Orthodontists are likely to be the dental clinicians who frequently assess the oral cavity of children and young people. Many patients’ first full jaw imaging will be requested by an orthodontist, and the soft-tissue examinations carried out throughout treatment can detect asymptomatic lesions. In addition, several of the most common oral soft-tissue entities are caused by trauma, with orthodontic appliances being a potential source of this trauma. In the past, most patients undergoing orthodontic treatment in the United Kingdom were children and young adults. On average, orthodontists in the United Kingdom start treatment in <30 adult patients a year. However, an increasing number of adults are undergoing orthodontic treatment, widening the range of diseases that may be encountered. This review discusses the common soft-tissue pathology an orthodontist will likely encounter and the uncommon but important disease that presents in children, young adults, and adults ( Table ). The pathology of the jaw bones and the management of soft- and hard-tissue pathology by the orthodontist will be discussed within Part 2 of this series of papers.

Common entities

The most commonly biopsied soft-tissue diseases in children aged <16 years include mucoceles, fibrous hyperplasia, fibroepithelial polyps, pyogenic granulomas, squamous papillomas, peripheral giant cell granulomas, hemangiomas, and frictional keratosis. ^, In addition, though infrequently biopsied, recurrent aphthous stomatitis (RAS), herpes simplex infections, geographic tongue, and gingival overgrowth (gingival hyperplasia) are commonly reported. ^, Moreover, these conditions are all commonly seen in adults. The above entities will be discussed below, except for giant cell granulomas, which will be discussed in the bone pathology section.

Mucoceles

Of the commonly biopsied soft-tissue pathologies, mucoceles are most likely to be encountered, ^, with mucoceles being more common in children and young adults than in older adults. They tend to present on the lower lip as a fluctuant blue, purple, gray, or mucosa-colored lump ( Fig 1 ). Most have a history of trauma and are <1 cm in diameter on average. Less frequently, they are seen at other sites of the oral cavity but rarely at the upper lip, where neoplasia is a more common cause of swelling. Approximately 90% of mucoceles are mucus extravasation reactions on histologic examination, with the remainder being mucus retention cysts. The histologic features of a mucocele include a lumen containing mucin, neutrophils, and macrophages, a lining of either compressed granulation tissue (mucocele) or ductal epithelium (mucus retention cyst), and a fibrous wall often with a chronic inflammatory infiltrate. When a mucus extravasation reaction affects the sublingual gland, a large swelling in the floor of the mouth may form, which is described as a ranula. Although some mucoceles will resolve without intervention, the mucocele and the associated gland most often must be removed to resolve the lesion, regardless of the mucoceles’ location in the oral cavity.

An example of a mucocele: A, Intraoral photograph of a mucocele on the lower right labial mucosa, identified after removal of fixed appliances; B, Intraoral photograph showing the lesion, which is polypoid, mucosa colored, and approximately 4 mm in diameter.

Fibrous hyperplasia and fibroepithelial polyp (fibroma)

Fibrous hyperplasia refers to reactive lesions comprising increased and often densely collagenous fibrous connective tissue. When a distinct polyp is formed, these lesions are described as fibroepithelial polyps (fibromas). These lesions are relatively common in children, comprising 35.8% of biopsied mucosal pathology in children, although they are more common in adult patients. Most lesions occur on the tongue or buccal mucosa; both sites are prone to trauma. Fibroepithelial polyps are well-demarcated sessile or pedunculated polyps that can be soft to firm, mucosa colored, and generally <1 cm ( Fig 2 ). Histologic examination shows a mass of densely collagenous fibrous connective tissue covered by epithelium that may exhibit hyperkeratosis and acanthosis. Inflammation is not present unless the lesion is ulcerated, and metaplastic bone formation may be seen if the lesion is present on the gingivae. When bone or calcifications are present, these lesions are sometimes referred to as peripheral ossifying fibroma. The term “giant cell fibroma” is sometimes used when large stellate or multinucleated fibroblasts are seen in the connective tissue of a fibrous polyp, although their presence is of unknown clinical significance. Excision of these lesions is curative ; however, a new lesion may form when trauma persists.

