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Pathology Pathology of the of the
Oral CavityOral Cavity
To learn:To learn: Disorders of the Oral Mucosa and Disorders of the Oral Mucosa and
GingivaGingiva Disorders of the Salivary glandsDisorders of the Salivary glands Disorders of the Teeth and Jaw bonesDisorders of the Teeth and Jaw bones Disorders due to the Systemic DiseasesDisorders due to the Systemic Diseases
Diseases of the Oral CavityDiseases of the Oral Cavity
Disorders of the Oral Mucosa Disorders of the Oral Mucosa and Gingivaand Gingiva
Ulcerative and inflammatory lesionsUlcerative and inflammatory lesions Aphtous ulcersAphtous ulcers Herpes virus infectionsHerpes virus infections Fungal infectionsFungal infections
Hyperkeratotic lesionsHyperkeratotic lesions LeukoplakiaLeukoplakia ErythroplakiaErythroplakia
TumorsTumors Benign tumorsBenign tumors Malignant tumorsMalignant tumors
Aphtous ulcersAphtous ulcers EExtremely common superficial xtremely common superficial
ulcerationsulcerations (erosions) (erosions) of the oral mucosa of the oral mucosa PPainfulainful Single or multipleSingle or multiple ShallowShallow HyperemicHyperemic (erythematous) or yellowish- (erythematous) or yellowish-
graygray Less than 5 mm in diameterLess than 5 mm in diameter
CCovered by a thin exudate and rimmed overed by a thin exudate and rimmed by a narrow zone of erythemaby a narrow zone of erythema
Ulcerative and inflammatory Ulcerative and inflammatory lesionslesions
Location:Location: Soft palateSoft palate Buccolabial mucosaBuccolabial mucosa Floor of the mouthFloor of the mouth Lateral borders of the tongueLateral borders of the tongue
Triggers or Etiology: Triggers or Etiology: Inflammatory bowel diseaseInflammatory bowel diseasess Behçet’s Behçet’s diseasedisease HHypersensitivityypersensitivity reactions reactions EEmotional stressmotional stress Endocrine influences Endocrine influences (pregnancy, (pregnancy,
menstruation) menstruation) Autoimmune reactions Autoimmune reactions ((involving both involving both
cellular and humoral mechanismscellular and humoral mechanisms)) Infectious diseasesInfectious diseases
OOrofacial herpetic infections are rofacial herpetic infections are caused by HSV type 1 (Hcaused by HSV type 1 (HHHV-1)V-1)
HHHHV-2 most often involves the genital tractV-2 most often involves the genital tract Most primary oral infections with Most primary oral infections with
HSV-1 are trivial “cold sores”HSV-1 are trivial “cold sores” AAdults harbor latent Hdults harbor latent HHHV-1V-1: :
upper respiratory tract infections upper respiratory tract infections excessive exposure to cold, wind, or excessive exposure to cold, wind, or
sunlight sunlight allergic reactionsallergic reactions
Herpes virus infectionsHerpes virus infections
HHerpetic gingivostomatitiserpetic gingivostomatitis
Generally acuteGenerally acute Common in AIDS patientsCommon in AIDS patients In severe cases In severe cases
keratoconjunctivitiskeratoconjunctivitis encephalitisencephalitis
Lesions:Lesions:1.1. the oral and pharyngeal mucosathe oral and pharyngeal mucosa
2.2. the tonguethe tongue
3.3. the gingivathe gingivaee
Herpes simplex Herpes simplex HHerpetic gingivostomatitiserpetic gingivostomatitis (HIV-positive patient) (HIV-positive patient)
Fungal infectionsFungal infections
Candida albicansCandida albicans SSuperficial, curdy, gray to white inflammatory uperficial, curdy, gray to white inflammatory
