Advanced Oral Pathology - PowerPoint PPT Presentation

Loading...

PPT – Advanced Oral Pathology PowerPoint presentation | free to view - id: a4e5d-Y2ZkM



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

Advanced Oral Pathology

Description:

Advanced Oral Pathology September 1, 2009 – PowerPoint PPT presentation

Number of Views:1554
Avg rating:4.0/5.0
Slides: 137
Provided by: stanley85
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Advanced Oral Pathology


1
Advanced Oral Pathology
  • Ulcerated Lesions
  • Papillary Lesions
  • Red Lesions
  • Pigmented Lesions

2
Oral Ulcers
  • Aphthous ulcers
  • Behçet syndrome
  • Agranulocytosis/cyclic neutropenia
  • Viral stomatitis
  • Necrotizing ulcerative gingivitis/stomatitits
  • Traumatic ulcer
  • TUGSE/Atypical histiocytic granuloma
  • Necrotizing sialometaplasia
  • Specific granulomatous ulceration
  • Squamous cell carcinoma

3
Recurrent Aphthous Stomatitis (Recurrent Aphthous
Ulcerations Canker Sores)
  • 3 main causes
  • Primary immunodysregulation
  • Decrease of mucosal barrier
  • Increase in antigenic exposure
  • 3 clinical variations
  • Minor - most common, 80 of cases
  • Major - Sutton's disease, 10 of cases
  • Herpetiform multiple small lesions, 10 of cases

4
Minor Aphthous Ulcers
  • Arise on non-keratinized mucosa (buccal and
    labial mucosae, ventral tongue, mucobuccal fold,
    floor of mouth, soft palate) the moveable
    mucosa
  • Erythematous macule develops an ulceration
    covered by a yellowish-white membrane and
    encircled by erythematous halo
  • Measures 310 mm in diameter, heals without
    scarring within 7-10 days, one to five lesions
    present during each episode, very painful
  • Recurrence rate varies (two episodes per month
    one episode every few years)

5
Minor Aphthous Ulcers
6
Major Aphthous Ulcers
  • Larger than minor aphthae, longer duration per
    episode
  • Ulcerations deeper than minor variant, measure
    1-3 cm in diameter, take from 2-6 weeks to heal,
    may cause scarring
  • Labial mucosa, soft palate, tonsillar fauces are
    most commonly affected

7
Major Aphthous Ulcers
8
Herpetiform Aphthous Ulcers
  • Greater number of lesions, most frequent
    recurrence
  • 1-3 mm in diameter, as many as 100 lesions at a
    time. Individual lesions may coalesce into
    larger ulceration.
  • Heal within 7-10 days, recurrences tend to be
    closely spaced

9
Herpetiform Aphthous Ulcers
10
Behçets Syndrome
  • Multisystem disorder ocular, mucocutaneous
    (oral/genital), joints (arthritis), CNS
    (paralysis dementia)
  • Strong association with HLA-B51 type
  • Oral involvement is first manifestation of
    disease in 25-75 of cases. Oral lesions similar
    to aphthous ulcerations, but involve soft palate
    and oropharynx. Eventually, 99 eventually
    develop oral lesions

11
Behçets Syndrome
  • Genital lesions occur in 75, are similar to oral
    lesions, recur less frequently often heal with
    scarring
  • Ocular involvement present in 70-85 of cases and
    can consist of one or more uveitis,
    conjunctivitis, papilledema, arteritis, hypopyon,
    cataract, glaucoma, neovascularization of iris
    retina
  • Positive pathergy test (needle puncture) for
    diagnosis in 50
  • Variable course, relapse/remit, usually decreases
    over time. Immunosuppressants for treatment.
    CNS involvement poor prognosis.

