Oral Pathology Flashcards
Premalignant and Malignant
Skin Findings
- Solar/Actinic Keratosis: precancerous
- Keratoacanthoma
- Basal Cell Carcinoma
- Squamous Cell Carcinoma
- Melanoma
Solar/Actinic Keratosis: precancerous
precancerous and caused by sun damage
"Actinic" = related to the sun "Keratosis" = white appearance (lots of keratin) precancerous
Description: white, scaly, crusty area
Keratoacanthoma
rapid growth (unlike basal cell carcinoma), low-grade malignancy, spontaneous resolution
o A number of these cases will resolve on their own
Description: round nodules with a central depression; the term is “UMBILICATED” (meaning round space in the middle) that is filled
with a keratin plug
Basal Cell Carcinoma
- slow-growing, low-grade malignancy; rarely
metastasizes - Most common human cancer
- Tends to occur a lot on the face (upper lip, nose, etc.)
- Description: Nodular with surface red blood vessels; can stick out or have ulcerations
Squamous Cell Carcinoma
- variety of clinical presentations, keratotic
- The most common cancer of the mouth
- Can be ulcerated, or sticking out
- Can be red or white or both
Melanoma
-About 5% of all skin cancers but is the worst case skin cancer
-Related to chronic sun exposure, but you can get
melanoma that arises de novo or from an existing mole
You can also have oral mucosal melanoma (not related to sun
exposure) – these are VERY rare (0.5% of all melanomas) but
basically a death sentence
- Immunotherapy is the new standard of treatment
Description: Pigmented, asymmetrical lesions
use ABCDE criteria to diagnosis
ABCDE Criteria
A: Asymmetric B: irregular Borders C: variable Color D: Diameter (larger than the head of a pencil eraser) E: Evolving
Seborrheric Keratosis (SK)
- Common after age 40
- Not caused by sun exposure
- No risk for skin cancer
- Raised growths on the skin with a waxy, “stuck-on” appearance
- May be multiple
• Commonly seen in African American patients
(think Morgan Freeman)
Examination of the Neck
• Must look at the midline and the lateral neck
• Feel for lymph nodes, examine for any thyroid enlargement (midline)
• Any neck mass in a patient over the age of 40 should be considered
malignant until proven otherwise!
• Most common congenital lateral neck mass: branchial cleft cyst
• Most common congenital midline neck mass: thyroglossal duct cyst
• Goiters are common as well
Branchial Cleft Cyst
Branchial fistulas (external) occur when the 2nd pharyngeal arch fails to
grow caudally over the 3rd and 4th arches
• Fistula (pipe) keeps 2nd, 3rd, and 4th clefts in contact with the surface
• Internal Branchial fistulas (rare) result from rupture of the membrane between 2nd cleft and 2nd pouch
• Branchial fistulas provide drainage for a lateral cervical cyst that failed to
disappear
• Branchial fistulas and Lateral cervical cysts are found directly anterior to
the sternocleidomastoid muscle
Thyroglossal Cyst
During migration of the thyroid gland from the foramen cecum, a canal
forms connecting the two (thyroglossal duct)
• Thyroglossal duct normally disappears. If not, you get a thyroglossal cyst
• found at midline
• If the patient sticks out their tongue or swallow, you can see the duct still and the lump will move
This should be treated because it can enlarge, impede function of other structures, or form a fistula which would lead to septsis and a whole bunch of bad stuff
OMF would remove it surgically; if sizable…. If its really small then you
Might not need to take it
Goiter
- thyroid mass that is often quite extensive and firm/glandular
- Can be caused by autoimmune diseases, iodine deficiency, or hyper/hypothyroidism
Head and Neck Lymph
Node Distribution
Two most
important groups
for us:
submandibular
and submental
lymph nodes
• Cancer of the
front of the
mouth or lip will drain into the submental area
• Rest of oral cavity or tongue will drain into submandibular area
• Lymphoma: Hodgkins & Non-Hodgkins/Metastatic Carcinoma (bump on the side of the neck that feels fixed and very hard)
Actinic cheilitis
• Mottled grey color of vermilion
• Blurred interface between the lip and skin
• Increased risk of squamous cell carcinoma
• Caused by too much sun exposure
• Eventually starts to ulcerate when progressing – should be
biopsied and removed before it turns into lip cancer
• Might feel firm when palpating sore
Angular Cheilitis
Location: commissures, often bilateral but can be unilateral
o Clinical Features
§ Erythema (redness)
§ Fissuring
§ Superficial erosion
§ May be red/ulcerated
o Etiology: candidiasis which is a fungal infection (may also be bacterial co-infection)
