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ORAL Pathology - Lecture notes

Dentistry (University of Perpetual Help System DALTA)

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ORAL PATHOLOGY

I. Introduction

Developing a Differential Diagnoses

1. Macule – entirely flat, usually pigmented
2. Plaque – slightly elevated with flat surface
a. hyperkeratosis – thickening of the keratin layer of the epithelium
b. orthokeratin – has a granular cell layer, but nuclei are lost
c. parakeratin – more rapid onset, nuclei are present, but no granular cell layer
d. acanthosis – thickening of the spinous cell layer
e. spongiosis – acanthosis with intercellular layer
3. Papule – a circumscribed elevated area <5mm in diameter; usually white or pink
4. Nodule – an elevated area of mucosa >5mm in size; often pink
5. Erosion – partial loss of epithelium; basal layer is in tact
6. Ulceration – full thickness loss of epithelium
7. Vesicle – elevated fluid filled lesion <5mm in diameter
8. Bullae – a large fluid filled lesion >5mm in diameter
9. Sessile – a growth pattern where the base is the widest part of the lesion
10. Pedunculated – a growth pattern where the base is narrower than the widest part of the
lesion
11. Papillary – numerous rounded surface projections “cauliflower like”
12. Verrucous –a rough or wart surface “church-spire like”

II. Soft Tissue Cyst

1. Dental Lamina Cysts of the Newborn

A. Gingival cyst –white soft tissue nodules on alveolar ridge

B. Epstein Pearls – multiple small white nodules along midline of hard palate
C. Bohn’s nodules – entrapped from minor salivary glands; primarily on soft and hard palate

2. Cysts of the Adult

A. Nasolabial cyst – nasolacrimal duct, swelling on the mucolabial fold and floor of the nose
B. Branchial Cleft Cyst – cystic transformation of salivary gland tissue present in cervical lymph
nodes
-freely movable mass along the anterior border of the SCM

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C. Thyroglossal duct cyst – remains in the foramen cecum

D. Dermoid cyst – it has sebaceous gland, hair follicles, and sweat glands.
E. Nasopalatine Duct cyst – MOST COMMON NON-ODONTOGENIC cyst

III. Pathology of the Teeth

1. Mesiodens – most common supernumerary teeth
2. Distomolars – 4th molar
3. Paramolar – facially or lingually in the maxillary posterior
4. Cusp of Carabelli – most common, palatal surface of ML cusp of Max 1 st molar
5. Talon’s cusp – lingual surface of Maxillary incisor or canine
6. Doak’s cusp – accessory cusp found on buccal surface of molars
7. Dens evaginatus –central groove of premolar
8. Gemination – one tooth bud attempts to make two; 2 crowns in one root
9. Fusion – two roots in one crown
10. Dilaceration – curvature of the root
11. Enamel Pearl – most commonly found in the furcation area molar
12. Taurodontism – “bull’s teeth”
13. Concrescence – fusion of teeth via cementum
14. Hypercementosis – excessive production of cementum
PIG ON TAP! : Paget’s disease, Idiopathic, Gigantism, Occlusal trauma, Non-Functional
tooth, Trauma, Acromegaly, Pericapical Granuloma

15. Amelogenesis Imperfecta –enamel only is affected

16. Dentinogenesis Imperfecta – associated with Osteogenesis Imperfecta
17. Dentin Dysplasia Type I – rootless teeth
18. Dentin Dysplasia Type II – Coronal dentin
19. Regional Odontodysplasia –teeth appear deformed clinically; enlarged pulp chamber
20. Hypophosphatemia – Vit D resistant
21. Hypophosphatasia – increased serum alkaline phosphatase
22. Fluorosis – when fluoride content of drinking water exceeds in 1ppm
23. Tetracycline stain – intrinsic stain affect during development of the tooth

IV. Odontogenic Cysts and Tumors

Odontogenic Cysts
1. Apical Periodontal Cyst – MOST COMMON ODONTOGENIC CYST

2. Residual cyst –cyst that persists after extraction

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3. Paradental cyst – buccal swelling adjacent to a molar (1 st lower molar = children; mand 3rd
molar=adult)
-associated with Enamel Pearl
-occlusal radiograph will show lingual displacement of tooth

4. Dentigerous cyst – THE MOST COMMON DEVELOPMENTAL CYST

-usually 3rd molar
-the only cyst that can develop into an Ameloblastoma
- “Rushton bodies”