12
Pathergy test 1) sterile needle stick 2)
immediately after the stick 3) 4) show the
area one day and two days after the needle stick,
respectively.
13
Behçets Syndrome
14
Neutropenia
  • Decrease in number of circulating neutrophils
  • Infection of oral mucosa may be initial sign of
    this disease
  • Neutropenia detected in infancy usually related
    to congenital abnormality
  • Neutropenia acquired later in life may result
    from leukemia, metabolic diseases, osteopetrosis,
    drugs, nutritional deficiency, viral or bacterial
    infections.
  • Oral lesions consist of ulcerations involving
    gingival mucosa

15
Agranulocytosis
  • Absence of granulocytic series cells,
    particularly neutrophils
  • May occur as result of decreased production or
    increased destruction of these cells
  • Most cases induced by exposure to particular
    drugs (e.g., anticancer chemotherapy)

16
Agranulocytosis
  • Bacterial infection often develops
  • Oral lesions common include necrotizing, deep,
    punched-out ulcerations of the buccal mucosa,
    tongue, palate
  • Gingivae are especially susceptible to infection
    resembles pattern of NUG

17
Cyclic Neutropenia
  • Regular periodic reduction in neutrophil count
  • Oral ulcerations develop on any oral mucosal
    surface that experiences even minor trauma,
    particularly lips, tongue, buccal mucosa,
    oropharynx
  • Gingiva is most severely affected region of oral
    cavity. Severe periodontal bone loss, marked
    gingival recession, tooth mobility are also
    characteristic.

18
Cyclic Neutropenia
19
Cyclic Neutropenia
20
Agranulocytosis/Cyclic Neutropenia
21
Viruses and oral disease
22
Herpes Simplex Virus
  • Primary infection - Initial exposure, often is
    asymptomatic
  • Secondary or recurrent HSV-1 infection
    reactivation of virus, viral shedding. Symptoms
    affect epithelium via sensory ganglion. Virus
    easily spread through active lesions or
    asymptomatic viral shedding. Virus may spread to
    other sites in same host.

23
Herpes Simplex Virus
  • Acute herpetic gingivostomatitis
  • Most common pattern of HSV-1 infection
  • Usually occurs 6 months 5 years of age
  • Pinhead vesicles, collapse to form small red
    lesions which develop ulceration
  • Movable and attached oral mucosa can be affected
  • Gingiva enlarged, painful, extremely erythematous
  • Resolves 5-7 days (mild) or 2 weeks (severe)

24
Acute herpetic gingivostomatitis
25
Acute herpetic gingivostomatitis
26
Recurrent intraoral herpes
27
Herpes Zoster - Shingles
  • Occurs after reactivation of VZV
  • Predisposing factors include immunosuppression,
    radiation, malignancies, old age
  • Presents as pain in epithelium innervated by
    affected sensory nerve (dermatome)
  • Pain normally present 1-4 days before development
    of cutaneous or oral lesions. Lesions resolve
    within 2-3 weeks in healthy individuals

28
Herpes Zoster - Shingles
  • Zoster sine herpete recurrence without lesions
  • Postherpetic neuralgia pain lasting longer than
    one month after episode
  • Ramsay Hunt syndrome
  • Cutaneous lesions of external auditory canal
    combined with involvement of facial, auditory
    nerves
  • Causes facial paralysis, hearing loss, vertigo
  • Oral lesions occur with trigeminal nerve
    involvement

29
Herpes Zoster - Shingles
30
Necrotizing Ulcerative Gingivitis
  • The condition was studied by French physician
    Hyacinthe Vincent (1890s) and is sometimes
    referred to as Vincent infection
  • Etiopathogenically associated with Fusobacterium
    nucleatum and Borrelia vincentii recent evidence
    that Treponema ssp., Selenomonas ssp.,
    Prevotella intermedia may play a role
  • Common in solders during WWI where poor
    conditions prevailed (trench warfare) became
    known as trench mouth

31
Necrotizing Ulcerative Gingivitis-Predisposing
Factors
  • Psychologic stress
  • Immunosuppression
  • Smoking
  • Poor nutritional status
  • Poor oral hygiene
  • Sleep deprivation
  • Recent illness (e.g., URI or flu)

32
Necrotizing Ulcerative Gingivitis
  • Young to middle aged adults
  • Whites gt blacks males gt females
  • Smoker gt non-smokers

33
Necrotizing Ulcerative Gingivitis
  • Interdental papillae are inflamed, edematous and
    hemorrhagic
  • Papillae are blunted and punched-out with
    craterlike necrosis and a gray pseudomembrane
    fetid odor exquisite pain sometimes
    lymphadenopathy, fever and malaise
  • Can be limited lead to loss of attachment and
    development of necrotizing periodontitis
    necrotizing mucositis/stomatitis or noma (cancrum
    oris)
  • Debridement, improved home care, rinses with
    chlorhexidine, hydrogen peroxide and saline
    sometimes antibiotics (metronidazole,
    tetracycline, penicillin) address cofactors such
    as poor nutrition hygiene, smoking stress

