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HYPERPLASTIC, NEOPLASTIC AND RELATED DISORDERS OF ORAL MUCOSA

DR. RIMA SAFADI ORAL AND MAXILLOFACIAL PATHOLOGY

Hyperplasia of oral mucosa


Localized hyper plastic lesions of oral mucosa Cause: chronic inflammation
   

Inflammation and repair together Production of granulation tissue Range: richly cellular and vascular Non inflamed, avascular, dense collagen avascular,

Hyperplasia of oral mucosa


Localized hyperplastic lesions of oral mucosa Location:
 

Any where in the mouth Gingiva: epulis

Hyperplasias of Oral Mucosa


Localized hyperplastic lesions of oral mucosa Pyogenic granuloma Peripheral giant cell granuloma *Peripheral ossifying fibroma *Irritation fibroma (focal fibrous hyperplasia) Giant cell fibroma Retrocuspid papilla *In your text book these are considered as fibrous epulius

Hyperplasia of Oral Mucosa


Fibroepithelial polyp Epulis Fissuratum, inflammatory fibrous Fissuratum, hyperplasia, denture irritation hyperplasia Inflammatory papillary hyperplasia (papillary hyperplasia of the palate)

Epulides
hyperplastic, hyperplastic, not neoplastic
Mostly from interdental tissue Irritation from dental plaque and calculus Types:
Fibrous epulis (ossifying fibroma, hyperplastic gingivitis)
commonest

Pyogenic granuloma Peripheral giant cell granuloma

Epulides
More common in females More in anterior to molar region Maxilla>mandible Recur if causative factor persists Or if incompletely excised as in PGCG

Fibrous epulis
Clinically: Pedunculated or sessile Firm Similar in color to adjacent gingiva Ulceration ++-

Fibrous epulis
Histopathology: Cellularity variable Mature collagen Inflammatory infiltrate


Mainly plasma cells

Bone formation Could be less cellular and less vascular

Fibrous epulis
Chronic hyperplastic gingivitis Or Peripheral ossifying fibroma

Peripheral ossifying fibroma


Histopathology: Fibrous proliferation Formation of mineralized product, cementum like High cellularity

Vascular epulis: Pyogenic granuloma


Origin of the name: Clinically: Soft, lobulated RedRed-purple often ulcerated Bleeding is common Rapid growth History of trauma

On gingiva 75% of the time or any other mucosal site 75%

Pyogenic granuloma
Pregnancy epulis: pyogenic granuloma in a pregnant female


 

Gradually increasing in size Regress after delivery Recur if excised in pregnancy and bleed

Pyogenic granuloma
Histopathology:  Highly vascular proliferation


 

Lobular organization (lobular capillary hemangioma) hemangioma) _+ Ulcerated surface Older lesions: more fibrous

Pyogenic granuloma
Treatment and prognosis


 

Conservative surgical excision down to periosteum Occasionally it may recur Pregnancy tumor: delay treatment, may resolve spontaneously

Peripheral giant cell granuloma


Exclusively on the gingiva or alveolar ridge Anterior to molar teeth Slightly More in mandible Dark red in color Commonly ulcerated Present interdentally


Buccal and palatal parts: hourhour- glass appearance

Peripheral giant cell granuloma


Need a radiograph to rule out central giant cell granuloma May reveal superficial bone erosions Pathogenesis: Most likely arise from periosteum Giant cells origin: Macrophages or osteoclasts

Peripheral giant cell granuloma


Histopathology: Giant cells variation in size and number of nuclei Richly vascular and cellular stroma

Peripheral giant cell granuloma


Histopathology: Extravasated RBCs and haemosiderin Stromal cells: Spindled or ovoid Macrophage or fibroblasts or endothelial cells Occasional bone formation

Peripheral giant cell granuloma


If multiple: Hyperparathyroidism OR RARELY Neurofibromatosis I

Peripheral giant cell granuloma


Treatment:
 

Local surgical excison to underlying bone Scaling and polishing Recurrence rate 10% 10%

Prognosis


HYPERPARATHYROIDISM

Fibroepithelial polyp (irritation fibroma)


The commonest lesion of the oral cavity A true tumor?


