Lab 1 (Soft Tissue Enlargement)

7/28/2019 Lab 1 (Soft Tissue Enlargement)

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Hyperplastic, Neoplasticand Related Disorders of

Oral MucosaLAB 1


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Hyperplasia:

-Increase in number of cells (proliferation of cells) in a

physiological manner which is responsive to a specificstimulus

-Microscopically cells resemble normal cells but are

increased in number

-Results in the gross enlargement of tissue

-Cells of hyperplastic growth remain subject to normal

regulatory control mechanisms

Neoplasia:

-The process underlying cancer and benign tumors

- Increase in number of cells (proliferation of cells) in a non-

physiological manner which is unresponsive to normal stimuli

- Cells are genetically abnormal


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-Usually localized

-Cause: chronic (low grade) irritation, such as:

Plaque & calculus

Lip/cheek biting

Ill-fitting/over-extended dentureSharp edge of a crown/bridge

-Clinical appearance: exophytic mass that is

increasing in size

-Histological appearance: granulation tissue with

variable amounts of blood vessels and cells

-Location: anywhere in the mouth

Reactive hyperplasia


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Examples of localized hyperplastic lesions of oral

mucosa:-Peripheral ossifying fibroma (considered as fibrous epulis)

-Irritation fibroma focal fibrous hyperplasia (considered as

fibrous epulis)

-Pyogenic granuloma-Peripheral giant cell granuloma (giant cell epulis)

-Giant cell fibroma

-Retrocuspid papilla

-Fibroepithelial polyp irritation fibroma, focal fibroushyperplasia

-Denture irritation hyperplasia epulis Fissuratum,

inflammatory fibrous hyperplasia

-Papillary hyperplasia of the palate inflammatory papillary

hyperplasia

Reactive hyperplasia


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Epulides

- Reactive localized tumor-like gingival enlargement

- Hyperplastic NOT neoplastic

- More common in females

- More common in maxilla

- More common in the anterior region of the oral cavity- Main etiological factors are: subgingival plaque/calculus

(chronic irritation) and trauma


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Epulides

- Treatment:

Identification and removal of etiological factorifpossible to allow lesion to regress by itself Excisional biopsy if required

- Causes of recurrence:

Etiological factor persists Lesion incompletely excised (as in PGCG)

- Types: Fibrous epulis (Chronic hyperplastic gingivitis &

peripheral ossifying fibroma) Vascular epulis (Pyogenic granuloma & pregnancy

epulis) Giant cell epulis (Peripheral giant cell granuloma)


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50 years old patient attended the dental

clinic for routine dental examination

Upon examination we discovered an

exophytic mass arising from gingiva palatal

to upper right central & lateral incisors

The lesion is painless (non-tender), pink in

color, firm to palpation, and has a non-

bleeding property

Histopathological examination is shown below

1- What do we clinically call this localizedgingival hyperplasia and how can we reach

the definitive diagnosis?!

2- Whats the most likely diagnosis?!

3- What pathological variety is this?!

4- Whats the other pathological

variety?!

5- Describe the usual

histopathological appearance?!

6- Whats the treatment?!


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Peripheral ossifying fibromaBone formation

Richly cellular fibrous stroma


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Fibrous epulis

The granulation tissue is highly cellular and showing signs ofcalcifications (figure B), here it is called peripheral ossifyingfibroma

A B


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25 years old non-pregnant female

attended the dental clinic concerned

about an exophytic mass arising from

buccal interdental gingiva of upper

right canine, 1st and 2nd premolars

Upon examination we found that the

lesion is painless (non-tender),

red/purple in color, soft to palpation,

and has a bleeding property on minor

provocation

The patient states that the lesion is ofrapid growth & of 3 days duration only

Histopathological examination is shown

below

1- What do we clinically call this localized

gingival hyperplasia and how can wereach the definitive diagnosis?!


3- What clinical variety is this?!

4- Whats the other clinical

variety?!


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about an exophytic mass arising

from buccal interdental gingiva of

upper right canine, 1st and 2nd

premolars





provocationThe patient states that the lesion is of

rapid growth & of 3 days duration only


below

5- Whats the most likely cause?!

6- Does this clinical variety only affect

the gingiva?!

7- Do the lesions elsewhere in the oral

cavity differ from the ones arising onthe gingiva?!


