Hard bony bumps under the gums (tori)

"Torus" is Latin for "bull", and these bumps probably get their name from their bulbous shape and the fact that they are made of strong, hard bone.  

Torus palatinus--These are simply hard, bony growths covered by firm, pink gum tissue on the hard palate.  They are solidly bound down to the underlying bone and cannot be moved around with finger pressure.  These start out as small hard bumps in the center of the palate in younger persons, but they tend to enlarge as the patient gets older. They develop very slowly and do not appear suddenly over the course of a few weeks or months.  They are considered normal anatomy unless they become too large or they interfere with the construction of an upper denture, in which case they are removed by an oral surgeon.  Sometimes, patients will have a large torus for years, but not realize that it was there all along until, one day, quite suddenly, they notice it for the first time.  At that point, they think they have developed oral cancer, but find, after considerable worry that it is really just their normal anatomy.

Torus Mandibularis--These are the same type of growths as the Torus Palatinus except that they grow on the inside of the lower jaw.  Again, they can grow quite large, or they may remain as small bumps.  They are also bound to the underlying bone and cannot be moved around with finger pressure.  These are also quite often mistaken by patients for oral cancer.  Very large mandibular torii can become a nuisance since they are covered with easily abraded soft tissue and can become quite sore when eating hard or irritating foods. In situations like this, it is advisable to visit an oral surgeon and have them removed.  The operation is not especially difficult, and aside from transient post operative discomfort, the effects are immediate and quite positive.

Exostoses

Exostoses are simply hard bumps that occur on the bone on the outside of the top or bottom teeth.  Like tori, they are solidly bound down to the underlying bone and are not movable.  They can be quite tiny, feeling like a large, immovable grain of sand under the gums, or they can be quite large as in the image to the right.  In general, they are considered normal anatomy and are left alone unless they interfere with the construction of a denture, in which case they are removed by an oral surgeon.

Tongue abnormalities

Burning mouth syndrome (BMS) (also known as burning tongue syndrome)

A small percentage of older men and women (mostly women), generally at, or around the age of menopause develop a problem with chronic burning pain and phantom tastes in their mouths.  It can occur on the palate, but most often centers on the tongue. The tongue itself looks perfectly normal.  It just develops a burning sensation that progresses throughout the day, disappears overnight, and reappears the next day after eating.  These patients may have seen numerous doctors to try to rid themselves of the annoying, and sometimes painful symptoms, but generally to no avail.  The problem has been ignored for centuries because there seemed to be no physical reason for the symptoms, and because it was believed that it was a hysterical symptom brought on by emotional distress.  In fact, the problem sometimes does respond to antidepressant drugs like Elavil.

A theory to explain some cases of BMS

Recent research (Google  Dr. Linda Bartoshuk)  has revealed a hypothesis (not proven) which might explain BMS (Burning Mouth Syndrome).  It involves actual damage to the seventh cranial nerve which supplies the taste buds in the anterior 2/3 of the tongue. This may be caused by the change in hormonal balance due to menopause and/or a viral infection.  The theory is that these persons have lost much of their ability to taste, even though many do not realize their loss since the brain is good at amplifying small signals.  This loss of the function in a branch of the 7th nerve (the corda tympani) leaves the trigeminal nerve in a position of dominance.   (The trigeminal is the nerve responsible for transmitting the sensations of touch and pain from the face and mouth to the brain.)  This theory assumes a sort of balance between the two nerves, and if a patient suffers a loss of ability to taste because of damage to the 7th cranial nerve, then the brain compensates for the loss of taste by amplifying the signals from both the corda tympani and the trigeminal nerve in the tongue and palate.  The increase in sensitivity in the trigeminal causes phantom pain in the structures of the mouth, sort of like turning up the volume on a weak radio station also increases the background hiss.  In addition, as a result of the exaggeration of the taste impulses from the 7th cranial nerve, the brain begins to generate phantom taste sensations.  This sort of taste hallucination is similar to the tactile "fat lip" sensation that a patient feels when the conduction of the trigeminal nerve is blocked by a shot of a local anesthetic to numb the lower teeth.  It's not really a fat lip, but the brain interprets it that way.  Same thing with phantom taste sensations.

Ways to treat BMS

Sometimes people develop this problem due to a hypersensitivity to some toothpaste or oral rinse that they have recently begun using. The first line of defense is to change your toothpaste to a type with only fluoride (Tom's of Maine is a reasonable choice) and cut out mouth rinses.  The type of toothpaste most often involved with this type of hypersensitivity are those containing pyrophosphates which are added to reduce the buildup of calculus (like Crest Complete or Colgate Total) Also try to determine if you have recently been taking a new medication who's introduction coincided with the onset of the symptoms.  A simple change of medication could make the difference. 