membranemembrane Fibrinosuppurative exudateFibrinosuppurative exudate + + C.albicansC.albicans withwith
an underlying erythematous inflammatory basean underlying erythematous inflammatory base Risk factors: Risk factors:
ddiabetiabetes mellituses mellitus neutropenineutropeniaa iimmunmmune deficiency syndromese deficiency syndromes AIDSAIDS aantibiotic therapyntibiotic therapy
Oral trushOral trush
Candida albicansCandida albicans
Hyperkeratotic lesionsHyperkeratotic lesions
LLeukoplakiaeukoplakia ((white plaquewhite plaque) ) WWhite plaque on the oral mucous membranes that hite plaque on the oral mucous membranes that
cannot be removed by scrapingcannot be removed by scraping Precancerous lesionPrecancerous lesion Range from completely benign epithelial thickenings to Range from completely benign epithelial thickenings to
highly atypical lesions with dysplastic changes that highly atypical lesions with dysplastic changes that merge with merge with carcinoma in situcarcinoma in situ (CIS) (CIS)
Etiology:Etiology: TobaccoTobacco
smoking (cigar, cigarette, pipe)smoking (cigar, cigarette, pipe) CChewinghewing tobaco tobaco
Alcohol Alcohol Chronic Chronic irritations (i.e. irritations (i.e. cheek bitecheek bite))
LeukoplakiaLeukoplakia
EErythroplakiarythroplakia (dysplastic leukoplakia) (dysplastic leukoplakia) RRed, velvety, possibly eroded areaed, velvety, possibly eroded area Higher risk of malignant Higher risk of malignant
transformationtransformation more thanmore than 50% 50%
Etiology:Etiology: Tobacco (cigarettes, pipes, cigars, and Tobacco (cigarettes, pipes, cigars, and
particularly chewing tobacco particularly chewing tobacco )) alcoholalcohol Chronic Chronic exposure to persistent irritants exposure to persistent irritants
ill-fitting denturesill-fitting dentures hot hot mealsmeals
HPVHPV
EErythroplakiarythroplakia
TumorsTumors
Benign tumors and tumor-like Benign tumors and tumor-like conditionsconditions
TumorsTumors Papilloma (Papilloma (HPV serotypes 6 and 11HPV serotypes 6 and 11)) Angioma (hemangioma & lymphangioma)Angioma (hemangioma & lymphangioma)
Tumor-like conditionsTumor-like conditions Fordyce spots (ectopic sebaceous glands)Fordyce spots (ectopic sebaceous glands) Mucocele (minor salivary glands – Mucocele (minor salivary glands –
destruction of ductus)destruction of ductus)
Malignant tumorsMalignant tumorsSSquamous cell carcinomaquamous cell carcinoma::
95% of cancers of the oral cavity 95% of cancers of the oral cavity andand the tonguethe tongue The small residual includes The small residual includes
adenocarcinoma (of adenocarcinoma (of salivarysalivary gland origin) gland origin) melanomamelanoma various carcinomasvarious carcinomas
SSquamous cell carcinomaquamous cell carcinoma (Epidermoid (Epidermoid carcinoma)carcinoma)
Location (most predicted):Location (most predicted): Lower lipLower lip Floor of the mouthFloor of the mouth Tongue (lateral borders)Tongue (lateral borders)
Etiology:Etiology: Leukoplakia and Leukoplakia and erythroplakiaerythroplakia Tobacco : Tobacco : alcohol&smoking, tobacco chewingalcohol&smoking, tobacco chewing IIll-fitting denturesll-fitting dentures JJagged teethagged teeth HPVHPV Sunlight Sunlight (lower lip)(lower lip) CChronic infectionshronic infections
MorphologyMorphology In the early stageIn the early stage::