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about an exophytic mass arising

from buccal interdental gingiva of

upper right canine, 1st and 2nd

premolars





provocationThe patient states that the lesion is of

rapid growth & of 3 days duration only


below

8- What are the clinical features of the

other clinical variety?!

9- Describe the usual histopathological

appearance?!

10- Whats the usual treatment?!


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Vascular spaces

Vascular epulis


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Pyogenic granuloma (lobular

capillary Hemangioma)

NOT only on the gingiva


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40 years old maleattended the dental

clinic concerned about an exophytic

mass arising from buccal interdental

gingiva of upper left canine, 1st and 2nd

premolars and recurring for the 3rd time


lesion is painless (non-tender), dark red

in color


below

1- What do we clinically call this localizedgingival hyperplasia and how can we

reach the definitive diagnosis?!


3- What are the main clinical features ofthis lesion?!

4- Whats the main radiographic feature

of this lesion?!

5- Why radiographs are usually needed

in the definitive diagnosis of this lesion?!

40 ld l tt d d th d t l


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mass arising from buccal interdental

gingiva of upper left canine, 1st and 2nd

premolars and recurring for the 3rd time

Upon examination we found that the lesion

is painless (non-tender), dark red in color


below

6- What other lesion to exclude?! And howto rule it out?!


appearance?!

8- What about the pathogenesis of the

lesion?!

9- What are the possible diagnoses if there

are multiple lesions?!


11- What about the prognosis?!


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Peripheral giant cell granuloma

Collections ofgiant cellslying in richly vascularand cellular stroma


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PGCG vs. CGCG (take a radiograph)

We need to exclude?! hyperparathyroidism

CGCG

35 ld f l tt d d th d t l


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35 years old femaleattended the dental


mass arising on the right buccal

mucosa


lesion is painless (non-tender), pink incolor, firm to palpation, and has a non-

bleeding property


below


2- What are the main clinical features of

this lesion?!

3- Is it a true benign tumor?!

4- If the lesion occurs in the palate under

a denture, what would it become?!


appearance?!



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Fibroepithelial polyp

Hypocellular fibrous tissue


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Chief Complaint: painless

(non-tender), pink andfirm swelling of the left

posterior buccal mucosa

of 2 months duration


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Chief Complaint: painless

(non-tender), pink andfirm swelling of the right

anterior buccal mucosa

and the hard palate


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Leaf Fibroma

In the palate under the denture,

Fibroepithelial polyp becomes flattened

and leaf-like


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Management =

Excisional biopsy


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20 years old femaleattended the

dental clinic concerned about an

exophytic mass arising on the

dorsum of the tongue


lesion is painless (non-tender), pink in

color, firm to palpation, and has a non-

bleeding property


below


2- What are the differences between

this lesion and Fibroepithelial polyp?!



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Giant cell fibromaA Fibroepithelial polyp in which a

distinctive histopathological feature

is found which is multinucleated

fibroblasts

Location (arises on keratinized

mucosa gingiva, hard palate, and

tongue)


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Retrocuspid papilla

- Same histopathology asgiant cell fibroma

multinucleated

fibroblasts

- Developmental lesion,

lingual to mandibular

canine on the interdental

papilla

- 25-99% of young adults

and children


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Some CLINICAL differential diagnoses for gingival

tumor-like enlargement:

1. Peripheral ossifying fibroma

2. Irritation fibroma

3. Pyogenic granuloma

4. Peripheral giant cell granuloma5. Giant cell fibroma

6. Retrocuspid papilla

60 ld f l tt d d th d t l


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clinic concerned about multiple folds of

tissue arising in the depth of vestibules

on the facial aspect of upper complete

denture flange

Upon examination we found that the folds

are painless (non-tender), pink in color,

firm to palpation, and have a non-bleeding

property

They arent grossly inflamed but

ulcerated at the base of the vestibuleHistopathological examination is shown

below


2- Whats the most likely cause?!3- In whom/which this lesion is more

common?!

4- Describe the Histopathological

appearance?!



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Denture irritation hyperplasia

Hyperplastic

epithelium

Hyperplastic

fibrous tissue

55 years old female attended the dental


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clinic concerned about the pebbled

appearance the hard palate shows

under the fitting surface of upper

complete denture


pebbles are painless (non-tender), red in

color, and inflamed


below


2- Whats the most likely cause?!