Doesnt increase significantly in size with time

Most common site is the buccal mucosa Labial mucosa tongue and gingiva Chronic minor trauma appears to be the cause Under denture: Leaf fibroma

Irritation fibroma
Histopathology

Giant cell fibroma and retrocuspid papilla


Distinctive histopathologic finding


Multinucleated fibroblasts

On keratinized mucosa: gingiva, gingiva, tongue and hard palate

Giant cell fibroma

Retrocuspid papilla
Same histopathology as giant cell fibroma Developmental lesion, lingual to mandibular canine on the interdental papilla 25-99% 25-99% of young adults and children

Denture irritation hyperplasia Epulis Fissuratum


Related to the flange of ill fitting denture

Denture irritation hyperplasia


Clinically: Multiple folds of tissue in the vestibule Firm and fibrous Commonly on the facial aspect of the flange


Leaf fibroma on the hard palate

Denture irritation hyperplasia


Histopathology

year old woman


LEAF FIBROMA

nts this palate. routine Denture .

Papillary Hyperplasia of the Palate


Ill fitting denture Continuous denture wearing Candida associated denture mucositis Histopathology

Connective tissue neoplasms


Swellings Resemble their counterparts in other sites in the body Tissue of origin

Tumors of fibrous tissue


Benign tumors (true fibroma) are rare Peripheral odontogenic fibroma Fibrous histiocytoma Nodular fasciitis (neoplastic like lesion) Fibromatosis

Gingival fibromatosis
This is not neoplastic

Aggressive fibromatosis

Tumors of fibrous tissue


Fibrosarcoma Rare in the oral cavity Relatively good prognosis 5 year survival rate is 70% 70%

Fibrosarcoma

Fibrosarcoma

Tumors of adipose tissue LIPOMA


Yellowish colored swelling most commonly in buccal mucosa and tongue Circumscribed mass of mature tissue:


Variable proportions of stroma and mature fat tissue: fibrolipoma, angiolipoma, myxolipoma fibrolipoma, angiolipoma, myxolipoma

Floats in formalin ** traumatic herniation of the buccal pad of fat in infants and young children

lipoma

Lipoma

liposarcoma

Lipoblasts with pleomorphic nuclei

Tumors of vascular tissues


Hemangioma:
May be hamartoma Common especially in oral cavity Mucosa, muscles, bone, major salivary gland Infants and childrenjuvenile hemangioma in parotid gland If multiple . think of syndromes???

Clinically
Dark red-purple redElevation: smooth, lobulated, lobulated, soft or hard Blanching on pressure May increase in size:
  

Hemangioma

hemorrhage thrombosis inflammation

Hemangioma

Hemangioma

Hemangioma

Hemangioma
Histopathology:


Capillary, cavernous and mixed Arteriovenous malformation (AVM)

Other Malformations:


Other vascular anomalies: sublingual varicosities Malignant vascular lesions: Kaposi lesions: sarcoma and angiosarcoma Angiomatous syndromes: syndromes:

Capillary and cavernous hemangioma

Cellular hemangioma

AVM

Kaposi sarcoma

Angiosarcoma

Sinosoidal vascular spaces lined by pleomophic endothelial cells

Angiomatous syndromes
StrurgeStrurge-Weber Syndrome
1.

2.

3.

Hemangiomatous lesions of one or more of the branches of the trigeminal nerve Ipsilateral hemangiomas and calcifications in the meninges over cerebral cortex Convulsions affecting the limbs on the opposite side

..Angiomatous syndromes:

Hereditary hemorrhagic telangiectasia


Multiple dilated capillaries Nose bleeding

Tumors of vascular tissues


Lymphangioma
Hamartomatous Predilection for the children and especially tongue Increase in size due to: inflammation, calcification, or sudden increase in size

Lymphangioma

Lymphangioma

Cystic hygroma
Early in development of lymphatic changes Detected at birth Up to 10 cm in diameter

Tumors of peripheral nerves


Nerve sheath tumors:
1. 2.