o Denture wearing is a risk factor
o Immunocompromised HIV patients or diabetic patients often have this; sometimes even vit/min deficient patients
o Treated with anti-fungal ointment and it will go away – doesn’t tend to be chronic, but can be recurring if you have not controlled
the underlying problem
Herpes Labialis
cold sores
o Tends to be recurrent
o Some patients may have it monthly, weekly, or
a couple times a year
o Tingling feeling, then become crops/groups of fluid filled vesicles,
then blister (this is the most infectious stage)
o Vesicles rupture then ulcerate and then crust
Squamous Cell Carcinoma (SCC) of lip
usually related to sun
exposure
Mass that feels firm/hard
Likely to also have enlarged lymph nodes
Mucocele
- A lesion formed when a salivary gland duct is severed and the mucous spills into the adjacent connective tissue
- Result of some event that leads to a break in the duct and the connective tissue moves aside and “bubbles up” forming a cyst like structure
- Is a “pseudocyst” (not lined by epithelium)
• Filled with mucous so it will feel soft and compressable
(fluctuant) upon palpation
- Might have blueish hue
- Need to be completely removed because the broken duct may still be there
- Might be history of them (recurrent)
- Other clinical clue: these might change in size depending on amount of salivation
- Most common location is the lower labial mucosa but can be found on any MOVABLE mucosa
Fibroma
Pink, firm, feel fibrous, and don’t change size
• These are very common and are due to chronic irritation or biting
• Sessile: lesion has a broad base
• Pedunculated: lesion has a smaller stalk than the top
• whole thing needs to be removed and you need to find the cause to remove the source
Tobacco pouch keratosis
• Usually in the
lower vestibule (where patients put their
tobacco pouch)
• These are considered precancerous and need a biopsy
Linear ulcer
can be a symptom of Crohn’s disease
Buccal Mucosa Variants of Normal
Linea Alba
Leukoedema
Fordyce Granules
Melanin Pigmentation
Linea Alba
a raised “white line” that extends anteroposteriorly on the buccal mucosa along
the occlusal plane
Histological appearance: epithelial hyperplasia (thickening of mucosa) and hyperkeratosis (release of keratin in thickened epithelium)
Leukoedema
Generalized, white (opalescent) appearance of the buccal mucosa
Disappears or lessens when tissue is stretched
Microscopic appearance: epithelial cells are larger and with clear
cytoplasm
Fordyce Granules
ectopic sebaceous glands
which are most commonly observed on the buccal mucosa and lips
Melanin Pigmentation (physiologic melanosis)
common on darker skinned patients
Fibroma
aka traumatic fibroma, irritation fibroma
§ Occurs as a result of chronic trauma
§ Histological appearance: dense, scar-like fibrous connective tissue surfaced by epithelium
§ Needs to be removed and treat the underlying cause (might be due to a sharp restoration)
Lichen Planus
autoimmune disease where you get white lines (striae) in your mouth
Dorsal Tongue Variants of normal
Pigmented fungiform papillae
Fissured tongue: the dorsal surface of the tongue has deep fissures or grooves; cause unknown
Hairy Tongue
- Benign conditions
- Elongated filiform papillae
- Cause unknown
- Black/brown/green hairy tongue – color due to chromogenic bacteria
- Papillae are easily stained by food or tobacco
- You can move papillae from side to side like a rug to help diagnose and differentiate from coated tongue
Geographic tongue (benign migratory glossitis)
• Erythematous patches on the dorsal and lateral tongue surrounded by a white or yellowish-
white perimeter
• The location of the patches changes
and there are times of remission (if a spot doesn’t move then it might need to be biopsied)
• Patients occasionally complain of a burning sensation
• Cause unknown – condition has been associated with
psoriasis
• Ectopic geographic tongue: can be on the floor or roof of the mouth or the cheek
Median rhomboid glossitis
• Flat or raised discrete erythematous area (red patch) in the midline of the
posterior dorsal tongue
• May be associated with candidiasis
- Etiology not clear
- Lesions never go away
Lateral Tongue Abnormal Findings
• Traumatic Ulcer: area with a yellow/white membrane that is missing epithelium (cancers can look like this too so be careful in diagnosing something as a traumatic ulcer – look for a
source of trauma and follow up)
• Benign Condition of Unclear Etiology
o Geographic tongue
• High risk area for squamous cell carcinoma
Ventral Tongue
Normal structures
