CT Hyperplasia ( Slide # 1+2)

8/3/2019 CT Hyperplasia ( Slide # 1+2)

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HYPERPLASTIC,HYPERPLASTIC,NEOPLASTIC ANDNEOPLASTIC AND

RELATED DISORDERS OFRELATED DISORDERS OF

ORAL MUCOSAORAL MUCOSA

DR. RIMA SAFADIDR. RIMA SAFADI

ORAL AND MAXILLOFACIALORAL AND MAXILLOFACIAL

PATHOLOGYPATHOLOGY


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Hyperplasia of oral mucosaHyperplasia of oral mucosa

Localized hyper plastic lesions of oralLocalized hyper plastic lesions of oral

mucosamucosa

Cause: chronic inflammationCause: chronic inflammation Inflammation and repair togetherInflammation and repair together

Production of granulation tissueProduction of granulation tissue

Range: richly cellular and vascularRange: richly cellular and vascular

Non inflamed,Non inflamed, avascularavascular, dense collagen, dense collagen


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Hyperplasia of oral mucosaHyperplasia of oral mucosa

Localized hyperplastic lesions of oralLocalized hyperplastic lesions of oral

mucosamucosa

Location:Location: Any where in the mouthAny where in the mouth

Gingiva: epulisGingiva: epulis


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Hyperplasias of Oral MucosaHyperplasias of Oral Mucosa

LocalizedLocalized hyperplastichyperplastic lesions of oral mucosalesions of oral mucosa

PyogenicPyogenic granulomagranuloma

Peripheral giant cellPeripheral giant cell granulomagranuloma

*Peripheral ossifying fibroma*Peripheral ossifying fibroma

*Irritation fibroma (focal fibrous hyperplasia)*Irritation fibroma (focal fibrous hyperplasia)

Giant cell fibromaGiant cell fibroma

RetrocuspidRetrocuspid papillapapilla

*In your text book these are considered as*In your text book these are considered as

fibrousfibrous epuliusepulius


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Hyperplasia of Oral MucosaHyperplasia of Oral Mucosa

FibroepithelialFibroepithelial polyppolyp

EpulisEpulis FissuratumFissuratum, inflammatory fibrous, inflammatory fibrous

hyperplasia,hyperplasia, denture irritation hyperplasia

Inflammatory papillary hyperplasia (papillaryInflammatory papillary hyperplasia (papillaryhyperplasia of the palate)hyperplasia of the palate)


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EpulidesEpulides

hyperplastichyperplastic, not neoplastic, not neoplasticMostly fromMostly from interdentalinterdental tissuetissue

Irritation from dental plaque and calculusIrritation from dental plaque and calculus

Types:Types: FibrousFibrous epulisepulis (ossifying fibroma,(ossifying fibroma, hyperplastichyperplastic

gingivitis)gingivitis)

commonestcommonest

PyogenicPyogenic granulomagranuloma Peripheral giant cellPeripheral giant cell

granulomagranuloma


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EpulidesEpulides

More common in femalesMore common in females

More in anterior to molar regionMore in anterior to molar region

Maxilla>mandibleMaxilla>mandible

Recur if causative factor persistsRecur if causative factor persists

Or if incompletely excised as in PGCGOr if incompletely excised as in PGCG


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FibrousFibrous epulisepulis

Clinically:Clinically:

Pedunculated orPedunculated or

sessilesessile

FirmFirm

Similar in color toSimilar in color to

adjacent gingivaadjacent gingiva

Ulceration +Ulceration +--


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Fibrous epulisFibrous epulis

Histopathology:Histopathology:

Cellularity variableCellularity variable

Mature collagenMature collagen

Inflammatory infiltrateInflammatory infiltrate

Mainly plasma cellsMainly plasma cells

Bone formationBone formation

Could be less cellularCould be less cellularand less vascularand less vascular


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Fibrous epulisFibrous epulis

Chronic hyperplastic gingivitisChronic hyperplastic gingivitis

OrOr

Peripheral ossifying fibromaPeripheral ossifying fibroma


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Peripheral ossifying fibromaPeripheral ossifying fibroma


Fibrous proliferationFibrous proliferation

Formation of mineralized product,Formation of mineralized product,cementumcementum likelike

HighHigh cellularitycellularity


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Vascular epulis: PyogenicVascular epulis: Pyogenic

granulomagranulomaOrigin of the name:Origin of the name:


Soft, lobulatedSoft, lobulated

RedRed--purple often ulceratedpurple often ulceratedBleeding is commonBleeding is common