It was discovered, quite by accident, that patients suffering from epilepsy who also suffered BMS experienced relief from the symptoms of both of these ailments by the administration of the epilepsy drugs clonazepam (Klonopin) and gabapentin (Neurontin). Thus a small, once or twice a day oral dose of of one of these drugs has been found to relieve the symptoms of BMS in most patients.  Alternatively, clonazepam may be dissolved in the mouth using 1/2 of a .5 mgm tablet twice a day.  Another drug which has been found to be useful in treating BMS is Chlordiazepoxide (Librium) not to exceed 10 mgm three times per day. 

Another treatment that may work (or at least reduce the symptoms) in about 1/2 of sufferers is capsaicin desensitization.  Capsaicin is the ingredient in hot peppers that makes them hot.  The regimen is dilution of one part Tabasco sauce in two or three parts water with the patient rinsing and expectorating (spitting out).  This is done every 2-3 hours at first, and tapering off over a day or two to once or twice a day.  Be careful.  Some people are hypersensitive to capsaicin, so if the burning is too severe, stop immediately!

Bald tongue (Atrophic glossitis)

As people begin to reach their senior years, sometimes they notice that their tongue begins to burn when eating sharp tasting foods.  A look in the mirror reveals a beefy red tongue lacking the filiform papillae which, in health, give the top (dorsal) surface of the tongue a normal, light pink, velvet appearance.   The loss of the filiform papillae is known as atrophic glossitis, and it may be caused by several different factors.

The first factor is nutrition.  Atrophic glossitis is most often caused by a lack of B vitamins in the diet.  The addition of daily doses of folic acid, niacin, vitamin B12, pyroxidine, riboflavin, and even Iron, all in the form of a simple daily multiple vitamin tablet may help to restore the tongue and relieve the burning on eating. 

The second factor is an oral yeast infection known as thrush, also known as candadiasis.  In older patients with weak immune function, the mouth acts as a good incubator for yeast cells.  These accumulate under a denture and often cover the tongue leaving a white coating that is easily scraped off revealing red tissue underneath.  This is easily treated with Mycelex troches, or a single Diflucan tablet.  Both of these are anti-fungal medications.  

The third factor is mechanical abrasion of the tongue against a rough dental appliance, or occasionally on the teeth themselves, producing a more localized, persistent area of smooth surface on the tongue.  This is treated by building a new denture and repairing or removing rough, broken teeth.  Sometimes it is as easy as scraping hardened dental calculus off the insides of the lower front teeth.

 

Lingual Tonsil--These are covered in depth above, but they are often mistaken for cancerous growths simply because people rarely look at this area of the tongue.  When they do, they see this normal bit of anatomy and assume that it is some sort of pathological growth.  It's not.  Here's a tip.  Whenever you see something you think may be an abnormality in your mouth, look for another one on the opposite side of the mouth.  If you see a "matched set", they are probably "normal anatomy".

Black or white hairy tongue--This condition is covered on the oral anatomy page.  It is NOT a sign of incurable disease.  It usually occurs during ordinary febrile illnesses and the "hair" can be scraped off easily with a tongue scraper.  The hairy coating is a breeding ground for various bacteria and yeasts, and sometimes responds well to topical fungicides such as Nystatin.  This condition is not contagious.  Click on the image to see other cases of white and black hairy tongue.

Geographic tongue--This condition is characterized by the disappearance of the filiform papillae from irregular patches on the top surface of the tongue.  Then, the patches "heal" up and reoccur on another part of the tongue at a later date.  This process keeps going on and on over time, and one can see lesions in varying stages of healing over large expanses of the tongue.  No one knows why some people get this condition.  It is thought to be an oral form of psoriasis (a common skin condition).  Patients who live with this problem frequently complain of pain on eating sharp foods.  Serious outbreaks can be treated with topical application of steroid gels.  Otherwise it is not treated.  It is not a contagious condition. Recently, it has been noted that this condition is seen more frequently in AIDS patients, however the presence of geographic tongue certainly does NOT mean that the patient has AIDS.  Click on the image to see more cases.

Macroglossia (large tongue) The tongue normally resides on the inside of the arch formed by the lower teeth.  Most people's tongues fit neatly into this space, however, a minority of people have tongues which are a bit larger than the space available.  This does not mean that the patient cannot actually fit their tongue into this space.  The tongue is a very flexible organ, and can accommodate itself to the prevailing conditions easily.  On the other hand, once fitted into the space, it relaxes and presses up against the teeth.  This causes the tongue to fill up the space available.   Tongues like this have scalloped edges like the one pictured to the right.  The scallops reflect the shape of the teeth as well as the spaces between them.  This condition is often associated with burning around the edges of the tongue.  Click the image to see why, and for larger images.