5. Eruption Cyst – variant of Dentigerous cyst.

-lesion appears as bluish-purple

6. Lateral Periodontal Cyst – most common location: mand PM and canine area
-multilocular = Botryoid odontogenic cyst

7. OKC – MOST COMMON MULTILOCULAR RADIOLUCENCY.

-mandible>Maxilla
-major component of the Nevoid Basal Cell Carcinoma
8. Calcifying Odontogenic Cyst – expansile intraosseous lesion.
**The only odontogenic cyst with radiopacities as a component

Odontogenic Tumors
Epithelial in Origin
1. Ameloblastoma – MOST COMMON EPITHELIAL ODONTOGENIC TUMOR
-originated from remnants of dental lamina
-most common in lower 3rd molar area
-Histologic variants:
a. Follicular – most common
b. plexiform
c. desmoplastic – fibro-osseous radiographic appearance
d. acanthomatous
e. granular cell
f. basal cell

2. CEOT – originated from Stratum Intermedium

-amyloid can be seen

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3. Squamous Odontogenic Tumor – see teeth in floating air

-lesion can mimic Juvenile Periodontitis or Eosinophilic Granuloma of bone

Mesenchymal in Origin
1. Odontogenic Fibroma – most common in female; maxilla
-if in anterior maxilla, it presents as a soft tissue cleft

2. Odontogenic Myxoma – MOST COMMON

-originated from cells that would have formed the dental follicle
-Post mandible

MIXED
1. Ameloblastic Fibroma
-assoc with Mand Molar
-can turn into malignant form
2. Ameloblastic fibrosarcoma
-rapid painful growth phase
3. Ameloblastic fibro-odontoma

4. Odontoma
4.1 Compound “toothlets”
-Max Anteriors
-composted of enamel, dentin and pulp
4.2 Complex – unrecognizable dental tissue.
-Mand Post

5. Adenomatoid Odontogenic Tumor

-slow growing and painless
-“2/3 tumor”
2/3 are female
2/3 are in Max Anteriors
2/3 are associated with an impacted tooth (canine)
2/3 are under the age of 20
-the only odontogenic tumor with duct-like tumor

V. Oral Manifestation of Systemic Disease

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1. Syphilis – Treponema pallidum

-Primary: Chancre (3 weeks)
-Secondary: 4-10 weeks; maculopapular rash; condyloma lata (papillary lesions)
*Lues maligna: can be seen in immunocompromised patients
-Tertiary stage- Gumma
*Luetic glossitis: atrophy and loss of dorsal tongue papilla
-Congenital Syphilis: (1) Huntchinson’s incisors and mulberry molars; (2) interstitial keratitis; and
(3) deafness

2. Sjogren syndrome
-Triad: (1) keratoconjunctivitis sicca; (2) xerostomia; and (3) RA

3. Wegener’s granulomatosis
-Triad: (1) Focal Necrotizing Vasculitis, (2) Necrotizing granuloma, and (3) Necrotizing glomerular
nephritis

4. Langerhan’s cell disease

4.1 Letterer-Siwe Disease – mainly in infants
4.2 Eosinophilic Granuloma – “teeth floating in air”; solitary bone lesions; mainly in
adults
4.3 Hand-Schuller-Christian disease
-mainly in adolescents
-“multiple punched-out appearance”
-Triad: (1) bone lesions, (2) exopthalmus, and (3) DI
-Birbeck granules

5. Hyperparathyroidism
Clinical Features: Stones, Bones, Moans and Groans
Stones – urinary tract stones
Bones –subperiosteal resorption
Moans – personality changes
Groans – abdominal pain

6. Gingival Hyperplasia
Drugs: Dilantin, Nifedipine, Cyclosporine A

7. Iron Deficiency Anemia –gastric mucosal degeneration from low iron

*Plummer-Vinson Syndrome

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Clinical Feature: “spoon-shaped nail”

8. Sickle Cell Anemia – a genetic disorder resulting from a substitution of thymine for an
adenine in DNA
Radiographic appearance: “hair-on-end” appearance

9. Sarcoidosis – unknown cause

-elevated Serum ACE levels

10. Paget’s Disease

-elevated serum Alkaline phosphatase but normal calcium and phosphorus levels

VI. Bone Pathology of the Head and Neck

1. Osteoradionecrosis – bone reaction to radiation with destruction of the blood vessels

*7500 rads
Treatment: Bisphosphanates

2. Cherubism – bilaterally enlarged mandible, eyes upturned toward heaven, failure of teeth to
erupt
-Radiographic appearance: “Soap-bubble”