An example of fibroepithelial polyps: A and B, Intraoral photographs showing fibroepithelial polyps on the right and left buccal mucosa. Both polyps are pedunculated and whiter than the surrounding mucosa, likely because of hyperkeratosis; C, After the removal of the Twin-block appliance (the source of the trauma causing the polyps), the polyps have almost completely resolved.

Pyogenic granuloma

Most (80%) of pyogenic granulomas occur on the gingivae. They appear as either sessile or pedunculate erythematous masses and are often soft and compressible ( Fig 3 ). They are rarely >2.5 cm in diameter and may be ulcerated. Generally, they are asymptomatic but can be infrequently associated with bone loss. ^, Histologically, these lesions are polypoid, comprising granulation tissue in a lobular pattern with overlying ulceration. Pyogenic granulomas develop in response to either chronic local irritation or as a result of hormonal changes. ^, As such, pyogenic granulomas are common in adolescence and may be seen when orthodontic appliances are causing mucosal trauma. If the source of irritation or trauma is removed, recurrence is uncommon after the excision of these lesions.

An example of a pyogenic granuloma: A, An intraoral photograph showing a pyogenic granuloma ( white ) on the patient’s palatal gingivae in association with the transpalatal arch; B, A further intraoral photograph showing the same pyogenic granuloma with the transpalatal arch removed. The lesion is an erythematous, pedunculated mass; C, An intraoral photograph showing almost complete resolution of the pyogenic granuloma 3 months after the removal of the transpalatal arch (the source of the trauma causing the pyogenic granuloma).

Squamous papilloma

Squamous papilloma is the most common benign epithelial entity in the oral cavity of both adults and children. It is driven by low-risk human papillomavirus infection and is usually present on the tongue or palate. Clinically, it appears as a fronded, pedunculated lesion, <1 cm in diameter and is usually white but may be mucosa colored ( Fig 4 ). The histologic features match the clinical presentation with exophytic fronds of hyperplastic, hyperkeratotic epithelium supported by vascular cores. Excision of these lesions is curative.

An example of a squamous papilloma. This lesion on the patient’s right dorsal tongue is a pedunculated polyp <5 mm in diameter; it did not recur after excision.

Hemangioma

Of all connective tissue tumors, hemangiomas are the most common in the oral cavities of children and young adults. ^, Moreover, they are one of the most common tumors in children. The clinical manifestation of hemangiomas varies with the type of hemangioma. Infantile hemangiomas are the most common, with congenital hemangiomas being rare. They appear as well-demarcated, red, expansile lesions and tend to involute over time; most resolve by 7 years old. Some hemangiomas may be large and persist into adulthood ( Fig 5 ). They often blanch with pressure. Many hemangiomas are managed conservatively and are allowed to involute; however, when a lesion is likely to have a significant cosmetic or functional impact, it may be treated with surgery or medications such as propranolol.

An example of a vascular malformation on the upper lip. This extraoral photograph demonstrates a large vascular malformation with a vascular appearance and a somewhat purple color. It would be pulsatile on palpation.

Frictional keratosis

Frictional keratoses are common, with a prevalence of 0.26%-5.3% in children and young adults, ^, although they are more common in adults. They are reactive lesions in response to chronic trauma. Given the reactive etiology, frictional keratoses typically lack sharp demarcation. The clinical appearance of these lesions is variable and depends on the extent of the trauma. They range from faint whitening of the mucosa to extensive thickening and roughening of the surface with an opaque white color. Moreover, these lesions may be associated with erosions of the mucosa or ulceration in which the trauma has led to loss of the epithelium. A common presentation is bilateral white lines along the occlusal plane described as linea alba. The histologic appearance comprises hyperkeratosis, epithelial hyperplasia, and possible edema with ballooning of the prickle cell layer keratinocytes. Few inflammatory cells will be observed in the epithelium and lamina propria. Frictional keratosis will resolve by removing the source of trauma, for example, by smoothing a restoration or trimming the distal ends of orthodontic archwires.