34
Necrotizing Ulcerative Gingivitis
35
Noma (Cancrum Oris Gangrenous Stomatitis
Necrotizing Stomatitis)
  • Rapidly progressive opportunistic infection
    caused by components of normal oral flora which
    become pathogenic during periods of compromised
    immune status
  • Necrotizing ulcerative gingivitis extends to
    involve adjacent soft tissue (acute necrotizing
    ulcerative mucositis) and adjacent bone

36
Noma
  • Treatment includes
  • Antibiotics
  • Correction of inadequate nutrition, hydration,
    electrolyte imbalance
  • Reconstruction

37
Noma
38
Noma
39
Traumatic Ulcerations
  • Surface ulcerations occur as a result of acute or
    chronic irritation or trauma
  • Occurs most often on tongue, lips, buccal mucosa.
  • Areas of erythema (red halo) that surrounds
    central yellow pseudomembrane (ulcer) or focal
    red ulcerated area without fibrin covering
    smaller, uncomplicated lesions heal within days

40
Traumatic Ulcerations
41
Traumatic Ulcerative Granuloma with Stromal
Eosinophlia(TUGSE)
  • Most often seen on tongue secondary to muscle
    damage
  • Deep pseudo-invasive inflammatory reaction that
    is slow to resolve

42
Traumatic Ulcerative Granuloma with Stromal
Eosinophlia(TUGSE)
43
Riga-Fede disease
  • Sublingual ulceration in infants, associated with
    nursing and natal/neonatal teeth.

44
Factitious Oral Injury
45
Atypical Histiocytic Granuloma
  • May be misdiagnosed as lymphoma.
  • Surface ulceration and underlying tumefaction.
  • Treatment involves removal of irritating cause

46
Atypical Histiocytic Granuloma
47
Necrotizing Sialometaplasia
  • Necrotizing sialometaplasia is an uncommon,
    locally destructive inflammatory condition of the
    salivary glands.
  • Although the cause is uncertain, most authors
    believe it is the result of ischemia of the
    salivary tissue that leads to local infarction.
  • The importance of this lesion rests in the fact
    that it mimics a malignant process, both
    clinically and microscopically.
  • Necrotizing sialometaplasia most frequently
    develops in the palatal salivary glands more
    than 75 of all cases occur on the posterior
    palate.

48
Necrotizing Sialometaplasia
  • The hard palate is affected more often than the
    soft palate.
  • About two thirds of palatal cases are unilateral,
    with the rest being bilateral or midline in
    location.
  • Necrotizing sialometaplasia also has been
    reported in other minor salivary gland sites and,
    occasionally, in the parotid gland. The
    submandibular and sublingual glands are rarely
    affected.
  • Although it can occur at almost any age,
    necrotizing sialometaplasia is most common in
    adults the mean age of onset is 46 years.
  • Males are affected nearly twice as often as
    females.

49
Necrotizing Sialometaplasia
50
Necrotizing Sialometaplasia
  • Characterized by acinar necrosis in early
    lesions, followed by associated squamous
    metaplasia of the salivary ducts.
  • Although the mucous acinar cells are necrotic,
    the overall lobular architecture of the involved
    glands is still preserveda helpful
    histopathologic clue.
  • There may be liberation of mucin, with an
    associated inflammatory response.
  • The squamous metaplasia of the salivary ducts can
    produce a pattern that is easily misdiagnosed as
    squamous cell carcinoma or mucoepidermoid
    carcinoma. This mistaken impression may be
    further compounded by the frequent association of
    pseudoepitheliomatous hyperplasia of the
    overlying epithelium. In most cases, however, the
    squamous proliferation has a bland cytologic
    appearance.

