Epithelial pathoses Flashcards
What are the types of benign epithelial white lesions?
Leukoedema (swelling of mucosa)
White sponge nevus
What are the types of HPV associated benign epithelial lesions?
Squamous papilloma
Verruca vulgaris
Condyloma acuminatum
What are the types of pigmented lesions that are benign epithelial pathoses?
Physiological and racial pigmentation
Oral melanotic macules
Oral nevi
What is the aetiology and pathogenesis of leukoedema?
Caused by keratinocyte oedema in response to mild irritation (cigarette and marijuana smoking, some toothpaste, mouth rinses, and physical trauma)
What are the clinical features of leukoedema?
Very common and especially common in dark skinned individuals. It has a milky white translucent surface that disappears with stretching.
What are the histopathologic features of leukoedema?
Acanthosis (always present)
Superficial keratinocyte oedema (enlarged, pale, and ballooned cells)
Anucleation
Jigsaw puzzle cell membrane
What is done for Leukoedema diagnosis?
Can be done clinically (blanching)
Generally does not require a biopsy for diagnosis
Leukoedema treatment:
No treatment required
Educate the patient about the condition
Avoid causative irritant if possible
What causes white sponge nevus?
Relatively rare:
Autosomal dominant with high degree of penetrance and variable expressivity.
Caused by a defect in normal keratinization (Mutation in keratin 4 and 13; KRT4 and KRT13)
What age does white sponge nevus typically show up?
Appears at early childhood or birth
What are the clinical features of white sponge nevus?
Usually bilateral and symmetric
• Asymptomatic white spongy plaques
Where are white sponge nevi typically seen?
Bilateral buccal mucosa
Ventral tongue
Lip mucosa
Soft palate
What are the histopathological features of white sponge nevus?
This must be seen for diagnosis: Perinuclear eosinophilic condensations of keratin
Parakeratosis and acanthosis
Spongy appearance
– Due to cytoplasmic vacuolation
Minimal to no inflammation
Does white sponge naevus have any malignant potential? Why or why not?
No, it is simply a defect in keratinization not a disorder of keratinocyte hyperplasia or dysplasia
How is white sponge nevus diagnosed?
Family history
Biopsy
How is white sponge nevus treated?
No effective treatment
Which types of HPV cause squamous papillomas?
HPV6 and HPV11 (Extremely low virulence and infectivity rate)
How common is squamous papilloma?
Occurs in 1/250 adults
Makes up 3% of all oral lesions
What does squamous papilloma look like?
Exophytic nodule
Soft, painless and usually pedunculated
Has numerous fingerlike surface projections which makes it resemble a cabbage or wart (pointed or blunted)
White, slightly red, or normal in colour
How does squamous papilloma grow?
Usually grows fast until 5mm then stops growing
What are the histopathological features of squamous papilloma?
Fingerlike proliferation of oral epithelium.
Fibrovascular connective tissue core which can have inflammation.
May have a thickened keratin layer
Koilocytes
What are koilocytes?
Virus-altered epithelial cells with crenated pyknotic nuclei surrounded by clear halos
Enlarged hyperchromatic nuclei with a folded appearance and prominent cytoplasmic halo
What are the cellular changes seen in squamous papilloma?
Binucleate cells
Dyskeratotic cells (Individual cell keratinisation)
Koilocytes
How is a squamous papilloma diagnosed?
Excisional biopsy including the base of the lesion
Which HPV types cause squamous papilloma?
HPV6 and HPV11
Which HPV types cause verruca vulgaris?
HPV2 most often
Can also be caused by HPV1, 4, and 57
How does HPV transmit from one person to another?
Autoinoculation
Is verruca vulgaris seen commonly in the mouth?
No, it is more common in the skin
Where is verruca vulgaris commonly seen?
Mostly seen in children but can develop in older adults as well.
Most commonly seen on hands
Where intraorally are you most likely to find verruca vulgaris?
Vermilion zone
Labial mucosa
Anterior tongue
Palate
What does verruca vulgaris look like?
Painless papule or nodule with papillary projections or a rough pebbly surface
What are the histopathological features of verruca vulgaris?
Acanthosis
Finger-like projections with connective tissue cores
Convergence of the projections towards the lesion
Hypergranulosis
Koilocytes
How can verruca vulgaris be diagnosed?
Biopsy
How is verruca vulgaris treated?
Skin lesions treated topically.
Oral lesions are treated with surgery, laser excision, cryotherapy, and electrosurgery.
What is condyloma acuminatum?
A venereal wart (STD)
What causes condyloma acuminatum?
Caused by HPV6 and HPV11 in 90% of cases
Coinfection with HPV 16 and 18 are high risk if seen in child consider child abuse.
How common is condyloma acuminatum?
1% of sexually active population due to HPV vaccine
Who most commonly gets condyloma acuminatum?
Teenagers and young adults
What does condyloma acuminatum look like in the mouth?
Typically a sessile, pink, well-demarcated, non-tender, exophytic mass with short, blunted surface projections
What are the histopathological features of condyloma acuminatum?
