Oral pathology Flashcards
What is the basic investigative process in oral pathology?
- Presentation of chief concers
- Information collection - medical history, patietn history, clinical examiantion and special tests
- Information collation
- Development of a differential diagnosis - list most likely diagnoses and do specific test to eliminate potential diagnoses
- Arrive to definitive diagnosis and commence treatment
What are the types of differential diagnosis?
- Clinical differential diagnosis
- Radiographic differential diagnosis
- Provisional/working/tentative diagnosis
- Histological differential diagnosis
- Definitive diagnosis
How is differential diagnosis structured?
It is based on likelihood and probability. It is listed from most likely to least likely
What information can help us with a differential diagnosis?
- Characteristics of the presenting lesion
- History taking
- Examination
- Investigation
Also some facts that need to be considered:
- Prevalence of the lesions
- Characteristics of these prevalent lesions
3.
How do we usually categorised oral lesions?
- Age group
- Site
- Pathogenesis (surgical sieve)
*Surveys of biopsies exclude clinically diagnosed oral lesions
What is the step by step process to understand the arisal of a certain oral lesion?
Use this scheme
- Developmental origin
- Inflammatory origin
- Hyperplastic origin
- Degenerative origin
- Hormonal origin
- Neoplastic origin
- Idiopathic origin
DIHDHNI
How do we take history about a lesion?
- Duration when the patient first started seeing the lesion
- Variations in site and character of the lesion
- Symptoms - related to the lesion and any systemic symptoms
- Onset - any associated hsitorical events related to the lesion
What is the systematic way to examine a lesion?
- Site - using anatomical terminology
- Size - measure with a probe
- Morphology - elevated, flat or depressed
- Colour - compare to adjacent normal tissue
- Consistency - how it feels (ONLY CLINICAL DO NOT SAY THIS IN EXAM), texture - how the surface looks like (PHOTOS ARE APPROPRIATE :))
What are some of the terminology in a lesion with elevated morpholoy?
Blisters - Fuild filled masses:
- Vesicle - upto 0.5cm
- Bulla - more than 0.5cm
- Pustule - pus of any size
Non-blisters - not fluid filled elevations
- Papule - upto 0.5cm
- Nodule - from 0.5cm to 2 cm
- Tumour - more than 2 cm
- Plaque - more than 0.5cm but it is only clightly raised
What are some of the terminology of a lesion with depressed or flat morphology?
Depressed:
1. Ulcer (epithelium lost) - if it is yellow tissue more likely to be an ulcer
- Erosion (epithelium lost)/atrophy - if it is redness tissue more likely to be an erosion/atrophy
Flat:
1. Macule - discoloration (freckel)
- Patch - big discolouration
What kind of structure is this?
A brown macule - a flat discoloration
Site - RHS lower vermilion shifted around 10 mm from the midline of the lips
Size - measure with peiro probe - around 5-10mm
Morphology - flat, round, heart shapped
Colour - brown
Consistency - NOPE IT IS A PHOTO - Texture - maybe rough, defiantly different from the normal lip
What kind of structure is this?
It is a white polyp
Site - RHS buccal mucosa adjacanet to the buccal surface of 45
Size - measure with perio probe - around 10-15mm
Morphology - elevated, rounded, sphere like
Colour - white, opaque, with small amounts of pink
Consistency - NOPE IT IS A PHOTO - Texture - rubbery
What constitutes the oral pharynx?
From uvuala to the posterior wall of the pharynx
What investigation do we have in oral pathology?
- Biopsy (taking the whole or some of the tissue) - histopathology (investigative process) and exfoliative cytology
- Adjunct diagnostic techniques - light-based and vital stains
- Other techniques - microbiology, biochemistry, serology
What are some of the types of biopsy?
- Scalpel biopsy - incisional or exitional - most common procedure
- Fine needle aspiration
- Core biopsy
- Exfoliative cytology - taking the gunk and spreading it over a film
What are the consideration during biopsy?
- The lesion in question
- Surrounding anatomy
What should you do with some of the lesions that you may encounter to understant if they are vascular?
Use a small, transparent plate and apply pressure - if the lesion stars to blanch, it is most likely to be vascular
What are some of the features of pathology that can be observed by a light based system such as Velscope?
In some instances, the pathological tissue may take up the light thus resulting in a shadowing of the structures.
Good adjunct but please do not use this as a basis of diagnosis.
What are some common stains in oral pathology?
- Haematoxylin and eosin
- Periodic Acid-Shiff - used for fungal infection
What is exfoliative cytology?