Raised, firm, pearly plaques Raised, firm, pearly plaques irregularirregular - - roughened roughened verrucose areas of mucosal thickeningverrucose areas of mucosal thickening
Differential diagnosis Differential diagnosis : : leukoplakialeukoplakia & & erythroplakiaerythroplakia
As these lesions enlargeAs these lesions enlarge:: protruding massesprotruding masses undergo central necrosisundergo central necrosis irregular, shaggy ulcer rimmed by irregular, shaggy ulcer rimmed by
elevated, firm, rolled borderselevated, firm, rolled borders
MicroscopyMicroscopy
with lwith leukoplakia and erythroplakia eukoplakia and erythroplakia well-differentiated keratinizing neoplasmswell-differentiated keratinizing neoplasms
or or anaplasticanaplastic or or sometimes sometimes undifferentiated (undifferentiated (sarcomatoidsarcomatoid))
tumorstumors Metastases:Metastases:
regional and regional and mediastinal lymph nodesmediastinal lymph nodes lungslungs liverliver bonesbones
SSquamous cell carcinomaquamous cell carcinoma
Disorders of the Salivary Disorders of the Salivary glandsglands
Inflammatory disordersInflammatory disorders SialadenitisSialadenitis Sjögren syndromeSjögren syndrome Mikulicz syndromeMikulicz syndrome
TumorsTumors Benign tumorsBenign tumors
Plemorphic adenomaPlemorphic adenoma Warthin tumorWarthin tumor
Malignant tumorsMalignant tumors Mucoepidermoid carcinomaMucoepidermoid carcinoma Adenoid cystic carcinomaAdenoid cystic carcinoma
Inflammatory Disorders of the Salivary Inflammatory Disorders of the Salivary glandsglands
VViraliral (mumps) (mumps) BBacterialacterial (complication of sialolithiasis) (complication of sialolithiasis) AAutoimmune originutoimmune origin
Sjögren’s syndromeSjögren’s syndrome:: involvement of the salivary glands involvement of the salivary glands xerostomiaxerostomia
((dry mouthdry mouth)) involvement lacrimal glands involvement lacrimal glands
keratoconjunctivitis sicca keratoconjunctivitis sicca ((dry eyesdry eyes))
Sarcoidosis :Sarcoidosis : bbilateral sarcoidosis of the parotid, ilateral sarcoidosis of the parotid,
submaxillary, and sublingual glands submaxillary, and sublingual glands uveuveaa involvement involvement
Mikulicz Mikulicz syndromesyndrome
Sjögren’s Sjögren’s syndromesyndrome
Tumors of the Salivary Tumors of the Salivary glandsglands
Benign tumorsBenign tumors
Plemorphic adenomaPlemorphic adenoma
Mostly parotid glandMostly parotid gland Painless swelling at the angle of the jawPainless swelling at the angle of the jaw Excision; may recur (10%)Excision; may recur (10%)
MicroscopyMicroscopy Composed of epithelial elements Composed of epithelial elements and and
myoepithelial cells myoepithelial cells dispersed dispersed throughout a matrix of throughout a matrix of mucoid, mucoid, myxoid, myxoid, chondroid tissuechondroid tissue
a mixed tumor a mixed tumor
Warthin TumorWarthin Tumor ((PPapillary Cystadenoma apillary Cystadenoma Lymphomatosum)Lymphomatosum)
Almost always in the parotid glandAlmost always in the parotid gland Small, Small, round to oval, encapsulated mass round to oval, encapsulated mass Excision; may recur (10%)Excision; may recur (10%) MicroscopyMicroscopy::
(1) (1) spaces are lined by a double layer of spaces are lined by a double layer of epithelial cellsepithelial cells
(2)(2) dense lymphoid stroma sometimes dense lymphoid stroma sometimes formforming ing germinal centersgerminal centers
Malignant tumorsMalignant tumors