3- Describe the Histopathological

appearance?!



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Papillary hyperplasia of the palate

Pseudo-epithelomatous hyperplasia


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clinic complaining from pain arising

from the lower right side

Upon examination we found an

ulcerated exophytic mass posteriorto last molar tooth

The lesion is indurated & fixed and

regional lymph nodes are enlarged


below


2- Whats the prognosis?!

40 years old male attended the dental


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clinic concerned about a recurrent

exophytic mass arising from lingual

gingiva of lower left canine, 1st & 2nd

premolars and 1st molar

The lesion is slowly growing, locally

aggressive & doesnt show any

metastatic potential


below


2- What about the histopathological

appearance?!

40 ld f l d d h d l


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clinic concerned about a swelling arising

from the left buccal mucosa

Upon examination the swelling is soft to

palpation and yellowish in colorHistopathological examination is shown

below


2- Where does it more commonly arise?!

3- Describe the behavior of this lesion if

dropped in formalin?!

4- Describe the histopathological

appearance?!


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Lipoma


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Liposarcoma

Lipoblasts with Pleomorphic nuclei

26 years old female attended the


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elevated dark reddish-purple lesion

present on the left soft palate for the

last 10 years

Upon examination, we found the lesion

to be diffuse, compressible (soft

consistency) and painless (non-

tender)


below


2- Is it a true tumor?!

3- Simple clinical test to confirm your

diagnosis?!

4- Where do oral lesions most

commonly arise?!

5- Are lesions usually solitary or

multiple?! And if they are multiple then

what syndrome should we think of?!

26 years old female attended the


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elevated dark reddish-purple lesion

present on the left soft palate for the

last 10 years

Upon examination, we found the lesion

to be diffuse, compressible (soft


tender)


below

6- If theres recent increase in size,

then suspect what?!


appearance?!8- What pathological variety is shown in

here?!


Hemangioma


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Hemangioma


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Blanching test

Hemangiomas

blanch under

pressure

H i


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Hemangioma


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Hemangioma histopathology

Capillary (C) OR cavernous (D)


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Cellular Hemangioma

Endothelial cells

A t i M lf ti


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Arteriovenous Malformation

Thin walled blood vessel

Thick walled blood vessel

Abnormal connectionbetween arteries and veins,

bypassing the capillary system


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- Local venousanomalies on the

vermilion border of the

lips

- Increase in frequency

with age

Venous lakes

S bli l i i i


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Sublingual varicosities

-Dilatation of ranine

veins

-Increase in frequency

with age

K i S


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Kaposi Sarcoma

Commonly found in the mouth of patient with AIDS

10 years old childwas admitted to


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y

the dental clinic to consult about this

clinical presentation he is present

with

Parents stated that he has frequent

convulsions of the limbs on the

right side


2- Describe the clinical features of

this condition?!

70 years old maleattended the


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y

dental clinic to consult about this

clinical presentation she is present

with

She complains from frequent nose

bleeding


2- Describe the clinical features of

this condition?!

H dit h h i


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Hereditary hemorrhagic

telangiectasia

10 years old malewas admitted to the


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dental clinic with his parents who

complained from a tongue lesion which

has been present since their child was

6 months of age. The lesion is currently

asymptomatic and slowly enlarging

Upon examination, we found the lesion to

be diffuse, compressible (soft


tender)

Histopathological examination is shownbelow


2- Is it a true tumor?!

3- Where do oral lesions most commonlyarise?!


appearance?!

5- What pathological variety is shown in

here?!


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Lymphangioma

Lymphatic fluid


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Lymphangioma

Doesnt blanch

8 years old malewas admitted to the


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dental clinic with his parents who

complained from a large swelling in the

neck side of their child which has been

present since birth

Upon examination, we found the lesion to

be fluctuant and more than 10 cm in

diameterand extending to the base of

the tongue & the floor of the mouth




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clinic complaining from a swelling

arising from the tip of the tongue


below


2- If there are multiple swellings of this

lesion then suspect what?!


appearance?!