It is the examination of cells scraped from the surface of the lesion - great for fungal infection - it is quick and easy but may not be used to more complex lesions with pathology below the surface
What is fine needle aspiratin used for?
It is mostly used for intraosseous pathology and fluctuant soft tissue pathology and neck masses
What is core biopsy used for?
It is used to remove the core of some tissues - it is similar to scalpel biopsy but it has more complication than fine needle biopsy.
Mostly used in biopsy in the abdomen but also can be used on a lymph node
What is the basic way of performing a biopsy?
- Select the right technique and perform
- Send for histopathological investigation
What is the aspiration test?
When you stick a needle into a bony cavity or a swelling, aspirate and determine what is inside.
This could be done to determine further steps - maybe even a biopsy!
You aspirated? What is in the needle? Is it a fluid? Is it solid tissue? Is it puss? Is it blood?
What can a microbial culture show us?
- If it is a fungul infection
- If it is a bacterial infection - antibiotic infection may be needed
- If it is a viral infection
What is a smere vs a swab?
Swab - microbial analysis - need to send to a lab for something like PCR
Smere - do a cell analysis - straight under the microscope - think exfoliative cytology
What kind of structure is this?
This is herpes labialis - please do not touch them
Site - LHS vermillion border and just below the lower LHS conissure
Size - scattered but overall spands around 10-20mm, irregularly shapped, diffused
Morphology - slightly elevated but mostly flat, distinct, spread, a crop of vesicles
Colour - yellow but also some of the lesion is similar to the vermilion border
Consistency - NOPE IT IS A PHOTO Texture - rough because some have been bursed but some are smooth
What kind of structure is this?
This is a traumatic ulcer
Site - the RHS lateral surface of the tongue
Size - around 0.5mm
Morphology - round, depressed, indented
Colour - red with yellow tinge white white defused borders - due to keratin build up
Consistency - SIKE IT IS A PHOTO - Texture - looks rough but needs to be assessed properly clinically
What kind of structure is this?
Multiple ulceration due to a viral infection - vesicles - please d
Site - RHS attached gingival near the posterior region to the mid-line of the hard palate
Size - multiple lesions, rnaging from 3-15mm in lengthm width of around 2 mm average
Morphology - flat, may be slightly elevated
Colour - Yellow
Consistency - PHOTO NO CONSISTENCY FOR YOU - Texture - appears to be smooth please check clinically
What are the two basic types of mucosa present in the mouth?
- Attached, orthokeratinised mucosa
- Non-attached, non-keratinised mucosa
What are some of the examples of oral mucosa and oral mucoperiosteum?
Oral mucosa - lining mucosa
Oral mucoperiosteum - attached gingiva
What are the four layer of the epithelium?
- stratum basale (D)
- stratum spinosum (C)
- stratum granulosum (B)
- stratum corneum (A)
E and F and the papillary and reticular layer accordingly
What are some the benign lesion of epithelial layer with idiopathic or developmental origin?
- Leukoedema
- White Sponge Nevus
- Epidermolysis Bullosa
What is a leukoedema?
It is a common developmental lesion of the oral mucosa. It is a variation of normal mucosa and it is more common in individuals with dark skin. Mainly in buccal mucosa
It can be implicated by the use of tobacco or alcohol.
They are asymptomatic, bilateral, poorly defined and it disappears when the mucosa is stretched or whipped with a gauze. Please consider not to stretched the attached gingiva!
What is the histology of leukoedema?
It appears in the supperficial half of the epithelium.
There are large vacuolated cells present with some Pyknotic nuclei.
Epithelial hyperplasia present as well as long elongated rete pegs
What is the management of leukoedema?
Unless there are any other worrying signs - no management is needed just monitoring
What is the White Sponge Naevus?
It is a rare inherited condition. It is autosomal dominants trait and it is early onset. Majority of cases present with oral lesion, other mucosal surface may be affected.
It is asymptomatic, diffuse, with white thickening and if irregular thickening
What is the histology of White Sponge Naevus?
It appears in the superficial layer of the epithelium.
Large vacuolated cells.
Pyknotic nuclei and thickened parakeratin layer
No dysplasia present
What is benign migratory glossitis?
It is also known as geographic tongue - it is quite common and the aetiology is well known
It is a result of loss (atrophy) of filiform papillae. Sometimes it can be sore but again not much can be done - if concerning please refer for biopsy
What can be commonly seen int eh benign migratory glossitis histologically?
