What is the recommended course of action for a 47-year-old patient with a hard, intermittent bump on the inner aspect of the mandible (lower jawbone)?

Hard, Intermittent Bump Below Jawbone on Inner Mouth

This presentation most likely represents a salivary stone (sialolithiasis) in the submandibular gland or duct, and you should perform bimanual palpation to confirm the diagnosis, followed by ultrasound imaging if a stone is palpated. 1

Clinical Assessment

The intermittent nature and hard consistency strongly suggest a salivary gland disorder rather than other oral pathology. Key diagnostic features to assess include:

• Timing of swelling: Salivary stones characteristically cause pain and swelling just before or during eating, when salivary flow increases 1
• Palpable mass: Bimanual palpation (one finger inside the mouth, one outside) can often detect the stone in the submandibular duct 1
• Salivary flow: Check for slow or absent salivary flow from the affected duct opening 1
• Associated tenderness: The submandibular gland itself may be tender on palpation 1

Diagnostic Workup

Ultrasound is the preferred initial imaging modality for suspected salivary gland disease. 1 This provides excellent visualization of stones and duct obstruction without radiation exposure.

If the clinical presentation is atypical or examination is limited, consider:

• Panoramic radiograph to rule out odontogenic causes (dental abscess, impacted tooth) 2
• CT imaging if deep space infection is suspected, particularly if there is trismus, fever, or rapidly progressive swelling 2

Differential Diagnosis Considerations

While salivary stones are most likely given the intermittent hard bump, other possibilities include:

• Reactive gingival lesions: These are typically fixed, not intermittent, and located on the gingiva itself 3, 4
• Odontogenic infection: Would present with continuous symptoms, not intermittent, and typically shows osteolytic changes around tooth roots on imaging 2
• Mucocele: Usually softer and fluctuant rather than hard 4

The intermittent nature effectively rules out most neoplastic or infectious processes, which would show progressive or constant symptoms.

Management Pathway

Refer to an oral and maxillofacial surgeon for definitive management of confirmed salivary stones. 1 Treatment options include:

• Conservative measures for small stones (hydration, sialagogues, gland massage)
• Surgical removal for larger or symptomatic stones
• Duct dilation or lithotripsy in select cases

Critical Pitfalls to Avoid

• Do not assume this is a simple gingival lesion without proper palpation and assessment of salivary function 1
• Do not order CT as first-line imaging for suspected salivary pathology—ultrasound is superior and avoids radiation 1
• Do not delay referral if a stone is confirmed, as chronic obstruction can lead to gland damage and recurrent infections 1
• Rule out dental causes if the patient has poor dentition or the location corresponds to tooth roots, as odontogenic infections are the most common cause of inflammatory disease in this region 2