N fib


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Neurofibroma


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Neurofibroma

Wavy spindled

cells

Neurofibroma


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Neurofibroma


li i l i i f lti l l


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clinic complaining from multiple large

masses of the skin causing

considerable disfigurement

Upon examination, we found the patient

to have some melanin pigmentationand Axillary freckling


2- How many types are there of this

condition?!3- What mutation leads to this condition?!

4- What are the clinical features of this

condition?!

5- What features of Neurofibroma areoften found in this condition?!


li i l i i f lli


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clinic complaining from a swelling

arising from right buccal mucosa

Upon examination, lesion is firm to

palpation but movable (not fixed),

somewhat Pedunculated and locatedabout 5mm from Stensens duct

It is ofunknown duration and painless

to palpation


below



appearance?!

3- What mutation leads to this condition?!

4- What are the clinical features of this

condition?!

5- What features of Neurofibroma are

often found in this condition?!

Schwannoma


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Capsule

Schwannoma

Schwannoma


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Schwannoma

Schwannoma


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Schwannoma

65 years old maleattended the dentalclinic complaining from a small nodule


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clinic complaining from a small nodule

arising just above the tissue covering

the mental foramen and started to

appearafter a surgery performed in

the areaPatient stated that it is slowly growing

in size

Upon examination, lesion is firm to

palpation, fixed to surrounding

structures and painful to palpationHistopathological examination is shown

below


2- Whats the cause behind this

condition?!

3- If there are multiple lesions, then

suspect what?!

4- What are the components of the

condition suspected and what can beused to screen it?!


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Traumatic neuroma

Nerve bundles


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Multiple mucosal neuromas

43 years old maleattended the

dental clinic concerned about a small


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dental clinic concerned about a small

swelling arising on the anterior 2/3s

of dorsum tongue

Patient stated that it is slowly

growing in sizeUpon examination, lesion is firm to

palpation, fixed to surrounding

structures and painless to palpation

Histopathological examination is

shown below1- Whats the most likely diagnosis?!

2- Whats the origin of this lesion?!

Due to proliferation of what cell?!

3- How did they conclude the actualorigin of this lesion?!

4- Where it more commonly occur in

the oral cavity?!


presentation?!


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Granular Cell Tumor

Granular cells

Hyperplasticepithelium

Pseudo

EpithelomatousHyperplasia


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Pseudo

Epithelomatous

Hyperplasia

Granular Cell Tumor


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Granular Cell Tumor

Pseudo

Epithelomatous

Hyperplasia

Granular Cell Tumor


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Feeling of

invasion

because of the

presence ofstriated skeletal

muscle fibers

between the

granular cells

but it is benign

Granular Cell Tumor

19 years old femalewas referred to thedental clinic by internal Medicine


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y

discipline to evaluate forpossible

odontogenic cause of right

submandibular swelling

Upon examination, right submandibularlymph nodes were enlarged & painless


below


2- Whats the most commonly affected

age group?!

3- Where is this condition usually

distributed?!

4- What lymph nodes are most commonlyinvolved?!

5- Whats the etiology of this condition?!

6- What about the prognosis of this

condition?!

19 years old femalewas referred to thedental clinic by internal Medicine


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y

discipline to evaluate forpossible

odontogenic cause of right

submandibular swelling

Upon examination, right submandibularlymph nodes were enlarged & painless


below

7- Whats the usual clinical presentation of

this condition?!

8- The histopathological diagnosis

depends on what??!

9- Describe the neoplastic component of

this condition?!

H d ki ' l h


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Reed Sternberg cell

lymphocytes

Hodgkin's lymphoma

Hodgkin's lymphoma


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Hodgkin s lymphoma

Malignant lymphomas


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lymphoma

Hodgkins Non-Hodgkin

B lymphoma (e.g. Burkitts)T lymphoma

Malignant lymphomas

25 years old maleattended the dentalclinic concerned about a swelling


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arising from the right half of the palate

Upon examination, swelling is large,

diffuse, fleshy, soft & ulcerated

Teeth in the area were mobileRadiographic examination suggested

severe bone destruction


below

1- What are the differential diagnoses?!2- Whats the most likely diagnosis?!

3- Where is this condition usually

distributed?!

4- When this condition is extra-nodal,

what other tissues it may affect?!5- Which lesions have better prognosis:

nodal or extra-nodal?!

6- Based on cell of origin, how many

types of this condition are there?!