Rapid growthRapid growth

History of traumaHistory of trauma

On gingivaOn gingiva 7575% of the time or any other mucosal site% of the time or any other mucosal site


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Pyogenic granulomaPyogenic granuloma

Pregnancy epulis:Pregnancy epulis:

pyogenic granulomapyogenic granuloma

in a pregnant femalein a pregnant female

Gradually increasing inGradually increasing insizesize

Regress after deliveryRegress after delivery

Recur if excised inRecur if excised in

pregnancy and bleedpregnancy and bleed


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Highly vascularHighly vascular

proliferationproliferation

Lobular organizationLobular organization

(lobular capillary(lobular capillary

hemangiomahemangioma))

_+ Ulcerated surface_+ Ulcerated surface

Older lesions: moreOlder lesions: morefibrousfibrous


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Treatment and prognosisTreatment and prognosis

Conservative surgical excision down toConservative surgical excision down to

periosteumperiosteum

Occasionally it may recurOccasionally it may recur

Pregnancy tumor: delay treatment, mayPregnancy tumor: delay treatment, may

resolve spontaneouslyresolve spontaneously


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Peripheral giant cell granulomaPeripheral giant cell granuloma

Exclusively on theExclusively on the gingivagingiva

or alveolar ridgeor alveolar ridge

Anterior to molar teethAnterior to molar teeth

Slightly More inSlightly More inmandiblemandible

Dark red in colorDark red in color

Commonly ulceratedCommonly ulcerated

Present interdentallyPresent interdentally

BuccalBuccal and palatal parts:and palatal parts:hourhour-- glass appearanceglass appearance


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Peripheral giant cellPeripheral giant cell

granulomagranulomaNeed a radiograph to rule out central giantNeed a radiograph to rule out central giantcell granulomacell granuloma

May reveal superficial bone erosionsMay reveal superficial bone erosions

Pathogenesis:Pathogenesis:

Most likely arise from periosteumMost likely arise from periosteum

Giant cells origin:Giant cells origin:

Macrophages or osteoclastsMacrophages or osteoclasts


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Giant cellsGiant cells variation invariation in

size and number ofsize and number of

nucleinuclei

RichlyRichly vascularvascularandand

cellular stromacellular stroma


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Extravasated RBCs andExtravasated RBCs and

haemosiderinhaemosiderin

Stromal cells:Stromal cells:Spindled or ovoidSpindled or ovoid

Macrophage orMacrophage or

fibroblasts or endothelialfibroblasts or endothelial

cellscellsOccasional bone formationOccasional bone formation


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If multiple:If multiple:

HyperparathyroidismHyperparathyroidism

OR RARELYOR RARELY

Neurofibromatosis INeurofibromatosis I


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Treatment:Treatment:

Local surgical excison to underlying boneLocal surgical excison to underlying bone

Scaling and polishingScaling and polishing

PrognosisPrognosis

Recurrence rateRecurrence rate 1010%%


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HYPERPARATHYROIDISMHYPERPARATHYROIDISM


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Fibroepithelial polypFibroepithelial polyp

(irritation fibroma)(irritation fibroma)The commonest lesion of the oral cavityThe commonest lesion of the oral cavity

A true tumor?A true tumor?

Doesnt increase significantly in size with timeDoesnt increase significantly in size with time

Most common site is theMost common site is the buccalbuccal mucosamucosa

Labial mucosa tongue andLabial mucosa tongue and gingivagingiva

ChronicChronic minor traumaminor trauma appears to be theappears to be the

causecause

Under denture: Leaf fibromaUnder denture: Leaf fibroma


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Irritation fibromaIrritation fibroma

HistopathologyHistopathology


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Giant cell fibroma and retrocuspidGiant cell fibroma and retrocuspid

papillapapilla

DistinctiveDistinctive

histopathologichistopathologic

findingfinding

MultinucleatedMultinucleatedfibroblastsfibroblasts

On keratinizedOn keratinized

mucosa:mucosa: gingivagingiva,,

tongue and hardtongue and hard

palatepalate


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Giant cell fibromaGiant cell fibroma


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Retrocuspid papillaRetrocuspid papilla

Same histopathology as giant cellSame histopathology as giant cellfibromafibroma

Developmental lesion, lingual toDevelopmental lesion, lingual to

mandibular canine on the interdentalmandibular canine on the interdentalpapillapapilla

2525--9999% of young adults and children% of young adults and children


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Denture irritation hyperplasiaDenture irritation hyperplasia

Epulis FissuratumEpulis Fissuratum

Related to theRelated to the

flange of ill fittingflange of ill fitting

denturedenture


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Multiple folds of tissue in the vestibuleMultiple folds of tissue in the vestibuleFirm and fibrousFirm and fibrous

Commonly on the facial aspect of theCommonly on the facial aspect of the

flangeflange Leaf fibroma on the hard palateLeaf fibroma on the hard palate


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y

ear o womanear o woman


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LEAF FIBROMALEAF FIBROMA

year o womanear o woman

nts thisnts thisalate.alate.

routineroutine

entureenture..


