The Diagnostic Process: Correlation of Gross Structure and Microstructure with Clinical Features

1
The Diagnostic Process Correlation of Gross
Structure and Microstructure with Clinical
Features

• DENT 512
• Lecture 2

2
Overview

• Normal Anatomy and Structures
• The Diagnostic Process
• Taking a History
• The Clinical Exam and Classification of Clinical
  Features
• Color
• Contour
• Palpation
• Delineation
• Symptoms
• Developing a Differential Diagnosis
• Common lesions
• Evaluating and managing the uncommon lesion

3
Normal Anatomy

• In order to recognize abnormal changes,
  familiarity of normal structures is essential
• Also important to be familiar with variations of
  normal anatomy
• Clinical and microscopic aspects of normal
  important

4
Patel VF et al. Advances in oral transmucosal
drug delivery. Journal of Controlled Release
2011153(2)106-116.
5
Epithelial vs mesenchymal tissues
Epithelial Mesenchymal
Epidermis of skin Fibrous connective tissue
Oral mucosal stratified squamous epithelium Muscle, nerves, adipose tissue
Glands salivary, adnexal, thyroid Cartilage and Bone
Enamel of teeth Dentin, cementum, and dental pulp
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Stratified squamous oral mucosal epithelium
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-Fibrous connective tissue -Neurovascular
bundles -Muscle fibers
8
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-Bone -Cartilage -Adipose Tissue
10
Enamel
Dentin
Dental Papilla
11
-Epidermis of skin -Dermis -Adnexal structures
(hair follicle, eccrine gland, sebaceous gland,
smooth muscle)
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Minor Salivary Gland
Parotid
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Oral and Perioral Systems

• 1. Mucous membrane
• stratified squamous epithelial lining
• lamina propria
• 2. Skin
• stratified squamous epithelium
• dermal appendage structures
• dermis
• 3. Glandular systems
• salivary glands
• sinonasal mucous glands
• thyroid and parathyroid gland

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Oral and Perioral Systems (Continued)

• 4. Bones
• maxilla
• mandible
• zygoma
• vomer
• palatine
• sphenoid
• hyoid
• temporal
• cervical vertebrae

3Dsciencepics.com
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Oral and Perioral Systems (Continued)
3Dsciencepics.com

• 5. Muscles
• facial expression
• mastication
• speech
• swallowing
• head movement

www.brittanica.com
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Oral and Perioral Systems (Continued)

• 6. Other systems
• a) teeth
• b) larynx and pharynx
• c) respiratory tract
• d) esophagus
• e) lymphatic and vascular system

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Diagnostic Sequence and Patient Management
19
Patient History

• Onset of lesion?
• Pattern of symptoms?
• Duration?
• Triggers?
• Systemic disease or symptoms?
• Observed previously? Prior reports/radiographs
  available?
• Prior treatment and response?
• Risk factors?

20
Consistent and Comprehensive Patient Exam

• Use same pattern every time
• Do not skip to chief complaint (you may miss
  other related or important findings)
• Be thorough
• Include palpation as well as visual exam

21
Optimizing Clinical Exam

• Visualize disease process in tissue
• Imagine why tissue could appear as it does

Clinical photo University of Florida Oral
Pathology Image Archives
22
Optimizing Clinical Exam

• Look for other associated manifestations
• Other areas of the oral cavity affected
• Extraoral findings skin, eyes, nails

Photos http//www.emedicinehealth.com/image-galle
ry/lichen_planus_2_picture/images.htm
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Identifying Likely Disease Process

• Many times most likely process may be narrowed
  down to 1-2 processes
• Developmental, Reactive, Neoplastic, Immune
  Related, Infective, Systemic
• Overlap may be present or two contributing
  factors
• Example autoimmune diseases with secondary
  opportunistic infections

24
Differences Between Benign and Malignant Tumors

• 1) Differentiation and Anaplasia
• 2) Rate of Growth
• 3) Local Invasion
• 4) Metastasis

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Differential Diagnosis Formation

