Superficial mucocele

Report of 4 cases

Ambrosio Bermejo, MD, DDS, PhD,a José M. Aguirre, MD, DDS, PhD,b Pia Lopez, MD, DDS,
PhD,a and María R. Saez, MD, DDS,a Murcia and Vizcaya, Spain
UNIVERSIDAD DE MURCIA AND UNIVERSIDAD DEL PAÍS VASCO EHU

Four cases of the lesion first described as superficial mucocele by Eveson in 1988 are reported. All of the lesions
developed in adult women; two of the women had concurrent oral lichen planus. The mucoceles were found on the soft
palate, the buccal mucosa, and the upper and lower labial mucosa. The etiologic factors and pathogenesis of this lesion are
discussed. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;88:469-72)

The mucocele is a common oral mucosal lesion origi-
nating from minor salivary gland. Clinically it appears
as a discrete, more or less soft, nonpainful swelling of
the mucosa.1-3 The lesion has no sex predilection and
occurs more frequently in children, adolescents, and
young adults. The lower labial mucosa is the most
frequent site of involvement, but mucoceles may
develop at virtually any location where minor salivary
glands occur, including the soft palate, retromolar
region, and buccal mucosa.1,2
As first defined by Eveson4 in 1988, the superficial
mucocele was a small, translucent, tense, subepithelial
vesicle affecting the oral mucosa. Lesions could be
either single or multiple. Occasionally the lesions were
persistently recurrent, with a pattern of rupturing,
causing slight discomfort to the patient and healing
within a few days. Until Eveson’s report, superficial
mucoceles were often misdiagnosed as pemphigoid,
bullous lichen planus, or herpes. Jensen5 reported addi-
tional cases in 1990.
The purpose of this article is to present 4 cases of
superficial mucocele and discuss its etiology and
pathogenesis.
CASE REPORTS
Case 1
A 24-year-old woman presented with “blister” formation
that had begun 3 months previously. The blisters appeared
every few weeks, burst easily, and did not bleed or cause pain.
No systemic problems were noted.
On clinical examination, a tense, well-defined vesicle 0.5
cm in diameter was seen on the soft palate. Direct immuno-
aMedicina
Bucal, Universidad de Murcia.
bMedicina Bucal, Universidad del País Vasco EHU.
Received for publication Dec 9, 1998; returned for revision Jan 21,
1999; accepted for publication Apr 29, 1999.
Copyright © 1999 by Mosby, Inc.
1079-2104/99/$8.00 + 0 7/14/100303
fluorescence was negative. The case was reviewed and diag-
nosed as recurrent superficial mucoceles (Fig 1).
Case 2
A 19-year-old woman reported that 2 weeks earlier she had
had a mucocele removed surgically from her lower lip. For a
number of days afterward, she had felt a growth at the site of
the operation.
Examination revealed a soft, tense, translucent vesicle 3
mm in diameter on the lower labial mucosa. The tongue
showed white annular lesions, typical of benign migratory
glossitis. The biopsy showed a superficial mucocele.
Case 3
A 56-year-old woman complained of blisters involving
various sites of the oral mucosa for 11⁄2 months. The blisters
caused the patient slight inconvenience when they ruptured.
The patient had simultaneous primary biliary cirrhosis.
Examination revealed white striations on the lower labial
mucosa and vermillion zone as well as the buccal mucosa
bilaterally. A clinical diagnosis of lichen planus was made. A
2-mm vesicle was seen on the soft palate, compatible with
superficial mucocele. With time, tense and translucent vesi-
cles 2 to 4 mm in diameter appeared on the buccal mucosa
bilaterally. (Fig. 2, A) Biopsy of the buccal mucosa confirmed
the diagnosis of lichen planus. The tense vesicles were diag-
nosed histopathologically as superficial mucoceles (Fig 2, B).
Case 4
A 55-year-old woman had noticed the presence of ulcers
involving her oral mucosa and complained of pruritic papular
lesions affecting the skin. Xerostomia and keratoconjunc-
tivitis sicca had been present for 10 years.
Oral examination revealed white striations involving the
lower lip. The dorsal tongue appeared atrophic. Ulcerated,
erythematous areas were seen on the dorsal tongue, floor of
the mouth, buccal mucosa bilaterally, gingivae, and hard
palate. The upper labial mucosa showed a tense, well-defined
vesicle 2 mm in diameter (Fig 3). The presence of small,
polygonal, purple papules on the trunk and extremities
suggested a clinical diagnosis of lichen planus. Concomitant