Numerous microabscesses in the surface of epithelium filled with neutrophils and lymphocytes
What is hairy tongue (aka coated tongue)?
It is a condition with poorly understood aetiology and a result of increased length of filliform papilla.
May be initiated by heavy smoking, atiobiotics and other.
Usually asymptomatic.
Increased number of chromogenic microorganisms thus a change in colour to usually darker one
What do we do in the instance of hariy tongue, migratory glossitis or other benign developmental deviation?
- Ensure the patient that this is not something pathological
- Take a smear if needed
What are the two major vascular changes and anomalies related to endothelial cell proliferations?
- Haemangioma - swelling of blood vessels
- Lymphangioma - swelling of lymph vessels
What is haemangioma?
It is a localised vascular proliferation that may be congenital or arise later in life.
Could be single or multiple and results in soft tissue lesions usually
What is the hsitological appearance of haemangioma?
- Layer of epileium
- Perforations of endothelial blood vessels and cells - forming capillaries
What type of haemangioma is this?
This is capillary haemangioma due to the small capillary vessels presence
What type of haemgioma is this?
This is cavernous haemangioma due to larger blood vessels present
What is lymphangioma?
It is a type of lesion that is present in tongue swelling. The epithelium lining is very thin with a large, lymph filled vascular spaces
What kind of condition is this?
This a lymphagioma of the tongue - due to the pink limp liquid being observed in the hghlighted areas
What kind of condition is this?
This a large cystic lymphagioma involving the lateral side of the neck.
It is a rare, congenital, lymphagiomic lesion.
What are lingual varices?
They are aqcuired malformation (age related - loss of elacticity in vein walls) of lingual vein that result in the focal dilation of a single vein.
They can be present on the ventral tongue and lower lip.
They are firm and blanch with compression.
What conditions is this?
This is a caliber persistent labial artery.
It occurs when the inferior alveolar artery maintains it’s size after leaving the mental forament and becomes superficial in the lower lip.
It can present as a nodule. PLEASE PULPATE IT BECAUSE IT WILL PULSE
What is normal physiological pigmentation?
It is usually:
1. Symmetrical
- Follows normal anatomy/tissue architecture
- Commonly seen in the gingivae
- Associated with increase melanin production
What is this condition?
Oral melanotic macule or focal melanosis or an intraoral freckle
It is a well demarcated, uniform in colour, asymptomatic and has the same consitency as the surrounding mucosa macule.
Histologically it is related to increase melanin deposition.
Sometimes can arise due to medication use specifically oral medications.
Remeber macules DO NOT CHANGE OVER TIME
What is this condition?
This iss a mucosal menocytic naevus.
It is a rare oral cavity lesion or patch.
It is bening proliferation of neaevus cells.
The lesion is not neoplastic but is a hamartomatous lesion
What us a hamartoma?
It is a tumour-like lesion.
Non-neoplastic proliferation of tissue.
It grows at the same rate as the surrounding tissue
What type of naevus is this?
This is a junctional naevus because is confined to the basal layer of the epithelium
What type of naevus is this?
This is intraomucosal naevus - because is is not in the epeithelium
What condition is this?
This is an amalgam tattoo - it is associated with some of the amalgam being incorporate into the adjcent soft tissue over time. PLEASE LOOK AT AMALGAM NEAR BY.
This lesion can grow but usually at a none alarming rate.
What does ectopic mean?
It is a tissues that are in an abnormal sire of position
What are Fordyce spots?
They are ectopic sebaceous glands that usually occur on the buccal mucosa - their instance increases with age.
They are slightly elevated yellowish nodules.
It arises due to the arisal of the tissue from the ectoderm during the embrio development
What are the histological features of the Fordyce spots?
They are very similar to sebaceous glands
What condition is this?
These are lingual tonsils.
This is part of the lymphoid tissue (Welder’s ring) that is used to fight infection.
The lymphoid tissue underneath the folliate papilla goes through lymphoid hyperplasia (growth) and result in an elevation on the postra-lateral tongue surface.
What type of nodules are theses?
This is lymphoid hyperplasia
What type of tissue is this?
This is lingual thyroid tissue
What are the Tori and exostoses?
They are bony protuberances.
Non-neoplastic.
Possibly inherited
Exotoses - multiple or single nodules at the buccal aspect of the alveolar bone
What type of cyst is this?
This is a nasopalatine cyst.
It is the most common non-odontogenic oral cyst.
It s asymptomatic unless secondarily inflamed.
What type of conditon is this and why?
These are fordyce spots
They are sebatious glands in the oral mucosa.
