Clinical Review & Education

JAMA Clinical Challenge

A Nodular Protuberance on the Hard Palate Barry Ladizinski, MD; Kachiu C. Lee, MD, MPH

Figure.

A 66-year-old man presents with a slowly enlarging growth in his mouth that appeared more than 20 years ago. He denies pain and discomfort but is concerned because the mass has increased in size during the past year. He does not wear dentures and denies trauma, use of tobacco Quiz at jama.com products, poor nutrition, and risky sexual practices. Family history is noncontributory. Physical examination reveals a healthy appearing male with a nontender, symmetric, nodular bony protuberance on the midline of the hard palate. Two prominent protuberances are also noted at the bilateral maxillary tuberosities (Figure). The remainder of the examination is unremarkable.

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WHAT WOULD YOU DO NEXT?

A. Do not intervene; the condition is benign B. Perform a biopsy of the lesion C. Obtain a computed tomography scan of the head D. Refer the patient to an oral surgeon for evaluation and full-mouth dental x-rays

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JAMA Clinical Challenge Clinical Review & Education

Diagnosis Torus palatinus

What to Do Next? A. Do not intervene; the condition is benign The key clinical feature is a nodular, stable or slowly growing palatine mass covered by vascular mucosa. This presentation is typical for torus palatinus.

Discussion Torus palatinus is an exostosis or benign bony overgrowth usually located symmetrically on the midline of the hard palate. Although often undiagnosed, torus palatinus is common and present in 12% to 27% of the population. The condition is more common in women and certain groups (eg, North Americans, Norwegians, Thais, and Eskimos). The etiology of torus palatinus is unclear; proposed mechanisms include genetics (possible autosomal dominant inheritance), trauma, vitamin deficiency, and dietary habits (eg, fish consumption). Although some reports document a clear genetic inheritance across 3 generations, others have noted the occurrence of torus palatinus after superficial trauma or occlusion stress. Another hypothesis suggests that the condition represents normal bony overgrowth or conformational changes occurring during development of the maxilla. This finding is supported by its association with the presence of maxillary third molars and its location along the medial palatine suture line of the hard palate.1 Torus palatinus can be flat, nodular, lobular, or spindle-shaped; prevalence studies have conflicting reports on the most common presentation. Although rare, reports of the condition in infants demonstrate the early presence of this overgrowth.2 Because torus palatinus in infants may be small and easily missed, this condition is likely underreported. Given that the condition is asymptomatic, most inARTICLE INFORMATION Author Affiliations: Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (Ladizinski); Department of Dermatology, Brown University, Providence, Rhode Island (Lee). Corresponding Author: Barry Ladizinski, MD, Johns Hopkins Bloomberg School of Public Health, 300 N Charles St, Ste 304, Baltimore, MD 21201 ([email protected]). Section Editor: Mary McGrae McDermott, MD, Senior Editor.

dividuals are not aware of its presence. As such, it is usually diagnosed incidentally in the second to fourth decade during routine physical or dental examination. Torus palatinus must be differentiated from other growths in the mouth that can present similarly, including other tori, fibromas, mucocele, calcinosis cutis, osteoma, and osteoid osteoma. Torus mandibularis is a bony growth of similar appearance that occurs on the mandible and is more common in men. The probability of having torus mandibularis is higher in individuals with torus palatinus and vice versa, leading to the hypothesis that the same pathogenesis underlies the development of both conditions. Torus palatinus and torus mandibularis are both typically asymptomatic, except when lesions grow to a size that interferes with daily activities such as chewing or speaking. Torus palatinus can be diagnosed through history and physical examination, although a biopsy may be warranted to distinguish between torus palatinus, osteoma, and osteoid osteoma. Torus palatinus is not associated with other systemic symptoms, and imaging is usually unnecessary. Radiographs will typically show a radiodense area of bone surrounded by normal-appearing bone. Because this is a benign condition, it does not need evaluation by an oral surgeon. Torus palatinus tends to grow gradually throughout life and does not have potential for malignant transformation. Because most lesions are asymptomatic and benign, treatment is usually not necessary. Occasionally the bone will be extirpated for prosthetic treatment or for use in autogenous cortical bone grafting.3 Torus palatinus may also be removed to allow for proper fitting of oral prosthetic devices, such as dentures.

Patient Outcome The patient was reassured that the condition was benign and instructed to return if the growth became symptomatic.

Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. Additional Contributions: We thank the patient for providing permission to share his information. Submissions: We encourage authors to submit papers for consideration as a JAMA Clinical Challenge. Please contact Dr McDermott at [email protected]

2. Beena JP. Torus palatinus in an infant: a case report. J Dent Child (Chic). 2012;79(3):181-184. 3. García-García AS, Martínez-González JM, Gómez-Font R, Soto-Rivadeneira A, Oviedo-Roldán L. Current status of the torus palatinus and torus mandibularis. Med Oral Patol Oral Cir Bucal. 2010;15(2):e353-e360.

REFERENCES 1. Cantín M, Fernández RF, Rojas M. A proposed explanation for the development of the torus palatinus. Clin Anat. 2011;24(6):789-790.

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JAMA April 16, 2014 Volume 311, Number 15

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A nodular protuberance on the hard palate.

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