Palatal and Gingival Cysts of the Newborn

Etiology

Palatal and gingival cysts of the newborn are developmental lesions that arise from the entrapment of epithelial remnants during embryogenesis.[12] These inclusion cysts—commonly classified as Epstein pearls (palatal cysts), Bohn nodules (gingival cysts located on the buccal and lingual aspects of the alveolar ridges), and dental lamina cysts (gingival cysts on the alveolar ridge crest)—result from residual epithelial tissue or dental lamina remnants that become trapped during palatal shelf fusion or alveolar ridge formation.[3][13]

Epstein Pearls

These are benign, keratin-filled cysts that develop from epithelial remnants trapped along the midline of the hard palate during the embryologic fusion of the palatal shelves. Epstein pearls are typically located on the median palatal raphe, and they commonly appear in newborns as small, white or yellowish papules.[6]

Bohn Nodules

These are benign, self-limiting cystic lesions that are commonly found in the oral cavity of newborns. They originate from remnants of minor salivary gland epithelium and are typically located along the buccal and lingual aspects of the alveolar ridges, away from the midline.[13][14]

Dental Lamina Cysts

In newborns, dental lamina cysts appear as benign, keratin-filled lesions that arise from remnants of the dental lamina—an epithelial structure involved in early tooth development. They are typically located on the crest of the alveolar ridges, either maxillary or mandibular, and often appear as multiple small, white or yellowish papules.[13]

Epidemiology

Palatal cysts are observed in approximately 30% to 50% of newborns,[6] and they are often considered a normal anatomic finding due to their high frequency. Gingival cysts are slightly less prevalent, with reported rates ranging from 13% to 50% in newborns.[11] A study found that palatal and alveolar cysts are more frequent in full-term infants (30%) compared to premature infants (9%). The risk of developing palatal and maxillary alveolar cysts increases with higher birth weight, gestational age, and postnatal age. No significant differences were observed in this study related to gender or race.[15][16][17]

Pathophysiology

Palatal development begins near the end of the eighth week of gestation. Each maxillary process forms a lateral palatine process within the oral cavity. These shelf-like structures grow horizontally from the lateral aspects of the mouth toward the midline and downward. Between the tenth and eleventh weeks of gestation (in utero), the lateral palatine processes fuse with each other, the smaller premaxillary process, and the nasal septum. Palatal fusions are usually complete by the end of the fourth month of gestation.

At this stage, a theory suggests that the epithelium trapped between the palatal shelves and the nasal process forms cysts known as "Epstein pearls." Another theory suggests these cysts may originate from epithelial remnants of the minor salivary glands in the palate. Additionally, remnants of the dental lamina are believed to persist within the alveolar ridge mucosa after tooth development, where they can proliferate to form keratinized cysts.[13][18]

Histopathology

Palatal and gingival cysts of the newborn are histologically characterized by keratin-filled cystic spaces lined with thin, stratified squamous epithelium. The epithelial lining is typically 2 to 3 cell layers thick, nonkeratinized or parakeratinized, and lacks rete ridges. The cyst lumen contains desquamated keratin, and the surrounding connective tissue appears unremarkable, with no signs of inflammation.[13] Although these cysts share similar microscopic features, such as thin epithelial linings and keratin content, they differ in anatomic location and embryologic origin.[13]

History and Physical

Palatal cysts, including Epstein pearls and Bohn nodules, are small, painless, white to yellow, firm, non-fluctuant papules typically measuring 1 to 3 millimeters in diameter. They often appear in clusters of 2 to 6 lesions but may also present as solitary cysts.[6] Although the distinction is not clinically significant, these cysts are named based on their location. Epstein pearls are found along the mid-palatine raphe and near the junction of the hard and soft palate (see Image. Epstein Pearls). In contrast, Bohn nodules are located on the buccal and lingual surfaces of the alveolar ridges (see Image. Multiple Bohn Nodules on the Maxillary Alveolar Ridge).[6]

Gingival cysts present as small, whitish papules measuring 2 to 3 millimeters in newborns. They can be either isolated or multiple and are typically located on the crest of the alveolar ridge.[3] They are more commonly found in the maxilla than the mandible and share the same histological features as palatal cysts. In individuals with cleft palate, palatal cysts appear with a similar distribution to those without cleft palate, except they are located at the margins of the palatal shelves rather than along the midline.[19] Epstein pearls resemble the equivalent of milia, which are white papules caused by retention of sebum and keratin in the hair follicles, and are frequently seen on neonates' faces.

Evaluation

Palatal and gingival cysts of the newborn are typically diagnosed based solely on clinical features.[3] Laboratory tests and imaging are not required, as these cysts do not affect the underlying bone.

Treatment / Management

Treatment or surgical intervention is unnecessary, as these lesions typically regress spontaneously within a few weeks to months.[6] They are rarely observed beyond 3 months of age. Parental concerns should be addressed through reassurance and, if needed, routine follow-up.

Differential Diagnosis

Palatal and gingival cysts of the newborn should be differentiated from natal and neonatal teeth, as well as congenital epulis. Natal and neonatal teeth are rare and typically appear in the lower central incisor region.[20] Natal and neonatal teeth are often mobile due to absent or underdeveloped roots and may require extraction to avoid accidental ingestion.[3] 

Natal and neonatal teeth may be associated with developmental anomalies and recognized syndromes, such as Rubinstein-Taybi, Hallerman-Streiff, Ellis-van Creveld, Pierre-Robin sequence, pachyonychia congenita, short-rib polydactyly syndrome type II, steatocystoma multiplex, cyclopia, and Pallister-Hall syndrome. Genetic evaluation is warranted if the patient presents with additional dysmorphic features.

Congenital epulis is a benign pedunculated soft-tissue mass ranging from 1 millimeter to several centimeters in diameter. The swelling is typically located in the anterior maxillary ridge and present at birth. Occasionally, it is diagnosed in utero.[11] These lesions can grow large enough to interfere with breathing and feeding, and are usually surgically excised within the first weeks of life.[11] They do not spontaneously regress or recur after surgical removal.[21]

Prognosis

Palatal and gingival cysts of the newborn typically involute or spontaneously rupture, releasing their keratin contents into the oral cavity within the first few weeks to months of postnatal life. These lesions are rarely observed beyond 3 months of age. However, some cystic epithelium may remain dormant in the adult gingiva. Palatal and gingival cysts of the newborn are believed to resolve spontaneously as their cystic walls fuse with the oral epithelium, allowing the contents to be discharged.[3]

Complications

Palatal and gingival cysts are self-resolving lesions that are usually discovered incidentally and are not typically associated with further complications. However, in some cases, large or numerous cysts may occasionally interfere with feeding, potentially causing poor weight gain or feeding difficulties. These cysts can occasionally be mistaken for more severe oral pathologies, which may lead to unnecessary interventions or parental anxiety. In rare instances, if cysts become infected or persist beyond infancy, further evaluation or minor surgical intervention may be necessary. Although complications are uncommon, accurate diagnosis and monitoring are crucial to ensure appropriate management and provide reassurance to parents.