LIP Actinic Cheilosis
A common condition caused by excessive exposure to sunlight manifesting as a crusting lesion of the lower lip; it may show evidence of dysplasia and superficial invasion; however, simple excision of actinic cheilosis usually cures this condition.
Aetiology: Sunlight (actinic radiation)
Location(s): Lower lip
Clinical Features: Thickening and crusting of the lower lip
Radiographic Features: None
Microscopic Features: Hyperkeratosis usually accompanied by dysplasia and superficial invasion
Complications: May progress to overt invasive squamous cell carcinoma
Treatment: Surgical excision with future protection of lower lip from sunlight
Prognosis: Good: 95% cure rate
Pathogenesis: Carcinogenic transformation of epithelial cells in lip
Benign Mixed Tumour
A relatively common benign neoplasm arising from the parenchyma and stroma of major or minor salivary glands manifesting as a submucosal "bump"; complete surgical excision will cure mixed tumours.
Aetiology: Unknown
Location(s): Major or minor salivary glands.
Clinical Features: Submucosal nodule in major or minor salivary gland; movable (at first) and covered with normal skin or mucosa.
Radiographic Features: None
Microscopic Features: Proliferating ducal epithelium; neoplastic stroma with many appearances.
Complications: Incomplete removal; may involve VII nerve in parotid gland.
Treatment: Surgical excision
Prognosis: Excellent with complete removal
Pathogenesis: Unknown
Pemphigus Vulgaris
A serious autoimmune systemic dermatologic disease that may affect the oral mucous membrane and skin; it manifests as large fluid-filled, rupture-prone bullae; it has a distinctive histologic appearance; anti-inflammatory agents are the only effective therapy; it has a high mortality rate.
Etiology: Autoimmune
Location(s): Anywhere on skin or oral mucous membrane.
Clinical Features: Large bullae on skin but soon rupture in the oral cavity leaving a ragged slough over a shallow ulcer.
Radiographic Features: None
Microscopic Features: "Intraepithelial clefting" and "tombstoning" is characteristic.
Complications: Intractable pain; interference with nutrition; fluid loss
Treatment: Corticosteroid therapy
Prognosis: May improve dramatically with therapy; remission common.
Pathogenesis: An autoimmune process is directed at skin and oral mucous membrane desmosomes; as a consequence, cells do not adhere to each other.
Primary Herpetic Gingivostomatitis
An acute initial infection with the Herpes simplex virus manifesting with fever, malaise, lymphadenopathy, and vesicles followed by ulcers; no current treatment will rid the patient of HSVI; most HSVI+ patients do not remember or did not experience primary herpetic gingivostomatitis.
Aetiology: Microbial infection with HSV
Location(s): Lips and intraoral mucous membrane
Clinical Features: Fever, malaise, lymphadenopathy. Oral mucosa is red with small blisters that soon burst leaving ulcers behind.
Radiographic Features: None
Microscopic Features: Intraepithelial vesicle; cytology smears may reveal signs of viral infection.
Complications: Rarely may produce fatal encephalitis; recurrence common.
Treatment: None, antiviral drugs (acyclovir) may prevent complications.
Prognosis: Good
Pathogenesis: HSV attacks oral epithelial cells producing blisters (vesicles) within the epithelial lining.
Pyogenic Granuloma
A common granulation tissue reaction to repeated injury appearing as a raised soft, red growth that bleeds easily; elimination of injury and surgical excision will cure a pyogenic granuloma.
Aetiology: Trauma
Location(s): Gingival margin and papillae the most common site
Clinical Features: Raised, soft, red lesion that bleeds easily
Radiographic Features: None
Microscopic Features: Granulation tissue covered with oral epithelium that may be ulcerated.
Complications: May recur if injury is not removed
Treatment: Surgical removal with elimination of irritation.
Prognosis: Excellent
Pathogenesis: Presumed continual repair evoked by repeated traumatic stimuli.
Recurrent Herpetic Gingivostomatitis
A very common stress-related reappearance of HSVI in previously infected patients manifesting as vesicles, then ulcers on the masticatory mucosa; the outbreak last 7-10 days with or without antiviral treatment.
Aetiology: Microbial infection
Location(s): Lips and/or masticatory mucosa (mucosa attached to bone).
