Tumours, Cysts, Lesions & Oral Cancer

ABSCESSES

WHAT IS A TOOTH ABSCESS?
A dental/tooth abscess is a localised acute infection at the base of a tooth, which requires immediate attention from your dentist. They are usually associated with acute pain, swelling and sometimes an unpleasant smell or taste in the mouth. More severe infections cause facial swelling as the bacteria spread to the nearby tissues of the face. This is a very serious condition. Once the swelling begins, it can spread rapidly. The pain is often made worse by drinking hot or cold fluids or biting on hard foods and may spread from the tooth to the ear or jaw on the same side.

WHAT CAUSES AN ABSCESS?
Damage to the tooth, an untreated cavity, or a gum disease can cause an abscessed tooth. If the cavity isn’t treated, the inside of the tooth can become infected. The bacteria can spread from the tooth to the tissue around and beneath it, creating an abscess. Gum disease causes the gums to pull away from the teeth, leaving pockets. If food builds up in one of these pockets, bacteria can grow, and an abscess may form. An abscess can cause the bone around the tooth to dissolve.

WHY CAN’T ANTIBIOTIC TREATMENT ALONE BE USED?
Antibiotics will usually help the pain and swelling associated with acute dental infections. However, they are not very good at reaching into abscesses and killing all the bacteria that are present. The Maxillofacial and oral surgeon will want to remove infected tissue as soon as it is possible to remove the source of infection and prevent future problems. They might use antibiotics to help them do this, but the physical removal and stopping of potential places for bacteria to hide and grow is very
important.

HOW IS AN ABSCESSED TOOTH TREATED?
Antibiotics may be prescribed to destroy the bacteria causing the infection. If the infection is not cured a hole can be drilled into the tooth to drain the infection. If the root of the tooth is infected, a root canal treatment is the recommended procedure (this tries to save your tooth by taking out the infected pulp). An apicectomy will be performed as a last resort to salvage the tooth. If this is unsuccessful the tooth may require extraction.

APICECTOMY

WHAT IS AN APICECTOMY?
An apicectomy is a minor procedure to remove the tip (apex) of the root of a tooth. This is only done if a root canal treatment has failed. The procedure may be carried out using either a local anaesthetic, with or without intravenous sedation, or a general anaesthetic in a hospital operating theatre. The choice between the methods will depend upon the degree of difficulty of the procedure, your medical history, and your personal preference.

During the procedure a small “window” is cut (with a scalpel) in the gum over the root of the tooth. Using a dental drill, the area around the end of the root is exposed to determine
the amount of root that should be removed. This portion of the root is then removed with the drill. Any infected tissue is removed from around the end of the root of the tooth.

Apicectomies are not very successful and have a 30-40% failure rate that results in the removal of the tooth.

Lesions in the mouth / oral pathology
The inside of the mouth is normally lined with a special type of skin (mucosa) that is smooth and coral pink in colour. Any alteration in this appearance could be a warning sign for a pathological process. The most serious of these is oral cancer. The following can be signs at the beginning of a pathologic process or
cancerous growth:

• Reddish patches (erythroplasia) or whitish patches (leukoplakia) in the mouth.
• A sore that fails to heal and bleeds easily.
• A lump or thickening on the skin lining the inside of the mouth.
• Chronic sore throat or hoarseness.
• Difficulty in chewing or swallowing.

These changes can be detected on the lips, cheeks, palate, and gum tissue around the teeth, tongue, face and/or neck. Pain does not always occur with pathology, and curiously, is not often associated with oral cancer. Lesions are growths or sores that occur in the mouth. These can sometimes resolve themselves after a week or two, and in other circumstances they need to be removed surgically.

There are a number of different types of lesions such as self-induced lesions, traumatic ulcers, irritation fibroma, nicotine stomatitis and tobacco pouch keratosis.

Self-induced lesions are due to habits such as scratching the gum with fingernails or lip, cheek and tongue biting. These usually require a biopsy to confirm the diagnosis.

Traumatic ulcers occur due to a trauma such as biting the lip, cheek, or tongue or from an irritation such as the sharp edge of dentures. Such lesions normally heal by themselves within 7-14 days however if they don’t, a biopsy is indicated.

Irritation fibroma is a lesion composed of dense, scar like connective tissue as a result of chronic trauma or habitual cheek biting or chewing. It is surgically removed and sent for a biopsy to confirm the diagnosis.

Nicotine stomatitis is a lesion induced by heavy smoking. Keratinization occurs resulting in raised red dots on the salivary glands. Tobacco pouch keratosis results in a white lesion from chewing tobacco. This lesion often disappears when tobacco is no longer chewed. In both nicotine stomatitis and tobacco pouch keratosis the smoking can cause an increased risk of squamous cell carcinoma (cancer), as well as an increased risk of caries, periodontal disease, attrition and staining of the teeth.

TORUS MANDIBULARIS / TORUS PALATINUS

WHAT IS TORUS MANDIBULARIS?