25 years old maleattended the dentalclinic concerned about a swelling


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arising from the right half of the palate

Upon examination, swelling is large,

diffuse, fleshy, soft & ulcerated

Teeth in the area were mobileRadiographic examination suggested

severe bone destruction


below

7- Which variety is this?!8- What are the different types of this

variety and what are their clinical

features?!

9- What is the genetic abnormality

leading to this variety?!10- Describe the histopathological

presentation?!

Burkitts lymphoma


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y pStarry Sky

Malignant B-lymphocytes

Non-neoplastic

macrophages

Burkitts lymphoma


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yStarry Sky

Malignant B-

lymphocytes

Non-neoplastic

macrophages

Lethal midline granuloma


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Lethal midline granuloma

T-cell lymphoma

- Also called nasal

NK/T-cell lymphoma

& Angiocentric T-

cell lymphoma- Leads to extensive

destruction of mid-

facial structures

- EBV is found in

some neoplastic cells

Case Report 1


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13 years old femaleis referred for

evaluation of an asymptomatic, 1 x 1.5

mm mass in the right buccal mucosa inthe premolar area at the level of the

occlusal plane. The patient wears full

orthodontic appliances. She believes

that the lesion was present before she

started the orthodontic treatment oneyear ago

The lesion seems localized, pink in

color, fibrotic & firm to palpation

1- What are the differentialdiagnoses?!

p

Differential Diagnoses


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Think of hyperplastic & benign neoplastic

lesions causing Localized Soft Tissue

Enlargements with a normal mucosa:1) Fibroepithelial polyp irritation fibroma

2) Giant cell fibroma

3) Fibro-lipoma

4) Neurofibroma5) Schwannoma

6) Mucosal neuroma

7) Granular cell tumor

8) Benign salivary gland tumors9) Low grade salivary adenocarcinoma

10) Non-Vascular Leiomyoma (from blood

vessels)

11) Rhabdomyoma (from Buccinator muscle)

Biopsy & Histopathological


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examination



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Granular cells

Hyperplasticepithelium

examination

PseudoEpithelomatous

Hyperplasia

D fi iti Di i


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Definitive Diagnosis

Granular cell tumor


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Think of hyperplastic & benign neoplastic

lesions causing Localized Soft Tissue

Enlargements with a normal mucosa:1) Fibroepithelial polyp irritation fibroma

2) Giant cell fibroma

3) Fibro-lipoma

4) Neurofibroma5) Schwannoma

6) Mucosal neuroma

7) Granular cell tumor

8) Benign salivary gland tumors9) Low grade salivary adenocarcinoma

10) Non-vascular Leiomyoma (from blood

vessels)

11) Rhabdomyoma (from Buccinator muscle)



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examination

Hypocellular fibrous tissue

Definiti e Diagnosis


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Management


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Management

Excisional biopsy

Case Report 3


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p

26 years old femaleis referred forevaluation of a diffuse,

compressible, non-tender,

purple surface lesion present on

the left soft palate

Patient stated it has been present

for the last 10 years and didnt

significantly increase in size

1- What are the

differential diagnoses?!



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g

Think of benign surfaceintravascular lesions:

1- Hemangioma

2- Varix or venous lake

3- Arteriovenous

malformation

4- Vascular Leiomyoma

EXCLUDE:

- Pyogenic granuloma

- Kaposis sarcoma

Biopsy & Histopathologicali ti


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examination



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Hemangioma

Management


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Management

No treatment

Case Report 4


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18 years old femaleis referred forevaluation of a non-tender dark-

reddish gingival swelling

recurring for the 3rd time

1- What are thedifferential diagnoses?!



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gThink of benign vascular

lesions causing Localized

Soft Tissue Enlargements

with a dark-reddish

mucosa:1- Pyogenic granuloma

2- Peripheral giant cellgranuloma

3- Central giant cell

granuloma

4- Brown Tumor ofhyperparathyroidism




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examination

With no radiographic abnormalities or

abnormal chemical tests findings



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Peripheral giant cell granuloma


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Clinical Pictures


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Clinical Pictures

Radiographic Picture


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Radiographic Picture



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examination

Plexiform Neurofibroma



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Neurofibromatosis Type I syndrome

Case report 5Ad lt l t t t t f ft ti l t f th i i


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Adult male requests treatment of a soft tissue enlargement of the gingiva.

