Today the lecture is about Hyperplastic,Neoplastic,and related disorders of Oral Mucosa

and you know from general pathology the difference between the hyperplasia and Neoplasia

Hyperplasia : Increase in the number of the cells >> continuous division but without metastases

Neoplasia : New growth with a change in the normal cell cycle >> uncontrolled division.

#Hyperplastic Legion of the Oral Cavity : 1 . Not benign Tumor They ARE Reactive* , There usually a stimulus that cause the Legion >< The stimulus usually low grade << IF it high grade irritation to the oral Mucosa, such a traumatic cheek bite ,, lead to ulceration usually >>

Pt with habitual cheek bite at a certain location >> There will be a time for the body to deposit fibrous tissue and lead to hyperplasia.

* Hyperplastic legions are REACTIVE Not Due to a genetic mutation in the cell cycle control >> Not benign Tumors .

2. because it's chronic irritation usually chronic inflammation you know that chronic inflammation associated with repair << Repair = granulation tissue >> Granulation tissue matures we have fibrous

tissue and decrease in the amount of the B.V

ALL of this the Granulation tissue and the mature dense collagen which avascular ( relatively not inflamed ) will give us exophitic mass.

Where can we see hyperplastic legions in the oral cavity !?

Everywhere 1. Gingiva ( Called epulis ) 2. Buccal mucosa 3. Soft and hard palat 4.floor of the mouth 5. Tongue.

Epulis : Hyper-plastic lesion in the gingiva

Localized hyperplastic lesions of oral Mucosa: 1 . Pyogenic Granuloma

2 . peripheral giant cell granuloma

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3. peripheral ossifying fibroma

4 . Irritation fibroma ( focal fibrous hyper-plasia )

5 . Gaint cell fibroma

6. Retrocuspid papilla

7 . Fibroepithelial polyp

8 . Epulis fissuratum , Inflammatory fibrous hyperplasia , denture irritation hyperplasia

9. Inflammatory papillary hyperplasia of the palate

Let US start with EPULIS:

Hyperplastic lesion occurring in Gingiva

( Hyperplastic legion = granulation tissue ) and by now you should know that the granulation tissue shows different amount of B.V and Fibrous tissue.

#If the granulation tissue gets more mature then we will have bale color lesion with more fibrous tissue > If The granulation is young and still immature we will have red legion with high amount of B.V and it will bleed easily.

More common to occur between the teeth Why !? because usually have plaque and calculus more between the teeth and the stimulation of them with bacteria will be more so we will have epulis more can occur also in anterior premolar region / Maxilla More than the mandible ( cus the pt are mouth breathers , the gingiva which irritated the upper not the lower << More borne to

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Pic # 1 : Exophetic Mass , wide base ,no constricted neck of the legion , not fiery red almost like the surrounding tissue

*mature granulation tissue , between the teeth

dry air >> Increase the inflammation>> #It can Recur if the : 1. Causative factor persists

2 .Incompletely excised as * PGCG

Epulis have Three Types :

1 . Fibrous Epulis : ( More fibrous tissue >> less B.V ) DOSENT bleed easily the most common type , Usually its ( sessile = wide broad base ) but it may be ( pedunculted = narrow base ) The lesion is having a space to occur between the lateral and canine but if there is no enough space the legion may squeeze it self between the teeth , usually firm , similar color with gingiva , ulceration depend on the trauma ^ _^ ( if it 2nd

traumatized it may ulcerate ) Histopathology:

pic # 2What I see in the histopathology : depend if I looking to hyperplastic gingivitis or peripheral ossifying fibroma

In hyperplastic gingivitis I see granulation tissue and some mineralized tissue or bone formation ( reactive bone formation , due to the present of inflammation ) Ossifying fibroma:

pic # 3

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*well-formed bundles of fibroblast * bone formation in

addition and collagen to the bundles

____________________________________________ this is the peripheral ossifying fibroma " ending by *oma* but not benign tumor " it's hyperplastic fibrous epulis , and

reactive to irritation . Different from the central ossifying fibroma which is benign tumor and it will keep growing and reach big sizes.

Pic # 4

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*we see a growth here in the buccal aspect of the teeth , anterior to the first molar which pedunculated " can be removed " has a constricted

neck .

2 .Vascular Epulis : ( More B.V >> less fibrous tissue ) young and bleed easily , usually red

It's other name : Pyogenic Granuloma is a vascular epulis occurring anywhere in the oral cavity , when it occur in the gingiva we call it Epulis :/ it's Soft / lobulated / red – purple / bleeds/rapid growth *usually there is a history of trauma specially when it occur in the buccal mucosa

##DR . has seen a mass in the buccal mucosa which red bleeding easily and it was of 2 days duration , but the mass was big So it shows rapid growth in the action of trauma.

It's occur in the gingiva 75% of the time , but it may occur in other site .

Other name of the pyogenic granuloma is Pregnancy tumor or Pregnancy epulis .

**it's pyogenic granuloma and occur more in the pregnancy women's due to the changes in hormones and Endothelial cell ( the lining of the B.V have a receptors of progesterone & estrogen so there may be increase in the granulation tissue formation , the response is higher and more vascular ) should not be removed during pregnancy , cus it will return back , we delayed until after delivery.

So it regress after delivery and then it will reach a static size,, it can be removed

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*red color compare to the surrounding mucosa grows rapidly

There was one case of pregnancy granuloma, it was very aggressive it destroy 6 / 7 and extend to the lingual and buccal aspect .

Why they call it " Pyogenic " ?! cus previosly think that pyogenic bacteria cause the lesion ( pyogenic = puss forming ) but here there is no puss << no role of pyogenic

bacteria >>

Where we can find the lesion: 1 .upper lib

2 .Gingiva 3 .Dorsum of the tongue

______________________________________ Pyogenic granuloma will mature with time it will form more fibrous tissue so it will look pale sometimes

Histopathology: look at the B.V you see numerous small capillary size B.V it's also called lobular capillary hemangioma .