Neurofibroma, solitary and multiple Neurilemmoma (Schwannoma)

Traumatic neuroma: non neoplastic




Multiple mucosal nueroma

Neurofibroma
Soliotary or Multiple/ associated with:


Neurofibromatosis, von Recklinghaisens disease of nerves


Cutaneous nerves Mutation in tumor suppressor gene: NF1 NF1

Neurofibroma

Neurofibroma

Neurofibroma
Histologically: Considerable variation Schwann cells and fibroblasts Varying amount of collagen and mucoid tissue A few nerve fibers run through the lesion May be circumscribed or diffuse

Neurofibroma

Neurofibroma

Neurofibromatosis I
NF1 NF1 mutation (tumor suppressor gene) Familial, AD or sporadic mutation Multiple neurofibromas of cutanous nerves
Intraoraly: mucosal swellings and bone involvement (mental and ID nerve)

CafCaf-au lait spots Other findings: axillary freckeling Malignant transformationin 5-15% of all 15% cases

Neurofibromatosis
Types I (skin) and II (central nervous system)


Plexiform neurofibromas are characterstic of Neurofibromatosis


Arise within or around nerve trunks A mass of nerves surrounded by Schwann cells and fibroblasts

Schwannoma (Neurilemmoma)
Encapsulated Nerve fibers dont pass through the lesion


May be over the capsule

Spindled cells with parallel nuclei

Traumatic neuroma
Non neoplastic disorganized overgrowth of nerve fibers, Schwann cells and scar tissue severed end of nerves Exaggerated regeneration of nerve tissue Clinical features  Slowly growing  Firm, fixed to surrounding structures  Painful to palpation  large nerves, such as mental foramen

MEN (multiple endocrine neoplasia)


Type IIb  Multiple mucosal neuromas  Phaecromocytoma  Medullary thyroid carcinoma

RET oncogene mutation




Can be used for screening

Granular cell tumor


Previously called : granular cell myoblastoma Arise from Schwann cells Etiology: benign neoplasm, probably of Schwann cells

Clinical features
Slowly growing. Most common in tongue. Firm, fixed to overlying mucosa and deep structures Multiple tumors may occur

Non encapsulated Feeling of invasion/but it is benign Granular cells: contain lysosomes

PsuedoPsuedo-epitheliomatous hyperplasia

Tunmors of muscles
Leiomyoma, leiomyomatous hamartoma, leiomyosarcoma Rhabdomyoma, rhabdomyosarcoma

Leiomyoma

Rhabdomyoma

Lymphoma
Hodgkins lymphoma NonNon-Hodgkins lymphoma

Hodgkins lymphoma
30% 30% of all lymphomas Young age group Cervical lymph nodes in 75% 75% ReedReed- Sternberg cell is the diagnostic cell: large cell with 2 nuclei or bilobed nucleus (mirror image) Genetic factors and viral infection (EBV) Prognosis: clinical staging and histologic grading Distribution: mainly nodal

Hodgkins lymphoma
Histopathologic types: Lymphocyte predominant Mixed cellularity Nodular sclerosis Lymphocyte depletion

NonNon-Hodgkins lymphoma
B cell: majority T cell/ NK

extra nodal  MALT lymphoma better prognosis than lymphoma nodal, remian localized for long periods  Salivary gland.Sjogren Syndrome and gland.Sjogren myoepithelial sialadentitis  Bone  AIDS

Burkits Lymphoma
Endemic and sporadic Endemic: Africa: EBV and Malaria Children 2-14 yrs
 

Starts in the jaws, maxillary and posterior Rapidly growing, multifocal Starts in the abdomen

Sporadic: no viral association




Chromosomal translocation 8,14. c-myc 14. cactivation

Starry Sky pattern


B cell type Dark small malignant lymphoid cells Pale stained macrophages Macrophages are not neoplastic

NK/T cell lymphoma


Angiocentric T cell lymphoma, lethal midline granuloma Extensive destruction of midline structures EBV in neoplastic cells

Lethal midline granuloma Tcell lymphoma