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Papillary Hyperplasia of the PalatePapillary Hyperplasia of the Palate

Ill fitting dentureIll fitting denture

Continuous dentureContinuous denture

wearingwearing

Candida associatedCandida associated

denture mucositisdenture mucositis



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Connective tissue neoplasmsConnective tissue neoplasms

SwellingsSwellings

Resemble their counterparts in other sitesResemble their counterparts in other sites

in the bodyin the bodyTissue of originTissue of origin


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Tumors of fibrous tissueTumors of fibrous tissue

Benign tumorsBenign tumors (true fibroma)(true fibroma) are rareare rare

Peripheral odontogenic fibromaPeripheral odontogenic fibroma

Fibrous histiocytomaFibrous histiocytomaNodular fasciitis (neoplastic like lesion)Nodular fasciitis (neoplastic like lesion)

FibromatosisFibromatosis


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GingivalGingival fibromatosisfibromatosisThis is not neoplasticThis is not neoplastic


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Aggressive fibromatosisAggressive fibromatosis


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Tumors of fibrous tissueTumors of fibrous tissue

FibrosarcomaFibrosarcoma

Rare in the oral cavityRare in the oral cavity

Relatively good prognosisRelatively good prognosis 55 year survivalyear survivalrate israte is 7070%%


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Tumors of adipose tissueTumors of adipose tissue

LIPOMALIPOMA

YellowishYellowish colored swelling most commonlycolored swelling most commonlyinin buccalbuccal mucosa and tonguemucosa and tongue

CircumscribedCircumscribed mass of mature tissue:mass of mature tissue: Variable proportions of stroma and mature fatVariable proportions of stroma and mature fat

tissue:tissue:

fibrofibrolipomalipoma,, angioangiolipomalipoma,, myxomyxolipomalipoma

Floats in formalinFloats in formalin

** traumatic** traumatic herniationherniation of theof the buccalbuccal pad ofpad offat in infants and young childrenfat in infants and young children


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lipomalipoma


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LipomaLipoma


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liposarcomaliposarcoma

Lipoblasts with pleomorphic nuclei


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Tumors of vascular tissuesTumors of vascular tissues

Hemangioma:Hemangioma:

May be hamartomaMay be hamartoma

Common especially in oral cavityCommon especially in oral cavity

Mucosa, muscles, bone, major salivary glandMucosa, muscles, bone, major salivary gland

Infants and childrenjuvenile hemangioma inInfants and childrenjuvenile hemangioma in

parotid glandparotid gland

If multipleIf multiple . think of syndromes???. think of syndromes???


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HemangiomaHemangiomaClinicallyClinically

DarkDark redred--purplepurpleElevation: smooth,Elevation: smooth,

lobulatedlobulated, soft or, soft or

hardhard

BlanchingBlanching onon

pressurepressure

May increase in size:May increase in size:

hemorrhagehemorrhage

thrombosisthrombosis

inflammationinflammation


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HemangiomaHemangioma


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HistopathologyHistopathology:: Capillary, cavernous and mixedCapillary, cavernous and mixed

Other Malformations:Other Malformations:

ArteriovenousArteriovenous malformation (AVM)malformation (AVM)

Other vascular anomalies: sublingualOther vascular anomalies: sublingual

varicositiesvaricosities

Malignant vascular lesionsMalignant vascular lesions: Kaposi: Kaposi

sarcoma andsarcoma and angiosarcomaangiosarcoma

AngiomatousAngiomatous syndromessyndromes::


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Capillary and cavernousCapillary and cavernous

hemangiomahemangioma


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Cellular hemangiomaCellular hemangioma


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AVMAVM


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Kaposi sarcomaKaposi sarcoma


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AngiosarcomaAngiosarcoma

Sinosoidal vascular spaces lined by pleomophic endothelial cells


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Angiomatous syndromesAngiomatous syndromes

StrurgeStrurge--Weber SyndromeWeber Syndrome

1.1. Hemangiomatous lesions of one or more ofHemangiomatous lesions of one or more of

the branches of thethe branches of the trigeminal nervetrigeminal nerve

2.2. Ipsilateral hemangiomas and calcifications inIpsilateral hemangiomas and calcifications inthethe meningesmeninges over cerebral cortexover cerebral cortex

