Peer Reviewed

Case In Point

A Case of Oral Tori in a 60-Year-Old Woman

Volume 60 - Issue 2 - February 2020

Authors:
Tejaswi Marri, BS; Cameron Dodd, BA; and Lynnette Mazur, MD, MPH
McGovern Medical School at the University of Texas Health Science Center, Houston, Texas

Citation:
Marri T, Dodd C, Mazur L. A case of oral tori in a 60-year-old woman. Consultant. 2020;60(2):45-47, 50. doi:10.25270/con.2020.02.00002

 

A 60-year-old woman presented for a routine checkup. She had no medical concerns but wanted to discuss treatment options for her oral tori (Figures 1 and 2). The bony lesions had first appeared in her 30s and had remained asymptomatic until the past 2 or 3 years. During that time, they had progressively grown and multiplied to the point that she was unable to eat without pain and/or bleeding. For the past several weeks, she had limited her diet to milkshakes and smoothies. Because of her worsening symptoms, she was referred to an oral maxillofacial surgeon for further evaluation and management.

Fig 1
Figure 1. Torus palatinus visible along the hard palate.

Fig 2 
Figure 2. Bilateral torus mandibularis visible along the lingual aspect of the mandible.

 

DISCUSSION

Oral tori are nonpathologic, nodular protuberances composed of cortical bone covered by a thin, poorly vascularized mucosa.1 The two most common forms are torus palatinus (TP) and torus mandibularis (TM).1,2 TP forms along the midline of the hard palate, whereas TMs form along the lingual aspect of the mandible and is usually bilateral.2,3 Tori typically develop during late adolescence and gradually increase in size throughout adulthood.3 When small, they rarely cause symptoms or pain and are usually an incidental finding during routine clinical or dental examinations.4

Their prevalence varies by ethnicity and geographical region, but tori are more commonly found in Eskimos, Native Americans, Norwegians, and Thais.4,5 Prevalence ranges from 12% and 14% in patients from Trinidad and Tobago, respectively, to 27% in patients from Thailand.1,6,7 In the United States, TP is the most prevalent torus, occurring in 20% of the population, while TM has a prevalence of 6%.8,9 TM is more common in men, whereas TP is more common in women.2,5,8,10 Concurrence of TP and TM ranges from 3% to 23%.1,7,11,12

Although the etiology of oral tori is unknown, genetic and environmental factors may have a role.13 Oral tori are thought to follow an autosomal dominant pattern of inheritance, and masticatory stress, masticatory hyperfunction and bruxism are thought to be risk factors.10,14 Superficial trauma in the oral cavity and lifestyle factors such as consumption of fish, a calcium-rich diet, and vitamin deficiency are also associated with their development.2,5-7,10,15 One study showed a higher bone-mineral density in patients with tori.16 There is also a correlation between tori and temporal mandibular joint dysfunction and obstructive sleep apnea.17,18

If radiologic studies are performed, radiopaque masses with a higher density than surrounding bone may be noted.4,5 Oral tori must be differentiated from other growths in the oral cavity, including ossifying fibroma, osteoma, mucocele, osteochondroma, osteoblastoma, osteosarcoma, and osteoid osteoma (Table).3,8,13 There does not appear to be a strong relationship between oral tori and other bone or hereditary exostoses. However, buccal exostoses may be associated with more serious syndromes such as Gardner syndrome and fibrous dysplasia.3,19

Table. Differential Diagnoses for Oral Tori

Condition

Clinical Features

Diagnostic Features

Ossifying fibroma20

Benign
Age: 12-30 years
Gender: 66% female, 33% male
Location: Maxilla > mandible
Presentation: Painless swelling often found incidentally

Radiography: Well circumscribed lesion with osteoblastic rimming
Histology: Fibrous stroma with lamellar bone or calcifications

Osteoma21

Benign
Age: Middle age
Gender: No predilection
Location: Surface of facial bones
Presentation: Most often asymptomatic and found incidentally; associated with Gardner syndrome

Radiography: Well defined smooth growth protruding from other bone Histology: Dense lamellar or trabecular bone in orderly arrangement

Osteochondroma22

Benign
Age: <30 years
Gender: Male > female
Location: Appendicular skeleton, pelvis, scapula, rarely found in cranial bones and can protrude into oral cavity

Radiography: Continuation of bone cortex and medullary cavity into bony outgrowth with calcified cartilaginous cap; cartilaginous cap best seen on computed tomography or MRI
Histology: Bony outgrowth that has a hyaline and fibrous cartilage cap

Mucocele23

Benign
Age: No predilection
Gender: No predilection
Location: Lower lip > tongue > buccal mucosa > palate
Presentation: Painless, transparent, cystic swelling that is soft and contains fluid

Diagnosed based on direct visualization of blue cystic swelling, history of trauma, and location of lesion
Histology: Mucin pooling surrounded by granulation tissue and fibrous tissue

Osteoblastoma21

Benign but aggressive
Age: 10-30 years
Gender: Male > female
Location: Most often in spine or long bones but can appear anywhere
Presentation: Bone pain not relieved by nonsteroidal anti-inflammatory drugs (NSAIDs)

Radiography: Well circumscribed lesion that can be radiolucent or have speckled mineralization; 4-6cm in size
Histology: Well-vascularized bone trabecular interwoven with fibrovascular component and osteoblasts lining periphery

Osteosarcoma of the jaw24

Malignant; type 1, unknown etiology; type 2, older patients with Paget disease, irradiation of the facial region, and fibrous dysplasia of the bone
Age: 30-40 years but can appear at any age
Gender: Male > female
Location: Maxilla, posterior portion and antrum; mandible, body>angle>symphysis>ascending ramus
Presentation: Typically asymptomatic; swelling is first sign

Radiography: Periosteum elevation with sunburst appearance
Histology: Several different subtypes, but all have tumor cells that produce osteoid
• Osteoblastic: Osteoid surrounded by fibroblast like cells
• Chondroblastic: Osteoid with chondroid tissue with large chondroblasts
• Fibroblastic: Spindle-shaped tumor cells with herringbone pattern

Osteoid osteoma21

Benign
Age: >25 years
Gender: Male > female
Location: Most commonly in femoral neck but can appear anywhere
Presentation: Bone pain that is relieved by NSAIDs

Radiography: Radiolucent osteoid core with surrounding sclerosis and mineralization
Histology: Well demarcated from surrounding bone; heavily vascularized stroma with immature woven bone with active osteoblasts and osteoclasts

A biopsy may be needed to distinguish oral tori from the other growths.3,4 Because they are self-limiting, benign, and typically painless, removal of tori is not warranted in most cases.5,9,13 Indications for surgical excision include esthetic concerns, disturbance of phonation, restriction of masticatory functions, sensitivity (due to thin overlying mucosa), traumatic inflammation or ulceration, retention of food particles, or to allow for proper fitting of oral prostheses.5,9,13,25 In some cases the cortical bone excised from the tori may be repurposed as a source for grafts in certain procedures.9 One study demonstrated positive results when using patients’ own tori for grafting bone defects between teeth when periodontal pockets are present.26 Tori can safely be used in place of other graft materials such as allografts, xenografts, alloplasts, and other locations of autografts.9,26

OUTCOME OF THE CASE

Because of the pain and difficulty with eating, our patient opted for surgical excision (Figure 3). Within a week after the procedure, she progressed from a liquid diet to soft foods without problem.

Fig 3
Figure 3. Postoperative photo of torus palatinus excision.

 

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