of the oral soft tissue are quite uncommon. It is rare for a squamous cell carcinoma to appear as a small exophytic red lesion with a smooth nonulcerated surface. In the case of gingival IH lesions adjacent to alveolar bony changes, malignant tumors must be given a high ranking except in the case of obvious chronic infection of the bone. A congenital hemangioma is present from birth, whereas a traumatic (acquired) hemangioma is really a type of IH lesion. Papillomas, condylomas, verrucae, and verrucous and squamous cell carcinomas are included for the sake of completeness. However, since the IH lesions have a basically smooth, evenly contoured surface, they should be readily differentiated from these epithelial growths that have rough pebbly to a cauliflower-like surface. The pyogenic granuloma may have an area on its otherwise smooth surface that is white, but this is necrotic material and can be easily removed, leaving a raw bleeding surface. Management Excisional biopsy in combination with elimination of the irritant is the treatment of choice for lesions of substantial size when the suspicion index is moderate to high. When the suspicion index is low, elimination of the irritant will result in significant reduction of the inflammatory component, making surgery easier. Small red lesions may shrink to a size that precludes treatment when the irritant is eliminated.
REDDISH ULCERS OR ULCERS WITH RED HALOS Ulcers are discussed at length in Chapter II. They are included here for completeness because ulcerative conditions frequently are first manifested as erythematous macules, for example, the recurrent herpetic lesion and the recurrent aphthous ulcer. Furthermore, in these conditions. when the reddish area ultimately ulcerates, the defect frequently has a reddish border (Fig. 5-6 and Plate B. 4). Such an observation might prompt the clinician to classify the entity as a red lesion; however, experience has demonstrated that for the purpose of a differential diagnosis it is more beneficial to classify these lesions as ulcers.
Differential Diagnosis The differential diagnosis of the various oral ulcers is covered in Chapter II. NONPYOGENIC SOFT TISSUE ODONTOGENIC INFECTION (CELLULITIS) This section includes a discussion of soft tissue odontogenic infections that either are caused by nonpyogenic bacteria or represent prepyogenic 'or postpyogenic stages of infections; that is, the causative bacteria may be nonpyogenic, or the infection has not reached the pus-forming or pus-pooling stage. Odontogenic infection may originate in three sites: the canals and periapex of pulpless teeth, the gingiva or bony pockets in periodontal disease. and the gingival operculum over an erupting tooth.
Features In most of these cases a suitable history and clinical and radiographic examinations coupled with pulp testing usually clearly indicate the diagnosis of dental infection (Fig. 5-7). The alveolar mucosa and gingiva are the most frequent sites of dental infection, but if the infection is permitted to spread, a number of the oral mucosal surfaces and the overlying skin may become involved. Various degrees of swelling show a hot, red, tender to painful surface. However, pus that has formed and pooled near the surface of the swollen tissue imparts a yellowish-white color to the central region of the swelling and renders the swelling rubbery and fluctuant to the touch (see Chapter 3). Ludwig's angina is an unusual example of a reddish soft tissue infection that is produced by a mixed infection of nonspecific microorganisms, but a nonpyogenic strain of streptococcus is almost invariably present. This condition causes a sudden swelling of the floor of the mouth and also of the submental and submaxillary spaces. often of such a magnitude that obstruction of the airway is threatened. In most cases a very red, moderately firm. painful swelling of the floor of the mouth produces an elevation of the tongue. The skin of the neck overlying the