Oral path 2 Flashcards
What does lichen planus mean?
Flat fungus - it is originally a tree disorder and IS NOT A FUNGUL INFECTION IN THE MOUTH
What are the most common lichen planus lesion appearances
- Striated lesions
- Erosive/ulcerative lesions - THESE ARE PAINFUL
- Atrophic lesion
What is lichen planus in oral pathology terms?
Oral lichen planus is a common immune-mediated (NOT AUTOIMMUNE) mucosal disease. It has an incidence of around 2.2%.
It is a chronic disease, often bilaterla and symmetrically distributed.
Common sites: buccal mucosa, dorsal surface of tongue and gingiva.
Could be triggered by medication, dental materials, mints and cinnamon
What are clinical features of oral lichen planus?
- Striae - most common, sharply defined and do not disapear when whiped
- Atrophic areas - read areas and thin mucosa
- Erosive areas - shallow area of ulceration
- White plaque - think about leukoplakia
White kind of appearance can the gingiva be if it is affected by lichenoid inflammation?
Desquamative gingivitis appearance - atrophic and “raw”.
Remember that this is not exclusive to lichen planus
What are some of the other, extraoral signs of lichen planus?
Cutaneous lesion on the flexour surfaces of the body.
Purple papules, scaly lesions.
Look at patients wrists
What is the pathology of lichen planus?
- Migration of T-lymphocytes into the epithelium
- Epithelium basal cell layer destruction - the stems cells within the basal cells are lost
- Epithelium becomes thinner and keratinised
- Further lymphocytes recruitment forms dense infiltrate below the epithelium
- Immune reaction leading to keratinocyte destruction
What are the option of clinical diagnosis of lichen planus?
- Very good medical history - all contact reactions, time noticed
- Histopathology - request histopathology after biopsy
- Immunofluorescence studies - pathology LAB ONLY - in lichen planus it is deposition of fibrinogen along the basement membrane - it appears shaggy
But the most important part - DISCLUDE ALL OTHER WHITE LESIONS THAT ARE SIMILAR
What is immunofluorescence or immunohistochemistry?
It is a test that can be used for autoimmune disease as well immune mediated conditions (such as lichen planus).
For this test - pathology lab needs to pick u the sample on the day. Please put the subject into saline.
What do we look for in autoimmune diseases?
Auto-antibodies - self anti-bodies that attack self cells.
What is the aetiology of lichen planus?
The main factor and process is not known but we have some associations.
What are the differential diagnosis for a lesion that is similar lichen planus?
- Lichen planus
- Lupus eythematosus
- Cheek biting/ frictional keratosis
- Graft versus host disease
- Candidosis
- Idiopathic leukoplakia
- Squamous cell carcinoma
- Chronic ulcerative stomatitis
What are the steps to diagnosis of lichen planus?
- History of drugs and/or systemic illness
- Location/pattern of lesions
- Histopathology and immunofluorescense
What is the reported rate of transformation rate of lichen planus into a malignancy?
Around 0.44%.
For which drugs could there be a lichenoid drug reaction?
ACE inhibtors, NSAIDS, Tetracyclines and many more
What oral lichenoid contact lesions?
They are lichenoid lesions that may occur due to contact with dental materials.
HISTORY and EXAMINATION is essential
What do you do if you confirm lichen planus?
- Long term monitoring
- Reducing factors associated with lichen planus such as tobaco or other
- Control of symptoms - use CHx and maybe avoid certain foods. Use Corticosteroids, topical injection, antifungal therapy.
What are the topical steroid used for lichen planus?
Betamethasome dipropionate 0.05% cream or ointment topically to the lesions, twice daily after meals, until symptoms resolve
What is lupus erythematosus?
It is an autoimmune disease.
Two main forms: Systemic lupus erythematosus and discoid (cutaneous) lupus ertyhematosus
What can you see histologically around lichen planus?
Melanin continetns - proliferation of melanin around the lichen planus.
This may be also een clinically - post inlammation pigmentation
What is aetiology of lupus?
Unclear but it does have auto antibodies circulating and it is genetic in nature
What is the common presentation of discoid lupus eythematosus?
They appear disc in shape and similar in appearance to lichenoid lesions but with some epidermal lesions also present in sun exposed areas.
What is some of the common aspects of discoid lupus erythematosus lesions orally?