Do not biopsy and reassure the patient that this is normal.
Pathogenesis: ectoderm refrences
What is hyperplasia?
It is an increase in the size of a particular tissue by increase in cell number - it is reversible and stimulus dependent
What is hypertrophy?
It is an increase in the size of particular tissue by increase in cell size.
What are the two main origins of hyperplastic lesions?
- Predominantly epithelial in nature
- Predominantly connective tissue in nature
What are the two basic morphological potentials of a lesion?
- Senssile lesion - broad based lesion
- Pedunculatedlesion - on a stalk - use a perioprobe to see if a lesion has a neck
What are some of the other adjectives that can be used to describe a lesion?
- Papillary - any small growth projectin into a cavity
- Verrucous - warty surface appearance (small hyperkeratinised projections)
- Epulis - lump on the gum non-neoplastic
What is fibroepithelial hyperplasia?
It is a growth of fibrous connective tissue underneath an epithelium
WHat are the clinical features of fibroepithelial hyperplasia?
It is a exophytic lesion.
Site is a site of trauma
Size is around 1-2mm upto 1cm
Moprphology could be sessile or pedunculated
Colour is similar to normal mucosa but could look inflamed
Consistency could be soft to hard depending on the age of the fibrous tissue
What is the aetiology, pathogenesis and treatment of fibroepethilial hyperplasia?
Aetiology: Chronic physical trauma, cheek biting, irritation from broken teeth etc.
Pathogenesis - cellular proliferation and production of cell product - predominantly connective tissue
Treatment: Excision of the tissue and removal of the cause
What is papillary hyperplasiaof the palate?
It is a nodular overgowth that is associated with dentures and S.Candida infection.
Associated with nodular hyperplasia in histological samples
What is the common histological presentation of the S.Candida infection
It is a presented as a nodule appearance with chronic inflammatory cell infiltrate
What condition is this?
This is fibroepithelial polyp. It is a localised fibroepithelial hyperplasia. Can occur anywhere but commonly sites prone to trauma.
It is similar to the colour of the surroinding tissue but may appear a bit more inflammaed.
What condition is this?
This is fibroepithelial polyp. It is a localised fibroepithelial hyperplasia. Can occur anywhere but commonly sites prone to trauma.
What is the histopathology of fibroepithelial polyp?
It is an overlying epithelium - hyperplastic or atopic or normal. Bulk lesion is made up of densely collagenous fibrous connective tissue.
MAY OCCUR WITH OSSIFICATION
What is the aetiology and treatment of fibroepithelial polyp?
Aetiology: chronic physical trauma and inflammation
Treatment: Excision
What is the aetiology and treatment of fibroepithelial polyp?
Aetiology: chronic physical trauma and inflammation
Treatment: Excision
What condition is this?
This is pyogenic granuloma.
It is a localised soft tissue lesion that is common in people who are pregnant due to the hormone imbalance.
Site: Anywhere but classically arises from the interdental papilla
What are the clinical features of pyognic granuloma?
Usually sensile
Sudden onset and rapid growth
Bright red and haemorrhagic, ulcerated surface.
Tissue may mature thus becomes fibrosed
What are the clinical features of pyognic granuloma?
Usually sensile
Sudden onset and rapid growth
Bright red and haemorrhagic, ulcerated surface.
Tissue may mature thus becomes fibrosed
What is the hsitopathology of Pyogenic granuloma?
Many lesions are made up of exuberant granulation tissue. It is a very vascular lesion with large numbers of thin walled dilated blood vessels lined by endothelial cells
What is the treatment for pyogenic granuloma?
Excision and removal of causative factors
What are some of the differential diagnosis for pyogenic granuloma?
- Neoplasm
- Heamongioma
What is peripheral giant cell granuloma?
It is a similar lesion to the pyogenic granuloma but it also involves bone tissue
What is the histopathology of the peripheral giant cell granuloma?
It is a well vascularised cellular tissue with mononuclear cells.
If you see multinucleadted diant cells - probs a peripheral giant cell granuloma
What is the imortant aspect of the peripheral giant cell granuloma?
It is important to determine that the lesion is not an intra-bony or central lesion which has perforated cortical bone
What is ulcerated fibrous epulis with ossification? what are the clinical features?
It is a relatively common oral lesion. Presents as localised lesion of gingiva like fibrous epulis and pyogenic granuloma.
Clinical features:
1. Painless
- Relatively rapid growth
- Size usually less than 1 cm
- Sometimes - surface ulceration
What is the histopathology of ulcerated epulis with ossification?