o Lingual varicosities
> Prominent, enlarged lingual veins
Floor of the Mouth
Normal findings:
> lingual frenum
> caruncle/orifices of Wharton’s ducts
Variant of Normal
> mandibular tori
Mandibular tori
aspect of the mandible composed of dense, compact bone
Autosomal dominant inheritance pattern
Floor of the Mouth Lesions
- Ranula
- Sialolithiasis
- Leukoplakia
- SCC
Ranula
- Essentially a mucocele specifically located on the floor of the mouth unilaterally
- Associated with the ducts of the sublingual and submandibular gland
- Treatment: complete surgical excision, portion of major gland may need to be removed in extensive cases
- May break through mylohyoid and become a “plunging” ranula
- Tend to be larger than a mucocele, so they are more difficult to remove
Sialolithiasis
• Salivary gland stones
• Most common location to find this is the floor of the
mouth – due to the curvature of the submandibular gland duct
• Hard-feeling stones – use bimanual palpation from outside and inside the mouth
•Clinical Features
> Minor glands: hard yellowish structure in soft tissue
> May be visible on a radiograph as radiopaque mass
> Patient may report recurrent swelling and pain at mealtimes (because you area creating more saliva which will be blocked by the stone)
• Occlusal radiograph is good to diagnose these (but these are not common)
• These need to be removed because they
block a salivary gland and lead to infection/swelling
Leukplakia
- Clinical, descriptive term
- A white, plaque-like lesion of the oral mucosa that cannot be rubbed off and cannot be diagnosed as a specific entity or disease
- Pre-malignant potential so need to be biopsied
SCC
- Cancers are often indurated (hard and fixed)
- Might be friable (fall apart) and bleed easily
- Red is worse than white (good to know when choosing biopsy sites)
Maxillary Torus
(Palatal Torus): exophytic mass of
normal compact bone in the midline of the palate
- Autosomal dominant inheritance pattern
Abnormal Findings on Hard Palate
Nicotinic stomatitis
Denture stomatitis
Thermal/ pizza burn
Salivary gland tumor
Nicotinic stomatitis
- Result from the heat produced from smoking; can also occur in people who drink a lot of hot beverages (but mostly by heavy smoking (pipe, cigar, cigarette)
- Histology: hyperkeratosis with inflamed minor salivary glands (red dots with white borders)
- This is not a premalignant condition
- Can cover the whole palate or just in certain areas
**BLOCK THE MINOR SALIVARY GLANDS ON THE PALATE
Denture Stomatitis
patient can get irritation/fungal infection if they don’t remove and clean their denture every night
Thermal/pizza burn
ask patient if they remember getting burnt
Salivary Gland Tumor
there are a lot of minor
salivary glands on the palate which can get
tumors that can be benign or malignant
Bifid Uvula
this is the mildest form of cleft palate
Papilloma
HPV-related wart (these can occur in other parts of the mouth as well, but this is a common location) - need to be surgically removed
The 3 Ps
• Pyogenic granuloma: red, spongy, bleed easily (occur
more in pregnant women)
• Peripheral ossifying fibroma: forms bone and feels
firmer
• Peripheral giant cell granuloma: may have a
blue/purple color and is harder than the pyogenic
granuloma but softer than the peripheral ossifying
fibroma
- These are very common lesions and need to be removed and biopsied
- These are usually hygiene related because the patient has food/plaque stuck between the teeth
• Need to removed AND scale and root plane (and give oral hygiene instruction) otherwise they tend to come back
Mucosal Smear
• Purpose: to examine the cells that can be collected by scraping the surface of a lesion (only for something in the keratin or the top of the epithelium)
• This technique is used for the diagnosis of:
- Oral candidiasis – a superficial proliferation of a fungal organism that is a component of the oral microflora
- Herpetic lesions – ulcers usually located on keratinized mucosa,
caused by the herpes simplex virus
• The mucosal smear involves taking a sample from the surface of the
epithelium
Smear technique
- The kit contains a wooden scraper and glass slides with fixative (you can also just use the wooden end of a cotton tip applicator)
- Light to medium scraping (shouldn’t hurt patient – no anesthesia needed)
- Spread cell sample evenly on the glass slide (not in a clump)
- Then fix sample with a few drops of alcohol fixative (just enough to
cover the cells) – let it air dry
-Note: don’t take the alcohol-soaked gauze out and wipe the slide,
instead just squeeze out a few drops of alcohol