51
Necrotizing Sialometaplasia
52
Tuberculosis (Specific granulomatous ulceration)
  • Chronic infectious disease spread
    person-to-person through airborne droplets
  • Less than 5 of patients with tuberculosis
    progress from infection to disease
  • Primary tuberculosis
  • Occurs in previously unexposed people
  • Results in localized fibrocalcified nodule at
    initial site of involvement
  • Vital organisms remain dormant in nodule for
    years
  • Usually asymptomatic

53
Tuberculosis
  • Secondary tuberculosis
  • Develops from reactivation of organisms in
    previously infected person
  • Immunocompromised patients (HIV infection)
  • Lesions located in apex of lungs
  • Productive cough, fever, malaise, anorexia,
    weight loss, night sweats, consumption

54
Tuberculosis
  • Oral lesions can be nodular, granular, ulcerated
    or firm leukoplakic areas
  • Oral lesions of primary tuberculosis involve
    gingiva, mucobuccal fold, areas adjacent to teeth
    and extraction sites while oral lesions of
    secondary tuberculosis present on tongue, palate
    or lip.

55
Tuberculosis
56
Tuberculosis
57
Tuberculosis
58
Tuberculosis
  • TB has existed for thousands of years, killing
    millions and millions of people. Some were
    influential and greatly contributed to humanity
    through art, music, and literature before they
    died.   
  • King Tutankhamen (Egyptian pharaoh)
  • Baruch Spinoza (Dutch philosopher) 
  • Simon Bolivar (Venezuelan revolutionary leader)
  • John Keats (English poet)
  • Edgar Allan Poe (American writer/poet)
  • Frederic Chopin (Polish composer/pianist)
  • Robert Louis Stevenson (Scottish writer)
  • Anton Chekhov (Russian writer)
  • Franz Kafka (Czech novelist)
  • Eleanor Roosevelt (American humanitarian/first
    lady)
  • Eugene ONeill (American playwright)
  • George Orwell (English novelist/essayist)

59
Tuberculosis
60
Oral squamous cell carcinoma
61
Oral squamous cell carcinoma
62
Papillary Oral Lesions
Cauliflower-like Lesions
63
Inflammatory Papillary Hyperplasia
  • Inflammatory papillary hyperplasia is a reactive
    tissue growth that usually, although not always,
    develops beneath a denture. Some investigators
    classify this lesion as part of the spectrum of
    denture stomatitis (see page 192). Although the
    exact pathogenesis is unknown, the condition most
    often appears to be related to the following
  • ? An ill-fitting denture
  • ? Poor denture hygiene
  • ? Wearing the denture 24 hours a day
  • Approximately 20 of patients who wear their
    dentures 24 hours a day have inflammatory
    papillary hyperplasia. Candida also has been
    suggested as a cause, but any possible role
    appears uncertain.
  • Inflammatory papillary hyperplasia usually occurs
    on the hard palate beneath a denture base.

64
Inflammatory Papillary Hyperplasia
  • The mucosa in inflammatory papillary hyperplasia
    exhibits numerous papillary growths on the
    surface that are covered by hyperplastic
    stratified squamous epithelium. In advanced
    cases, this hyperplasia is pseudoepitheliomatous
    in appearance. The connective tissue can vary
    from loose and edematous to densely collagenized.
    A chronic inflammatory cell infiltrate is usually
    seen, which consists of lymphocytes and plasma
    cells. Less frequently, polymorphonuclear
    leukocytes are also present. If underlying
    salivary glands are present, they often show
    sclerosing sialadenitis.

65
Inflammatory Papillary Hyperplasia
66
Inflammatory Papillary Hyperplasia
67
Squamous Papilloma
  • A benign proliferation of stratified squamous
    epithelium, resulting in a papillary or
    verruciform mass. Presumably, is induced by the
    human papillomavirus (HPV). Viral subtypes 6 and
    11 have been identified in up to 50 of oral
    papillomas, as compared with less than 5 in
    normal mucosa. Recent research has shown that 81
    of normal adults have buccal epithelial cells
    that contain at least one type of HPV, although
    case control studies using more rigorous criteria
    have usually shown distinct differences, with
    high levels of HPV in oral lesions and low levels
    in normal controls.
  • Sites of predilection include the tongue, lips,
    and soft palate, but any oral surface may be
    affected.