Clinical Features: Vesicles followed by ulcers located on lips and/or on mucosa attached to bone.
Radiographic Features: None
Microscopic Features: Intraepithelial vesicles
Complications: None; may recur many times
Treatment: None; antiviral therapy may abort attack in very early stages
Prognosis: Good; resolves in 7-10 days
Pathogenesis: After primary infection; virus remains hidden in the trigeminal nerve; stress or disease may cause another outbreak.
Squamous Cell Carcinoma
A common epithelial malignancy of the oral mucosa appearing as a red, white, or ulcerated "sore"; if larger than 1.0cm. Invasion invariably will have occurred; radical treatment and radiation maybe required causing deformities and radiation side-effects.
Aetiology: Alcohol or tobacco or sunlight
Location(s): Intraoral or lip mucosa
Clinical Features: White, red, or crusting flat or raised mucosal lesion.
Radiographic Features: None unless there is bone invasion
Microscopic Features: Typical invasive squamous cell carcinoma
Complications: Invasion, local metastasis, surgical mutilation, oral radiation damage
Treatment: Wide or radical surgical excision; radiation.
Prognosis: Cure rates vary with site and stage when treated.
Pathogenesis: Carcinogenic transformation of epithelial precursor cells
Mucosa: Reactions to Injury
General Features
The oral mucous membrane is subject to daily trauma.
The mucosa that lines the oral cavity is subject to considerable abuse. Rough food, hot food, spicy food, cigarettes, alcohol, toothpicks, and other materials find their way into the mouth and contact the oral mucosa. While the oral tissues have considerable tolerance to such insults, from time to time damage will occur and a lesion will develop. Some lesions will be composed of granulation tissues, some will be composed of fibrous connective tissue, and still others will be composed of epithelium. Because these conditions are a reaction to some irritant they are often called "reactive lesions." They arise from the epithelium or connective tissue of the mucous membrane and usually produce an exophytic, raised, surface lesion. While their clinical features may resemble that of a neoplasm, the reactive lesions are not spontaneous new growths; rather they are examples of hyperplasia caused by some local injury. Like other forms of hyperplasia, these "growths" are self-limiting and will regress with removal of the offending irritant or, at the very least, not recur when they and their cause is removed.
Overgrowth of Granulation Tissue
Granulation tissue may form in response to injury.
It will be remembered that the formation of blood vessels and new fibroblasts producing collagen fibers -- granulation tissue -- is an early step in connective tissue repair. When the oral mucosa is injured repeatedly, excessive amounts of granulation tissue may be produced in the lamina propria of the oral mucous membrane. This excessive granulation raises the overlying epithelium producing a raised lesion. The large numbers of new capillaries, fibroblasts, and new collagen results in a soft, red lesion that easily bleeds.
Pyogenic Granuloma
A common granulation tissue reaction to repeated injury appearing as a raised, soft, red growth that bleeds easily; elimination of the injury and surgical excision will cure a pyogenic granuloma. Synonyms: granuloma gravidarum, epulis granulomatosum.
Pyogenic granulomas commonly occur in children and adult females.
The name "pyogenic granuloma" is a misnomer; they rarely product pus (pyo- = pus, -genic = producer) and they are not true granulomas. They are common lesions that may occur more frequently in children and adult females than in adult males.
Pyogenic granulomas are caused by repeated injury.
Pyogenic granulomas usually result from chronic mechanical irritation. Foreign bodies like calculus and popcorn fragments may stimulate exuberant granulation tissue formation.
When associated with pregnancy, they are "granuloma gravidarum."
They may occur pregnant females who because of "morning sickness" or hormonally-induced gingival tenderness let their oral hygiene deteriorate. The resulting accumulation of plaque and calculus stimulate pyogenic granuloma formation. In this setting (pregnancy) a pyogenic granuloma is often known as a" pregnancy tumour" or, better, "granuloma gravidarum."
When they follow tooth extraction, they are "epulis granulomatosum."
Pyogenic granulomas may also be arising shortly after tooth extraction. In this setting they are usually caused by bone fragment or a piece of calculus being left in the socket. These post-extraction pyogenic granulomas are often known as "epulis granulomatosum" (epulis = of the gums, granulomatosum = increase of granulation tissue).
