Oral Path 3

fibroma AKA

irritation fibroma, traumatic fibroma, focal fibrous hyperplasia, fibrous nodule

most common tumor of oral cav

fibroma

fibroma location

buccal mucosa \> labial mucosa, tongue, gingiva

fibroma clinical features

soft to firm, tumor like growth. non ulcerated

fibroma tx and prognosis

conservative surgical excisionrecurrence rare

giant cell fibroma

• Not associated with trauma or irritation• Asymptomatic, sessile or pedunculated nodule

giant cell fibroma location

• Mandibular gingiva, tongue, palate (often areas without trauma)• Papillary surface common

giant cell fibroma age

younger than fibroma- 60% less than 30yo

retrocuspid papilla

- resembles giant cell fibroma histopathologically- common in children and adolescents

retrocuspid papilla location

lingual mand gingiva adjacent to cuspid, often bilateral- small pink papule

giant cell fibroma microscopic features

- Thin, atrophic epithelium- Loose fibrous CT- Large, multinuclear, stellate fibroblasts

giant cell fibroma tx and prognosis

- Conservative surgical excision (Retrocuspid papillae can be monitored clinically)- Rare recurrence

epulis fissuratum aka

inflammatory fibrous hyperplasia, dentureinjury tumor, denture epulis

Epulis Fissuratum

• Associated with flange of an ill-fitting denture• Single or multiple folds of vestibular tissue (Usually labial or buccal)• Denture flange fits in between the folds

epulis fissuratum location

• Maxilla

epulis fissuratum age and gender

- middle aged or older adults- F \>> M

epulis fissuratum microscopic featurers

Occasional osseous and chondromatous metaplasia(denture sits in that groove)

epulis fissuratum tx and px

- Surgical removal- Denture reline or remake- Good prognosis

inflammatory papillary hyperplasia aka

denture papillomatosis

inflammatory papillary hyperplasia etiology

- ill fitting denture- poor denture hygiene- mouth breathing or high palatal vault (dentate pts)

inflammatory papillary hyperplasia clinical features

• Multiple papillary growths on hard palate• Usually asymptomatic

inflammatory papillary hyperplasia microscopic features

- Hyperplastic squamous epithelium- Occasional pseudoepithelomatous hyperplasia- Chronic inflammation

inflammatory papillary hyperplasia tx and px

- Surgical excision- Denture reline- Leave denture out at night- Good prognosis

3 Ps of localized gingival mass

1. peripheral ossifying fibroma2. peripheral giant cell granuloma3. pyogenic granuloma

Peripheral Ossifying Fibroma

thought to arise from PDL- pale pink gingival growth- spindle cell proliferation with variable calcifications- firm to boney consistency

Peripheral Ossifying Fibroma demographics

young adults, female 2:1

Peripheral Ossifying Fibroma lcoation

anterior jaws

Peripheral Ossifying Fibroma tx and px

excision, removal local irritants15% recurrence

Peripheral Ossifying Fibroma histology

can see bone formation

peripheral cell granuloma

- alveolar or gingivial mass- bluish-red mass, may be ulcerated, may cause 'cupping' of underlying bone- soft consistency

peripheral cell granuloma demographics

adults40-50s

peripheral cell granuloma microscopic features

- Abundant multinucleated giant cells- Marked hemorrhage -\> hemosiderin- Acute and chronic inflammation- Occasional reactive bone or dystrophic calcification

peripheral cell granuloma tx and px

- local surgical excision- aggressive scaling and root planing- 10-18% recurrence

pyogenic granuloma

- Rapidly growing, painless, reddish mass• Any body surface

bleeds easily• Gingiva, lips, tongue

may affect skin

pyogenic granuloma demogrpahics

- children and young adults• Frequently occurs during pregnancy

pyogenic granuloma microscopically

granulation tissue

pyogenic granuloma tx and px

Excise (avoid in 1st and 3 rd trimester), remove irritants

15% recur

lipoma

• Benign tumor of adipose tissue• Common in head and neck

occasionally found intraorally

lipoma demographics

adults

lipoma clinical features

• Slow-growing, non-tender, soft, doughy, usually encapsulated• Yellow if close to the surface