68
Oral Papilloma (oral wart)
69
Verrucae (warts)
  • Self-limiting epidermal tumors caused by HPV
  • Any age but most common in children/adolescents
  • Grey to tan papules with rough pebble-like
    surface, flat or cauliflower-like mass
  • Verruca vulgaris / verruca plantatis Dorsum of
    hands, periungual, palm/sole, face rare
    intraoral
  • Genital wartscondyloma acuminatum

70
Verruca vulgaris
71
Verruca vulgaris
72
Verruca vulgaris (skin wart)
73
Oral (Squamous)Papilloma
74
Oral Squamous Papilloma
  • Characterized by a proliferation of keratinized
    stratified squamous epithelium arrayed in
    finger-like projections with fibrovascular
    connective tissue cores.
  • The connective tissue cores may show inflammatory
    changes, depending on the amount of trauma
    sustained by the lesion.
  • The keratin layer is thickened in lesions with a
    whiter clinical appearance, and the epithelium
    typically shows a normal maturation pattern.
  • Occasional papillomas demonstrate basilar
    hyperplasia and mitotic activity, which can be
    mistaken for mild epithelial dysplasia.
    Koilocytes, virus-altered epithelial clear cells
    with small dark (pyknotic) nuclei, are sometimes
    seen high in the prickle cell layer.

75
Oral Squamous Papilloma
76
Oral Papilloma (oral wart)
Immunohistochemical stain for common human
papillomavirus in an oral wart. Positive,
brown-staining nuclei are seen in upper level
keratinocytes. Nononcogenic subtypes (HPV
subtypes 2, 6, 11, 57) (
77
Oral Papilloma (oral wart)
78
Condyloma Acuminatum
  • Condyloma acuminatum is a virus-induced
    proliferation of stratified squamous epithelium
    of the genitalia, perianal region, mouth, and
    larynx.
  • One or more of the HPV types 2, 6, 11, 53, and 54
    are usually detected in the lesion. However, the
    high-risk types 16 and 18 also are found with
    frequency, especially in anogenital lesions.
    Condyloma is considered to be a sexually
    transmitted disease (STD), with lesions
    developing at a site of sexual contact or trauma.
  • This lesion represents 20 of all STDs diagnosed
    in STD clinics and may be an indicator of sexual
    abuse when diagnosed in young children. It is not
    unusual for oral and anogenital condylomata to be
    present concurrently.

79
Oral Condyloma Acuminatum
www.lib.uiowa.edu/.../lichen_planus_3_030916.jpg
www.nature.com
80
Condyloma Acuminatum
  • Condyloma acuminatum is a benign proliferation of
    acanthotic stratified squamous epithelium with
    mildly keratotic papillary surface projections.
    Thin connective tissue cores support the
    papillary epithelial projections, which are more
    blunted and broader than those of squamous
    papilloma and verruca vulgaris, imparting an
    appearance of keratin-filled crypts between
    prominences.
  • The covering epithelium is mature and
    differentiated, but the prickle cells often
    demonstrate pyknotic nuclei surrounded by clear
    zones (koilocytes), a microscopic feature of HPV
    infection. Ultrastructural examination reveals
    virions within the cytoplasm or nuclei of
    koilocytes, and the virus also can be
    demonstrated by immunohistochemical analysis, in
    situ hybridization, and PCR techniques.

81
Oral Condyloma Acuminatum
82
Verruciform Xanthoma
  • Verruciform xanthoma is an uncommon, benign oral
    mucosal lesion that occasionally may be found on
    the skin, typically on the genitalia. The cause
    is unknown.
  • Clinically, verruciform xanthoma is well
    circumscribed, with a granular to papillary
    surface. The size of this lesion ranges from 2 mm
    to more than 2 cm. Either an exophytic or a
    depressed surface is present, and the lesion may
    occasionally be ulcerated. The level of
    keratinization of the surface influences the
    color, which ranges from white to red.
  • The majority of cases have been reported in
    whites there is no gender predilection. The
    average age of patients is 45 years, with a few
    cases reported within the first and second
    decades. The lesions are usually discovered
    incidentally.

