Oral Patho 1

7/29/2019 Oral Patho 1

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Hyperplastic,Neoplastic,and related disordersToday the lecture is about

of Oral Mucosa

and you know from general pathology the difference between the

hyperplasia and Neoplasia

continuous division>>: Increase in the number of the cellsHyperplasia

but without metastases

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

uncontrolled division .

Not benign Tumor They1 .:Hyperplastic Legion of the Oral Cavity#

use the Legion >< The, There usually a stimulus that ca*ARE Reactive

irritation to the oralstimulus usually low grade >Mucosa

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 .flammation you knowusually chronic inirritationchronic.because it's2

that chronic inflammation associated with repair > Granulation tissue matures we have fibrous tissue and decre

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


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Localized hyperplastic lesions of oral Mucosa :

1. Pyogenic Granuloma

2. peripheral giant cell granuloma

3.peripheral ossifying fibroma

plasia )-4. Irritation fibroma ( focal fibrous hyper

cell fibroma5. Gaint

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


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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 thestimulation 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 > 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 # 2

What I see in the histopathology : depend if I looking to

hyperplastic gingivitis or peripheral ossifying fibroma


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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

* well-formed bundles of fibroblast * bone formation in addition

and collagen to the bundles

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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

2. Vascular Epulis : ( More B.V >> less fibrous tissue ) young and

bleed easily , usually red

*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 .

*red color compare to the surrounding

mucosa grows rapidly


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It's other name : Pyogenic Granuloma is a vascular epulis occurring

when it occur in the gingiva we call itanywhere in the oral cavity ,

purple / bleeds/rapid growthSoft / lobulated / red:/ it'sEpulis

cially when it occur in the*usually there is a history of trauma spe

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 othersite .

Pregnancy tumor orOther name of the pyogenic granuloma is

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

pyogeniccus previosly think thatWhy they call it " Pyogenic " ?!

ion ( pyogenic = puss forming ) but here therebacteria cause the les

is no puss >

There was one case of pregnancy granuloma, it was very

aggressive it destroy 6 / 7 and extend to the lingual and buccal

aspect.


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Where we can find the lesion :

1. upper lib

2. Gingiva

3. Dorsum of the tongue

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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 granuloma ( when it perforated the

bone ) .

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 .


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* 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 dont 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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** Here it seem that the patient has buccaly erupted 3rd molar , more

borne to cheek biting to buccal mucosa , it not a tumor because doesnt

increase significantly in size with time , it's grows a reach certain size

and stop .

## Sharp sever trauma dont give us fibrous polyp , it will result in ulcerof 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 dont see here a bundles of fibroblast , I see amount of collagen

pale pink : collagen , black dots : some of them are lymphocytes or

fibroblast .


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

** Treatment : excision or surgical removal .

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 ) > as a small nodules lingual to

lower canine , and the histology of them > 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 andfibrous , not cellular not vascular .


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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 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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Oral Patho 1