Fissured Tongue (Scrotal tongue) Fissured tongue, also known as scrotal tongue is characterized by folds and fissures in the dorsal (top) surface of the tongue.  The fissures are of variable depth and usually extend laterally from a median groove as is pictured in the thumbnail. This condition does not cause any symptoms, unless food particles and debris lodge in the depths of the fissures causing a mild glossitis (inflammation of the tongue).  It is considered to be a normal form of tongue anatomy.

Enlarged Circumvallate Papillae--Circumvallate papillae, described above are part of the normal anatomy of the tongue.  Generally, these structures are flat and innocuous, however occasionally, a patient presents with enlarged papillae.  They are considered normal.  The whiteness on the rest of the tongue in this image is the appearance of the filiform papillae in the glare of a flash camera.

Median Rhomboid Glossitis--This is a common condition, considered to be normal anatomy.  It consists of a discrete, red, "bald" area on the back of the tongue in the center.  It was once thought to be a remnant of embryonic development, however it seems to respond to Nystatin and other anti fungal medications which infers that it is actually a chronic fungal infection.  It can be quite large covering a full 1/3 to 1/2 of the surface of the tongue.  It is rarely treated, and is not contagious.

Ankyloglossia (tongue tied)--When the tongue is anchored to the floor of the mouth by a very short lingual frenum (the chord that runs from the underside of the tongue to the floor of the mouth), it tends to limit the mobility of the tongue.  This limits the ability of the patient to "stick out" the tongue and negatively effects speech.  This condition is called ankyloglossia (literally "tied tongue").  The abnormality is easily corrected by an oral surgeon.  The procedure is called a lingual frenectomy.  A horizontal incision is made through the lingual frenum and the tongue is lifted up causing the horizontal incision to widen out into a vertical slit.  This vertical slit is then sutured (sewn) releasing the tongue.  Click on the image to view the complete operation.  Visit the site of Dr. Bechara Y. Ghorayeb, MD who leant this image to me.

Abnormalities of the gums

Gingivitis--Normally the gums are a fairly uniform shade of pink.  If plaque is left around the necks of the teeth for a long time, however, the margins of the gums react by becoming red, swollen, and sometimes misshapen as seen in the image to the right.   Although this looks terrible, the condition generally goes away with the removal of the plaque through good, once a day oral hygiene. This condition is covered quite well on my page on periodontal disease.

Periodontitis--If oral hygiene remains very poor for long periods of time after the age of 25, the damage to the gums goes beyond a simple inflammation of the margin of the gums.  The condition can become quite severe and cause an erosion of the bone that supports the teeth, allowing the teeth to become loose and painful to touch.  The ultimate result of this can cause the loss of the teeth.  This condition is covered on my page on periodontal disease.

Trench Mouth (Acute Necrotizing Ulcerative Gingivitis--ANUG)--During World War I, soldiers had little opportunity to brush their teeth and they were under tremendous psychological and physical stress.  This combination, stress and poor oral hygiene can lead to a very severe form of gingivitis in which the margins of the gums actually begin to rot (necrotize).  This condition happens even today whenever a person fails to brush his/her teeth and lives under stressful conditions (or has any medical condition which lowers the functioning of his or her immune system).  The gums become quite sore to touch and the breath takes on a characteristic fetid (bad) odor.  In spite of the alarming appearance, this condition is quite easy to treat using light debridement (cleaning) and hydrogen peroxide, and with good oral hygiene will not return.

Pericoronitis--This condition is covered on the extraction page.  It is simply an infection around an unerupted tooth.  In this case, it has occurred around a wisdom tooth.  Like all infections, it responds to debridement (cleaning) and antibiotics, although it will reoccur several times a year until the impacted tooth is extracted.

Parulus--Better known as a "gum boil", this sore happens on the gums at the tip of the root of a tooth in which the nerve has died.  The nerve in the tooth dies because of deep decay, as in this thumbnail, or because of some other traumatic event that disturbs the blood flow to the nerve.  The parulus  is the result of the pressure of an abscess in the bone due to the toxic nature of dead nerve tissue.  It is an attempt by the body to allow drainage of pus.  The treatment for this condition is either extraction or a root canal for the offending tooth.