Pyogenic granulomas often occur near the gingival margins.
Most pyogenic granulomas arise from the gingiva, a logical location given the exposure of the gingival tissues to repeated injury. These lesions tend to arise from the interdental papillae or the gingival margins. They may be located elsewhere, the tongue for example, depending on the site of repeated injury. As already mentioned, pyogenic granulomas may also arise from recent tooth extraction sites (epulis granulomatosum).
Pyogenic granulomas are raised, soft, and red; bleed easily and are painless.
Regardless of their location, all pyogenic granulomas look pretty much alike. They are elevated from the surface and are soft, red, painless, and bleed easily. Most are under a centimetre in size but rapidly-growing ones can reach several centimetres in diameter. The lesions may appear to sit on the mucosa, a feature known as "sessile growth," or they may be attached to the mucosa by a constricted stalk ("pedunculated growth"). The exposed surface is often ulcerated.
Pyogenic granulomas are composed of granulation tissue.
As already stated, pyogenic granulomas are composed largely of granulation tissue (fibroblasts, collagen fibrils, endothelial cells, new capillaries). In addition surface ulceration is common; if ulcerated, many neutrophils may be present.
Removal of the irritant and removal of the lesion will cure pyogenic granulomas.
Identification and removal of the causative irritant along with excision of the lesion should result in complete resolution. Recurrence is related to inadequate elimination of the irritant or incomplete removal of the lesion.
pyogenic granuloma
Peripheral Giant Cell Granuloma
An uncommon reactive growth of granulation tissue in youngsters appearing as a red-purple, raised mass arising from the gingiva; removal of irritant and the lesion will cure peripheral giant cell granulomas. Synonyms: peripheral giant cell reparative granuloma, peripheral giant cell tumour.
"Peripheral" means arising from the coverings of bone; i.e., gingiva.
Lesions arising within bone are often described as being "central." On the other hand, the word "peripheral" is commonly used, as with present lesion, to indicate an origin outside of bone (e.g., the oral covering mucosa).This differentiation between "central" and "peripheral" issued in cases where similar lesions occur in each site. While the current discussion concerns the peripheral variety of giant cell granuloma, there is a less common central variety that will not presented.
Peripheral giant cell granulomas are responses to injury.
Most consider the peripheral giant cell granuloma to be a local reparative reaction to some irritant. Whether or not the lesion arises from the periodontal ligament has been debated, with out resolution, for decades. Other that it’s presumed reactive origin; little more is known about its cause.
PGCG's arise from the gingiva; they are raised purple lesions.
Peripheral giant cell granulomas are found arising from the gingiva or alveolar mucosa covering either the maxilla (more common) or the mandible. It more commonly affects children and teenagers than adults with females affected more commonly than males. The resulting lesion varies in size from 0.5¬5.0centimeters; it is typically soft and purple. It is the purple color, as well as microscopic features, that differentiate this lesion from the more common pyogenic granuloma.
PGCG's are composed of granulation tissue with giant cells.
The microscopic features are distinctive: the lesion is composed of granulation tissue that has many dilated capillaries that are engorged with blood. It is the vascularity of this lesion that is responsible for its dark purple color. As the name given this lesion implies, giant cells are a prominent microscopic feature. It has been suggested that these large multinucleated cells are osteoclasts an observation that may explain bone resorption often associated with peripheral giant cell granulomas.
Elimination of the cause and the lesion will cure PGCG's.
Surgical excision along with identification and elimination of the causative irritation will cure this lesion. Because it arises in the gingiva around teeth, it may be difficult to eradicate completely without removal of gingival and periodontal fibers that assist in investing and attaching the teeth. It is the reluctance to enter the periodontium that results in the incomplete removal and recurrence of peripheral giant cell granulomas.
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| Peripheral giant cell granuloma |
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Irritation fibrosis |
Overgrowths of Fibrous Connective Tissue
Sometimes reactions to repeated injury result in the formation of dense fibrous connective tissue rather than the formation of granulation tissue. While the lesions to be described next probably started out being composed of granulation tissue, their persistence is accompanied with decreased vascularity and cellularity and increased fibroblastic activity and collagen deposition, a change reminiscent of scar formation in wound repair. These lesions, then, are equivalent to cicatrisation (scar formation) in the face of repeated injury (wounding) of the oral mucosa.
