REVIEW ARTICLE

“A REVIEW OF 9 PALATAL SWELLINGS”

Santosh Patil1
Suneet Khandelwal2
BharatiDoni3
Farzan Rahman4

Palatal swellings can at times be a challenging task for a clinician to diagnose. A mass or swelling of the palate
can result from developmental, inflammatory, reactive or a neoplastic process. In differential diagnosis, swellings
of odontogenic origin (cyst or tumor) must be considered because they are very common. This article reviews
various common palatal swellings, their clinical presentation, differential diagnosis and management aspects.
KEYWORDS: Differential diagnosis, hard palate, swelling, inflammatory, cystic, neoplastic.
How to cite this article: Patil S, Khandelwal S, Doni B, Rahman F. A Review of 9 Palatal Swellings. J Pak Dent
Assoc 2013;22(2):134-139.

INTRODUCTION Figure 1: Midline palatal abscess

P alatal swellings may result from a variety of etiological

factors, and can originate from the structures within
1
the palate or beyond it. They may be painful when infected
or painless as in the case of benign swellings. They may
be congenital or acquired in origin. Swellings of congenital
origin are associated with unerupted teeth and torus
palatinus while acquired conditions resulting in palatal
swellings include dental abscess, salivary gland neoplasms,
fibro-osseous lesions, fibrous lumps, epithelial and
connective tissue neoplasms such as papilloma, squamous
cell carcinoma of palate or antrum, brown tumor etc. These
swellings can be best examined by inspection and palpation
1. Department and institution: Dept of Oral medicine and
radiology Jodhpur Dental College, Jodhpur National
similar with most oral lesions. Radiographs can aid in
University, Jodhpur (Raj).342001. India.
ruling out pathologies such as abscesses and periapical
2. Department and institution: Dept of Oral pathology
and microbiology DeshBhagat Dental College, Muktsar inflammatory conditions. Routine panoramic radiography
India. can help to discover bony masses arising from the maxilla.
3. Department and institution: Dept of Oral medicine and As with any lesion, the final diagnosis is achieved after
radiology NIMS Jaipur (Raj).342001. India. the histological examination; a biopsy must be performed
4. Department and institution: Dept of Oral pathology which either will be excisional for a small lesion not
and microbiology Jaipur Dental College Jaipur (Raj). thought to be malignant or incisional for a possible
342001. India. malignant lesion or a large lesion. We hereby present a
Correspondence: Dr Santosh Patil review of the various palatal swellings.
<drpsantosh@gmail.com> Palatal abscess represents a palatally draining infection

JPDA Vol. 22 No. 02 Apr-June 2013 134

 Patil S, Khandelwal S, Doni B, Rahman F
of pulpal or periodontal origin. It is observed as a fluctuant
swelling in the premolar and molar region, lateral to midline
2
(Figure 1). Palatal abscess may mimic minor salivary
gland tumor or radicular cyst and can pose a difficulty in
diagnosis. History and clinical examination along with
radiographs will aid in diagnosing this condition. The fate
of the infection depends on the numbers and virulence of
Figure 2: Pyogenic granuloma extending to the palate
the bacteria, host resistance, and associated and/or related
anatomic structures.
Histopathology reveals exudate, necrotic debris,
infiltration of the neutrophils and histiocytes. Treatment
includes either extraction or a pulpectomy of involved
3
tooth and/or drainage with antibiotic coverage. However,
in rare cases palatal abscess can be localized adjacent to
the midline and can pose a difficult diagnostic dilemma
for the clinician. The taking of the history and intraoral
examination are valuable diagnostic tools in conjunction
with radiographic examination for the evaluation of palatal
abscess.
Pyogenic granuloma (PG) is an inflammatory
4
hyperplasia which is not uncommon in the oral cavity.
5
Hartzell in 1904 introduced the term pyogenic granuloma.