3.3. ConvulsionsConvulsions affecting the limbs on theaffecting the limbs on the

opposite sideopposite side


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..Angiomatous syndromes:..Angiomatous syndromes:

Hereditary hemorrhagic telangiectasiaHereditary hemorrhagic telangiectasia

Multiple dilated capillariesMultiple dilated capillaries

Nose bleedingNose bleeding


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Tumors of vascular tissuesTumors of vascular tissues

LymphangiomaLymphangioma

HamartomatousHamartomatous

Predilection for the children and especiallyPredilection for the children and especially

tonguetongue

Increase in size due to: inflammation,Increase in size due to: inflammation,

calcification, or sudden increase in sizecalcification, or sudden increase in size


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Lymphangioma

L h i


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Lymphangioma


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Cystic hygromaCystic hygroma

Early in developmentEarly in development

of lymphatic changesof lymphatic changes

Detected at birthDetected at birth

Up toUp to 1010 cm incm indiameterdiameter


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Tumors of peripheral nervesTumors of peripheral nerves

Nerve sheath tumors:Nerve sheath tumors:

1.1. Neurofibroma, solitary and multipleNeurofibroma, solitary and multiple

2.2. Neurilemmoma (Schwannoma)Neurilemmoma (Schwannoma)

Traumatic neuroma: non neoplasticTraumatic neuroma: non neoplastic

Multiple mucosal nueromaMultiple mucosal nueroma

N fibN fib


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NeurofibromaNeurofibroma

Soliotary orSoliotary or

Multiple/ associated with:Multiple/ associated with:

Neurofibromatosis, vonNeurofibromatosis, vonRecklinghaisens disease of nervesRecklinghaisens disease of nerves

Cutaneous nervesCutaneous nerves

Mutation in tumor suppressor gene: NFMutation in tumor suppressor gene: NF11


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Histologically:Histologically:

Considerable variationConsiderable variation

Schwann cells and fibroblastsSchwann cells and fibroblastsVarying amount of collagen and mucoidVarying amount of collagen and mucoid

tissuetissue

A few nerve fibers run through the lesionA few nerve fibers run through the lesionMay be circumscribed or diffuseMay be circumscribed or diffuse


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Neurofibromatosis INeurofibromatosis I

NFNF11 mutation (tumor suppressor gene)mutation (tumor suppressor gene)

Familial, AD or sporadic mutationFamilial, AD or sporadic mutation

Multiple neurofibromas ofMultiple neurofibromas ofcutanouscutanousnervesnerves

Intraoraly: mucosal swellings and boneIntraoraly: mucosal swellings and bone

involvement (mental and ID nerve)involvement (mental and ID nerve)

CafCaf--au lait spotsau lait spots

Other findings: axillary freckelingOther findings: axillary freckeling

Malignant transformationinMalignant transformationin 55--1515% of all% of all


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NeurofibromatosisNeurofibromatosis

Types I (skin) and II (central nervousTypes I (skin) and II (central nervous

system)system)

Plexiform neurofibromas arePlexiform neurofibromas arecharacterstic of Neurofibromatosischaracterstic of Neurofibromatosis

Arise within or around nerve trunksArise within or around nerve trunks

A mass of nerves surrounded by SchwannA mass of nerves surrounded by Schwann

cells and fibroblastscells and fibroblasts


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Schwannoma (Neurilemmoma)Schwannoma (Neurilemmoma)

EncapsulatedEncapsulated

Nerve fibersNerve fibers dont passdont pass through thethrough the

lesionlesion May be over the capsuleMay be over the capsule

Spindled cells with parallel nucleiSpindled cells with parallel nuclei


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Traumatic neuromaTraumatic neuroma

Non neoplastic disorganized overgrowth ofNon neoplastic disorganized overgrowth ofnerve fibers, Schwann cells and scar tissuenerve fibers, Schwann cells and scar tissue

severed end of nervessevered end of nerves

Exaggerated regeneration of nerve tissueExaggerated regeneration of nerve tissue

Clinical featuresClinical features

Slowly growingSlowly growing

Firm, fixed to surrounding structuresFirm, fixed to surrounding structures

Painfulto palpationPainfulto palpation

large nerves, such as mentallarge nerves, such as mental

foramenforamen


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MEN (multiple endocrineMEN (multiple endocrine


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MEN (multiple endocrineMEN (multiple endocrine

neoplasia)neoplasia)

TypeType IIbIIb

Multiple mucosal neuromasMultiple mucosal neuromas

PhaecromocytomaPhaecromocytoma Medullary thyroid carcinomaMedullary thyroid carcinoma

RETRET oncogeneoncogene mutationmutation

Can be used for screeningCan be used for screening


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Granular cell tumorGranular cell tumor

Previously called : granular cellPreviously called : granular cell

myoblastomamyoblastoma

Arise from Schwann cellsArise from Schwann cells

Etiology: benign neoplasm, probably ofEtiology: benign neoplasm, probably of

Schwann cellsSchwann cells



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Slowly growing.Slowly growing.

