Hyperplastic, Neoplastic and Related Disorders of Oral MucosaDr. Rima Safadi Oral and Maxillofacial Pathology

Hyperplasia of oral mucosaLocalized 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

Hyperplasia of oral mucosaLocalized hyperplastic lesions of oral mucosa Location:

Any where in the mouth Gingiva: epulis

Hyperplasias of Oral MucosaLocalized 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 MucosaFibroepithelial polyp Epulis Fissuratum, inflammatory fibrous hyperplasia, denture irritation hyperplasia Inflammatory papillary hyperplasia (papillary hyperplasia of the palate)

Epulideshyperplastic, not neoplasticMostly 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 epulisClinically: Pedunculated or sessile Firm Similar in color to adjacent gingiva Ulceration +-

Fibrous epulisHistopathology: Cellularity variable Mature collagen Inflammatory infiltrate

Mainly plasma cells

Bone formation Could be less cellular and less vascular

Fibrous epulisChronic hyperplastic gingivitis Or Peripheral ossifying fibroma

Peripheral ossifying fibromaHistopathology: Fibrous proliferation Formation of mineralized product, cementum like High cellularity

Vascular epulis: Pyogenic granulomaOrigin of the name: Clinically: Soft, lobulated Red-purple often ulcerated Bleeding is common Rapid growth History of trauma

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

Pyogenic granulomaPregnancy epulis: pyogenic granuloma in a pregnant female

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

Pyogenic granulomaHistopathology: Highly vascular proliferation

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

Pyogenic granulomaTreatment and prognosis

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

Peripheral giant cell granulomaExclusively 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: hour- glass appearance

Peripheral giant cell granulomaNeed 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 granulomaHistopathology: Giant cells variation in size and number of nuclei Richly vascular and cellular stroma

Peripheral giant cell granulomaHistopathology: Extravasated RBCs and haemosiderin Stromal cells: Spindled or ovoid Macrophage or fibroblasts or endothelial cells Occasional bone formation

Peripheral giant cell granulomaIf multiple: Hyperparathyroidism OR RARELY Neurofibromatosis I

Peripheral giant cell granulomaTreatment:

Local surgical excison to underlying bone Scaling and polishing Recurrence rate 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 fibromaHistopathology

Giant cell fibroma and retrocuspid papillaDistinctive histopathologic finding

Multinucleated fibroblasts

On keratinized mucosa: gingiva, tongue and hard palate

Giant cell fibroma

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

Denture irritation hyperplasia Epulis FissuratumRelated to the flange of ill fitting denture

Denture irritation hyperplasiaClinically: 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 hyperplasiaHistopathology

LEAF FIBROMA

Papillary Hyperplasia of the PalateIll fitting denture Continuous denture wearing Candida associated denture mucositis Histopathology

Connective tissue neoplasmsSwellings Resemble their counterparts in other sites in the body Tissue of origin

Tumors of fibrous tissueBenign tumors (true fibroma) are rare Peripheral odontogenic fibroma Fibrous histiocytoma Nodular fasciitis (neoplastic like lesion) Fibromatosis

Gingival fibromatosisThis is not neoplastic

Aggressive fibromatosis

Tumors of fibrous tissueFibrosarcoma Rare in the oral cavity Relatively good prognosis 5 year survival rate is 70%

Fibrosarcoma

Fibrosarcoma

Tumors of adipose tissue LIPOMAYellowish 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

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 tissuesHemangioma: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???

ClinicallyDark red-purple Elevation: smooth, lobulated, soft or hard Blanching on pressure May increase in size:

Hemangioma

hemorrhage thrombosis inflammation

Hemangioma

Hemangioma

Hemangioma

HemangiomaHistopathology:

Capillary, cavernous and mixedArteriovenous malformation (AVM)

Other Malformations:

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

Capillary and cavernous hemangioma

Cellular hemangioma

AVM

Kaposi sarcoma

Angiosarcoma

Sinosoidal vascular spaces lined by pleomophic endothelial cells

Angiomatous syndromesStrurge-Weber Syndrome1.

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 telangiectasiaMultiple dilated capillaries Nose bleeding

Tumors of vascular tissuesLymphangiomaHamartomatous Predilection for the children and especially tongue Increase in size due to: inflammation, calcification, or sudden increase in size

Lymphangioma

Lymphangioma

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

Tumors of peripheral nervesNerve sheath tumors:1.2.

Neurofibroma, solitary and multiple Neurilemmoma (Schwannoma)

Traumatic neuroma: non neoplastic

Multiple mucosal nueroma

NeurofibromaSoliotary or Multiple/ associated with:

Neurofibromatosis, von Recklinghaisens disease of nervesCutaneous nerves Mutation in tumor suppressor gene: NF1

Neurofibroma

Neurofibroma

NeurofibromaHistologically: 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 INF1 mutation (tumor suppressor gene) Familial, AD or sporadic mutation Multiple neurofibromas of cutanous nerves Intraoraly:

mucosal swellings and bone involvement (mental and ID nerve)

Caf-au

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

NeurofibromatosisTypes I (skin) and II (central nervous system)

Plexiform neurofibromas are characterstic of NeurofibromatosisArise 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 neuromaNon 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 tumorPreviously called : granular cell myoblastoma Arise from Schwann cells Etiology: benign neoplasm, probably of Schwann cells

Clinical featuresSlowly 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

Psuedo-epitheliomatous hyperplasia

Tunmors of musclesLeiomyoma, leiomyomatous hamartoma, leiomyosarcoma Rhabdomyoma, rhabdomyosarcoma

Leiomyoma

Rhabdomyoma

LymphomaHodgkins lymphoma Non-Hodgkins lymphoma

Hodgkins lymphoma30% of all lymphomas Young age group Cervical lymph nodes in 75% Reed- 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 lymphomaHistopathologic types: Lymphocyte predominant Mixed cellularity Nodular sclerosis Lymphocyte depletion

Non-Hodgkins lymphomaB cell: majority T cell/ NK

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

Burkits LymphomaEndemic 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 activation

Starry Sky patternB cell type Dark small malignant lymphoid cells Pale stained macrophages Macrophages are not neoplastic

NK/T cell lymphomaAngiocentric T cell lymphoma, lethal midline granuloma Extensive destruction of midline structures EBV in neoplastic cells

Lethal midline granuloma Tcell lymphoma