Mucoepidermoid carcinomaMucoepidermoid carcinoma- Particularly the minor salivary glandsParticularly the minor salivary glands- Radiation-induced neoplasmRadiation-induced neoplasm - Mixture of squamous cells, mucus-secreting Mixture of squamous cells, mucus-secreting
cellscells- May May recur recur (( 30% 30%))- Disseminate to distant sitesDisseminate to distant sites (30%) (30%)
Adenoid cystic carcinomaAdenoid cystic carcinoma- Particularly the minor salivary glandsParticularly the minor salivary glands- Frank pain due to Frank pain due to neural invasionneural invasion- Microscopy: round-cystic spaces filled by mucusMicroscopy: round-cystic spaces filled by mucus
Tumors of the Salivary glandsTumors of the Salivary glands
Disorders of the Teeth and Jaw Disorders of the Teeth and Jaw bonesbones
TeethTeeth CariesCaries Inflammation (pulpitis, apical granuloma & Inflammation (pulpitis, apical granuloma &
cyst)cyst) Jaw bonesJaw bones
FracturesFractures Inflammation (osteomyelitis)Inflammation (osteomyelitis) Cysts (odontogenic; non-odontogenic)Cysts (odontogenic; non-odontogenic) TumorsTumors
Soft tissuesSoft tissues Bone & CartilageBone & Cartilage OdontogenicOdontogenic
Odontogeic cysts & tumorsOdontogeic cysts & tumors
Disorders due to the Disorders due to the Systemic DiseasesSystemic Diseases
INFECTIOUS DISEASESINFECTIOUS DISEASES Measles:Measles: Koplik’s spots Koplik’s spots Infectious mononucleosis:Infectious mononucleosis: acute acute
tonsillitis/pharyngitis, cervical tonsillitis/pharyngitis, cervical lymphadenopathylymphadenopathy
Diphtheria:Diphtheria: pseudomembrane pseudomembrane (tonsils/retropharynx)(tonsils/retropharynx)
AIDS:AIDS: Herpesvirus infection Herpesvirus infection (gingivostomatitis), (gingivostomatitis), Candida albicansCandida albicans, , Kaposi sarcomaKaposi sarcoma
DERMATOLOGIC DISORDERSDERMATOLOGIC DISORDERS
Lichen planus:Lichen planus: reticulate, white (keratotic) reticulate, white (keratotic) lesionslesions
Pemphigus:Pemphigus: vesicles and erosions vesicles and erosions Bullous pemphigoid:Bullous pemphigoid: bullae and erosions bullae and erosions Erythema multiforme Erythema multiforme (Stevens-Johnson (Stevens-Johnson
syndrome):syndrome): maculopapular-vesiculobullous maculopapular-vesiculobullous lesionslesions
follows an infectionfollows an infection drugdrug cancercancer auto-immune disorderauto-immune disorder
Pemphigus vulgarisPemphigus vulgaris
HEMATOLOGIC HEMATOLOGIC DISORDERSDISORDERS
Pancytopenia and/or LeukemiaPancytopenia and/or Leukemia gingivitisgingivitis pharyngitispharyngitis tonsillitistonsillitis neck cellulitis (Ludwig’s angina)neck cellulitis (Ludwig’s angina)
Monocytic leukemiaMonocytic leukemia gingival infiltrationgingival infiltration
MISCELLANEOUSMISCELLANEOUS Melanotic pigmentation:Melanotic pigmentation:
Albright’s syndromeAlbright’s syndrome Peutz-Jegher’s syndromePeutz-Jegher’s syndrome
Dilantin (phenytoin):Dilantin (phenytoin): gingival hyperplasia gingival hyperplasia Pregnancy:Pregnancy: granuloma gravidarum granuloma gravidarum Other Syndromes:Other Syndromes: oral manifestations can oral manifestations can
be found in the hereditary or acquired be found in the hereditary or acquired syndromessyndromes Teeth anomaliesTeeth anomalies MacroglossiaMacroglossia Bifid palate/tongue/lipBifid palate/tongue/lip Hemangiomas, ect.Hemangiomas, ect.
Peutz-Jegher’s syndrome; Gingival Peutz-Jegher’s syndrome; Gingival hyperplasiahyperplasia
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