**SEE GENERAL PATHOLOGY!

REV IEW!
1. Common in Maxilla
A. Paget’s disease
B. Fibrous dysplasia
C. Juvenile Ossifying Fibroma

2. Common in Males
A. Acute Osteomyelitis
B. Chronic Osteomyelitis
C. Paget’s disease
D. Langerhan’s cell disease
E. Osteoid osteoma
F. Osteoblastoma

VII. Allergic, Immunologic, and

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Dermatologic Diseases

1. White Sponge Nevus – white, rough, surface lesion due to epithelial thickening on buccal
mucosa bilaterally
-mimic the cheek biting or squamous cell carcinoma

2. Darrier’s disease
- a defect in the adhesion of epithelial cells
-mimic papillary hyperplasia and nicotinic stomatitis
-appear red, pruritic papules

3. Pemphigus vulgaris
-most common type of pemphigus
-initial lesion: vesicle and bulla
-Tzanck cells: acantholytic epithelial cells with enlarged dark nuclei
-Nikolsky sign: blisters in oral cavity

4. Cicatricial Pemphigoid
-autoantibodies formed against a component of the basement membrane
-appearance of vesicles and ulcers
-Nikolsky sign
-Gingiva is almost always involved with diffuse erythema

5. Lichen Planus –Cytotoxic cell mediated hypersensitivity

-Wickham striae: lace-like network

6. Systemic Lupus Erythematosus

-antibodies are formed against cells and tissues
-Kidney disease: fatal to patient
-Heart disease
-Clinical Manifestation: Butterfly rash

7. Angioedema
-diffuse rapid swelling of soft tissues

VIII. Benign and Malignant Epithelial Lesions

1. Verruca vulgaris –HPV 2,4 and 40)

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-often seen in children

-spread through tips of fingers to fingers in mouth

2. Conyloma Acuminatum (HPV 6,11,16 and 18)

-sexual contact

3. Focal Epithelial Hyperplasia (HPV 13 and 32)

-affects labial, buccal and lingual mucosa

4. Keratoacanthoma
-superficial invasive squamous cell carcinoma
-a self limiting epithelial proliferation with clinical and histological similarities to SCC
-Muire-Torre: sebaceous neoplasm, kerathoacanthoma
-Ferguson-Smith: occur by themselves
-Etiology: SUN

5. Leukoplakia – NOT A DISEASE

- white patch or plaque that CANNOT be rubbed-off
-pre-malignant lesion

6. SCC
A. Lip cancer
-90% lower
-MOST COMMON EXTRAORAL
B. Tongue
-lateral and ventral surfaces are common
-tobacco and alcohol user
C. Floor of the Mouth
-cervical lymph nodes metastasis can occur
D. Palatal Cancer
-soft palate is most common

IX. Malignant Soft Tissue Tumors

1. Fibrosarcoma
-fibrous connective tissue in origin
-capable of distant metastasis

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2. Rhabdomyosarcoma
-MOST COMMON SOFT TISSUE SARCOMA in CHILDREN
-skeletal muscle

3. Leimyosarcoma

4. Liposarcoma – adipose

5. Hemangiopericytoma – originates from the pericytes in the walls of capillaries

-Infantile Hemangiopericytoma – single or multiple dermal and subcutaneous nodules

X. Soft Tissue Neoplasm

1. Inflammatory Fibrous Hyperplasia

-irritation to denture

2. Peripheral Ossifying Fibroma

-seen exclusively in Gingiva
-originates from PDL

3. Giant Cell Fibroma

-3 common sites: gingiva, tongue and palate
-when in gingiva, palatal part of 22 and 27

4. Fibroma
-firm, asymptomatic nodule
-buccal mucosa and lower lip

5. Neurofibroma
-seen on the tongue
-originates from perineural fibroblasts

6. Neurofibromatosis
-café-au-lait spots
-skeletal abnormalities: macrocephaly

7. Neurilemoma

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-originates from Schwann cells

-Histologic: Antoni A and Antoni B

8. Hemangioma
-see at birth or childhood
-lips, tongue and buccal mucosa
-Types: capillary hemangioma: red to purple; no bruit nor thrill, and cavernous hemangioma:
purple to dark