lipoma histology

Demarcated or encapsulated collection of mature fat cells

lipoma tx and px

Excisional biopsy. No recurrence

traumatic neuroma

• Uncommon reaction to sectioning of a nerve (amputation neuroma)• Smooth-surfaced, dome-shaped papule, usually \>1 cm- may be tender on palpation

traumatic neuroma location

tongue, buccal vestibule (mental foramen region common) affected

traumatic neuroma microscopically

• Microscopically, a tangled mass of peripheral nerve fibers is seen• Usually set in a collagenous background

traumatic neuroma tx

surgical excision- lack of sensation in supplied areas- prevent resected ends from meeting

Neurilemoma (Schwannoma)

benign tumor of schwann cell origin- most in adults

Neurilemoma (Schwannoma) clinical features

Slow-growing, solitary, encapsulated, rubbery-firm, non-tender mass

nerilemmoma (schwannoma) location

• 25-48% in head and neck including oral cavity• Lips, tongue, buccal mucosa• May be seen within the mandible

nerilemmoma (schwannoma) histology

• Well-developed CT capsule• Benign proliferation of spindle-shaped schwann cells• Antoni A and Antoni B patterns are seen, with Antoni A characterized by palisaded nuclei arranged around Verocay bodies

Antoni B

nerilemmoma (schwannoma)-- no pattern of nuclei

antoni A

nerilemmoma (schwannoma)- Antoni A characterized by palisaded nuclei arranged around Verocay bodies- verocay bodies - pink areas of cytoplasm

nerilemmoma (schwannoma) tx and px

• Treatment: conservative excision• Lesion usually "shells out" due to dense CT capsule• Virtually no tendency to recur• Extremely rare malignant transformation

neurofibroma

• Benign tumor of neural fibroblast origin• Over 90% are solitary

remainder are multiple and associated with neurofibromatosis

neurofibroma clinical features

• Soft, dome-shaped, non-tender, superficial nodule affecting skin or mucosa• Demarcated, but unencapsulated

neurofibroma tx and px

• Treatment consists of conservative excision• Prognosis is generally good• Uncommon possibility of malignant transformation to malignant peripheral nerve sheath tumor

especially rare for small, superficial lesions

neurofibromatosis transmission

Approx half are transmitted AD trait

other half new mutations

neurofibromatosis skin lesions

- cafe au lait spots- multiple neurofibromas- axillary freckling (crowe sign)

cafe au lait spots

Neurofibromatosis- Light brown macules with smooth ("coast of California") borders. Usually 6 or more, greater than 1.5 cm

multiple neurofibromas

small, discrete lesions or massive, pendulous ones

lisch nodles

neurofibromatosis- benign pigmented nodule of iris

oral lesions of neurofibromatosis

Oral lesions consist of neurofibromas that may affect the tongue (macroglossia), gingiva or bone

Neurofibromatosis tx and px

• removing traumatized neurofibromas or disfiguring lesions• Genetic counseling• Decreased longevity (from 8-15 years)• Follow for potential malignant transformation (5%)

MEN1

Parathyroid, pancreatic tumors, phaeochromocytoma, and pituitary tumors. Majority of tumors in people with MEN1 are benign. However, approximately 1 out of 3 pancreatic neuroendocrine tumors and mediastinal neuroendocrine tumors are malignant

MEN 2a

MEN1 and medullary carcinoma of thyroid

men 2B

MEN 2a and NEUROMAS(mouth symptoms)

