Diagnostic Approach to Jaw Masses

Initial Assessment and Imaging

The American Academy of Otolaryngology-Head and Neck Surgery recommends beginning with periapical intraoral X-ray using a paralleling technique as the first-line imaging for localized dental pathology, and if this reveals periapical pathology that is unclear or suggests malignancy risk factors, proceed immediately to CT with contrast 1, 2
Identify patients at increased risk for malignancy based on physical examination characteristics, including fixation to adjacent tissues 1, firm consistency 2, size >1.5 cm 4, mass present ≥2 weeks without significant fluctuation 3, and ulceration of overlying skin 4
Document the duration of mass, as masses of uncertain duration or >2 weeks warrant imaging 3

Consider periapical abscess/granuloma as the most likely diagnosis given root canal history, presenting as firm swelling above tooth apex 1, 2
Failed endodontic treatment is a possibility, with persistent infection and periapical bone loss 1
Torus palatinus/maxillary exostosis is a benign bony overgrowth, typically midline and slow-growing 4
Odontogenic cyst or tumor, such as dentigerous cyst, ameloblastoma, or odontogenic keratocyst, should be considered 3
Squamous cell carcinoma is a primary concern in adults with firm, fixed masses 5, 3
Metastatic disease, lymphoma, and salivary gland malignancy are also potential diagnoses 3, 4, 5

The AAO-HNS strongly recommends CT with contrast (or MRI with contrast) for patients at increased malignancy risk 4
CT delineates bone involvement, soft tissue extent, and relationship to adjacent structures 1
Do not delay CT imaging if malignancy risk factors are present 3
If imaging suggests malignancy or remains unclear, urgent referral to oral-maxillofacial surgery or head-neck surgery is necessary 5, 3
Biopsy (incisional or FNA) is required for definitive diagnosis 4

Follow-up X-rays should be obtained at 3 months, 6 months, 1 year, then annually for 3 years to assess healing after endodontic treatment 1, 6
If a fistula is present, take an intraoral radiograph with gutta-percha cone inserted into the fistula tract to identify the source 1, 2
Patients with periodontal disease history have an increased risk of periodontal abscesses with rapid tissue destruction 4