Recurrent aphthous stomatitis

RAS is a common noninfectious ulcerative condition of the oral cavity with a lifetime prevalence of approximately 40% that disproportionately affects young adults. ^, RAS causes recurrent painful ulcers that may present as single or multiple lesions across the oral cavity. They usually heal over a few weeks. There may be a period of months or sometimes years among bouts of ulcers. ^, It is uncommon for these ulcers to appear on the keratinized mucosa, whereas ulcers caused by herpes simplex virus (HSV) often occur on the keratinized mucosa of the gingivae or palate. The ulcers are shallow, with a yellow base and an erythematous rim ( Fig 6 ). ^, Although the causes of RAS are poorly understood, there are many suggested predisposing factors. These include family history, trauma, some drugs, iron or B12 deficiencies, hormonal changes, or stress. However, the evidence to support these causative factors is weak. RAS is classified into minor (most cases), major (the minority of cases), and herpetiform (rare) types depending on the size, number, and location of the ulcers. RAS is usually diagnosed from a patient’s history and a clinical examination of the ulcers present ; histologic examination of tissues is rarely helpful. ^, However, further investigation by an appropriate specialist may be valuable to rule out systemic causes of oral ulcers such as Crohn’s disease or celiac disease. ^, Moreover, this specialist will be able to instigate the management of the patient’s RAS; the goal of treatment is symptomatic relief as RAS is not curable. If possible, topical agents are more appropriate as they have fewer systemic adverse effects. ^, Generally, this comprises topical corticosteroids to reduce the inflammation driving ulcer formation, benzydamine hydrochloride for analgesia, and chlorhexidine or tetracycline mouthwashes, which may reduce the duration of ulcers. ^, If topical therapy fails or a patient’s RAS is severe, systemic treatments such as oral corticosteroids including prednisolone or immunomodulatory agents may be provided. ^, However, there is limited evidence supporting any one option ; therefore, the potential adverse effects from systemic therapies must be cautiously weighed against the potential benefits.

An example of minor recurrent aphthous stomatitis: A – C, Intraoral photographs showing aphthous ulcers on the right buccal mucosa and right and left ventral tongue. Each ulcer has a yellow to gray base and erythematous rim.

Herpes simplex virus infections

HSV infections are very common, with 25%-30% of children estimated to be affected by primary herpetic gingivostomatitis (PHG). Approximately 30% of young adults have recurrent herpes labialis (RHL), and although less common than RHL, recurrent herpetic stomatitis (RHS) may also be observed. Most infections are caused by HSV-1 followed by HSV2. PHG prodromal symptoms include fever, nausea, malaise, and headache, ^, with additional symptoms of salivation, pain, halitosis, and lymphadenitis as the clinical lesions develop. ^, PHG presents as a combination of gingivitis and ulcers. ^, The ulcers begin as multiple small vesicles on the oral mucosa, pharynx, or perioral skin, breaking down and coalescing into larger irregular ulcers. ^, The lesions usually resolve completely within 2 weeks. ^, RHL results from reactivation of HSV, which lies quiescent in sensory neurons, often of the trigeminal nerve. Usually, the perioral skin and vermillion mucosa are affected. ^, RHL may be accompanied by a prodrome of paresthesia, burning, or itching at the site of reactivation. The lesions appear as red macules, which become vesicles before breaking down into crusted pustular scabs or ulcers ( Fig 7 ). RHS has an entirely intraoral presentation, usually affecting the keratinized mucosa with a limited number of small ulcers, in contrast to RAS, which often affects the nonkeratinized mucosa. RHS often has a palatal distribution and may occur after local anesthetic injection; the ulcers usually heal within 10 days. Generally, the clinical picture is sufficient to diagnose an HSV infection; however, a swab of the lesion for polymerase chain reaction analysis to identify viral DNA can be used when appropriate. These conditions are usually self-limiting and are treated with supportive advice and antivirals such as acyclovir. ^, There is limited evidence for the use of topical or systemic antivirals to prevent RHL. As there is a risk of transmission of HSV to the orthodontist while a lesion is active, it is essential to wear personal protective equipment. Moreover, there may be a benefit in delaying all but urgent treatment until the lesion has resolved to prevent infection risk. ^,

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