It is a very cellular lesion - well vascularised and collagenous. IT CONTAINS CALCIFICATIONS.
What are generalised gingival hyperplastic lesions?
They are lesion that occur due to underlying factors such as plaque or use of certain medications such as hypertension medication (calcium channel blockers) or anti-covulsants or immunosupresants.
Drug Induced Gingival Overgrowth is one of them
What is a linea alba?
It is a lesion occurring on the buccal mucosa as a result of a local mechanical trauma
What is the clinical presentation of linea alba?
It is usually symptomless and is very very common.
It presents as a white, narrow, linear lesion on the buccal mucosa.
Could be unilateral or bilateral
What is the histopathology of linea alba? What is the management of linea alba?
A thichening of the prickle cell layer can be observed. Hyperkeratosis occurs. Nothing cna be done to manage it - just please do not bite your cheek.
What is morsicatio buccarum?
It is cheek biting which causes chronic mechanical trauma.
Clinical presentation is a unilateral or bilateral white patch on the buccal mucosa, which is rough and whitenned. Usually symptomless
What is frictional keratosis?
It is similar to the cheek biting and linea alba but usually occurs on commonly traumatised sites such as the lips, lateral border of the tongue, buccal mucosa, edentulous alveolar ridge.
Appears as a poorly demarcated white lesion.
What happens histologically in frictional keratosis? What is the management?
Histological features:
1. Hyperkeratosis
- No dysplastic changes
Management:
- Identify and try and remove a cause - might be difficult with edentulous patients
- Always biopsy if in doubt :)
What is smoker’s keratosis?
It is a diffused, white, moderately thickened palate that can be sometimes roughened.
It usually involves the entire palate with characteristic, red, minor salivary gland dots.
Associated with tobacco smoking, especially reverse smoking.
What condition is this?
This chronic hyperplastic candidiasis.
It is usually a single, fixed, white or mix of white and red patch that syays when whipped.
May occur anywhere but common sites are the tongue and buccal mucosa.
What is the histopathological appearance of chronic hyperplastic candidiasis?
Thickening large bulbus epithelial with keratinisation
What are histopathological features of the giant cell fibroma? What are the clinical features?
The main difference between giant cell fibroma is the Giant Stellate Cells rather than the osteoclast like cells.
The clinical features are similar: small, raised, pedunculated lesion that is asymptomatic
What is traumatic neuroma? What are it’s clinical signs?
It is a lesion thatoccurs due to the damage of a nerve trunk following some sort of injury (like surgery or pressure on dentures).
Essenially - the repair of the axon does not go as planned and the lesion if fully comprised of the neural tissue.
Clinical features: small swelling or nodule on mucosa near mental foramen, alveolar ridge, lips or tongue. Pressure on the nodule cuases pain
What is histapathology and treatment of traumatic neuroma?
Histopathology: Presents as a mass of irregular bundle situated in variable amount of connective tissue stroma.
Treatment: surgical excision
What is this condition?
This is verruciform xanthoma, it is a rare lesion that mimic squamous cell carcinoma.
It is flat, velvety, pebbly.
What is the histopathological appearacnce of verruciform xanthoma?
It is usually associated with foamy, lipid filled marophages.
The lesion is bening
Observe the lesion below. Describe the abnormality.
Extra info: It is a firm in consistency
Site - RHS buccal mucosa, adjacent to the premolar teeth
Size - around 10-20 mm in diamtere
Morphology - elevated sessile nodule
Colour - similar colour of the surrounding tissue
Consistency - firm - Texture - smooth
List and justify the most likely clinical diagnosis?
Extra info: It is a firm in consistency
Fibroepithelial polyp - due to a firm consistency with whiteish, keratinised superior surface.
Also the location is commonly traumatised.
Fibroepithelial polyp is also a relatively common lesion.
What is the management for this lesion?
Extra infro: It is firm in consistency
- No urgent referral needed
- Ask the patient if has changed in signs and symptoms
- Suggest the patient that a surgical incision might be a good option as part of a histopathological investigation option or just to monitor the lesion
- Try to reduce the potential traumatising habbits
Outline the pathogenesis of this abnormality/ variation
Extra info: It if firm in consistency
Proliferation and production of cell products - predominantly fibrous connective tissue - reactive hyperplasia (reacting to an injury)
Observe the lesion below. Describe the abnormality.