Irritation Fibrosis
A very common overgrowth of fibrous c.t. in the face of repeated injury appearing as a firm, pale raised lesion covered with normal mucosa; removal of the irritant and removal of the lesion will cure irritation fibroma.Synonyms: irritation fibroma, fibroma.
Most believe the lesion to be reactive; some believe it neoplastic.
As its name was designed to indicate, "irritation fibrosis" arises from repeated mildtrauma to the oral mucous membrane. Habitual cheek biting is but one example of repeated mild trauma that is associated with this condition. There is continual debate in oral pathology circles about whether this lesion is reactive hyperplasia or a benign neoplasm. Those who subscribe to the reactive hyperplasia hypothesis use the term "irritation fibrosis" while those supporting the benign neoplasm hypothesis use the term "irritation fibroma" or, more simply "fibroma."
Irritation fibrosis appears as a firm, pale raised lesion.
Irritation fibrosis is a commonly encountered condition that can occur at any age but it is more commonly seen in patients 20 to 40 years of age. It occurs most commonly on the buccal mucosa (cheek biting) with the tongue and gingiva being less common sites. It manifests as a firm, pale, raised lesion that is attached to the underlying mucosa by a pedunculated (constricted) or sessile (broad) base and is the same color as the surrounding normal mucosa.
Irritation fibrosis is composed of dense collagenous c.t.
Irritation fibrosis, as the "fibrosis" part of its name implies, is composed of dense collagenous fibrous connective tissue covered with normal mucosal epithelium. Blood vessels are not prominent in these lesions, a finding consistent with the fact that its color is not redder than the surrounding mucosa. In short, irritation fibrosis is composed of scar tissue.
Removal of the irritant and the lesion will cure irritation fibrosis.
Simple excision of the lesion and its base will cure. Like other reactive lesions, is necessary to identify and eliminate the irritation source if the lesion is not to recur.
Peripheral Fibroma
A fairly-common overgrowth of fibrous c.t. in the face of injury manifesting as a pale, firm, raised gingival lesion covered, often, with ulcerated mucosa; removal of the irritant and surgical removal of the lesion will cure peripheral fibroma. Synonym: peripheral granuloma.
Peripheral granulomas are reactions to injury.
Like other reactive lesions, it is postulated that peripheral fibromas are caused by repeated trauma. More specifically, this lesion sometimes arises near chunks of calculus and overhanging or open restorations. Those that consider this lesion to be a reaction to chronic injury call it "peripheral granuloma"; others who believe it to be a benign neoplasm call it "peripheral fibroma."
Peripheral granulomas are raised, pink, gingival growths.
A peripheral fibroma is a fairly common lesion arising at any age. It invariably occurs on the attached gingiva adjacent to a tooth and is firm, raised lesions of a color similar to, not generally redder than, the surrounding mucosa. While the mucosa covering the lesion resembles that surrounding it, ulceration may occur manifesting as a red surface spot.
Peripheral granulomas are composed of dense fibrous c.t.
The microscopic features of peripheral fibromas are variable. Most are composed of fibrous connective tissue that is more cellular (i.e., more fibroblasts) and less dense (i.e., looser collagen texture). Sometimes bone or cementum may be produced a finding that encourages some to make the diagnosis of "peripheral ossifying (cementifying) fibroma." It is, of course, the microscopic features that confer the clinical features upon lesions. If a peripheral fibroma is composed of dense fibrous c.t., it will be firm and pale pink in color. On the other hand, of the lesion is more cellular and more vascular, it will be softer and redder.
Removal of the irritant and the lesion will cure peripheral granulomas.
Complete excision of peripheral fibromas will be curative. Identification and removal of the causative irritant coupled with complete removal will insure against recurrence of the lesion.
Peripheral fibroma
Pseudoepitheliomatous Hyperplasia
Sometimes epithelial hyperplasia mimics squamous cell carcinoma.