Although PG may be seen at any age, the peak incidence
is seen in 2nd decade with increased predilection towards
6 5
the female sex. Anterior gingiva is more commonly
affected. Apart from gingiva, buccal mucosa, palate and
lips and tongue are the other sites which are frequently
affected by pyogenic granuloma. PG presents as a solitary
smooth or lobulated mass, majority being pedunculated
and some sessile (Figure 2). The surface of the lesion is
usually ulcerated, friable and covered with white necrotic
material resembling pus, because of which the clinicians
may have called this lesion as PG. The colour vary
135
A Review of 9 Palatal Swellings
according to the age of the lesion, the younger lesions
usually appear highly vascular when compared to older
ones which appear pink. The diameter of pyogenic
granulomas varies from few millimetres to few centimetres.
Histopathological examination of PG reveals a highly
vascular proliferation which resembles a granulation tissue.
These lesions consist of proliferating endothelial tissue,
which is canalised into a rich vascular network with
minimal collagen support, presence of polymorphs and
chronic inflammatory cells can be appreciated in the
edematous stroma along with microabcsess formation,
Figure 3: Radicular cyst located on the lateral
part of palate
mixed inflammatory cell infiltrate of neutrophils are seen
near the ulcerated surface, whereas deeper areas show
chronic inflammatory cells. Even though the diagnosis of
pyogenic granuloma can be accurately done clinically,
radiographs and histopathology aid in the confirmation
and treatment. Radiographs help to know the underlying
bone loss which will rule out peripheral giant cell
granuloma, malignancies and other similar appearing
conditions. Surgical excision and removal of irritants is
usually curative, the excision should extend down to the
periosteum and the adjacent teeth should be thoroughly
scaled to remove source of irritation. A recurrence rate of
16% is seen after surgical excision.
Radicular cyst (RC) is the most common odontogenic
cyst which arises from the epithelial cell rests of Malassez
in response to inflammation. These cysts can occur in the
periapical area of any teeth, at any age but are seldom seen
in association with primary teeth. They are most commonly
found at the apices of the involved teeth, but sometimes
may be seen at the lateral aspects of the roots in relation
to lateral accessory root canals.
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 Patil S, Khandelwal S, Doni B, Rahman F
Clinically the cyst appears as a well defined swelling
with consistency ranging from hard to soft (Figure 3). RC
is usually located in the anterior part of the upper jaw
7
where traumatic injuries are common. The cyst is usually
Figure 4: Anterior palatine swelling
painless and may become painful when secondarily infected.
Radiographically most of these cysts presents as a pear-
shaped or round unilocular radiolucent lesions in the
periapical region of the involved tooth. Occasionally these
cysts may displace and cause mild resorption of the roots
of adjacent teeth. Radiographically, it is difficult to
distinguish between a granuloma and a cyst. Aspiration of
the swelling helps in differentiating between a cystic and
solid lesion.
Radicular cyst should be differentiated from other
similar palatal swellings by locating associated discolored
and nonvital tooth. The treatment involves extraction of
the affected tooth or root canal treatment if the tooth can
8
be preserved.
Nasopalatine cyst (NPC) or Nasopalatine canal cyst or
Median anterior maxillary cyst occurs in 1% of population,
th th
usually seen from 4 to 6 decades with 3:1, male to female
9
ratio and shows predilection for Caucasian individuals.
It was believed to arise from remnants of nasopalatine
duct, an embryologic structure connecting the oral and
nasal cavities in the area of incisive canal.
The common location of nasopalatine cyst is the midline
of anterior maxilla near the incisive foramen (Figure 4).
The cyst is often asymptomatic unless they are infected.
Sometimes minor tolerable symptoms such as swelling,
burning sensation, numbness over palatal mucosa and
discharge may be present. A combination of swelling,
discharge and pain may be seen. Discharge may be mucoid,
in which case the patients feel a salty taste, or it may be
JPDA Vol. 22 No. 02 Apr-June 2013 136
A Review of 9 Palatal Swellings
Figure 5: Dome shaped swelling on the hard palate
purulent during which the patients may complain of a foul
taste. Cysts which occur near the surface will be fluctuant
and blue and the deeper cysts are covered with normal
overlying mucosa which may be ulcerated due to trauma.