Pyogenic granuloma (Pregnancy tumor)--The pyogenic granuloma is a relatively common overgrowth of red granulation tissue that happens in response to chronic irritation.  Granulation tissue is the body's initial response to healing any injury, and consists of raised, soft, red tissue that bleeds easily.  In the case pictured here, it appeared as a response to chronic irritation from the accumulation of plaque under an orthodontic wire.  It can occur at any age, but is most common in teenagers and young adults.  It is frequently seen in pregnant women where it is triggered by hormonal imbalance due to pregnancy.  Click on the image to enlarge.

Abnormalities of the lips and the inside of the cheeks

Aphthous ulcer--Better known as Canker sores, these lesions are very painful (unlike most oral cancers).  The pain can be quite severe involving wide areas of the mouth or head. (See discussion of referred pain.)   Aphthous ulcers occur generally on the soft unattached gingiva, in the vestibule or on the cheek mucosa, on the floor of the mouth, or on the under-surface or lateral borders of the tongue.  Upon rare occasion, they occur on the soft palate (see image on the left, and click it for a larger view).  They are characterized by a white center surrounded by a thin red, inflamed border.  No one knows exactly why some people seem prone to these sores, or why they occur at all.  They are NOT due to a dietary deficiency!  They are related to stress and possibly food sensitivities.  They generally disappear spontaneously within 10-14 days.  They may be  treated for quicker resolution in either of two ways: Topical applications of steroids such as "Lidex gel" ® or "Kenalog and Orabase" ® (Note: Lidex is approximately ten times stronger than Kenalog, but Kenalog has the advantage of the Orabase which acts as a Band-Aid and keeps it in place longer).  These drugs are applied after meals and before bedtime, and both are prescription drugs.  They generally reduce or eliminate pain immediately and bring about resolution of the canker in two to three days. Cautery using either chemical or laser treatment.  Chemical cautery agents  include silver nitrate (generally on a wooden stick) or commercial agents such as Debacterol®, both of which are applied by a dentist or physician and offer immediate pain relief.  Over-the-counter agents such as Zilactin®, Ora5® and Gly-Oxide® are mild cautery agents that work more slowly. Laser treatment is quick and painless and also offers immediate pain relief. Canker sores are not contagious.  For more on aphthous, click on one of the images above.   Stenson's Duct-- The opening of the duct of the parotid saliva gland is called Stenson's Duct.  Everyone has two of them.  They are located on the inside of each cheek beside the upper molars (back teeth).  They can be felt with the tip of the tongue as small "flaps" of cheek mucosa ("skin") running from the back to the front of the mouth, about a half inch long and about even with the chewing surfaces of the top back teeth.  Unless they become infected they are difficult to see, so I have provided two images.  They tend to have a bluish tint which is sometimes more easily seen than the actual tissue flap.  One, or upon rare occasion, both of these can become infected, in which case they may manifest as  swollen, red and sore bumps in the same location.  This is most likely to happen when saliva flow is reduced from its normal levels, often due to prolonged usage of decongestants and antihistamines or other drugs which cause dry mouth.  Infection of Stenson's duct is another example of a retrograde infection in which normal oral bacterial flora ascends up the duct because too little saliva is descending from the parotid glands into the mouth.  The usual treatment is a course of antibiotics (generally penicillin or Zithromax).

Herpes Labialis-- Better known as "Cold sores", These sores are the result of an infection with a common virus known as Herpes Labialis.  The virus is very contagious, and if one member of a family comes down with this lesion, others in the family may be prone to get it as well.  They most usually occur on the corners of the lips, however they can occur inside the mouth in young children (as a primary, or first infection), or in individuals with compromised immune systems.  This condition is well covered on my page on AIDS, however, the presence of this sore does NOT imply the presence of HIV!   A typical cold sore lasts from 7 to 14 days if left untreated.  It may be treated using acyclovir cream (Zovirax®) or penciclovir cream (Denavir®).  Herpes simplex is a very contagious virus.  If one person in a family gets a cold sore, then others in the family may get one also.

Angular Cheilitis--This lesion presents as dry, scaly, red skin at the corners of the lips.  It frequently occurs in cold, dry weather.  People who produce a lot of saliva or tend to have moist corners of the lips due to poorly fitting dentures are especially prone to this problem.  It is also frequent in persons who have reduced immune function.  It is caused by a persistent yeast infection, and is easily treated with daily applications of an antibiotic specific for yeast like nystatin cream, or a cream that contains both a yeast specific antibiotic and a steroid, such as Mycolog II®,.  This condition is also covered on my page on AIDS, but the presence of these lesions does NOT imply the presence of HIV.  Angular cheilitis is not contagious.