Common in buccal mucosa, gingiva and vermillion.
Plaque or erosions
White keratotic stria
What are some of the common aspect of histology of discoid lupus erythematosus lesions?
Similar to lichen planus but the sub-epithelial band is not as uniform than in lichen planus.
Also - lupus band test that is shown in immunoflurescence due to deposition of immunoglobulin and C3 - very very distinct unlike the shagging like in lichen planus
What are the clinical features of systemic lupus erytehmatosus?
Butterfly rash in young woman - could be the first sign.
Oral ulcers - pretty common
What is the most important difference between discoid and systemic lupus erythematosus?
In discoid lupus erythematosusthere are no major systemic sympotms while the systemic one ususally present with systemic symptoms
What is erythema multiforme?
It is a self limiting hypersensitivity reaction which presents itself as recurrent oral ulceration and blistering.
Cell-mediated hypersensitivity reaction - usually trigered by drugs and viruses.
What some of the intra-oral and extra-oral manifestations of erythema multiforme?
- Oral lesions - swollane and crusted lips that are bleeding - widespread erosive lesions and lots of pain
- Cutaneous lesions - “target lesions”
What is the histology of erythema multiforme?
- Keratosis at the top
- Apoptosis of basal keratinocytes
- Intraepithelial vesicle formation
- Lymphocyte and macrophage perivascular inflitrate in connective tissue
What is important to ask a patient that you suspect has erythema multiforme?
Previous virus or drug use history
What is Steven Johnson syndrome?
It is a more advanced systemic form of erythema multiforme and it can progress. PLEASE LET THE GP KNOW DUE TO SIGNIFICANT RISK OF DEATH
What do autoantibodies attack?
The usually attack desmosomes that combine cells - and create blister or vesicles
What is a vesicle?
It is a blister less than 5mm in diameter
What is a bulla?
It is a blister more than 5 mm diameter
What is acantholysis?
It is a blister that separates keratinocytes
What is pemphigus vulgaris?
Pemphigus is a group of potentially life threatening disease that has an autoimmune basis.
The autoantibodies attack the desmosomes (desmoglein 1 & 3 types) between the cells.
Clinical features - very fragial oral mucosa - think Nikolsky sign and widespread painful erosion.
Very bad because they may cause infection
What is mucous membrane pemphigoid?
It is a chronic subepidermal/subepithelial blistering, scarring autoimmune disease with a predilection for stratified squamous mucous membranes and occasionally skin.
This conditions attacks hemidesmosomes - the conectors between the basal epithelium and the connective tissues.
This conditions can result in OCULAR SCARRING - VISION WILL BE AFFECTED.
What are the clinical features of pemphigus?
- Very fragile blistering intraepithelialy
- Residual erosion
- Nikolsky sign - rub the tissue and blister signs appears
What are some of the other signs of pemphigus extra-oraly?
- Erisions and crusts on the face
- Extensive denudation of the entire neck and back
- Distal onychodystrophy and transverse Beau’s line of the thumb nails
- DIrect immunofluorescence microscopy of a perilesional biopsy soecimen shows intercellular deposits of IgG in the epidermis - CHICKEN WIRE PATTERN
What are some of the histological features of pemphigus?
- Loss of intercellular adhesion
- Acantholysis
- Tzanck cells - detached epithelial cells
- Intraepithelial blisters
What is the management of pemphigus vulgaris?
- Early diagnosis is important - differentiation from other veisculobullours diseases. Biopsy of perilesional mucosa with immunofluorescence studies -INCISIONAL BIOPSY OF NON-ULCERATED TISSUES
- Topical steroids in combination with systemic treatments
- Systemic steroid and immunosuppressive agents
What are the clinical features of mucous membrane pemphigoid?
- More common in females
- Oral ucosa often first site of involement erosion on non-keratinised mucosa desquamative gignivitis.
What is histology pemohigoid?
There is a large loss of attachment and separation of full thickness of pithelium from connective tissue at the basement membrane. With the epithelium forming the rooft of the blister
What is the treatment of mucous membrane pemphigoid?
For only oral lesions:
Topical steroid
For widespread lesions:
1. Systemic steroids
2. Immunosuppressive medication
Referral to the specialist
What are diagnostic steps of mucous membrane pemphigoid? Why should we refer these patient to a specialist?