Extra info: The patient is a regular smoker with no other known heal issues, Their denture has become wobbly as this grown has been slowly increasing in size over the past months. It is firm in concistency
Site - around the lingual oral mucosa - adjacent to the lingual surfaces of 34 and 35
Size - around 15-20 mm in length
Morphology - elevated, elongated, nodule
Colour - similar to the attached gingiva
Consistency - it is firm texture - it is smooth
List and justify the most likely clinical diagnosis?
Extra info: The patient is a regular smoker with no other known heal issues, Their denture has become wobbly as this grown has been slowly increasing in size over the past months. It is firm in consistency
Fibroepithelial hyperplasia - denture induced.
Because:
- Denture present - which is a causative factor
- Clinical presentation - keratinisation of the tissues, slow growth and location
- THIS IS A COMMON LESION - say that on the exam
What is the management for this lesion?
Extra info: The patient is a regular smoker with no other known heal issues, Their denture has become wobbly as this grown has been slowly increasing in size over the past months. It is firm in consistency
- Examine the denture and the fit of the denture - it might need to be adjusted or raplced
- While waiting - might not retain the denture for long times in the mouth
What is the management for this lesion?
Extra info: The patient is a regular smoker with no other known heal issues, Their denture has become wobbly as this grown has been slowly increasing in size over the past months. It is firm in consistency
Proliferation and production of cell products - predominantly fibrous connective tissue - reactive hyperplasia (reacting to an injury)
What would a biopsy of this lesion show?
Extra info: The patient is a regular smoker with no other known heal issues, Their denture has become wobbly as this grown has been slowly increasing in size over the past months. It is firm in consistency
Thickened epithelial and thickened keratin layer
What is a traumatic eosinophilic ulcer?
It is a bening chronic ulcer usually presenting on the tongue.
It is crateriform in shape.
What is the histopathological significance of eosinophilic ulcer and why should it worry us?
Eosinophilic ulcers are usually associated with an abnormal presentation of eosinophils thus it is important to send a biopsy sample of the ulcer for histopathological investigation to ensure it is not malignant
What is this condition?
This is a minor aphthous ulcer - which one of the most common ulcer of infectious origin.
It usually occurs in non-keratinised mucosa, it is shallow and rounded.
It has erythematous margins and yellowish floor
What is this condition?
This is a major Aphthous Ulcer - an uncommon ulcer of infectious origin.
It is usually very large and can involve keratinised mucosa. This need to be reffer for biopsy because this could be a melignancy.
What is this condition?
This is Herpetiform aphthous ulvers - it is an uncommon and are very very small.
Named herpetiform due to the resemblance of the ulcers to those of herpetic stomatitis
What are the oral manifestations of Crohn’s disease?
- Diffuse lip swelling
- Coble stone thickening of the mucosa
- Ulcers
Observe the lesion below. Describe the abnormality.
Extra info: History of tongue biting 4 months ago
followed by pain. The borders are firm in
consistency.
Site - RHS lateral surface of the tongue, in close proximity to the posterior lingual surface of Q4 posterior teeth
Size - 10-15mm
Morphology - a central depression with well defined borders
Colour - border: white in colour, depression: red in colour with small tinge of yellow
Consistency - borders are firm - texture - smooth
List and justify the most likely clinical diagnosis?
Extra info: History of tongue biting 4 months ago
followed by pain. The borders are firm in
consistency.
Most likely to be Chronic Traumatic Ulcer
- Due to history of previous tongue biting (trauma)
- It is a common lesion
Firm and consistent borders should raise some alarm bells
Outline the management of this patient
Extra info: History of tongue biting 4 months ago
followed by pain. The borders are firm in
consistency.
(previous history, exam, palpations done)
- Referral for biopsy due to the length of the lesion being there and also the firm border are concerning
- Find the cause and try to remove it
If the lesion was biopsied - what would you see microscopically?
Extra info: History of tongue biting 4 months ago
followed by pain. The borders are firm in
consistency.
- Missing epithelium layer or orthokeratinised squamous epithelial cells or hyperplastic epithelium
- Sometimes some loss in fibrous connective tissue
- Eosinophilic ulcers are usually associated with an abnormal presentation of eosinophils thus it is important to send a biopsy sample of the ulcer for histopathological investigation to ensure it is not malignant
- Fibrousis on the borders of the ulcer - dense pink collagen
The lesion resolved in two weeks
following biopsy. How would that help
you arrive at a definitive diagnosis?
Extra info: History of tongue biting 4 months ago
followed by pain. The borders are firm in
consistency.
If it resolves - it is a confirmation that it was an Acute Traumatic Ulcer
Observe the lesion below. Describe the abnormality.