A torus mandibularis is a slow-growing, tumor-like bony growth that develops on the inner (lingual) surface of the lower jaw bone (the mandible). Tori are smooth and can be either broad and flat or knob-shaped. They vary considerably in size, from a few millimeters to several centimeters in diameter. They may be singular nodules or multiple nodules that fuse together, extending two to four centimeters along the inner surface of the lower jaw. Normally, tori are bilateral, which means they occur on both the left and right sides of the mouth. Their growth pattern is so gradual that many patients assume they are normal and that everyone has them.Typically they are little more than an annoyance, causing no pain and requiring no treatment unless they interfere with the placement of a denture. When the torus is large, it is subject to irritation and ulcerationfrom repeated trauma. Once injured, the ulceration can
be slow to heal because of the limited number of blood vessels on their thin tissue surface. The tendency to develop these growths appears to be hereditary.

WHAT IS TORUS PALATINUS?
Torus palantinus is a bony protrusion on the palate. Palatal tori are usually present on the midline of the hard palate. Most palatal tori are less than 2 cm in diameter, but their size can change throughout life. Prevalence of palatal tori ranges from 9% – 60% and are more common than bony growths occurring on the mandible, known as torus mandibularis. Although some research suggests palatal tori to be genetic, it is generally believed that palatal tori are caused by several factors. They are more common in early adult life and can increase in size. In some older people, the size of the tori may decrease due to bone resorption. It is believed that tori of the lower jaw are the result of local stresses and not solely by genetic influences. Sometimes, the tori are categorized by their appearance. Arising as a broad base and a smooth surface, flat tori are located on the midline of the palate and extend symmetrically to either side. Spindle tori have a ridge located at their midline. Nodular tori have multiple bony growths that each has their own base. Lobular tori have multiple bony growths with a common base. Palatal tori are usually a clinical finding with no treatment necessary. It is possible for ulcers to form on the area of the tori due to repeated trauma.

TREATMENT
We will remove a torus mandibularis / Torus palantinus surgically in the following situations:
• It interferes with the placement of a denture.
• To guard against the infection that can result from persistent ulceration on the skin that covers the growth.
• It interferes with speech or comfortable positioning of the tongue.

Salivary Gland Diseases
Your salivary glands produce as much as a 1.5 litre of saliva each day. Saliva is important to lubricate your mouth, help with swallowing, protect your teeth against bacteria, and aid in the digestion of food. The three major pairs of salivary glands are:

• parotid glands on the insides of the cheeks
• submandibular glands at the floor of the mouth
• sublingual glands under the tongue

There are also several hundred minor salivary glands throughout the mouth and throat. Saliva drains into the mouth through small tubes called ducts. When there is a problem with the salivary glands or ducts, you may have symptoms such as salivary gland swelling, dry mouth, pain, fever, and foul-tasting drainage into the mouth. Salivary stones can interfere with the function of the salivary glands or block the ducts so they can’t drain saliva. When saliva can’t exit through the ducts, it backs up into the gland, causing pain and swelling that gets progressively worse. Unless the blockage is cleared, the gland is likely to become infected.

Bacterial infection of the salivary gland, most commonly the parotid gland creates a painful lump in the gland, and foul-tasting pus drains into the mouth. It is more common in older adults with salivary stones, but it can also happen in babies during the first few weeks after birth. If not treated, salivary gland infections can cause severe pain, high fevers, and abscess (pus collection). Bacterial infections generally cause one-sided salivary gland swelling. Cysts can develop in the salivary glands if injuries, infections, tumours, or salivary stones block the flow of saliva Viral infections such as mumps, flu, and others can cause swelling of the salivary glands. Swelling happens in parotid glands on
both sides of the face, giving the appearance of “chipmunk cheeks.” It usually begins approximately 48 hours after the start of other symptoms such as fever and headache. Other viral illnesses that cause salivary gland swelling could include for example the Epstein-Barr virus, cytomegalovirus, Coxsackievirus, and the human immunodeficiency virus.

Several different types of tumours can affect the salivary glands. They can be cancerous (malignant) or noncancerous (benign). The two most common tumours are pleomorphic adenomas and Warthin’s tumour. Pleomorphic adenomas most commonly affect the parotid glands, but can also affect the submandibular gland and minor salivary glands. The tumour is usually painless and grows slowly, are benign (noncancerous) and are more common in women than men. Warthin’s tumour is also benign and affects the parotid gland. Warthin’s tumour can grow on both sides of the face and affects more men than women. Sjögren’s syndrome is a chronic autoimmune disease in which cells of a person’s immune system attack the salivary and other
moisture-producing glands, leading to dry mouth and eyes. About half of people with Sjögren’s syndrome also have enlargement of the salivary glands on both sides of the mouth, which is usually painless. Treatment for salivary gland problems depends on the cause. For stones and other blockages of the ducts, treatment begins with the manual removal of stones, warm compresses, or sour candies to increase the flow of saliva. If simple measures don’t relieve the problem, surgery may be required. Surgery is usually required to remove large cysts and benign/malignant tumours. Some benign tumours are treated with radiation to keep them from coming back. Some cancerous tumours require radiation and chemotherapy. Other problems may be treated with medications only. For example, bacterial infections are treated with antibiotics. Medications can also be prescribed for dry mouth.