Ulceration is + / - due to secondary trauma to the legion.When the legion become old it will be more fibrous.

Treatment : 1. In pregnancy we will delay it 2 .Need conservative surgical removal

**and make sure that the cause is removed .

Now we know 2 types of Epulids fibrous epulis ( 1. Chronic hyperplastic gingivitis 2. Peripheral ossifying fibroma )

And vascular epulis ( called pyogenic granuloma ) THIRD TYPE OF EPULIS:

3 .Peripheral gaint cell granuloma : you remember the central gaint cell granuloma in the bone , having 2 clinical variant aggressive and non-aggressive but it's not a tumor the same here this is not a tumor it have the same histology as the central gaint cell granuloma , it may be also associated with hyper- parathyrodisim , if it's multiple , and it may be extension to the central gaint cell

6 | P a g eWhat is the differences between the peripheral gaint cell granuloma and pyogenic granuloma!?

the peripheral occur only in the gingiva , or only in the* alveolar mucosa while the pyogenic anywhere in the oral

cavity .

granuloma ( when it perforated the bone ).

*the gingiva after the extraction of the tooth .

##Peripheral gaint cell granuloma is dark red as you know , cus it's vascular and sometimes we can see hemosiderin ,, can bleed easily ) =

We need a radiograph why ?! To roll out central legion , it may be a continuation of a central legion.

The origin of these Multinucleated gaint cells , from either macrophages or periosteum ( they think it's from periosteum cus it's not occurring in other location of the jaw except the alveolar mucosa or gingiva )

##I f it presented interdentally seques between the teeth and give a hour glass appearance .

Stroma " supporting tissue , cells between the multinecluated gaint cell" : spindled cell or ovoid , can be macrophage and may contain fibroblast or endotheial cells.

Treatment : surgical removal down to the periosteum don’t leave any part of the legion , cus there is recurrent rate of 10%.

Other Hyperplastic lesion : In General the fibroepthelial polyp is the most common lesion in the oral cavity at all , most common in the in the buccal mucosa / labial mucosa / tongue and gingiva , also known as irritation fibroma , not

neoplastic , reactive lesion , more fibrous and collagen tissue ,

Caused by chronic minor trauma appears to be the cause /ill-fitting denture / sharp cusp.

**The net result will be excessive amount of fibrous tissue as A reaction of the trauma , the body is trying to protect him self .

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What is the differences between the peripheral gaint cell granuloma and pyogenic granuloma!?

the peripheral occur only in the gingiva , or only in the* alveolar mucosa while the pyogenic anywhere in the oral

cavity .

**Here it seem that the patient has buccaly erupted 3rd molar , more borne to cheek biting to buccal mucosa , it not a tumor because doesn’t increase significantly in size with time , it's grows a reach certain size and stop.

##Sharp sever trauma don’t give us fibrous polyp , it will result in ulcer of sever injury , but the fibrous tissue formation need time ( chronic minor trauma ).

Look at this lesion , here in the surface epithelium and it look atrophic actually in the buccal mucosa we have broad rete ridges ,

cus it's pushed by the underlying fibrous tissue .

The fibrous tissue tissue here is relatively avascular , also is not cellular I don’t see here a bundles of fibroblast , I see amount of collagen pale pink : collagen , black dots : some of them are lymphocytes or fibroblast.

##All over it's fibrous , and the epithelium is mainly atrophic

**Treatment : excision or surgical removal.

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Now we have a variant of irritation fibroma : Gaint cell fibroma

We have an interesting finding microscoply , it's gaint fibroblast

And the fibroblast it self not spindle , it's having still late appearance and some time it's multinucleated .

**More fibrous tissue . the best location is keratinized mucosa : 1. Dorsum of the tongue

2 .Gingiva

We have other gaint cell fibroma but appear in other location ( specific location ) << lingual to the lower canine >> as a small nodules lingual to lower canine , and the histology of them << Gaint

cell Fibroma >> and it called " Retrocuspid papilla "

Considered as a normal variation , cus high percentage of the adults and children are having retrocuspid papilla , and it usually bilateral , they think that covers neurovascular bundles.

Excessive amount of fibrous tissue and hyperplasia of the* oral mucosa ( mean surface epithelium and the underlying tissue ) , when I say hyperplasia of the oral mucosa , I mean the underlying tissue ( C.T in general ) C.T may be give you hyperplastic lesions , they look like folds and between the folds fissures and these fissures may be ulcerated cus inside them they will be the denture flange , and cus the denture is ill-fitting it will cause minor chronic trauma of the mucosa ,, there is enough time for the body to form fibrous tissue , it will give the lesion specific name ( epulis fissuratum ) another common name is ( Denture irritation hyperplasia ).

**more common buccaly ** more common also in the upper denture .

##If occurred under the denture in the palate , it will be squeezed cus of the denture , and give us appearance of the leaf called ( Leaf Fibroma )

Microscopically : I see exophitic mass , the underlying tissue is pale and fibrous , not cellular not vascular .

Sometimes the palate show small papillary projection , next to each other the denture here either it's ill-fitting , or the pt wear the

patient day and night . This lesion is papillary hyperplasia, numerous papillary projection in the palate , reactive to a chronic minor trauma over long duration.

Later on in the chapter of infections Candida will colonize the

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surface of the denture, specially the upper denture. Histopathology : The underlying mucosa , or sub mucosa is hyperplastic forming fibrous tissue going under these projections , not cellular all of the deep pink is collagen , fibrous tissue.

__________________________________________________Done by : Heba Radaideh

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