Lumps, Bumps and sores page

Sores, Bumps, Lumps and abnormalities in the mouth that are commonly mistaken for cancer but are NOT

Bald tongue (Atrophic glossitis)

AtrophicGlossitisAs 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. (for a much larger image click here,)

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 candidiasis.  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

LingualTonsilThese are covered in depth on the Oral Anatomy page, 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


Hairy tongue 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.  See my page on Halitosis for detailed instructions on treating this condition.

GeographicThumbGeographic 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)

Macroglossia2The 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_tongueFissured 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

The circumvallate papillae 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)

ankyloglossiaWhen 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, MDwho lent this image to me.

Abnormalities of the gums


gingivitisNormally 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.


periocaseIf 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)

AnugDuring 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.


pericoronitisThis 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.


ParulusToothbrushAbrasionBetter 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 parulis  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)

Pyogenic_granulomaThe 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

StensonsDuctWithAphthous-CopyBetter 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.

aphthousUpon rare occasion, they occur on the soft palate (Click the image 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.

Canker sores are not contagious.  For more on the several forms of aphthous and their treatment, click on one of the images above.

This condition happens in two varieties, each of which has its own treatment protocol:

Minor aphthous is defined as the occasional, small ulcer that most persons experience no more than once or twice a year.  These lesions are generally small (2-4 mm), and the ulcers are treated as isolated entities (one at a time).

Treatment for Minor Aphthous

  • Topical applications of steroids such as “Lidex gel”  or “Kenalog in 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 the steroid 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.  I prefer Kenalog in Orabase in my own practice
  • Aphthasol paste ® is a prescription drug that is applied directly to the ulcer four times a day (the same as Kenalog in Orabase).
  • Cautery using either chemical or laser treatment.  This type of treatment is palliative only, and does not treat the underlying condition.  Cautery is done in the dental office to relieve the pain caused by a specific aphthous ulcer.
    • 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.

Major aphthous , also called Sutton’s disease is defined as a chronic condition in which patients are plagued with multiple aphthous lesions occurring several times a month.  These ulcers are generally quite large, on the order of the size of a dime, and they often heal leaving scar tissue behind.   Major aphthous associated with HIV can cause much larger lesions.  Major aphthous has no known cure, but chronic aphthous lesions may be treated using the following methods:

Treatment for Major Aphthous

  • If you suddenly develop chronic major aphthous lesions, It is wise to check with your physician to see if there is an underlying cause such as an immune problem, or an underlying chronic illness such as Bechet, Chrohn’s or celiac disease.
  • Vitamin B12 has been found to be effective in reducing the frequency and severity of the lesions in patients suffering from major aphthous.  1 mg is dissolved under the tongue every evening.  Some formulations of vitamin B12 are manufactured specifically for this route of administration.
  • Other vitamin and mineral supplements such as iron, folic acidand zinc have been known to reduce the number and frequency of aphthous lesions.
  • Steroid mouth rinse– Betamethasone sodium phosphate (Betnesol mouthwash/Diprolene) one 0.5mg tablet dissolved in 5 to 10 ml of water.  Patients rinse using this solution four times a day (after meals and before bed) whenever lesions are present.  Another method is for the patient to mix about 1/4 inch of Fluocinonide (Lidex) cream or gel in four ounces of water.  This mouth rinse is used the same way that betamethasone is used.  Remember–Never swallow a steroid mouth rinse!  Steroids are powerful drugs and mouth rinses made with them should be used sparingly since they can have systemic effects, even when used topically.
  • Avoid oral products containing sodium lauryl sulfate as studies have implicated this common ingredient as a causative factor in the formation of aphthous.
  • Laser treatment is quick and painless and also offers immediate pain relief.

Sores, Lumps and Bumps Page 3==>>

<<==Sores Lumps and Bumps Page 1