Larger cysts penetrate labial plate to produce swelling
below maxillary labial frenum unilaterally. Displacement
of teeth is seen very rarely. Occasionally the cyst may also
bulge in nasal cavity and distort the nasal septum. This
10
cyst is usually treated with surgical enucleation.
Pleomorphic adenoma (PA) is a common benign salivary
gland neoplasm regardless of site. It is characterised by
neoplastic proliferation of parenchymatous glandular cells
along with myoepithelial components, having a malignant
potentiality. This tumor presents as a slow growing, firm
painless mass, with a slight female predilection (Figure
5). Its most common intraoral site is posteriolateral part
of the palate followed by lip, buccal mucosa, floor of the
11
mouth, tongue tonsil, pharynx and retromolar area. MRI
is an essential tool for the imaging of soft palate tumors
as it aids in determining the extent and nature of the lesion,
local spread and also the neoplastic status. The tumors
involving the soft palate and the adjoining areas especially
the parapharyngeal spaces are also known to arise as an
extension from the deep lobe of the parotid gland. Such
tumors have to be distinguished from those arising de
novo. This can be differentiated by a distinct fine lucent
line representing the compressed layer of fibro adipose
tissue between the tumor and the deep lobe of parotid
when seen on a MRI scan. Histopathologically, a mixture
of neoplastic glandular epithelium and myoepithelial cells
are seen in this tumor. Along with this a variety of patterns
may also be seen. Excision of the tumor and the adjacent
tissue is the treatment of choice. In the hard palate there
may be fusion of the capsule with the periosteum, so
 Patil S, Khandelwal S, Doni B, Rahman F
Figure 6: Palatal mass with finger like projections
subperiosteal dissection along with excision may be
12
considered.
PA should be differentiated from palatal abscess by
absence of pain and failure to locate an infectious source.
Malignant minor salivary gland tumors may sometimes
mimic pleomorphic adenoma but they are associated with
pain and ulceration of the overlying mucosa.
Papillomas are benign tumors that are composed of
benign epithelium and a small amount of supporting
connective tissue. The etiology of papillomas still remains
unclear. Viral origin has always been suspected but studies
did not arrive at a conclusion. In a small number of cases
antigens of the human papilloma virus (HPV) have been
noted. It is not clear till date that all intraoral squamous
papillomas are etiologically related to cutaneous verruca
vulgaris. Intraoral papillomas appear as an asymptomatic,
well-circumscribed, pedunculated or sessile growths with
numerous, small finger-like projections (Figure 6). They
are generally less than 1 cm in diameter, average size is
usually 3 to 4 mm and are most often solitary. No sexual
predilection is noted. Papillomas may be found anywhere
in the oral cavity, but they have a predilection for the hard
13
and soft palate, the uvula, lips and the tongue.
Generally, the clinical appearance of oral papillomas
is hardly distinguishable from that of common warts
(verrucae vulgaris). For an accurate differential diagnosis,
it is necessary that any HPV that is normally found in skin
lesions also be identified in the intraoral lesion. The
papilloma viruses present in skin lesions that have been
14
associated to intraoral common warts are HPV-2 and 57.
A logical association for clinical diagnosis would be to
establish a connection between the presence of common
warts in the child’s hands and fingers, habits such as
thumbor finger-sucking and onychophagia, and the oral
137
A Review of 9 Palatal Swellings
15
papilloma lesion. The histological examination of these
lesions reveals the proliferation of the spinous layer cells,
following a digitiform pattern with a delicate core of
fibrous connective tissue constituting the supporting stroma.
Variable degrees of inflammatory reaction can be observed
in this stroma, depending on the existence of epithelial
Figure 7: Solitary swelling on the palate
ulcerations. The treatment of choice is surgical excision,
which should include the base of the mucosa into which
the pedicle or stalk inserts. The specimen should be sent
for histopathologic examination to confirm the clinical
diagnosis of papilloma and to assure that the surgical
intervention and treatment management of the pathology
were adequately performed. With proper excision,
papillomas rarely recur, except in cases involving the
13
larynx.
Fibroma also referred to as irritation fibroma, is by far
the most common of the oral fibrous tumorlike growths.