Incisional biopsy of non-affected area - looking for gravestone appearance. This occurd due to binding of immunoglobulin to the basement membrane.
Because MUCOUS MEMBRANE PEMPHIGOID MIGHT EFFECT THE EYES.
Where are the minor salivary glands?
- Oral mucosa
- Pharynx and tonsillar area
- Larynx, trachea, major bronchi
- Nasopharynx, nasal cavity and paranasal sinuses
What are some reactive salivary gland lesions?
- Mucoceles:
- Mucus extravasation mucocoeles
- Mucus retention cyst - Necrotising sialometaplasia
- Radiation related lesions
- Salivary gland obstruction
What are some infective salivary gland lesions?
- Mumps
- Bacterial parotitis
What are some of the miscellaneous salivary gland lesions?
- Age-related changes to the salivary gland
- Sialadenosis
What is mucoele?
It is a clinical term that includes mucus extravasation pehnomenon and mucus retention cyst
What are the histological differences between serous and mucus acinii?
Serous - more purple like shown in picture on the left
Mucus - more pale and bubbly like shown on the right
What is ranula?
It is a clinical term that includes mucus extravasation phenomenon and mucus retention cyst - however it occurs specifically in the floor of the mouth
What are clinical features of mucus extravasation mucocoele?
- Most common in the lower lip
- Painless smooth-surfaced mass
- May have bluish colour
- consistency - fluid like
- Associated with trauma
- NOT A TRUE CYST - granulation tissue capsule
What is the most basic explanation of formation of a cyst from a salivary gland?
- The duct of the salivary gland is damage
- The saliva in able to float in the surrounding tissue - mucus extravasation
- Saliva accumulates
- Inflammatory reaction begins - granulation tissues forms - reactive change to saliva gland occur (acinar atrophy and inflammation)
What a cyst?
It is a fluid filled cavity that may or may not be lined an epithelium (true cyst have an epithelium) that is abnormal in nature.
Note - the fluid is not puss -
What is a mucous retention cyst?
It is a cyst that occurs during the obstruction of salivary flow
It is less common than extravasation mucocoeles.
The mucosa is intact and the cyst is not surrounded by granulation tissue.
Acinnar inflammation will still occur.
What is meal time syndrome?
A sialolith is present in the salivary gland - during meal time salivary flow increases - resulting in a mucus retention cyst - this condition is known as sialadenitis
What is the treatment for sialoliths?
Surgical removal of stone with/without gland
What is necrotising sialometaplasia?
It is one of the mimics of oral cancer but it is a benign condition which usually affect the palate.
Aetiology - slaivary gland ischaemia due to local trauma - LOCAL ANAESTHETIC - salivary gland inferction characterised by loss of acini and inflammation with ductal mataplasia - cuboidal and columnar epithelium becomes squamous
What is the histological appearance of necrotising sialometaplasia?
Squamous metaplasia of ducts mimicking invasive squamous cell carcinoma - but main difference is there no major cellular atypia
What is mumps?
It is a disease that mainly affect the parotid gland.
It is caused by a paramyxovirus
Acute onset with pain and bilateral parotid swelling, difficulty swallowing and fever.
Management: rest, lots of fluid, management of pain and antipuruetic
What is acute bacterial sialadentitis?
It is bacterial infection of the salivary glands that may be caused by xerostomia or sialoliths.
Might have systemic symptoms
Management: Antimicrobilas and drainage of the puss
What is the most common salivary gland to get a sialolith?
Submandibular, because:
- The duct is bent
- Gravity - the duct that come out sublingually is affected by it
- Content is mainly serous
What are some of the age related changes of the salivary glands?
- Acinar atrophy
- Fibrosis
- Fatty infiltration
- Diffuse chronic inflammatory infiltrate
Why is there high risk of xerostomia post head and neck radiation therapy?
Patient with head and neck cancer that recieved radiation therapy may have atrophy of acini - thus are unable to produce saliva
What are the most common site of salivary gland tumour? WHat is the most malignant site?
Most common site is related to parotid salivary gland.
Most malignant is sublingual gland.
What are the geneneral clinical differences between a bening salivary gland tumour and malignant salivary gland tumour?
Both grow slowly usually
But malignant once are hard, can ulcerte and may cause ner palsie
What are some of the common investigation we can use for salivary gland tumour?
- Excisional biopsy
- Fine needle aspiration an cytology
What is pleomorphic adenoma?