MEN type 2B transmission

AD

triad of MEN type 2B

- Medullary carcinoma of the thyroid- Pheochromocytoma (adrenal medulla)- Mucosal neuromas

medullary carcinoma of the thyroid

MEN 2B- Aggressive tumor of parafollicular cells (C cells)- Increased serum / urinary calcitonin levels- Requires prophylactic thyroidectomy- Average age of death

Pheochromocytoma

- 50% of MEN, Type 2B cases- Frequently bilateral or multifocal- Secrete catecholamines- Sweating, diarrhea, headaches, flushing, heart palpitations, HTN- Increased urinary vanillylmandelic acid (VMA)

oral mucosa neuromas

MEN 2B- First manifestation- Soft, painless papules or nodules- Lips, anterior tongue, buccal mucosa, gingiva and palate- Characteristic bilateral commissural neuromas

MEN type 2B microscopic features

- Hyperplasia of nerve bundles- Thickened perineurium (**know pic)

granular cell tumor demographics

usually 30-50yF\>M (2:1)

granular cell tumor clinical features

• Develop on any cutaneous or mucosal surface, 40% on dorsal tongue• Slow-growing, asymptomatic, demarcated (though unencapsulated), non-tender, yellow-pink submucosal nodule• Most are less than 1 cm. in size

granular cell tumor microscopic features

• Collection of mesenchymal cells with a granular-appearing cytoplasm• PEH (pseudoepitheliomatous hyperplasia) is present in about 30% of granular cell tumors - may be mistaken for scc microscopically

granular cell tumor tx and px

• Conservative excision is usually curative• Prognosis is excellent

congenital epulis

• Rare lesion of undetermined histogenesis• Found at birth on the maxillary ridge of girl babies

congenital epulis clinical features

• Smooth-surfaced, often pedunculated• Vary in size

cogenital epulis microscopically

• Microscopically shows a benign proliferation of cells having granular cytoplasms• No pseudoepitheliomatous hyperplasia• Not of neural origin

congenital epulis tx and px

• Conservative excision• No tendency to recur• Some reports of spontaneous involution without surgery

hemangioma

- Benign tumor of infancy- Arise within 8 weeks of birth- Rapid endothelial growth- Involution

vascular malformation

- Structural anomalies- Normal endothelial growth- Present at birth- Persist throughout life

hemangioma of infancy

• F\>M (3-5:1)• Whites \> other ethnicities• Most common in head and neck (60%)• Usually solitary (80%)• Firm, rubbery, red ("strawberry"), non-blanching bosselated mass (superficial), blue if deep

hemangioma of infancy microscopic features

• Plump endothelial cells• Endothelial cells flatten• Vascular spaces become more prominent• Eventual involution

hemangioma tx and px

• "watchful neglect"• Propranolol• Corticosteroids• IV antimetabolites• Surgery• Laser ablation• Sclerotherapy

low flow venous malformations

- Variable size, compressible- Blue- Thrombosis and phlebolith formation

high flow AV malformations

- Palpable thrill or bruit- Skin is warm to touch- Pain, bleeding, ulceration

intrabony malformations

- Venous or A-V malformation- F\>M- Mandible\>>maxilla (3:1)- Asymptomatic, soap bubble-like multilocula rradiolucency- "Sunburst" periosteal reaction- Cortical expansion- angiography before biopsy

vascular malformation histology

• No endothelial proliferation• Dilated vessels• A-V malformation contains arteries, veins and capillaries

vascular malformation tx and px

- embolization- resection- inc bleeding risk

encephalotrigeminal angiomatosis aka

sturge weber syndrome

encephalotrigeminal angiomatosis transmission

congenital abnormality NOT inherited or genetic

encephalotrigeminal angiomatosis clinical features

• Patients exhibit "Port wine stain" (nevus flammeus) in distribution of CN V• Involvement of deeper soft tissues and meninges• Seizure disorders, mental retardation and hemiplegia• Migraines, stroke, GH deficiency, hypothyroidism• Glaucoma and vascular ocular malformations