o Submit sample on slide once alcohol has dried
Oral Candidiasis
- Mucosal lesions of oral candidiasis can be either red (erythematous) or white or both
- Lesions are a response to a proliferation of a fungal organism that is a component of the oral microflora
- The mucosal smear takes a sample from the superficial layers of the epithelium (where candida resides)
- The fungal organisms that cause oral candidiasis are located in the superficial aspect of the epithelium – the mucosal smear collects the appropriate sample to make the diagnosis
- The laboratory uses a special stain (PAS) to show the fungal organisms in the keratin/epithelium when doing a surgical biopsy
Positive Mucosal Smear
Hyphae have to be invading epithelial
cells in order to have a positive diagnosis
Oral Herpetic Lesions
• There is herpes labialis on the lips that has visible vesicles that crust over
– usually in the mouth you will not see this, instead you will see ulcers
• You don’t really need a surgical biopsy for herpes
• Herpes virus takes cells and combines the nuclei to create large TZANCK
CELLS (these are multinucleated)
• Mucosal smears positive for herpes: you can see the Tzanck cells with
many nuclei
The Brush Biopsy
• Purpose: to examine a complete transepithelial sample of cells (goal is to
get all layers of epithelium; collect superficial, intermediate, and basal
cells)
• This is technique sensitive and the patient will report a little bleeding and
discomfort
• This technique collects cells from all the layers of the epithelium – from
the basal cells to the surface keratin layer
• The brush biopsy technique will collect cells from all the layers of the
epithelium
• A special brush is used to collect the sample from the epithelium and put
sample on a slide and fix with alcohol
• The brush is twisted through the epithelium to collect cells from all the
layers
Brush Biopsy Technique
• STEPS:
o Place sample on slide
o Fix with alcohol fixative
o Allow slide to air dry
o Send slide and laboratory request form to OralCDx
• Biopsy Result Options:
(1) Negative
(2) Atypical cells warranting further investigation (a real biopsy)
(3) Positive (net step: surgical biopsy)
(4) Insufficient for diagnosis (you didn’t submit a good sample)
• When to use this?
o Epithelial lesions: flat
white leukoplakias
o Lesions that have a very low index of suspicion: traumatic cheek /
lip chewing
o Lesions that clinician strongly suspects to be frictional hyperkeratosis due to chronic trauma / irritation
• Uses for brush biopsy: chronic lip biting, chronic cheek biting – can be
used as a starter step if the patient is worried about getting a biopsy
• Contraindications for brush biopsy:
o Non-epithelial nodular lesions such as soft tissue / salivary gland
tumors
o Ulcerated areas (because there is no epithelium there)
o Red lesions in high risk areas (these should have a real scalpel
biopsy)
o Pigmented or vascular lesions (these have a soft tissue component
so you won’t get a good diagnosis from this)
Incisional Biopsy
a representative sample of the lesion is taken and
submitted for microscopic examination
Excisional Biopsy
the entire lesion is removed and submitted for microscopic examination
Basic criteria for Biopsy
used to determine whether to perform incisional or
excisional biopsy:
1) Size of lesion: 1 cm guideline (under 1cm = excisional; over 1cm = incisional)
2) Location of lesion: access, proximity to vital structures
3) Degree of suspicion: very suspicious lesions should have incisional
biopsy and vice versa (if it is very suspicious leave the margins for the surgeon to observe so incisional is better)
4) Use clinical judgment for fibromas and pedunculated lesions
(should take the whole fibroma because there is no reason to leave it there, even if it is over 1cm)
Indications for Biopsy
• Lesions that have been present for more than 2 weeks with no healing or
decrease in size
- Lesions in high risk areas
- Suspicious lesions
Characteristics of
Suspicious Lesions
- Erythroplasia: lesion is totally RED or has a speckled red appearance
- Ulceration: lesion is ulcerated or presents as an ulcer
- Long duration: lesion has persisted for more than two weeks
- Fast growth rate: lesion exhibits rapid growth
- Bleeding: lesion bleeds on gentle manipulation (tumors are very vascular)
- Induration: lesion and surrounding tissue is firm to the touch
- Fixation: lesion feels attached to adjacent structures
General Biopsy Techniques
• Avoid ulcerated necrotic areas (unless entirely ulcer)
• Take a wedge of tissue: narrow deep specimen better than broad shallow