Most common inMost common in

tongue.tongue.

Firm, fixed toFirm, fixed to

overlying mucosaoverlying mucosa

and deep structuresand deep structures

Multiple tumors mayMultiple tumors mayoccuroccur


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Non encapsulatedNon encapsulated

Feeling of invasion/but it is benignFeeling of invasion/but it is benign

Granular cells: contain lysosomesGranular cells: contain lysosomes


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PsuedoPsuedo--epitheliomatousepitheliomatous


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pp

hyperplasiahyperplasia


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Tunmors of musclesTunmors of muscles

Leiomyoma, leiomyomatous hamartoma,Leiomyoma, leiomyomatous hamartoma,

leiomyosarcomaleiomyosarcoma

Rhabdomyoma, rhabdomyosarcomaRhabdomyoma, rhabdomyosarcoma


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LeiomyomaLeiomyoma


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RhabdomyomaRhabdomyoma

L hL h


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LymphomaLymphoma

Hodgkins lymphomaHodgkins lymphoma

NonNon--Hodgkins lymphomaHodgkins lymphoma

H d ki l hH d ki l h


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3030% of all lymphomas% of all lymphomas

Young age groupYoung age group

Cervical lymph nodes inCervical lymph nodes in 7575%%

ReedReed-- Sternberg cell is the diagnostic cell: largeSternberg cell is the diagnostic cell: largecell withcell with 22 nuclei or bilobed nucleus (mirrornuclei or bilobed nucleus (mirror

image)image)

Genetic factors and viral infection (EBV)Genetic factors and viral infection (EBV)

Prognosis: clinicalPrognosis: clinical stagingstaging and histologicand histologic gradinggrading

Distribution: mainly nodalDistribution: mainly nodal


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H d ki l hH d ki l h


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Histopathologic types:Histopathologic types:

Lymphocyte predominantLymphocyte predominant

Mixed cellularityMixed cellularity

Nodular sclerosisNodular sclerosis

Lymphocyte depletionLymphocyte depletion

NN H d ki l hH d ki l h


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NonNon--Hodgkins lymphomaHodgkins lymphoma

B cell: majorityB cell: majority

T cell/ NKT cell/ NK

extra nodalextra nodal MALT lymphomaMALT lymphoma better prognosis than better prognosis than

nodal, remian localized for long periodsnodal, remian localized for long periods

Salivary glandSalivary gland.Sjogren Syndrome and.Sjogren Syndrome and

myoepithelial sialadentitismyoepithelial sialadentitis BoneBone

AIDSAIDS


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B kit L hB kit L h


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Burkits LymphomaBurkits Lymphoma

Endemic and sporadicEndemic and sporadic

Endemic: Africa:Endemic: Africa: EBV and MalariaEBV and Malaria

ChildrenChildren 22--1414 yrsyrs

Starts in the jaws, maxillary and posteriorStarts in the jaws, maxillary and posterior

Rapidly growing, multifocalRapidly growing, multifocal

Sporadic: no viral associationSporadic: no viral association

Starts in the abdomenStarts in the abdomenChromosomal translocationChromosomal translocation 88,,1414. c. c--mycmycactivationactivation

Starr Sk patternStarr Sk pattern


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Starry Sky patternStarry Sky pattern

B cell typeB cell type

Dark small malignant lymphoid cellsDark small malignant lymphoid cells

Pale stained macrophagesPale stained macrophages

Macrophages are not neoplasticMacrophages are not neoplastic

NK/T cell lymphomaNK/T cell lymphoma


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NK/T cell lymphomaNK/T cell lymphoma

Angiocentric T cell lymphoma, lethalAngiocentric T cell lymphoma, lethal

midline granulomamidline granuloma

Extensive destruction of midline structuresExtensive destruction of midline structures

EBV in neoplastic cellsEBV in neoplastic cells

Lethal midline granulomaLethal midline granuloma


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Tcell lymphomaTcell lymphoma

CT Hyperplasia ( Slide # 1+2)

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