9. Sturge-Weber syndrome
-vascular malformation of cerebral meninges causing neurologic disorders
-affects the gasserian ganglion – “port wine stain”

10. Lymphangioma
-tonue, lips and neck (cystic hygroma)

XI. Salivary Gland Pathology

Benign
1. Mixed Tumor – MOST COMMON SALIVARY GLAND TUMOR
-mixed because it has mesenchymal and epithelial –like formation

2. Myoepithelioma
-40% parotid; 21% hard and soft palate

3. Warthin’s tumor
-95% parotid gland
-Associated with smoking
*Most likely to be bilateral

4. Basal cell adenoma

-Parotid

5. Canalicular Adenoma
-most common in upper lip

Malignant

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1. Mucoepidermoid carcinoma – MOST COMMON MALIGNANT

-2nd MOST COMMON SALIVARY GLAND TUMOR

2. Acinic cell adenocarcinoma – 2nd MOST COMMON MALIGNANT

-parotid gland
-slow growing

3. Adenoid Cystic Carcinoma

-“cheese like pattern”
-will exhibit pain and paresthesia

4. Polymorphous Low-Grade Adenocarcinoma

-minor gland tumor
-“Indian-file”
-most common in palate

5. Carcinoma Ex-Mixed Tumor

-rapid growth after long indolent course
-most common in parotid 65%

Non-Neoplastic Disorders
1. Mucus Escape Reaction
-bluish dome shape swelling
-lower lip

2. Sailolithiasis
-deposition of calcium salts around the duct
-Stone: Sialolith

3. Necrotizing Sialometaplasia
-idiopathic cause
-most common: posterior hard palate
-“My palate fell out”
-exhibit crater-like ulcerations

4. Benign Cyst of the Parotid

-idiopathic cause
-can be associated with HIV

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5. Benign Lumphoepithelial lesions

-bilateral painless swlling of lacrimal and salivary glands
-80% in parotid

XII. Pigmented and Vascular Lesions

1. Ephelis
-macular pigmented lesion in sun-exposed areas
-vermillion border

2. Lentigo simplex
-tends to occur in areas that are not exposed in sunlight

3. Nevi
A. Melanocytic nevi – most common human tumor
B. Congenital nevi – appears at birth, “bathing trunk” nevus
C. Blue Nevi – proliferation of dermal melanocytes
C.1 Common blue – palate and hands
C.2 Cellular blue – buttocks

4. Malignant Melonoma
-tumors of melanocytes
-commonly seen in head and neck
-“ABCD”
A- asymmetry
B- orders --- irregular
C- olor --- brown, black
D- iamater -- >6mm in diameter
-Locations: BANS
B – ack; interscapular area
A- rm; posterior part
N- eck; posterolateral
S-calp

-Types:
A. Superficial – most common form of melanoma with radial growth

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B. Acral Lentigenous- most common in Blacks, most common form in Oral cavity: hard
palate, gingiva and alveolar mucosa
C. Nodular – lesions begin in vertical growth
D. Lentigo Maligna

XIII. Syndromes of the Head and Neck

45X0 – Turner
45Y – Lethal
47XXX – Superwoman
47XX& - Klinefelter
47XY or Trisomy 21 – Down Syndrome

1. Gardner syndrome
-see polyps of large intestine
-Clinical features: osteomas, fibromas of the skin, multiple unerupted permanent and
supernumerary

*5 Hereditary syndromes with intestinal polyposis

1. Garnder syndrome
2. Familial Polyposis coli
3. Peutz-Jeghers syndrome
4. Turcot’s syndrome
5. Cowden syndrome

2. Crouzon’s syndrome
-“frog-like face” (mid face hypoplasia)
-Crouzon’s with syndactyly and hearing loss due to stapes fixation = Apert’s syndrome

3. Cleidocranial dysplasia
-“wormian bodes” – suture remains open
-prominent frontal, parietal and occipital bones
-oral: high arched palate, small Maxillary

4. Nevoid Basal Cell carcinoma syndrome

-Clinical features: Multiple OKC, bifid ribs, kyphoscoliosis, and calcification of the falx cerebri

5. Papillon-Levefre syndrome

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-periodontitis in children

6. Cowden syndrome
-Clinical Features: multiple nodular and popular lesions resulting in cobblestone appearance
-most common sites: tongue, buccal mucosa, and gingiva

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