83
Verruciform Xanthoma
84
Verruciform Xanthoma
  • Verruciform xanthoma demonstrates papillary,
    acanthotic surface epithelium covered by a
    thickened layer of parakeratin.
  • On routine hematoxylin and eosin staining, the
    keratin layer often exhibits a distinctive orange
    coloration. Clefts or crypts between the
    epithelial projections are filled with
    parakeratin, and rete ridges are elongated to a
    uniform depth.
  • The most important diagnostic feature is the
    accumulation of numerous large macrophages with
    foamy cytoplasm, which typically are confined to
    the connective tissue papillae. These foam cells,
    also known as xanthoma cells, contain lipid and
    periodic acid-Schiff (PAS)- positive,
    diastase-resistant granules.

85
Verruciform Xanthoma
86
Papillary SCC
  • Papillary (exophytic) SCC represents an uncommon
    but distinct subtype of head and neck SCC. The
    demographics for this subtype of SCC are similar
    to those of conventional SCC, with the tendency
    to affect men more than women and to occur in
    adults, with a mean age in the 7th decade of
    life. Papillary SCCs predilect to the larynx
    (most common), oral cavity, oro- and hypopharynx,
    and sinonasal tract. Symptoms vary according to
    the site of involvement. Papillary SCC usually
    arise de novo without identification of
    coexisting benign lesion such as a papilloma,
    although association with precursor papilloma or
    occurrence in patients with previous history of a
    papilloma at the site of the papillary SCC has
    been reported. Human papillomavirus (HPV) by in
    situ hybridization and polymerase chain reaction
    have been detected in papillary SCC.

87
Papillary SCC
  • Papillary SCC is most often seen as a solitary
    lesion with an exophytic or papillary growth.
    Tumor size may range from 2 mm up to 4 cm.
    Histologically, papillary SCC has filiform growth
    with finger-like projections and identifiable
    fibrovascular cores or a broad-based bulbous to
    exophytic growth with rounded projections
    resembling a cauliflower-like growth pattern, in
    which fibrovascular cores can be seen but tend to
    be limited to absent. The squamous epithelium is
    cytologically malignant, and this malignant
    epithelium identifies these tumors as carcinomas,
    separating them from papillomas. Surface
    keratinization is generally limited and often
    absent. Definitive invasion may be difficult to
    demonstrate in biopsy specimens, with the
    carcinomatous epithelium suggesting an in situ
    process rather than invasive carcinoma. However,
    the extent of growth with the formation of a
    clinically appreciable exophytic mass goes beyond
    the general concept of an in situ carcinoma.
    These tumors should be considered as invasive,
    even in the absence of definitive stromal
    invasion

88
Papillary SCC
Papillary squamous cell carcinoma. A, filiform
growth with finger-like projections and
identifiable fibrovascular cores. B, broad-based
bulbous to exophytic growth with rounded
projections resembling a cauliflower-like growth
pattern with fibrovascular cores. C, the squamous
epithelium is cytologically malignant.
89
Ductal Papillomas of Salivary Glands
  • Sialadenoma papilliferum
  • Intraductal papilloma
  • Inverted ductal papilloma

90
Sialadenoma Papilliferum
  • At low power, the sialadenoma papilliferum is
    somewhat similar to the squamous papilloma,
    exhibiting multiple exophytic papillary
    projections that are covered by stratified
    squamous epithelium.
  • This epithelium is contiguous with a
    proliferation of papillomatous ductal epithelium
    found below the surface and extending downward
    into the deeper connective tissues.
  • Multiple ductal lumina are formed, which
    characteristically are lined by a double-rowed
    layer of cells consisting of a luminal layer of
    tall columnar cells and a basilar layer of
    smaller cuboidal cells.
  • These ductal cells often have an oncocytic
    appearance. An inflammatory infiltrate of plasma
    cells, lymphocytes, and neutrophils is
    characteristically present. (Because of their
    microscopic similarity, this tumor has been
    considered to be an analogue of the cutaneous
    syringocystadenoma papilliferum.)