It is a tumour of variable capsulation characterised microscopically by architectural pleomorphism.
It is very common bening neoplasm and occurs mostly in parotid gland. Painless for the patient.
What is the histology of pleomorphic adenoma?
The histoloy might be marked variation. Usually involves squamous metaplasia, keratin and sebaceous glands
What is basal cell adenoma?
It is a rare bening neoplasm characterised by basaloid appearance of the tumour cells
What is the histology of mucoepidermoid carcinoma?
Usually they are charecterised as low, medium or high grade. the most cystic it is the lower the grade.
Usual suspects - mucous cells and infiltrative appearance
What is the histology of adenoid cystic carcinoma?
Solid islands, cords, strands of darkly tained epithelial cells in fibour connective tissues.
Swiss-cheese pattern
What is the histological features of Sjogren’s syndrome
- Lymphocytic periductal infiltration of slivary glands
- Acinar cell destruction
- Proliferation of ductal elements to form islands of epithelium
What are the main features os benign salivary gland tumours and malignant salivary gland tumours?
Benign (on the left):
- Slow-growing
- Soft and rubbery
- Common in parotid tumours
- DO not ulcerate
- No associated nerve signs
Malignant (on the right):
- Many slow growing
- Sometimes hard consistency
- Rare
- May ulcerate and invade bone
5, May cause cranial nerve palsie
What is a pleomorphic adenoma?
It is a type of benign neoplasma that is the most common one - histological presentation are the pleomorphic cells, it comes in blobes and is usually incapsulated.
It is non-ulcerated, slow growing and painless
What is a mucoepidermoid carcinoma?
It is a malignant glandular epithelial neoplasm characterised by mucous, intermediate and epidermoid cells with columnar clear cell and oncocytoid features.
This is the most common malignant salivary neoplasm.
Cystic and solid area mixed in
What is adenoid cystic carcinoma?
Adenoid cystic carcinoma is a basaloid tumour consisting of epithelial and myoepithelial cells in variable morphology, It has a relentless clinical course and usually a fatal outcome.
It is slow growing and it may ulcerate or be painful.
Histologically: solid islands, crods, strands of darkly staining epithelial cels in delicate fibrous connective tissue stroma - perineural invasion is common
What is the basic histology of the cyst?
- Lumen on the inside
2/ Epithelial lining surrounding the lumen
- Capsule around the epithelium and lumen that may be inflamed or may not be inflamed
What are the clinical features of radicular cyst?
- They are asosciated with roots of non-vital tooth
- Radiographically it presents as a well defined radiolucency
- Histologically the lumen contains debris
What are residual cyst?
Radicular cysts that are “left” within the jawbones after extraction of tooth.
Histologically similar to a radicular cyst but it may have less inflammatory cells
What is a dentigerous cyst?
It is a developmental odontogenic cyst of the jaws surrounding the crown of an unerupted tooth, the lining attached to the cementoenamel junction
What is an odontogenic keratynocyst?
It is a genetic mutation of PTCH1 gene that activates cell proliferation. It is an aggressive cyst.
It arises from dental lamina and is significant due to active epithelial growth rather than take up of water.
There is a risk of recurrence and occurs in the posterior body and the ramus.
Associated with Gorlin Syndrome or Naevoid Basal Cell Carcinoma Syndrome (same thing)
What is the lining of odontogenic keratynocyst histologically?
Thing lining of parakeratinised stratified squamous epithelium with palisading hyperchromatic basal cells
What are calcifying odontogenic cyst?
It is a developmental odontogenuc cyst characterised histologically by ghost cells, which often calcify.
Common in young patients.
Radiographic appearance - most lesion present as well-defined radiolucnecny containing verying amounts of radiopaque material.
What are clinical features of ameloblastomas?
- Slow destructive area
- Expansion rather than perforation
- Seldom painful
- Somehow it can mestasise but it is very rare
Radiographically:
- Typically well defined, multilocla radiolucency
- FLOATING TOOTH APPEARANCE
What is the histology of ameloblastoma?
Core components: Outer layer adjacent to CT resembling pre-ambeloblasts and centra, more loosely organised zone like stellate reticulum cystic breakdown
*there is no mineralised dental tissues or matrices
What are the two main histological types ameloblastomas?