• Consider most likely diagnoses, but account for
  rare diagnoses that may cause danger to the
  patient (syndrome related, malignant) that must
  be ruled out
• Formulate working diagnosis based on most likely
  entity

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Plan of Action

• Can clinical diagnosis can be reached with
  relative certainty?
• If not, is biopsy needed to exclude dangerous
  entities or establish diagnosis for appropriate
  treatment?
• Can provisional treatment be done prior to biopsy
  ex smooth filling, eliminate trauma, trial
  treatment of antifungal, perio debridement?
• If lesion does not respond as expected to
  treatment, biopsy is indicated and should not be
  delayed
• If observation chosen
• Be vigilant about followup

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Features Obtained by Examination

• Color
• Red, white, yellow, pigmented, ulcerated
• Contour
• Appearance (smooth, rough, flat, elevated,
  sessile, pedunculated)
• Delineation of lesion (well defined, poorly
  defined)
• Palpation findings
• Fluctuant, firm, soft, hard
• Symptoms
• Pain elicited via examination?

28
Color differential within normal oral mucosa

• Masticatory Mucosa
• More mechanical stressthicker keratin results in
  lighter pink color
• Lining Mucosa
• Less mechanical stressless keratin and better
  visibility of vascular submucosa results in
  increased pink or red coloration

29
Color Change

• Red
• May be due to vascular dilitation, proliferation
  of vessels, extravasation of blood, atrophy of
  mucosa
• White
• Usually due to increased surface keratin or
  fibrosis
• Yellow
• Adipose tissue, intramucosal keratin entrapment,
  sebaceous glands
• Pigmented
• Foreign material, melanin, or blood products

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White Lesions

• Usually due to thickened epithelium or keratin
  layer
• Often suggestive of reactive or neoplastic
  process

LR Eversole. Clinical Outline of Oral Pathology
Diagnosis and Treatment. 3rd Edition. 1992.
31
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Traumatic hyperkeratosis
Clinical photo University of Florida Oral
Pathology Image Archives
33
Leukoedema
Clinical photo University of Florida Oral
Pathology Image Archives
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Candidiasis
Clinical photo University of Florida Oral
Pathology Image Archives
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Oral Hairy Leukoplakia
Clinical photo University of Florida Oral
Pathology Image Archives
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Oral lichenoid mucositis
Clinical photo University of Florida Oral
Pathology Image Archives
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Dysplasia
Clinical photo University of Florida Oral
Pathology Image Archives
38
Red or Pigmented Lesions

• Red lesions usually due to increased vascularity
  or atrophic (thinned) epithelium
• Reactive, neoplastic, autoimmune processes
• Pigmented lesions
• Foreign material
• Melanin
• Blood or blood product (hemosiderin)

LR Eversole. Clinical Outline of Oral Pathology
Diagnosis and Treatment. 3rd Edition. 1992.
39
(No Transcript)
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Erythema migrans
Clinical photo University of Florida Oral
Pathology Image Archives
41
Mucous Membrane Pemphigoid
Clinical photo University of Florida Oral
Pathology Image Archives
42
Dysplasia
Clinical photo University of Florida Oral
Pathology Image Archives
43
Pigmented Oral Lesions
Kauzman A. et al. Pigmented Lesions of the Oral
Cavity Review, Differential Diagnosis, and Case
Presentations. J Can Dent Assoc 2004
70(10)6823.
44
Melanotic Macule
Clinical photo University of Florida Oral
Pathology Image Archives
45
Amalgam Tattoo
Clinical photo University of Florida Oral
Pathology Image Archives
46
Ulcerated Lesions

• Due to loss of epithelial layer
• Can be autoimmune, infective, secondary to trauma
  or neoplasia

LR Eversole. Clinical Outline of Oral Pathology
Diagnosis and Treatment. 3rd Edition. 1992.
47
Vesicular Lesions

• Due to separation within or below epithelial
  layer
• Usually autoimmune or infective (viral)