91
Sialadenoma Papilliferum
92
Ductal Papilloma
Inverted ductal papilloma
Intraductal papilloma
93
Proliferative Verrucous Leukoplakia
  • A subset of idiopathic leukoplakia
  • Associated with HPV subtypes 16 and 18
  • Recurrent/persistent multiple sites typical
  • Progression from simple keratosis to
    well-differentiated verruciform lesions
  • High risk of malignant transformation to
    verrucous carcinoma or squamous cell carcinoma

94
Proliferative Verrucous Leukoplakia
95
Clinical Appearances of Oral Leukoplakia
96
Proliferative Verrucous Leukoplakia
PVL
97
Proliferative Verrucous Leukoplakia
98
Progression of PVL
99
Warty Dyskeratoma
  • Warty dyskeratoma (focal acantolytic
    dyskeratosis) is a distinctly uncommon solitary
    lesion that can occur on skin or oral mucosa.
  • It is histopathologically identical to Darier's
    disease. For this reason, the lesion has been
    termed isolated Darier's disease. The lesion is
    not otherwise related to Darier's disease,
    however, and its cause remains unknown.

100
Warty Dyskeratoma
101
Keratoacanthoma
102
Focal Epithelial Hyperplasia
  • FEH is a virus-induced, localized proliferation
    of oral squamous epithelium that was first
    described in native Americans and Inuits
    (Eskimos).
  • Is currently known to exist in many populations
    and ethnic groups and is apparently produced by
    the HPV type 13 and possibly 32.
  • In some populations, as many as 39 of children
    are affected.
  • Multiple papillary lesions similar to focal
    epithelial hyperplasia arise with increased
    frequency in AIDS patients

103
Focal Epithelial Hyperplasia
  • Usually a childhood condition, occasionally
    affects young and middle-aged adults.
  • There is no gender bias.
  • Sites of greatest involvement include the labial,
    buccal, and lingual mucosa, but gingival and
    tonsillar lesions also have been reported.
  • FEH typically appears as multiple soft,
    non-tender, flattened or rounded papules, usually
    clustered and the color of normal mucosa.
  • Occasional lesions show a slight papillary
    surface change. Individual lesions are small (0.3
    to 1.0 cm), discrete, and well demarcated, but
    they frequently cluster so closely together that
    the entire area takes on a cobblestone or
    fissured appearance.

104
Focal Epithelial Hyperplasia
  • The hallmark is an abrupt and sometimes
    considerable acanthosis of the oral epithelium.
  • Because the thickened mucosa extends upward, not
    down, the lesional rete ridges are at the same
    depth as the adjacent normal rete ridges. The
    ridges themselves are widened, often confluent,
    and sometimes club shaped.
  • Some superficial keratinocytes show a koilocytic
    change similar to that seen in other HPV
    infections. Others occasionally demonstrate an
    altered nucleus that resembles a mitotic figure
    (mitosoid cell). Virus-like particles have been
    noted ultrastructurally within both the cytoplasm
    and the nuclei of cells within the prickle cell
    layer, and the presence of HPV has been
    demonstrated with both DNA in situ hybridization
    and immunohistochemical analysis.

105
Focal Epithelial Hyperplasia
Mitosoid cells
106
Associations With Melanin Pigmentation of Oral
Mucosa
  • PHYSIOLOGIC OR SYNDROMIC ASSOCIATIONS
  • ? Racial or physiologic pigmentation
  • ? Peutz-Jeghers syndrome
  • ? McCune-Albright syndrome
  • ? LEOPARD syndrome (lentiginosis profusa, no
    intraoral melanosis)
  • ? Cronkhite-Canada syndrome
  • ? Bloom syndrome
  • ? Dunnigan syndrome
  • ? Dyskeratosis congenita
  • ? Endocrine candidosis
  • ? Incontinentia pigmenti
  • ? Oculo-cerebro-cutaneous syndrome
  • ? Rothmund-Thomson syndrome
  • ? Trisomy 14 mosaicism
  • ? Unusual facies, vitiligo, spastic paraplegia
    syndrome
  • ? Xeroderma pigmentosum
  • ? Addison disease
  • ? Neurofibromatosis
  • From Bouquot JE, Nikai H Lesions of the oral
    cavity. In Gnepp DR Diagnostic surgical
    pathology of the head and neck, pp 141238,
    Philadelphia, 2001, WB Saunders.