Sometimes inflammation in the connective tissue supporting an epithelial covering membrane will cause hyperplasia of the overlying epithelium (like in inflammatory papillary hyperplasia). Occasionally the resulting hyperplasia appears to "invade" the underlying connective tissue resembling squamous cell carcinoma. Close examination, however, reveals the absence of the cytologic features of malignancy (dysplasia or anaplasia). This false cancer-like change is known as "pseudoepitheliomatous hyperplasia" (pseudo- = false,-epitheliomatous = like a squamous cell carcinoma). This change is often seen in inflammatory papillary hyperplasia; pathologists not familiar with this condition may "over-diagnose" it and call it invasive squamous cell carcinoma -- a mistake with potentially tragic consequences. As SCC of the hard palate is very uncommon (in the U.S.), a diagnosis of SCC in this location should not be accepted without examination of the biopsy specimen by a trained oral pathologist.
Reactive Responses of Salivary Glands
If saliva spills into c.t., an immune response will follow.
The major function of salivary glands is to manufacture, secrete, and deliver saliva into the oral cavity. The components of saliva are secreted directly from epithelial acinar cells into an epithelial-lined duct that delivers it onto an epithelial-lined mucosal surface. Because the body's immune system considers saliva to be a foreign substance (antigenic), the manufacturing and delivery system just described insures that saliva does entering the connective tissues and thereby elicit an immune response.
In addition to the major three, there are thousands of minor glands.
Most saliva is manufactured by three major glands: the parotid, submandibular, and sublingual. The rest is produced by thousands of small salivary acini located in the oral submucosa and scattered throughout the mouth (e.g., palate, tongue, buccal mucosa). These small clumps of salivary gland tissue are known collectively as the "minor salivary glands."
Mucocele and Ranula
A common foreign-body reaction to spilled saliva caused by traumatic injury to a minor salivary gland duct appearing as a raised, soft, translucent, bluish lesion; removal of the lesion will cure a mucocele. Synonym: mucocoele, mucous escape reaction.
"Mucous escape phenomenon" is a synonym for"mucocoele."
The term "mucous escape phenomenon" is term coined as are placement for the older designation of "Mucocele." Although "Mucocele," meaning "mucous cavity" aptly describes its clinical appearance, oral pathologists felt "mucous escape phenomenon" more accurately described the pathogenesis of the condition. Being easier to say and write, the term "Mucocele" is still commonly used.
Mucoceles are reactions to spilled saliva through an injured duct.
Mucous escape phenomena are caused by traumatic damage to a minor salivary gland excretory duct with subsequent leakage of saliva into surrounding connective tissues eliciting a chronic inflammatory foreign-body reaction. While minor salivary ducts are most susceptible to such injury, on occasion a sublingual gland duct may also be subjected to trauma. There are number of trauma sources that cause these lesions; some include orthodontic appliances, habitual cheek/lip biting/sucking, and blows to the lips or cheeks.
Mucoceles appear raised, sessile, soft, fluctuant, translucent, and bluish.
Most mucous escape phenomena arise in the lips or labial/lingual alveolar mucosa. They may also arise in the floor of the mouth producing a distinctive lesion known as a "Ranula." Where ever they arise, mucous escape reactions appear as a raised, sessile, soft, "fluctuant," translucent, bluish lesion. The lesion appears to be just under the surface causing its covering mucosa to be stretched thin. All these clinical features make recognition of the true nature of the condition fairly clear-cut. In the floor of the mouth, the lesion may become large enough to resemble a frog's belly -- hence the name "Ranula" (ranus = common frog). On uncommon occasions, however, the lesion is situated more deeply in the underlying connective tissues. In these cases the lesion appears as a submucosal swelling that does not display the clinical features described above.
Mucoceles consist of saliva surrounded by chronic inflammation.
The microscopic features of mucous escape phenomena consist of a central pool of mucus surrounded by a chronic inflammatory reaction and granulation tissue. Macrophages are particularly prominent and appear to be phagocytosing the spilled mucus.
Surgical excision will cure mucocoeles.
Simple excision of the lesion is curative. They seldom recur unless, of course, the area is re-injured. Large ranulas may be unroofed (the" roof" being submitted for microscopic examination) and allowed to heal by secondary intention.
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| Epulis fissuratum |
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Inflammatory papillary hyperplasia |
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