Patient Presentation
A 2-year-old female came to clinic for her well child care. Her parents had no concerns except they had noted a "bump" in the middle of the roof of her mouth. They were not sure how long it had been there for, but had noticed it about 2 weeks previously when they were brushing her teeth. It hadn't changed over time and didn't seem to bother her.
The past medical history was non-contributory. She had seen a dentist twice in her life whom the parents said had no concerns.
The pertinent physical exam noted a happy toddler with normal vital signs and growth around 50%. Her oral examination was difficult to perform because she would refuse to open her mouth adequately. The lesion was estimated to be about 10 mm in size, slightly elevated from the surrounding palatal structures and was midline close to the hard and soft palate interface. The lesion appeared to have normal mucosa covering it. Surrounding erythema or ulcerations could not be determined. The rest of her oral cavity could not be examined. Her neck had some shotty anterior cervical nodes but no significant adenopathy. Her face appeared normal without obvious lesions or masses externally. The rest of her examination was normal.
The diagnosis of a probable benign lesion was made but the pediatrician was not certain because she could not examine the area fully. She recommended to make an appointment with the patient's dentist. The dentist saw her 1 week later and confirmed this was a torus palatinus or a benign exostosis.
Discussion
Exostoses are dense cortical nodular osseous structures that are benign but which can cause problems due to size or location. The tissue grows outward from the bone. Long bone locations are common.
Bone spurs are a common exostosis that is specifically an osteophyte as it occurs along a joint margin. Enthesophytes are benign bony projections from the tendon or ligament insertion. Some exostoses have specific names such as Surfer's ear (occurring in the ear canal) or Haglund's deformity (or pump bump) that occurs on the back of the heel. People with hereditary multiple exostoses have multiple exostoses that often occur around the knee. It occurs in 1:50,000 people.
Learning Point
Oral exostoses are named for their location. Torus palatinus is located midline on the hard palate. Torus maxillaris which is usually located bilaterally along the buccal and palatal bony shelves in posterior molar areas. Torus mandibularis which are located bilaterally along the mandibular lingual cortical plate. Palatal and maxillary locations are more common. As they are bony and have normal oral mucosa overlying them they may appear yellow or whitish. They usually do not require treatment unless they cause functional problems (e.g. has a crevice that food becomes trapped in and could have risk for aspiration of the food) or needing orthodontic or prosthodontic treatment and the prosthesis would rub on the tori if not recontoured.
Oral exostoses are an anatomical variation. The prevalence varies in different populations significantly with torus palatinus occurring in 1.4% - 66% with high rates (most quote 20-30% overall) in Asians, and Eskimos people. It is thought that the condition's cause is multifactorial with increased risk also because of trauma, hypermasticatory activities and possible Vitamin D or other diet related factors. The differential diagnoses includes other oral growths including "...fibromas, mucoceles, osteomas, osteochrondromas, and osteoid osteomas." They do not appear to have increased risk of malignant transformation but can grow with age.
Questions for Further Discussion
1. What common lesions occur in newborn infants' oral cavities?
2. What are the guidelines for initiation of routine dental care in infants and young children?
3. What treatment can be offered for people with exostoses in non-oral body locations?
Related Cases
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for these topics: Bone Diseases and Child Dental Health.
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
Yildiz E, Deniz M, Ceyhan O. Prevalence of torus palatinus in Turkish schoolchildren. Surg Radiol Anat SRA. 2005;27(5):368-371. doi:10.1007/s00276-005-0003-x
Chatterjee S. Bony bumps in the mouth. Cleve Clin J Med. 2016;83(1):17-18. doi:10.3949/ccjm.83a.15033
Aron J, Raithel SJ, Mannes AJ. Torus Palatinus and Airway Management. Anesthesiology. 2017;127(1):164. doi:10.1097/ALN.0000000000001566
Akintoye SO, Mupparapu M. Clinical Evaluation and Anatomic Variation of the Oral Cavity. Dermatol Clin. 2020;38(4):399-411. doi:10.1016/j.det.2020.05.001
Author
Donna M. D'Alessandro, MD
Professor of Pediatrics, University of Iowa
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