107
Associations With Melanin Pigmentation of Oral
Mucosa
  • CHRONIC TRAUMA OR IRRITATION OR ENVIRONMENTAL
    POLLUTANT
  • ? Chronic mucosal trauma or irritation (chronic
    cheek bite)
  • ? Chronic autoimmune disease (erosive lichen
    planus, pemphigoid)
  • ? Smoker's melanosis
  • ? Yusho (chronic exposure to high levels of PCB)
  • SYSTEMIC MEDICATIONS
  • ? Chloroquine and other quinine derivatives
  • ? Phenolphthalein
  • ? Estrogen
  • ? AIDS-related medications
  • From Bouquot JE, Nikai H Lesions of the oral
    cavity. In Gnepp DR Diagnostic surgical
    pathology of the head and neck, pp 141238,
    Philadelphia, 2001, WB Saunders.

108
Oral Melanin Pigmentation
Smoking-associated melanosis
Physiologic (racial) pigmentation
109
Erythroleukoplakia (as a cause of redness)
110
(No Transcript)
111
Oral Melanotic Macule
112
(No Transcript)
113
Melanoacanthoma
114
Nevocellular Nevus (Skin)
  • Congenital or acquired neoplasm of melanocytes
  • Tan/brown, uniformly colored, lt5 mm, papules with
    well-defined rounded borders
  • Maturation decreased lack junctional activity,
    cords of smaller cells with little pigment

115
Nevocellular nevi
116
Nevi
Junctional
Compound
Intradermal
Blue
117
Oral Melanoma
118
Mucosal (oral) melanoma
119
Mucosal (oral) amelanotic melanoma
120
Malignant Melanoma
  • Cutaneous melanoma associated with sun damage or
    dysplastic nevi
  • CDKN2A mutation common (cyclin-dependent kinase
    inhibitor)
  • Itching, variegation, enlargement, irregular
    borders, new mole
  • Radial/vertical growth dictates behavior
  • Metastasis to lymph nodes, liver, lungs brain

121
Melanoma of skin
122
Prognosis related to depth of invasion (skin)
123
(No Transcript)
124
Amalgam Tattoo and Other Localized Exogenous
Pigmentations
  • Implantation of dental amalgam resulting in
    clinically evident pigmentation
  • Black, blue, or gray macules
  • Most common sites are gingiva, alveolar buccal
    mucosa
  • Fragments can be densely radiopaque

125
Amalgam Tattoo and Other Localized Exogenous
Pigmentations
  • Can be implanted in several ways
  • Amalgam dust in oral fluids
  • Broken amalgam pieces in extraction sites
  • Dental floss contaminated with amalgam particles
  • Amalgam from endodontic procedures left in soft
    tissue
  • Fine metallic particles driven by drill pressure
  • Radiographs confirm diagnosis, no treatment
    necessary
  • Other accidental localized foreign body tattoo is
    possible, also intentional intraoral tattoos

126
Amalgam Tattoo
127
Geographic Tongue(benign migratory glossitis
erythema migrans)
128
Erythematous Candidiasis
  • Several presentations
  • Acute atrophic candidiasis (antibiotic sore
    mouth)
  • Central papillary atrophy (median rhomboid
    glossitis)
  • Chronic multifocal candidiasis
  • Angular cheilitis (involvement of angles of
    mouth)
  • Denture stomatitis (erythema localized to
    denture-bearing areas removable dental prosthesis)

129
Erythematous Candidiasis
130
Candidiasis
  • The histopathologic features include increased
    thickness of parakeratin in conjunction with
    elongation of rete ridges. Typically, there is
    chronic inflammatory cell infiltrate in the
    connective tissue immediately subjacent to the
    infected epithelium, and small collections of
    neutrophils (microabscesses) are often in the
    parakeratin layer and superficial spinous cell
    layer near the organisms. The candidal hyphae are
    embedded in the parakeratin layer and rarely
    penetrate into the viable cell layers of the
    epithelium unless the patient is extremely
    immunocompromised.

131
Hemangioma (cavernous)
132
Peripheral Giant Cell Granuloma
133
Pyogenic Granuloma
134
Varix
135
Thrombocytopenia
  • Decreased number of circulating blood platelets
  • Reduced production malignant cells in bone
    marrow, cancer chemotherapy
  • Increased destruction immunologic reaction,
    abnormal blood clot formation
  • Condition often detected because of presence of
    oral lesions (petechiae, ecchymosis, hematoma)

136
Thrombocytopenia
About PowerShow.com