COM May 2004

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Multiple Intraoral Soft Tissue Swellings

Dolphine Oda, BDS, MSc
doda@u.washington.edu

Contributed by
Drs. Joseph Chasteen and Edmond Truelove
Department Oral Medicine, School of Dentistry, University of Washington

Case Summary and Diagnostic Information

This patient presented with dental pain and multiple soft tissue swellings in the mouth, head and neck area, as well as in other parts of the body.

History of present Illness

This is a 43-year old white male who presented to the University of Washington Oral Medicine clinic with “dull pain in the right lower jaw” of three months’ duration. The patient had attempted previously to save badly carious teeth #s 30 & 31. Both teeth were tender to percussion with failing restorations. In addition to the carious teeth, this patient had multiple soft tissue swellings in the mouth, head and neck area, as well as other parts of his body.

Medical History

This patient is an adopted child and therefore was not aware of a family history of parents or siblings with multiple nodules. His past medical history is otherwise unremarkable. 

Clinical and Radiographic Findings

The clinical examination revealed numerous nodules on the head and neck area, including the oral cavity (Figure 1). The nodules were smooth-surfaced and were of variable shape and size. In the oral cavity the nodules involved the buccal mucosa, lips and palate. 

Figure 1. Multiple nodules on the lips and buccal mucosa. Also notice the gingival hyperplasia at the edentulous left maxilla.

Hyperplasia of the gingiva at the left maxilla was associated with irregular-looking alveolar bone (Figure 2). The patient had three impacted teeth: #s 1, 17 and 32. Teeth #s 17 and 32 demonstrated dentigerous cyst with irregular bone overlying the dentigerous cysts. The alveolar nerve canal was slightly widened at the right side . Most of the remaining teeth demonstrated secondary caries.

Figure 2. Panoramic view at first presentation demonstrating many failing restorations, three impacted teeth, irregular bone structures at the left maxilla and mild expansion of the inferior alveolar canal at the right side of the mandible.

Excisional Biopsy

The incisional biopsy revealed a piece of oral mucosa covered with stratified squamous epithelium and supported by connective tissue which was almost completely occupied by a lesion of neural origin. The latter was made up of lobules of myxoid neural tissue, in some areas, with central nerve bundles. These lobules are surrounded by a connective tissue capsule (Figure 3). The neural bundles were made up of spindle-shaped cells with wavy nuclei suspended on a delicate background of collagen fibers. Immunohistochemistry markers with S-100 protein were positive for nerve fibers (Figure 4).

Figure 3. Low power (x100) histology shows multiple lobules of well-demarcated nerve tissue separated by denser connective tissue.

Figure 4. Low power (x100) immunohistochemistry using antibody to S-100 protein. The nerve lobules are positive with central areas of more concentrated staining consistent with a central nerve bundle.

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