LR Eversole. Clinical Outline of Oral Pathology
Diagnosis and Treatment. 3rd Edition. 1992.
48
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Aphthous Ulceration
Gnepp. Diagnostic Surgical Pathology of the Head
and Neck. 2nd edition. Saunders. 2009.
Clinical photo University of Florida Oral
Pathology Image Archives
50
Herpes Simplex Virus-Recurrent
Clinical photo University of Florida Oral
Pathology Image Archives
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Significant overlap with recurring acute oral
ulceration though patients usually will be
affected nearly constantly with chronic as
opposed to recurring with full resolution between
flare-ups in acute types such as RAS minor and
recurrent HSV
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Pemphigus Vulgaris
Clinical photo University of Florida Oral
Pathology Image Archives
53
Traumatic Ulceration
Clinical photo University of Florida Oral
Pathology Image Archives
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Squamous Cell Carcinoma
Clinical photo University of Florida Oral
Pathology Image Archives
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Contour
Melanotic macule

• Macule
• Flat, occurs as a result of color change
• Elevated (Raised) Lesion
• Sessile (broad based elevation)
• Pedunculated (connected by stalk)

Pyogenic granuloma
Clinical photo University of Florida Oral
Pathology Image Archives
56
Surface Characteristics

• Rough-Surface Rule lesion usually originates
  from surface epithelium
• Exceptions
• PEH
• malignancy originating in the connective tissue
  to later involve the epithelium
• Smooth-Surface Rule lesion usually originates
  below the surface epithelium (mesenchyme,
  salivary,etc)
• Exceptions
• a) intra-epithelial vesicles and bullae, e.g.
  herpes, pemphigus
• b) late malignant tumors originating below the
  surface epithelium

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SCCA
Granular Cell Tumor
Clinical photo University of Florida Oral
Pathology Image Archives
58
Submucosal Swellings

• Due to proliferation of mesenchymal tissue or
  epithelial mass within connective tissue
• Usually neoplastic, developmental, or reactive

LR Eversole. Clinical Outline of Oral Pathology
Diagnosis and Treatment. 3rd Edition. 1992.
59
(No Transcript)
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Benign salivary tumor Pleomorphic Adenoma
Clinical photo University of Florida Oral
Pathology Image Archives
61
Reactive Gingival Lesion --Peripheral Ossifying
Fibroma
Clinical photo University of Florida Oral
Pathology Image Archives
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Benign neural lesion Palisaded Encapsulated
Neuroma
Koutlas IG, Scheithauer BW. Palisaded
Encapsulated (Solitary Circumscribed) Neuroma
of the Oral Cavity A Review of 55 Cases. Head
and Neck Pathol 201041526.
63
Delineation of a Lesion

• Delineation of a lesions depends upon
• 1. Firmness of the mass
• 2. Discreteness of its borders
• 3. Relative consistency of the surrounding
  tissues
• 4. Thickness and nature of the overlying tissue
• 5. Sturdiness of the underlying platform

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Borders of a Mass

• Malignancies usually have ill-defined borders via
  visual or palpation technique
• Due to invasion
• Due to fibrotic response
• Exceptions inflammation usually also ill-defined

Diagnostic Surgical Pathology of the Head and
Neck. Gnepp, DR. editor. 2nd edition.
65
Mobility

• Freely moveable mass most likely a benign,
  possibly encapsulated process
• Mass is bound to skin/mucosa or to the underlying
  tissue may be due to
• 1. fibrosis following inflammation
• 2. infiltrating malignant tumor originating in
  skin or mucosa
• 3. infiltrating malignant tumor originating in
  deep tissue
• 4. malignancy invading in both directions

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Epidermal Inclusion Cyst
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Three Modifying Factors of the Consistency of a
Tissue

• 1. The depth of a mass in tissue i.e. a soft
  mass deep in tissue will seem firmer.
• 2. A thick layer of overlying tissue, especially
  muscle or fibrous connective tissue will modify
  or mask the consistency.
• 3. Soft glandular tissue surrounded by a dense
  connective tissue capsule will seem firmer than
  it is.