Extra info: Patient recently quit smoking. No known
systemic disease other than managed
hypertension. Patient has no fever or
other systemic signs or symptoms.
Site - RHS anterior ventral and dorsal surface of the tongue
Size - 4 ulcers from RHS to LHS - 2mm 1mm 3mm 3.5mm
Morphology - rounded, depressed ulcers
Colour - borders: red center: yellow
Consistency - SIKE IT IS A PHOTO
Texture - Glossy
List and justify the most likely clinical diagnosis?
Extra info: Patient recently quit smoking. No known
systemic disease other than managed
hypertension. Patient has no fever or
other systemic signs or symptoms.
Minor aphthous ulcer related to stress
Outline the management of this patient.
Extra info: Patient recently quit smoking. No known
systemic disease other than managed
hypertension. Patient has no fever or
other systemic signs or symptoms.
If it is their first ulceration:
- Manage pain
- Review in 2 weeks
If the duration if reoccurring
- Send to an oral surgeon for a biopsy
- Send to a GP for a underlying health issue assessment
What is this condition?
This is necrotising gingivitis. It is usualy caused by a presence of an opportunistic bacteria and an underlying stress factor.
Clinical features: necrosis of the papilla, sudden onset, ulcer covered by greyish pseudomembrane from surrounding mucosa
Treatment:
- OHI
- Debridement
- CHx
- Metronidozole 400mg 6 hourly for 5-7 days
What is this condition?
This is cancrum oris (noma) - it is a destructive condition involving oral soft tissues and jawbone.
Usually associated with children who are malnourished and have lower immunity due to systemic infections.
Thought to arise from NG
What is this condition?
This is actinomyces - an infection characterised by multiple foci of chronic suppuration.
Patient present with firm swelling commonly in the submandibular region with variable pain symptoms.
Treatment: prologned antimicrobial treatment after cultures
What are the histological features of Actinomyces?
- Chronic granulomatous inflammation surrounded by abundant granulation tissue and fibrosis
- Granules consisting of tangled meshes of organisms may be seen
What are some of the oral manifestations of congenital syphilis?
- Notched permanent incisors
- Hypoplastic first molars
- Saddle bone deformity
What are the lesion of the primary syphilis?
It is a chancre - which occurs at the site of primary inoculation 3-4 weeks after infection.
Lesions are high infectious - be careful!
Heals naturally
What are the lesion of the secondary syphilis?
They are usually described as some mucous patch, rash or condyloma lactum.
Usually occur 6-8 weeks after primary stage.
Still infectious - please be careful
What are the lesion of the tertiary syphilis?
They are called Gumma - they usually involve the hard palate perfiration or syphilitic glossitis
What are the oral manifestation of Tuberculosis?
Mulitlobular ulcerated growth due to immundeficency - histologically it is associated with granuloma inflammation.
What are the oral manifestations of Leprosy?
Nodular mucosa lesions are present in 20-60% of the patient
What is the acute pseudomembranous candidosis or thrush?
it is most common type of acute candidiasis.
This is a lesion/lesions that is associated with soft, white/yellow plaque that can be lifted off the mucosa.
These plaques represent inflammatory exudate, dead cells and fungal colonies
Whatis a Chronic Hyperplastic Candidosis?
It is lesion/lesions that may occur anywere but are common to the tongue and buccal mucosa.
Present as white or mixed white/red patches or plaques on the mucosa.
THIS LESION CAN RESEMBLE OTHER PATHOLOGY - like lichen planus or early squamous cell cercinoma biopsy and re-biopsy after antifungal treatment
What is the basic progress of infection and manifestations with a herpes simplex virus?
- An inividual is seronegative
- Exposure to the virus occurs
- Primary disease - Subclinical Gingivostomatitis is considered to be primary disease
- An inidividual becomes seropositive
- Reactivation of the diseases (aka Secondary disease) may occur due to stressors - usually results in a cold sore
- Resolution of the cold sore - return to being seropositive
What is gingivostomatitis?
It is a widespread vesicular eruption involving skin, vermillion and mucosa.
It results in painful widespread infection that can be observed in the photo.
It is associated with young children or older adult who are immunocomprimised
What is recurrent herpes simlex vitus?
It is a vesicular eruption affecting perioral skin, lips, gignivae and palate - knowns as harpes labialis
What are the histological features of herpetic lesions?
- Intraepitheial vesicle formation - aka acantholysis
- The vesicles contain inflammatory cells and exudate
- Destruction of epithelial cells
What does the reactivation vericells virus lead to?
