A 22-year-old female visited a general dentist for an initial examination. During the intraoral exam, a dome-shaped red lesion was noted on the ventral tongue.
Joen Iannucci Haring, DDS, MS
History
The patient was aware of the small, dome-shaped lesion on her tongue and stated that it had been present for at least two weeks, perhaps longer. The lesion was described as painless and had no history of bleeding. When questioned about trauma, the patient recalled biting her tongue prior to the appearance of the lesion.
The patient appeared to be in a general, good state of health and denied any history of serious illness. A review of the medical history revealed no significant findings. At the time of the dental appointment, the patient was not taking any medications.
Examinations
The patient`s blood pressure, pulse rate, and temperature were all found to be within normal limits. No enlarged lymph nodes in the head and neck region were detected upon palpation. Oral examination revealed a small, dome-shaped lesion on the ventral tongue (see photo). Palpation of the lesion revealed a well-circumscribed, soft, and fluctuant mass. Further examination of the oral tissues revealed no other lesions present.
Clinical diagnosis
Based on the clinical information presented, which of the following is the most likely clinical diagnosis?
* pleomorphic adenoma
* hemangioma
* mucocele
* granular cell tumor
* lipoma
Diagnosis
mucocele
Discussion
The mucocele (also known as mucous extravasation phenomenon mucous escape reaction) is a common oral lesion that arises secondary to trauma. A traumatic injury results in the severance of a minor salivary gland duct and produces a pooling of mucous into the surrounding connective tissue. The extravasation of mucous into the surrounding connective tissue induces an inflammatory-type reaction. A wall of granulation tissue results and surrounds the pool of mucin; a fibrous barrier is formed and contains the mucous. The adjacent minor salivary gland also undergoes an inflammatory-type reaction secondary to the retention of mucous.
Clinical features
The mucocele is most often seen in children and adolescents; most of these lesions occur in individuals under the age of 21. The mucocele is found wherever minor salivary glands are found. The lower lip/labial mucosa is the most common location, accounting for 75 percent of all cases. A mucocele is usually located lateral to the midline. The upper lip is rarely involved. Other sites of involvement include the buccal mucosa, ventral tongue, floor of the mouth, palate, and retromolar pad area.
The typical mucocele appears as a sessile, dome-shaped mass with a smooth surface. The size of the lesion may range from a few millimeters to a few centimeters in diameter. The color of a mucocele appears bluish if the lesion is located close to the surface. Deeper lesions appear reddish or the color of normal mucosa. The mucocele is asymptomatic; no pain is associated with this lesion.
The history of a patient with a mucocele includes some sort of trauma to the affected area. Most mucocele reach maximum size within several days after injury. The mucocele may fluctuate in size and persist with a history of enlargement and regression. Superficial lesions may rupture and resolve spontaneously, but often recur. Most mucocele recur unless treated.
Diagnosis and treatment
A diagnosis of a mucocele is based on its clinical appearance, history, and histologic examination. A history of trauma to the area followed by the development of a sessile, compressible mass is characteristic of a mucocele. When a history of trauma cannot be confirmed, other lesions (lipoma, vascular malformations, or salivary gland tumors for example) should be considered in the differential diagnosis. A biopsy and histologic examination are necessary to establish a definitive diagnosis.
The recommended treatment for the recurring mucocele is surgical excision. Simple incision or aspiration of the contents of the mucocele is not considered adequate treatment. If incised, the mucocele tends to fill again as it heals. To prevent recurrence of the lesion, the removal of the associated minor salivary gland along with a pool of mucous is necessary.
Joen Iannucci Haring, DDS, MS, is an associate professor of clinical dentistry, Section of Primary Care, The Ohio State University College of Dentistry.