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Four Factors Which Determine If Fluctuance Can Be
Perceived

• The mass must contain a liquid or gas in a
  relatively enclosed cavity
• The mass must be located in a superficial plane
• The mass must be in a fluctuant stage
• Developing fibrosis around the mass may obscure
  the fluctuance

Ranula
Clinical photo University of Florida Oral
Pathology Image Archives
69
Conditions That Mask Fluctuance

• 1. Deep mass
• 2. Fibrosis
• 3. Wrong stage of certain lesions, e.g.
  actinomycosis, certain infections, hematoma

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Possible Causes of Pain

• 1. Pain because of inflammation
• 2. Painful tumors
• 3. Pain because of sensory nerve encroachment
• Tenderness in a mass usually indicates the
  presence of a low-grade inflammation and internal
  pressure

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Unilateral or Bilateral Masses

• Bilateral masses in the same location are most
  likely normal anatomic structures or
  developmental in origin
• There are exceptions however

Photo courtesy Dr. S. Gordon
72
Multiple Lesions

• These must alert the examiner to the following
  possibilities
• 1. Systemic disease
• 2. Disseminated disease
• 3. Syndromes

Radiograph University of Florida Oral Pathology
Image Archives
Nevoid Basal Cell Carcinoma Syndrome
73
Other palpation techniques

• Percussion (tapping area to evaluate sound
  produced) often used to evaluate teeth
• Auscultation (listening) may be helpful in
  evaluation of TMJ or other areas of the head and
  neck

74
Correlation of Radiographic Findings

• Evaluate relationship to teeth and adjacent
  structures
• Vitality testing
• Relationship to anatomical structures such as
  sinus, major nerves and vessels, TMJ
• Always correlate clinically in relation to
  radiographic features
• Expansion present?
• Tenderness to palpation or percussion?
• Surface change?

75
Radiolucent Lesions

• Due to loss of bone by aggregation of reactive
  soft tissue, cyst, or non-calcified tumor
• Reactive (PA granuloma or cyst), Developmental,
  or Neoplastic
• Most important signs to look for are expansion,
  destruction or movement of adjacent structures,
  pain or paresthesia

LR Eversole. Clinical Outline of Oral Pathology
Diagnosis and Treatment. 3rd Edition. 1992.
76
(No Transcript)
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Dentigerous Cyst
Radiograph University of Florida Oral Pathology
Image Archives
78
Nasopalatine Duct Cyst
Radiograph University of Florida Oral Pathology
Image Archives
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Lateral Periodontal Cyst
University of Florida Oral Pathology Image Archive
Radiograph University of Florida Oral Pathology
Image Archives
80
Odontogenic Keratocyst (Keratocystic Odontogenic
Tumor)
Radiograph University of Florida Oral Pathology
Image Archives
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(No Transcript)
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Glandular Odontogenic Cyst
Radiograph and photomicrograph from Fowler CB et
al. Glandular odontogenic cyst analysis of 46
cases with special emphasis on microscopic
criteria for diagnosis. Head Neck Pathol 2011
Dec5(4)364-75.
83
Ameloblastoma
Radiograph University of Florida Oral Pathology
Image Archives
84
Odontogenic Myxoma
University of Florida Oral Pathology Image Archive
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Radiopaque Lesions

• Due to replacement of normal bone by either more
  densely ossified bone or lesion producing some
  type of calcified material
• Neoplastic, Reactive, Systemic, Developmental
• Most important signs to look for are expansion,
  destruction or movement of adjacent structures,
  pain, or paresthesia