While the terminology implies a benign neoplasm, most
if not all fibromas represent reactive focal fibrous
hyperplasia due to trauma or local irritation. Although the
term focal fibrous hyperplasia more accurately describes
the clinical appearance and pathogenesis of this entity, it
is not commonly used.
A fibroma may occur at any oral site, but it is seen
most often on the buccal mucosa along the plane of
occlusion of the maxillary and mandibular teeth as depicted
below. It is a round to ovoid, asymptomatic, smooth-
surfaced, and firm sessile or pedunculated mass
(Figure 7). The diameter may vary from 1 mm to 2 cm.
The surface may be hyperkeratotic or ulcerated, owing to
repeated trauma.
Fibromas are most often observed in adults, but they
may occur in individuals of any age and either sex.
Histologically, a fibroma is an unencapsulated, solid,
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 Patil S, Khandelwal S, Doni B, Rahman F
Figure 8: Palatal swelling with surface ulceration
nodular mass of dense and sometimes hyalinized fibrous
connective tissue that is often arranged in haphazard
fascicles. A mild chronic inflammatory infiltrate may be
present. The surface epithelium may be hyperkeratotic,
either hyperplastic or atrophic, and it may be ulcerated.
The clinical differential diagnosis of a fibroma includes
giant cell fibroma, neurofibroma, peripheral giant cell
granuloma, mucocele, and benign and malignant salivary
gland tumors. Conservative excisional biopsy is curative,
and its findings are diagnostic. Recurrence is possible,
16,17
however, if the offending irritant persists.
Adenoid cystic carcinoma (ACC) or Cylindroma first
described by Theodore Bilroth in 1856, is the commonest
minor salivary gland tumor and accounts for 10% of all
18
salivary gland tumors. This tumor is seen in patients
19
beyond 50 years of age with male prediliction. It appears
as slow progressing, slightly painful, indurated swelling
lateral to the midline. The overlying mucosa may show
telangectasias or ulceration (Figure 8). Progression of this
tumor is usually slow and metastasis is seen in late stages
leading to poor prognosis. Microscopic features show lack
of encapsulation and invasion into adjacent hard and soft
tissues. Tumor cells characteristically invade perineural
lymphatics, the classic pattern show hyperchromatic,
monomorphic cuboidal cells arranged in islands forming
multicystic cribriform patterns resembling Swiss cheese.
Cylindroma may resemble other benign and malignant
salivary gland tumors, sarcomas or carcinoma of maxillary
sinus with palatal invasion. Its classical presenting features
20
help to differentiate it from the above said conditions.
Clinical differential diagnosis included a benign or a
low grade malignant neoplasm of minor salivary glands,
reactive/inflammatory condition of minor salivary glands,
a malignant growth of the maxillary sinus, benign
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A Review of 9 Palatal Swellings
Figure 9: Palatal mass with irregular surface
mesenchymal neoplasm and much less likely a slow-
growing malignant mesenchymal neoplasm.
Squamous cell carcinoma (SCC) is seen commonly
in older men and it is the most common malignant tumor
of the oral cavity representing about 90% of all oral
21
malignancies. SCC is an important cause of morbidity
and mortality worldwide with an incidence rate that varies
widely. The etiology appears to be multifactorial and
strongly related to lifestyle, mostly habits and diet
(particularly tobacco alone or in betel, and alcohol use),
although other factors, such as infective agents, also are
implicated. Immune defects, defects of carcinogen
metabolism, or defects in DNA-repair enzymes underlie
some cases. Clinically, SCC appears as painless, slow
growing swelling; as the lesion enlarges it may become
an exophytic mass with a fungating or papillary surface
(Figure 9). Carcinoma of the maxillary alveolar ridge may
extend to involve palate and it may mimic a pyogenic
granuloma when located adjacent to a tooth. The diagnosis
will be confirmed after histopathologic examination, which
will reveal dysplastic features and invasion. Depending
upon the size and location of the tumor it is treated by
22
surgical excision or radiation therapy.