specimen
• Select the “worst-looking” area to biopsy: red areas better to biopsy than white areas, rough-surfaced areas better than smooth areas
• Multiple areas may be biopsied when the lesion is large or shows
significant variation
• Always be aware of regional anatomy
Biopsy Site Selection
• Red area (choose red area over white)
• Rough area (choose rough area over smooth)
• Peri-ulcer
• Velscope and T Blue (Velscope emits green light and wherever you see
black through that light is an area you should biopsy; Toludine blue stained areas should be biopsied)
• Striated areas for Lichenoid lesions (white striae) – in this case you biopsy the white striae, not the red areas
o Red areas will show
inflammation
o When you think
something is Lichenoid
because it has striae,
biopsy the white
o When you don’t have
striae and have a mixed
red and white lesion,
biopsy the red because
you suspect cancer
• Perilesional for Pemphigus/Pemphigoid (go near peeling area)
Biopsy Supplies
• Blade handle with a No. 15 blade
o Disposable ones are not as good
• Small soft tissue forceps with minimal teeth
• Local anesthetic solution and syringe
• Retractor appropriate for the site
• Suction source and surgical suction tip (can’t use big suction tip)
• Gauze
• Sutures for traction or closure, if indicated
• Labeled specimen bottle containing formalin and biopsy request form –
also be sure to label the site if you are taking multiple biopsies
Anesthesia for Oral
Biopsies
- Local infiltration with minimal lidocaine with epi
- Never inject directly into lesion (it will distort it)
- Inject slowly so as not to distort tissue
- Inject at multiple points surrounding lesion
- Test area before proceeding to biopsy
Punch Biopsy
• Available in different diameters: 2.0 – 5.0 mm
• 4.0 mm punch good for most oral biopsies
• May be incisional or excisional biopsy depending on size of lesion and size
of punch
• Advantages:
o Ease of technique
o Sutures generally not required
o Usually faster, better healing
o More useful for lesions located on fixed, non-moveable tissue
• Disadvantages:
o May not be adequate for deep lesions
o Difficult to use for lesions on freely movable tissues
How to tell mental foramen
is not a periapical
radiolucency?
trabeculae are superimposed, lamina
dura is still intact, or take a
different angle and use the SLOB rule
Periapical Granuloma
Mass of chronically inflamed granulation tissue that forms at the apex of the root of a non-vital tooth
Periapical Cyst
Caused by pulpal necrosis secondary to dental caries or trauma; Cyst and granuloma radiographically
Look the same so you would need to biopsy for definitive diagnosis
Residual Cysts
• The term RESIDUAL CYST is used most often for retained radicular cysts from teeth that have been removed
• A RADICULAR CYST is a cyst which has developed from embryonic tissue
remains, usually due to a dentogenous inflammational stimulus
Root Resorption
Root resorption is known to occur after trauma and in response to inflammation
Internal Root Resorption
Internal resorption is a condition where the slow or fast resorption of the dentin of the pulp, and the internal walls of the root canals occur
Periapical Cemento- Osseous Dysplasia (PCOD)
is a benign condition of the
jaws that may arise from the fibroblasts of the periodontal ligaments
- It is most common in African-American females
- The three types are periapical cemento-osseous dysplasia, focal cemento-osseous dysplasia, and florid cemento-osseous dysplasia
• PCOD occurs most commonly in the mandibular anterior region, while FOCAL appears predominantly in the mandibular posterior region, and
FLORID in both maxilla and mandible in multiple quadrants
Hypercementosis
is an idiopathic, non-
neoplastic condition characterized by the excessive buildup of normal cementum (calcified tissue) on the roots of one or more teeth
• A thicker layer of cementum can give the tooth an enlarged appearance, which mainly occurs at the apex or apices of the tooth
• Down Syndrome and
Paget’s Disease patients
have a predisposition for
this
Dens Invaginatus
also known as dens in dente
(“tooth within a tooth”) is a condition found in teeth
where the outer surface folds inward
• Dens invaginatus is a malformation of teeth most
likely resulting from an infolding of the dental papilla
during tooth development or invagination of the
enamel organ in dental papillae
Fissural Cysts: Nasopalatine,
Globulomaxillary, and
Median Palatine Cysts
A cyst derived from epithelial remnants entrapped along the fusion line of embryonal processes