LR Eversole. Clinical Outline of Oral Pathology
Diagnosis and Treatment. 3rd Edition. 1992.
86
(No Transcript)
87
Cemento-Osseous Dysplasia
Radiograph University of Florida Oral Pathology
Image Archive
88
Adenomatoid Odontogenic Tumor
Radiograph University of Florida Oral Pathology
Image Archive
89
Calcifying Odontogenic Cyst (sometimes found with
odontoma)
Radiograph University of Florida Oral Pathology
Image Archive
90
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Odontoma
Radiograph University of Florida Oral Pathology
Image Archive
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Osteoblastoma
Radiograph University of Florida Oral Pathology
Image Archive
93
The 15 Most Common Oral Pathoses (via Oral Exam
only)(Based on examination of 23,616 U.S.
adults excludes caries periodontitis)
Diagnosis Rank Number of Lesions per 1,000 Adults Number of Lesions per 1,000 Adults Number of Lesions per 1,000 Adults
Diagnosis Rank Males Females Both
Leukoplakia 1 42.5 13.1 23.7
Torus palatinus 2 13.2 21.7 18.7
Irritation fibroma 3 13.0 11.4 11.9
Fordyce granules 4 17.7 5.2 9.7
Torus mandibularis 5 9.6 7.9 8.5
Leaf-shaped fibroma (under denture) 6 0.4 12.9 6.7
Hemangioma 7 8.4 4.1 5.6
Inflammatory ulcer 8 5.4 5.1 5.2
Inflammatory erythema 9 4.5 4.8 4.7
Papilloma 10 5.3 4.2 4.6
Epulis fissuratum 11 3.4 4.4 4.0
Lingual varicosities 12 3.5 3.4 3.5
Fissured tongue 13 3.5 3.1 3.3
Geographic tongue 14 3.4 3.0 3.1
Papillary hyperplasia of palate 15 1.7 3.8 3.0
References Bouquot JE. J Am Dent Assoc 1986
11250-57 www.oralpath.com
94
Variants of normal or lesions with high
confidence of clinical diagnosis-Often not
needing biopsy

• Torus/exostosis
• Fordyce granule
• Varicosity
• Amalgam tattoo
• Lingual tonsil
• Geographic tongue
• Oral infectious disease (including
  fungal-candidiasis, viral-HSV)

95
Photos courtesy Dr. S. Gordon
96
Biopsied Adult Oral Lesion Frequency
Jones AV, Franklin CD. An analysis of oral and
maxillofacial pathology found in adults over a
30-year period. J Oral Pathol Med 200635392-401.
97
Jones AV, Franklin CD. An analysis of oral and
maxillofacial pathology found in adults over a
30-year period. J Oral Pathol Med 200635392-401.
98
Jones AV, Franklin CD. An analysis of oral and
maxillofacial pathology found in adults over a
30-year period. J Oral Pathol Med 200635392-401.
99
Biopsied Pediatric Oral Lesion Frequency
Shah SK, Le MC, Carpenter WM. Retrospective
review of pediatric oral lesions from a dental
school biopsy service. Pediatr Dent 20093114-9.
100
Evaluating and managing an uncommon lesion

• Practice the ability to recognize the unusual
• Retain an index of suspicion for all lesions and
  avoid making assumptions based on your clinical
  impression
• Look for warning signs of dangerous lesions
• Paresthesia, ill-defined lesions, rapid expansion
  or growth, systemic or related findings
• Unusual or uncharacteristic presentations of
  common or normally clinically recognizable
  lesions may require biopsy for definitive
  diagnosis
• Many dangerous lesions can mimic benign
  conditions
• If lesions do not respond to treatment as
  expected, follow up with biopsy or referral for
  further diagnosis

101
Uncommon presentation
Clinical impression reactive gingival lesion
(peripheral ossifying fibroma)
Microscopic diagnosis well differentiated
squamous cell carcinoma
102
Conclusions

• To optimize your oral pathology patient
  management
• Follow a consistent and complete oral exam on all
  patients
• Visualize likely histologic cause of clinical
  changes
• Evaluate the likely disease process responsible
• Base differential diagnosis and management on
  most likely entity but do not fail to account for
  potentially dangerous or clinically relevant
  entities that may mimic other lesions
• Follow 14 day observation rule for suspected
  traumatic lesions and refer for biopsy unresolved
  lesions or lesions that fail to respond to
  therapy as expected!