It leads to shingles.
Shingles may result in oral manifestations like vesicular lesiosn aorund the oral cavity.
What is Oral Hairy Leukoplakia?
It is a oral manifestation that relates to the Epstein Barr Virus and is associated with HIV invection
What is this condition?
Extra information: The patient is from Greece?
This a kaposi’s sarcoma - an oral lesion associated with Herpes Virus 8 - it is very aggresive in it’s course
What is a solitary fibrous tumour?
The solitary fibrous tumours are benign neoplasms that arise from combination of altering hypocellular and hypercellular areas.
It consists of bands of hyalinised collagen in between spindle shaped cells.
What is a myxoma?
It is an uncapsulate lesion with infiltrative growth and stellate and spindle.
Occurs as bubbly in appearance.
What is a lipoma?
It is an uncommon lesion in the oral cavity - most commonly filled with adipose tissue (fat cells)
Whats is neurilemmoma?
They are benign neoplasm associated with schwann cells.
Could occur as a asymptomatic, submucosal mass
What is neurofibroma?
It is usually a multiple lesion - it is asymptomatic and is related to neurofribromatosis
This lesion could turn malignant
What is a granular cell tumour?
It is a painless smooth swelling on the tognue related to large granular cells.
Histologically it relates to hyperplasia in an odd way where it looks like it’s invading other tissue
What is a leukoplakia?
It is a predominantly white plaque of questionable risk having excluded other known diseases or disorders that carry no increased risk of cancer
What is proliferative verrucous leukoplakia?
Proliferative verrucous leukoplakia is a progressive, persistent and irreversible disorder characterized by the presence of multiple leukoplakia that frequently become warty.
What is eryhtroplakia?
Erythroplakia is a predominantly fiery red patch that cannot be characterized clinically or pathologically as any other definable disease
What is lichen planus?
A lichen Planus is a chronic inflammatory disorder of uknown etiology with characteristis relapses and remissions, displaying white reticular lesions, accompanied or not by atrophic, erosive and ulcerative and/or plaque type areas. Lesion are frequently bilaterally symmetrical.
Desquamative gingivitis may be a feature.
What condition is this?
This is an oral lichenoid lesion - which is similar to oral lichen planus but is usually around a single site.
Usually associated with medications and go away when medication is stopped
What is oral submucous fibrosis?
Oral submucous fibrosis is a chronic, insidious disease that affects the oral mucosa, initially resulting in loss of fibroelasticity of the lamina propria and as the disease advances, results in fibrosis of the lamina propria and the submucosa of the oral cavity along with epithelial atrophy.
Associated with tobaco products that stay in the crevaces of the oral cavity for a long time
What is actinic cheilitis?
Actinic cheilitis is a disorder that results form sun damage and affects exposed areas of the lips, most commonly the vermillion border of the lower lip.
What is the clinical presentations of malignant lesions?
RULE acronym:
- Red/white
2.Ulcer
3.Lump
Exceeding 3 weeks in duration
What are some of the other presentations of oral cancer coudl arise?
- Non-healing extraction socket
- Pigemented lesion (melanoma) with irregular borders
What is the pathology of squamous cell carcinomal?
- Invasion of malignant epithelial
- Localised tissue destruction like bone erosion - floating tooth on the radiograph (primary intraosennous carcinoma
- Spread to the lymphatic system
- Distant metastasis
What is the grading of tumours?
It is a process of examining the degree of differentiation of cells
Grade 1 - well differentiated squamous cell carcinoma
Grade 2 - moderately differentiated squamous cell carcinoma
Grade 3 - Poorly differentiated squamous cell carcinoma
Grade 4 - anaplastic - fucked
The greater the grade the worst a prognosis
What lesion is associated with human papilloma virus?
Squamous papilloma.
An asymptomatic, solitary lesion that is associated with cauliflower like apperance
What are the histological features of squamous papilloma?
Exaggerated growth of usually parakeratinsed benign squamous epithelium.
Finger-like projections of epithelium with central cres of fibrovascular tissue
What is another type of lesion that can be caused by HPV?
Genital warts in the mouth or Oral Condyloma Accuminatum.
It is an infections lesion that can cause transmission through direct contact.
It presents as a broad based pink nodule that grows and coalesce (come as one)
What are the oral manifestation of non-hodgkins lymphoma?
Large ulceration, swelling, pain, paraesthesia and losse teeth
Aetiology is unknowns
What is the main feature of oral malignant melanomas?
They have a defused appearance