469
470 Bermejo et al
Fig 1. Case 1. A, Clinical appearance of superficial mucoceles of soft palate. B, Histopathologic features of
superficial mucocele (hematoxylin-eosin, original magnification ×40).
Sjögren syndrome was also present. The biopsy confirmed the
diagnosis of lichen planus and superficial mucocele.
DISCUSSION
In 1988, Eveson4 described 8 cases of a new noso-
logic entity that he called superficial mucocele. The
lesion consisted of a small subepithelial vesicle, typi-
cally only a few millimeters in diameter, filled with
mucus. The mucus was deposited at the interface
between the epithelium and the connective tissue, thus
causing the epithelium to expand and stretch, forming
a dome with thin and delicate transparent walls. All of
the cases described in our report showed the clinical
and histopathologic features noted by Eveson.4
Superficial mucoceles seem to have a predilection for
females; indeed, all of Eveson’s patients were women,
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
October 1999
as were all of the patients in our series. The typical
mucocele is more common in patients less than 30
years of age (more than 50% of all cases), whereas the
superficial mucocele is more frequent in patients over
the age of 30.4,5 The sites of superficial mucocele
involvement are often the soft palate, retromolar
region, and buccal mucosa.4,5 A patient with this type
of mucocele often presents with a vague history of
recurrent blister formation. The blisters, which may be
either single or multiple, soon burst, leaving slightly
painful erosive areas that heal within a few days.6
Because these lesions have not been defined as
distinct clinical entities in most textbooks of oral
pathology, superficial mucoceles often cause diag-
nostic problems. Each of the 8 cases reported by
Eveson4 was initially diagnosed as bullous lichen
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
Volume 88, Number 4
Fig 2. Case 3. A, Right buccal mucosa shows tense vesicle corresponding to superficial mucocele. B,
Histopathologic features of lesion (hematoxylin-eosin, original magnification ×20).
planus (5 cases), mucous membrane pemphigoid (2
cases), or recurrent oral herpes (1 case).
In our case 1, the finding of a subepithelial vesicle
with an entirely intact epithelium and the recurrent
nature of the lesion suggested a diagnosis of benign
mucous membrane pemphigoid. However, results of
direct immunofluorescence studies were negative,
the contents of the vesicle were periodic acid–Schiff-
positive, and no other signs or symptoms were
evident, all of which led to a final diagnosis of super-
ficial mucocele.
In 5 of the patients reported by Eveson4 there was
concomitant bullous lichen planus. There are distinct
clinical and microscopic differences between the bulla
of lichen planus and the mucocele; the former is often
flaccid and opaque,7 whereas the vesicle of the super-
Bermejo et al 471
ficial mucocele is translucent and tense, being similar
to a dewdrop. In our case 3, with histopathologically
con-firmed lichen planus, it was possible to verify the
periodic appearance of tense, translucent blisters that
were compatible, both clinically and histologically,
with superficial mucoceles. Our fourth patient also
presented with reticular and erosive lichen planus that
developed into blisters clinically identical to those
described by Eveson.4
The fact that in 5 cases described by Eveson4 the
superficial mucoceles appeared simultaneously with
lichen planus, as they did in 2 of our patients, suggests
that lichen planus may be related to the development of
superficial mucoceles. We believe that the mechanism
of formation could be similar to that involved in
miliaria crystallina. Miliaria are thought to be caused
472 Bermejo et al
Fig 3. Case 4. Superficial mucocele affecting upper labial
mucosa.
by the retention of sweat in the tissues as a result of
blockage of or damage to sweat gland ducts. On the
basis of the extent of obstruction or damage, 3 types of
miliaria have been described: crystallina, rubra, and
profunda.8 Each of these types has its own clinical
features. In crystallina, the obstruction is very superfi-
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
October 1999
cial and the vesicle that results from the sweat retention
is located just below the horny layer of the skin. With
respect to its clinical appearance on the skin, the lesion
is like a small, tense, transparent dewdrop, with neither
inflammatory base nor symptoms. Crystallina is
frequent in children after minor skin injury that is
followed by sweating, and it may be also seen during
fever associated with profuse perspiration.8
In patients with chronic erosive lichen planus, the
oral mucosa undergoes continuous erosion and re-
epithelialization that is caused by the offending infil-
trate and by traumatic damage. At one stage, the outlet
of a small salivary duct might become blocked or
rupture, causing mucus to collect below the epithelium.
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4. Eveson JW. Superficial mucoceles: Pitfall in clinical and micro-
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5. Jensen JL. Superficial mucoceles of the oral mucosa. Am J
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6. Scully C. The oral cavity. In: Rook A, Wilkinson DS, Ebling
FJG, editors. Textbook of dermatology. Oxford: Blackwell
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Wilkinson DS, Ebling FJG, editors. Textbook of dermatology.
Oxford: Blackwell Scientific Publications; 1992. p. 1745-62.
Reprint requests:
José M. Aguirre, MD, DDS, PhD
Medicina Bucal. Departamento de Estomatología
Universidad del País Vasco E.H.U.
Leioa 48940. Vizcaya
Spain