Acanthosis
Mild keratosis
Papillary projections (blunted and broader than squamous papilloma)
Thin connective tissue core
Koilocytes
How is condyloma acuminatum diagnosed?
Excisional biopsy if appropriate
How is condyloma acuminatum treated?
Conservative surgical excision
Cryotherapy
Laser ablation
Topical treatment (Imiquimod, podophyllotoxin and sincecatchins)
What are the sites of physiologic and racial pigmentation?
Gingiva
Buccal mucosa
Lips
Palate
Tongue
What are the histopathologic features of physiologic and racial pigmentation?
Presence of increased amounts of melanin deposition within the basal cell layer
How is racial pigmentation diagnosed?
Clinical diagnosis
Biopsy is indicated if pigmentation is of recent onset as an adult or patient reports physical symptoms that may be related to a systemic disorder
How is racial pigmentation treated?
No treatment needed
What causes oral melanotic macules?
Idiopathic or post-inflammatory
Who most commonly gets oral melanotic macules?
Most common oral mucosal lesion of melanocytic origin.
affects 3% of the population
Mostly people of the 5th or 6th decade of life.
Females more often than males 2 - 3:1
What do melanotic macules look like?
Solitary, asymptomatic, well-circumscribed lesions.
Uniformly tan to dark brown
Typically are less than a cm in diameter
What are the histopathologic features of oral melanotic macules?
Normal stratified epithelium
Increased melanin production in the basal and parabasal layers
Without increase in number of melanocyes
Extra melanin is seen in melanophages
How is oral melanotic macule diagnosed?
Excisional biopsy of suspected lesions
How do oral nevi arise?
Melanocytic growth and proliferation
Increase in melanin pigment synthesis. (dermal melanocytic nevi: BRAF mutation but in oral unknown)
Who are oral nevi most common in?
F>M
2nd - 4th decade of life
What are the clinical features of oral nevi?
<1cm
Solitary
Most common on the palate
What are the types of oral nevi?
Intramucosal nevus (64-80%)
Blue nevus (8 - 17%)
Compound nevus (6 - 17%)
Junctional (uncommon)
What are the histopathologic features of intramucosal nevi?
Nests and theques of epithelioid cells with pigment content lie just beneath the epithelium
More pigment close to the epithelium
No nuclear polymorphism
What are the histopathologic features of junctional nevi?
Many nests of benign nevus cells in the BASAL LAYER ONLY
What are the histopathologic features of compound nevi?
Combination of intramucosal
and junctional nevus
What are the histopathologic features of a blue nevus?
Discrete proliferation of spindled nevus cells:
– Variable melanin
– Benign nuclei
How is an oral nevus diagnosed?
Through history and a biopsy if appropriate
How is an oral nevus treated?
No treatment is required unless cosmetically indicated
What is nicotine stomatitis?
A reactive keratosis to heat (not nicotine)
What cause nicotine somtitis?
Usually caused from pipe smoking
Often seen in heavy cigarette smokers or those who drink very hot beverages
What are the clinical features of nicotine stomatitis?
Symmetric
Painless or sensitive
Often affects the hard palate (sometimes the soft palate as well)
White cast (variable intensity)
Red punctate papules (represent the opening of excretory salivary ducts)
What are the histopathological features of nicotine stomatitis?
Hyperkeratosis or parakeratosis
With or without reactive epithelial atypia
Variable chronic inflammation
Squamous metaplasia of excretory salivary ducts
Chronic sialodochitis (periductal inflammation)
How is nicotine stomatitis diagnosed?
Clinical presentation and history
Early mucosal changes are generally reversible on stopping the habit.
What are the adverse outcomes that can can develop with nicotine stomatitis?
Leukoplakias that develop require close follow-up and surveillance biopsies
What causes hairy tongue?
Dry mouth and soft diet.
Lack of vegetables and little water drinking
What are the features of hairy tongue?
Elongated filiform papillae (may be stained)
What are the histopathologic features of hairy tongue?
Hyperplastic filiform papillae
Spires of parakeratin with many bacterial colonies
How is hairy tongue diagnosed?
Diagnosis is through clinical examination
How is hairy tongue treated?
Improving diet (fresh pineapple helps)
What causes verruciform xanthoma?
It is a reactive lesion (Histiocytic response to products of epithelial breakdown)
Accumulation of lipid-laden macrophages
Benign papillary proliferation of stratified squamous epithelium
Who most commonly gets verruciform xanthoma?
Both males and females of the 5th and 6th decade of life.
What are the clinical features of verruciform xanthoma? which tissue are they typically seen on?
Discrete, nontender, yellowish, or mucosa-coloured plaque
Pebbly, warty appearance
Some are also flat
75% are located on the keratinized tissues (gingiva and hard palate)
Also popular near excision sites because of epithelium breakdown.
What are the histopathologic features of verruciform xanthoma?
Acanthosis
Elongated rete ridges:
Generally of the same length and confluent at the tips
Parakeratosis
Bright eosinophilic hue
How can verruciform xanthoma be diagnosed and treated?
Incisional or excisional biopsy
Excision is the treatment of choice