CONCLUSION
It is well understood that the palatal mass can pose a
difficult diagnostic dilemma for the clinician. The swelling
may present with the common characteristics and may be
indistinguishable clinically. Emphasis is placed on the
importance of obtaining a thorough and comprehensive
history and collecting relevant laboratory information.
Finally, a biopsy of the palatal mass may be necessary to
arrive at definitive diagnosis and determine the optimal
management of the patient.
138
 Patil S, Khandelwal S, Doni B, Rahman F
REFERENCES
1. Scully C, Porter S. Orofacial Disease: Update for the
Dental Clinical Team: 7. Complaints Affecting
Particularly the Palate or Gingivae. Dent Update
1999;26:308-313.
2. Sumer AP, Celenk P. Palatal abscess in a pediatric
patient: report of a case. Eur J Dent 2008;2:291-293.
3. Maestre Vera JR. Treatment options in odontogenic
infection. Med Oral Patol Oral C r Bucal 2004;9:19-
31.
4. Leyden JJ, Master GH. Oral cavity pyogenic granuloma.
Arch Dermatol 1973;108:226-228.
5. Jafarzadeh H, Sanatkhani M, Mohtasham N. Oral
pyogenic granuloma: a review. J Oral Sci 2006;48:167-
175.
6. Saravana GH. Oral pyogenic granuloma: a review of
137 cases. Br J Oral Maxillofac Surg 2009;47:318-319.
7. Nair PN. New perspectives on radicular cysts: do they
heal? Int Endod J 1998;31:155-160.
8. Valois CRA, Costa-Junior ED. Periapical cyst repair
after nonsurgical endodontic therapy- case report. Braz
Dent J 2005;16:254-258.
9. Cicciu M, Grossi GB, Borgonovo A, Santoro G, Pallotti
F, Maiorana C. Rare bilateral nasopalatine duct cysts:
a case report. Open Dent J 2010;4:8-12.
10.Hegde RJ, Shetty R. Nasopalatine duct cyst. J Indian
Soc Pedod Prev Dent 2006;24:31-32.
11.Dhanuthai K, Sappayatosok K, Kongin K. Pleomorphic
adenoma of the palate in a child: A case report. Med
Oral Patol Oral Cir Bucal 2009;14:E73-75.
12.Kaminski M, Janicki K: A case of giant pleomorphic
139
A Review of 9 Palatal Swellings
adenoma of the cheek with two malignant centers.
Otolaryngol Pol 2002;56:385-387.
13.Abbey LM, Page DG, Sawyer DR. The clinical and
histopathological features of a series of 464 oral
squamous cell papillomas. Oral Surg Oral Med Oral
Pathol 1980;49:419-428.
14.Syrjanen S, Puranen M. Human papillomavirus
infections in children: the potential role of maternal
transmission. Critical Rev Oral Biol Med 2000;11:259-
274.
15.Yoshpe NS. Oral and laryngeal papilloma: a pediatric
manifestation of sexually transmitted disease? Int J
Pediatric Otorhinolaryngol 1995;31:77-83.
16.Barker DS, Lucas RB. Localised fibrous overgrowths
of the oral mucosa. Br J Oral Surg 1967;5:86-92.
17.Esmeili T, Lozada-Nur F, Epstein J. Common benign
oral soft tissue masses. Dent Clin North Am
2005;49:223-240.
18.Dutta NN, Baruah R, Das L. Adenoid cystic carcinoma-
clinical presentation and cytological diagnosis. Indian
J Otolaryngol Head Neck Surg 2002;54:62-64.
19.Weinberg MA, Estefan DJ. Assessing oral malignancies.
Am Fam Physician 2002; 65:1379-1384.
20.Giannini PJ, Shetty KV, Horan SL, Reid WD, Litchmore
LL. Adenoid cystic carcinoma of the buccal vestibule:
A case report and review of the literature. Oral Oncol
2006;42:1029-1032.
21.Lawoyin JO, Lawoyin DO, Aderinokun G. Intra-oral
squamous cell carcinoma in Ibadan: a review of 90
cases. Afr J Med Sci 1997;26:187-188.
22.Neville BW, Day TA. Oral cancer and Precancerous
Lesions. CA Cancer J Clin 2002;52:195.
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