Fordyce granules: Normal or abnormal structures?

Patients often notice areas of their mouths at various times that may have been present previously, yet suddenly become noticeable to them. Fordyce granules are variants of normal anatomy that, on occasion, cause benign areas of the body to change in color, size, or shape. In her oral pathology column, Nancy W. Burkhart, EdD, BSDH, AFAAOM, discusses the what, why, and how about Fordyce granules so that you can properly inform and care for your patients.

Dec 2nd, 2018
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One day his lip looks normal, and the next day he notices some bumps. Your patient starts to worry. Here’s what you need to know when he comes in and asks, “Do you think this appears normal to you?”

Nancy W. Burkhart, EdD, BSDH, AFAAOM

Patients often notice areas of their mouths that may have been present previously, yet suddenly become noticeable to them. On occasion, Fordyce granules may change, making them appear more prominent. For instance, androgenic hormonal changes due to puberty or pregnancy may affect an area of the body, causing a benign structure to change in color, size, or shape. An example of this is gingival overgrowth. These changes in hormonal levels may cause a previously benign growth to appear different in color or become more obvious, such as Fordyce granules.

Changes of this nature may cause a patient to bring noted variations to the attention of his or her dental hygienist or dentist with questions such as, “Do you think this appears normal to you?” and “What has caused this growth?” Dental professionals should be able to respond to these questions in a way that will allay any fears of malignancy or, in the case of possible premalignancy or malignancy, equip the patient to make an informed decision regarding the course of action. Patients may see multiple practitioners who do not recognize the granules as being Fordyce granules. Dentists and hygienists can be available to offer calming professional advice.

The patient in Figure 1 had concerns about the appearance of his lips and wanted to know what was occurring and how he could treat these white papules on his lip. Note the granules in the upper right lip area and on the vermilion border of the lower lip.

Figure 1:Fordyce granules in the upper right lip area and on the vermilion border of the lower lip. Photo courtesy of Carol Perkins, BA, AS, RDH.

Fordyce granules may be found on the lips, the buccal mucosa, the anterior tonsillar pillar or the retromolar area, and in other body sites including the genitals. Fordyce granules are present in approximately 80% of the population1,2 and reported in most literature as equally found in males and females.3 The granules may be more visual during puberty and beyond. They may be enlarged or more prominent in patients with hyperlipidemia and other metabolic states.2 The granules are not painful, and an altered state of “itching” is uncommon. They usually measure approximately 1 mm to 3 mm in diameter and may be noticed in small numbers or in the hundreds.

Patients will usually be particularly concerned when they notice the granules on their lips or genital areas. This is usually because these areas may be noticed by a partner during sexual activity and, of course, lead to some concern related to the etiology. The papules may be found on the penis and/or scrotum in males and on the labia in females. The spots may be noticed and elevate concerns that there could be a sexually transmitted disease involved. This may bring patients in to see their physician for evaluation. An emotional component could be present as well, and the patient may exhibit a loss of confidence. The yellow or white papules may appear more prominent depending upon the location and the number of granules existing in any given area of the body.

Figure 2:Fordyce granules are normal sebaceous granules composed of lobules of rounded cells with abundant clear, but coarsely granular, cytoplasm. Photo courtesy of David Klingman, DMD, diplomate of the American Board of Oral and Maxillofacial Pathology.

Fordyce granules are benign and require no treatment unless they present a cosmetic concern. However, in rare cases when they form keratin-filled cysts, sebaceous cell hyperplasia and adenoma have been reported.4 At this point, the appearance may be quite different, and the granules may require treatment.

In Figures 2 and 3, the Fordyce granules are depicted as normal sebaceous granules composed of lobules of rounded cells with abundant clear, but coarsely granular, cytoplasm. Fordyce granules are a variant of normal tissue anatomy, but with any tissue change, pain, exudate, ulceration, or notable enlargement may raise suspicion for an abnormality. In such cases, further evaluation may be prudent.

Dermatologists may provide treatments for patients who find certain Fordyce granules to be unsightly. Available treatments include electrodessication or carbon dioxide (CO2), pulse dye lasers, and the micropunch technique. Again, Fordyce granules are variants of normal anatomy and do not require treatment in their normal state. These would be purely esthetic concerns and are not usually covered by insurance companies. This should be discussed with patients prior to any treatment considerations.

Figure 3:Fordyce granules are a variant of normal tissue anatomy, but with any tissue change, pain, exudate, ulceration, or notable enlargement may raise suspicion for an abnormality. In such cases, further evaluation may be prudent. Photo courtesy of David Klingman, DMD, diplomate of the American Board of Oral and Maxillofacial Pathology.

As always, listen to your patients and continue to ask good questions!

References

1. Neville BW, Damm DD, Allen CM, Chi AC.Oral and Maxillofacial Pathology. 4th ed. St. Louis, MO: Elsevier; 2016.

2. Gaballah KY, Rahimi I. Can presence of oral Fordyce’s granules serve as a marker for hyperlipidemia?Dent Res J (Isfahan). 2014;11(5):553-558.

3. DeLong L, Burkhart NW.General and Oral Pathology for the Dental Hygienist. 3rd ed. Baltimore, MD: Wolters Kluwer; 2018.

4. Madani FM, Kuperstein AS. Normal variations of oral anatomy and common oral soft tissue lesions: evaluation and management.Med Clin North Am. 2014;98(6):1281-1298. doi:10.1016/j.mcna.2014.08.004.

NANCY W. BURKHART, EdD, BSDH, AFAAOM,is an adjunct associate professor in the Department of Periodontics-
Stomatology, College of Dentistry, Texas A&M University, Dallas, Texas. Dr. Burkhart is founder and cohost of the International Oral Lichen Planus Support Group (dentistry.tamhsc.edu/olp/) and coauthor of General and Oral Pathology for the Dental Hygienist, in its third edition. Nancy was awarded an affiliate fellow status in the American Academy of Oral Medicine in 2016. She was awarded the Dental Professional of the Year in 2017 through the International Pemphigus and Pemphigoid Foundation and is a 2017 Sunstar/RDH Award of Distinction recipient. She can be contacted at nburkhart@tamhsc.edu.

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