Introduction

Torus Palatinus (TP) is a bony growth that develops slowly along the centre of the roof of the mouth, primarily rising from the maxillary bone, and affects 20-40%¹ of the general population. The prevalence of TP ranges between 2% 56%² and usually presents between the ages of 20-50.³

The variation in prevalence is attributed to its usually painless and asymptomatic nature, with most cases being discovered accidentally through routine dental examinations or by the patient themselves.² TP presents in different shapes and sizes, with the most common being flat and symmetrical. 

Treatment options are only considered for those who experience difficulty in swallowing, chewing and speech or in cases where the presence of the growth impacts the ability to create and fit dental appliances.³ Studies have highlighted that the development of TP is multifactorial, meaning its development is influenced by a variety of factors, though it is widely accepted that its cause is 30% hereditary and 70% environmental.³ Understanding how environmental factors, more specifically diet and nutrition, contribute to the development of TP could guide preventative and management strategies. 

How do bones grow?

Bone remodelling and essential nutrients 

Bone remodelling is a physiological process regulated by specific bone cells. Osteoclasts break down old bone tissue, and osteoblasts build new bone to replace it. This process occurs throughout life to maintain bone strength and adapt to different mechanical pressures. The balance between bone breakdown and bone formation is essential, as disruptions can lead to conditions such as TP, characterised by abnormal bone growth.  

The environment plays a large role in the development of healthy bones. Nutrient deficiencies can lead to poor mineralisation and weaknesses, while excessive nutrient consumption can lead to abnormal remodelling. Calcium and vitamin D are two essential nutrients involved in regulating bone growth.⁴

What causes TP?

TP is a multifactorial condition, with a range of different causes that could impact its progression. Several factors, including dietary patterns and genetics, contribute to its development. However, the limited data available due to TP often being asymptomatic leads to gaps in research, as many cases go undiagnosed. Moreover, the variation in presentation adds additional complexity. Nevertheless, studies have suggested potential causes and factors that influence the development of TP.^2,5,6

Dietary patterns 

Nutritional influence

Several nutrients have been suggested to play a role in the development of TP through their interactions with bone growth and remodelling.⁴ Studies have shown that imbalances in nutrition could contribute to bone metabolism, potentially promoting abnormal bone growth.

Calcium 

Calcium is an essential mineral nutrient involved in bone health and development. Adequate levels of calcium are necessary to support bone metabolism and remodelling.⁴ The presence of TP is characterised by abnormal bone growth, and it was therefore suggested that calcium could play a role in this process, either through an imbalance in calcium levels or the abnormal deposition of the nutrient in the bones. 

Studies have shown a greater incidence of TP in patients with hypercalcemia⁵ - a condition characterised by excessive calcium. Another study identified pronounced TP in individuals who had undergone chronic phenytoin therapy for epilepsy.³ Phenytoin has been reported to affect calcium homeostasis and bone metabolism by increasing the number of osteoblasts when used for long periods of time.⁷ This highlights its potential impact on abnormal remodelling and the development of bone growths. 

Vitamin D

Vitamin D is a nutrient that plays a critical role in bone health by enhancing calcium absorption and, therefore, bone growth. Its active form, calcitriol, stimulates osteoblast function while influencing osteoclast activity, maintaining a balance between breakdown and deposition.⁴ Excessive vitamin D may promote uncontrolled bone formation, contributing to TP development. 

A study suggested that diets based on saltwater fish, which are rich in Vitamin D3, lead to a greater prevalence of the condition.^2,5 This was evidenced by the increasing occurrence of TP in the Greenlandic Norse population when their diet changed to caribou, fish and sea mammals,⁶ suggesting a dietary influence.

Malnutrition 

Malnutrition, due to both nutrient deficiencies and unbalanced diets, significantly affects bone metabolism and remodeling.⁴ Adequate nutrient consumption is essential to maintain bone integrity, and disruptions can lead to abnormal bone growth. 

High levels of unsaturated fatty acid consumption have been suggested to be linked to TP progression by promoting bone growth. It is hypothesised that the omega-3 polyunsaturated fatty acids present in saltwater fish may explain the higher prevalence of TP in island groups or populations.^2,5

Additionally, it is also suggested that the decreased ability to absorb food in elderly populations could result in malnutrition and therefore may affect the occurrence of TP.⁶

Mechanical stress

Excessive muscle activity of the masticatory system - the chewing muscles - can lead to abnormal activity of the muscles themselves. This includes teeth grinding or clenching. It has been suggested that eating tough foods could put pressure on the roof of the mouth, which could lead to thickening of the bone that, over time, could promote the development of TP.^2,8

Genetics 

Some studies have suggested that the inheritance of TP is passed through a dominant gene located on the non-sex chromosomes with reduced penetrance. This means the gene is only required from one parent, as evidenced by 85% of individuals with TP having at least one parent who was affected.⁸ However, it is important to consider that not everyone who carries the gene will develop the condition. Those who are genetically predisposed and are exposed to environmental factors, such as diet and nutrition, are more at risk. 

Living with TP 

Although surgical treatment isn’t recommended for TP unless it is interfering with daily life,¹ there are suggestions to potentially reduce discomfort:

• Consider a well-balanced diet with moderate calcium and vitamin D intake 
• Consider diversifying your protein consumption from fish to other high-protein sources, such as lean meats or tofu, to balance nutrient consumption 
• Consider a diet rich in vitamins, including vitamin C and vitamin K, essential for bone health⁴ 
• Avoid hard foods that may irritate the hard palate or the torus
• Avoid teeth grinding to reduce pressure on the hard palate 

FAQs

Can diet alone prevent torus palatinus?

No, it has been suggested that diet and nutrition play a role in bone health and may promote abnormal bone growth. It is not directly a cause of Torus Palatinus, but rather a contributing factor. A well-balanced diet is crucial for overall bone health and should be considered to support bone metabolism and potentially reduce discomfort.

What foods should I avoid with torus palatinus?

Avoid consuming hard foods such as nuts, raw vegetables and tough breads. Sticky foods such as candies or dried fruits may cause discomfort around the bony growth and cause retention of food remains.^9,10

Can Tori become cancerous?

Tori are benign growths that are not cancerous and cannot evolve into cancer. They are located on the roof of the mouth and rarely interfere with normal functions.¹⁰

What does the torus palatinus look like?

Torus Palatinus has a variety of clinical appearances that can present in lobular, fusiform, nodular or flat in shape. They also vary in size, from a few millimetres to larger protrusions. Tori are only removed if they cause pain or interfere with daily life.²

Summary 

Torus Palatinus is a common condition characterised by a bony growth forming on the roof of the mouth. Although harmless, some individuals could experience difficulty in daily functions such as chewing or swallowing. The condition arises through a combination of different factors and is most common in genetically predisposed individuals exposed to environmental factors. Studies have suggested a link between the development of Torus Palatinus and certain dietary patterns or nutritional influences that directly affect bone metabolism and remodelling. This includes excessive consumption of calcium or vitamin D and malnutrition through unbalanced diets. These studies have shown that cultural and regional dietary habits influence the development of Torus Palatinus, with a higher prevalence in island regions. Surgical treatment to remove the growth is recommended only if it causes discomfort in daily life. Therefore, managing Torus Palatinus through assessing dietary habits and considering modifications to promote a nutrient-rich lifestyle is a potential strategy to live with or reduce the risk of developing Torus Palatinus.