- Folicular - discrete islands of tumour
- Plaxiform - irregular masses or strands
What are the two different types of ameloblastomas depending on cell type?
- Acanthomatus - folicular and may produce keratin
- Basal - basal, cuboidal cells present
What is a Unicystic ameloblastoma?
It is an ameloblastoma with a single cystic cavity with wall tissue being the worst clinically.
More likely to be unilocular and may be enucleated
What is a
Peripheral or multicystic ameloblastoma?
It is an ameloblastoma with multiple cystic cavity.
It is worst than unicystic ameloblastoma.
This requires excision.
What is clacifying epithelial odontogenic tumour?
It is also known as Pindborg tumour
It is a bening epithelial odontogenic tumour that secretes amyloid protein and tends to calcify.
Radiographic appearance: Radiopacity inside the radiolucency
What is adenomatoid odontogenic tumour?
It is a benign encapsulated epithelial odontogenic tumour that contains rosette or duct-like structure and has an indolent behaviour.
Treatment with enacliation
What are odontomas?
Odontomas are mixed odontogenic hamartomas that mature from soft tissues.
IT IS MOST COMMON IN YOUNG PATIENTS.
Two types:
-Complex - irregular mass of calcified material - top image
-Compound - variable number of small tooth-like structues - bottom image
Treatment: Surgical enucleation
What is odontogenic myxoma?
It is a benign neoplasm histologically resembling odontogenic extomesenchyme and chracterised by sparse spindle.
Radiographic features: Soap bubble appearance - very multilocular, may be well or poorly defined
Treatment: resection
What is cementoblastoma?
It is a distinctive benign tumour that is intimately associated with the roots of the teeth.
It is characterised by formation of calcified cementum like tissue which is deposited directly on tooth root.
Radiographic appearance: well-defined radiopaque mass closely associated with tooth root and often surrounded by radolucent halo.
Treatment: extract tooth and enucleate or locally resect tumour
What are the clinical features of fibrous dysplasia?
Radiological:
Radiolucency or mixed appearance, ill-defined margins and narrowing of the periodontal ligament
What is the histology of fibrous dysplasia?
- Well vascularised fibrous cellular connective tissue
- Irregular trabeculae of immature woven bone - osteoid bone is the precursur
What are the clinical features of cemento-ossifying fibroma?
Clinical
1. Painless
2. Slow growing
Radiographic
1. Well demarcated
2. Mixed radiopacity/lucency
What is the histopathology of cemento-ossifying fibroma?
- Well defined, sometimes encapsulated lesion
- Hypercellular fibrous tissue
- Variable amounts of calcified tissue
What a cemento-ossseous dysplasia?
It is a non-neoplastic fibro-osseous lesion of the tooth bearing regions of the jaws.
It is not common
What are the radiologic features of cemento-osseous dysplasia?
- Radiolucent and than mixed lesions
- Well defined
- Thin radiolucent rim
- Lesions that are not fused to roots of the teeth
What is a simple bone cyst?
It is an intraosseous cavity that is devoid of an epithelial lining and can be empty, blood filled or serous fluid filled.
Also know as a traumatic cyst.
It is pseudo cyst, because it is essentially some blood vessels and inflammed tissues - surgical intervention usually results in positive outcomes.
What is a Tori?
It is a non-neoplastic, localised hyperplasia of dense lamellar bone.
Usualy in the palatle midline or mandible.
What is osteosarcoma?
It is a group of malignant bone tumours. Creates bone expansion. Grows fast and could be ulcerated. THIS IS A TRUE NEOPLASTIC TUMOUR.
What is alveolar osteitis?
It is a complication of tooth extraction - aka dry socket.
Localised inflammation of the bone, due to lack of blood clot formation or early lysis of clot.
It can progress to osteomayalitis.
Clinical signs: PAIN
What is focal sclerosing osteitis?
It is asymptomatic condensation of the bone also known as condensing osteitis.
Maybe included in a differential of cemento-ossifying fibroma.
What are the common clinical signs of acute oseomyelitis?
Requires some time to develop rediographically.
Loss of trabeculae, formation of necrotic bone sequestra - radiopaque areas within the jaws.
What are histopathological signs of acute osteomlyolitis - particularly dead bone?
A lot of bacterial colonies and empty lacunae.
What are the radiographical features of chronic osteomyelitis?
Radiolucency with focal areas
Moth eaten appearance