The lesion has been present since two weeks and is progressively

increasing in size. It is not painful and bleeds easily. The patient states that

brushing his teeth or eating rough food makes the lesion bleed

Medical History: The patient states that he smokes cigarettes, half a pack per

day

Dental History: No abnormalities are identified.

Clinical Findings: The lesion is a well-circumscribed, 0.5 x 1.0 cm,

erythematous soft tissue enlargement on the gingiva lingual to the

maxillary central incisors. The lesion bleeds easily during gentle probing.

The lesion is compressible and non-tenderto palpation. It is fixed to the

surface mucosa and underlying structures. The surface is smooth, but there

is an area of ulceration covered by a fibrin clot. The lesion blanches uponpressure. Lymphadenopathy is not present

Radiographs: reveal no associated bony abnormalities

What are the differential diagnoses?!

Clinical Picture


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Clinical Picture



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Think of benign &

malignant vascular

lesions causing Soft

Tissue Enlargements with

a dark-reddish mucosa:1- Pyogenic granuloma

2- Peripheral giant cellgranuloma

3- Central giant cell

granuloma

4- Brown Tumor ofhyperparathyroidism


6- Malignant vascular tumors

Lesions to exclude


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Hyperplastic lesionsthat dont blanch on pressure e.g. fibrousepulis peripheral ossifying fibroma, irritation fibroma,giant cell fibroma

Peripheral odontogenic fibroma (doesnt blanch)

Hemangioma & Lymphangioma (because they are congenital orappear in childhood)

Tumors of nerves (Schwannoma, Neurofibroma, mucosal neuroma,and granular cell tumor) as they dont blanch on pressure

Tumors of adipose tissue: Angio-lipoma (extremely rare on thegingiva, mostly it doesnt blanch on pressure)

Tumors of muscles :

- Rhabdomyoma (no skeletal muscles in the gingiva)

- Non-vascular Leiomyoma

Salivary gland tumors (because salivary glands are not present on the

gingiva and do not blanch)

Biopsy & Histopathologicalexamination


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examination

Vascular spaces



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Pyogenic granuloma

Case report 6Patient: Adult woman


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Patient: Adult woman

Chief Complaint: patient requests treatment ofa soft tissue enlargement

of the gingiva. The patient has been aware of the enlargement for five

months, during which time it has slowly increased in size. It does notbleed and is non-painful except when traumatized while eating. The lesion

has never been treated.

Medical History: The patient states that she smokes occasionally.

Dental History: The last time the patient received dental treatment was eightor nine months ago.

Clinical Findings: The lesion is a well-circumscribed, 0.8 x 1.0 cm soft

tissue enlargement labial and distal to tooth # 27. It is firm, non-tender,

has a smooth surface, and is fixed to surface mucosa and underlying

structures. The lesion has a normal mucosal colorand does not blanch.All teeth in the area test vital to electrical and thermal stimulation. The lesion

does not bleed during examination. There are no palpable lymph nodes

Radiographs reveal no bony abnormalities in the area

What are the differential diagnoses?!

Clinical Picture


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Differential DiagnosesThi k f h l ti &


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Think of hyperplastic &

benign neoplastic lesions

causing Localized SoftTissue Enlargements with a

normal mucosa:1- Fibrous epulis peripheral

ossifying fibroma2- Irritation fibroma

3- Giant cell fibroma

4- Peripheral odontogenic fibroma

5- Neurofibroma

6- Schwannoma7- Mucosal Neuroma

8- Granular cell Tumor

9- Non-Vascular Leiomyoma

Lesions to exclude


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Hyperplastic lesionsthat blanch on pressure e.g. Pyogenic

granuloma & peripheral giant cell granuloma

Tumors of adipose tissue: Fibro-lipoma (extremely rare on thegingiva, mostly it doesnt blanch on pressure)

Tumors of muscles :- Rhabdomyoma (no skeletal muscles in the gingiva)- Vascular Leiomyoma

Salivary gland tumors (because salivary glands are not present onthe gingiva and do not blanch)

Biopsy & Histopathologicalexamination


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examinationBone formation

Richly cellular fibrous stroma



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Fibrous epulis peripheral

Documents

Lab 1 (Soft Tissue Enlargement)