Mucocele--A mucocele (pronounced "muco-seel") is a mucous filled sac that forms, generally on the soft, pink mucosa on the inside of the lips or cheeks as the result of a traumatic incident that causes the patient to lacerate the tissue.  If you gently bite the inside of your lower lip, you will notice that the tissue, held between the teeth, is sort of bumpy.  Each of those little bumps represents a mucous or saliva gland, and each of these glands has a tiny duct that empties the mucous produced by that gland inside the mouth on the surface of the mucosa.  If, due to a traumatic incident one or more of these ducts are severed, the mucous produced by the gland may not be able to reach the surface of the mucosa and it may produce a bluish blister filled with mucous.  The blister breaks every so often, heals up and then refills with mucous, only to burst again later.  These lesions are generally removed by an oral surgeon.  They are not dangerous.

Fordyce Granules--These are tiny yellowish flecks that appear on the inside of the cheek mucosa and on the lips.  They are actually misplaced sebaceous glands. Sebaceous glands normally occur in the skin outside of the mouth, and their function is to keep the skin moist and lubricated.  Since the mouth is always moist anyway, they have no real function there, but their presence is considered normal.

Lichen Planus--Lichen Planus is actually a dermatological autoimmune disease that is often first diagnosed by a dentist due to its characteristic appearance in the mouth. In the mouth it appears as a series of filamentous, white, lacey lines on the inside of the cheeks or on nearly any other oral tissue.   Lesions can occur on other parts of the body as well, most notably on the skin of the anticubital space (inside of the elbows).  Most of these lesions are painless, but sometimes they occur on attached tissue such as the palate where they can be quite painful.  They can also cause quite a bit of burning in the mouth when eating sharp foods.  The image on the right is a fairly common presentation, and an obvious diagnosis.  the image on the left shows a more subtle presentation under the tongue.  Click on either image to see it full size.  This condition is thought to be an autoimmune condition associated with exposure to drugs to which the patient may be sensitive.   It is especially associated with certain antihypertensive drugs, NSAIDs, tetracycline and several sulfonamides, as well as a number of "recreational" drugs.  The condition often improves with the cessation of the offending drug.  The condition is more of a nuisance than a disability.  The oral symptoms are often treated with steroid mouth rinses.  If the symptoms are not severe, it is not treated at all.  Lichen planus is not a contagious condition. Chronic lichen planus has been known to (very rarely) morph into squamous cell oral cancer.

Fibroma--Fibromas are overgrowths of connective tissue.  In the oral cavity they occur as firm, well defined "lumps" of uniformly pink tissue.  They are generally not bound down to any underlying tissue, so their movement is limited only by the overlying tissue.  They generally grow to a particular size (most commonly a centimeter across or less) and then stop growing.  They can remain unchanged for many, many years.  They are either ignored or removed by an oral surgeon.  They are totally harmless unless they interfere with normal functioning.   They are not contagious.

Nicotinic Stomatitis

Nicotinic Stomatitis is a condition characterized by inflammation of the soft palate due to the irritation of excessive amounts of cigarette smoke.  It appears as red, raised bumps on the soft palate.  In and of itself, this is not a dangerous condition, and it resolves when the smoking habit stops.  However, it is often associated with the condition called leukoplakia, described above.  Leukoplakia is considered a pre cancerous lesion which can transform into squamous cell carcinoma.  Nicotinic stomatitis is caused almost exclusively by pipe smoking and is not contagious.  It should be noted, however, that the development of this condition is an indication that the patient may be prone to the development of smoking related cancers.  Click on the image for much more on nicotinic stomatitis.

  Amalgam Tattoo

An Amalgam Tattoo is exactly what the name implies.  Most cavities in back teeth are filled with silver amalgam.  Silver Amalgam is NOT poisonous, or in any way harmful to the human body, but when a small amount of it is introduced into an open wound in the mouth, it remains under the mucosa and causes a characteristic blue-gray tattoo.  This occurs most frequently when a tooth is extracted and some of the amalgam that was part of the filling in the original tooth breaks off and falls into the open socket.  It also happens frequently during the removal of old amalgam fillings if the dentist accidentally nicks the gums introducing some of the amalgam "flash" into the wound.  This is a totally harmless condition.  However the characteristic appearance of an amalgam tattoo can look a lot like a very dangerous cancer called "melanoma".  Melanoma is characterized by painless lesions that appear tan to dark brown to black in appearance with diffuse edges while amalgam tattoos appear blue-gray and have more well defined edges.  Melanoma is a very rare cancer in the oral cavity, and if you see a lesion like this in your mouth, it is MUCH more likely to be an amalgam tattoo that you never noticed before than a melanoma.   Amalgam tattoos appear suddenly after a dental procedure and remain the same size throughout life.  Melanoma tends to grow and change shape within a matter of a week or two.

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