Post on 19-Mar-2022
PATHOLOGY OF THE ORAL
CAVITY & SALIVARY GLAND
Professor Dr . Nafea Sami ,MRC-Path
Department of Pathology - 4th Stage
Al –Anbar medical college 2020-2021
OFTHE ORAL CAVITYANATOMY & HISTOLOGY Anatomy
Orifice to digestive & respiratory tracts
Lips, buccal mucosa, tongue, soft & hard palate
Teeth & periodontal tissue.
Histology
Lined by nonkeratinized stratified squamous epithelium
Minor salivary glands & sebaceous glands in lips & buccal mucosa
Lymphoid tissue .
DISEASE OF ORAL CAVITY :
Congenital anomalies, e.g. cleft lip & cleft palate, macroglossia, branchial cleft
cysts
Inflammations: Aphthous ulcers, Herpes stomatitis, Candidiasis ...
Pre-malignant lesions: leukoplakia, erythroplasia
Tumors: Squamous cell carcinoma
Salivary gland inflammations
Salivary gland tumors
ULCERATIVE & INFLAMMATORY LESIONS OF THE ORAL CAVITY
(CANKER SORES) APHTHOUS ULCERS
Extremely common, up to 40% of population.
Single or multiple shallow fibrin & exudates-coated painful ulcers with erythematous rim of oral mucosa, usually <1 cm, may coalesce together to be larger .
The etiology Unknown (?viruses, hypersensitivity).
Triggered by stress, fever, menstruation, pregnancy, certain foods; may be familial .
May be associated with inflammatory bowel disease & Behcet syndrome.
Self limiting in a few weeks, may recurrent in same or different location in oral cavity.
ULCERATIVE & INFLAMMATORY LESIONS OF THE ORAL CAVITY
HERPETIC STOMATITIS HSV I>>II; person to person transmission ( Kissing ).
After primary infection it is usually asymptomatic but virus will persist in perioral ganglia(triageminal ) in dormant state
Reactivation: fever, sun or cold exposure, URTI, ..
Herpes labialis: cold sores or fever blisters
Vesicular lesion, edema, degeneration of epidermis
Tzanck test: diagnostic test for HSV (intranuclear inclusions & giant cells) in smear of blister fluid .
In immunocompromised: virulent dissiminated infection: gingivostomatitis, encephalitis , keratoconjuctivitis...
ULCERATIVE & INFLAMMATORY LESIONS OF THE ORAL CAVITY
FUNGAL INFECTIONS Candida albicans is part of normal flora (30-40%)
Oral candidiasis (moniliasis, thrush): common in association with other medical disorders ( Comorbidity) .
Diabetes mellitus
Anemia
Antibiotic or glucocorticoid Rx
Immunodeficiencies & debilitating diseases
Soft white cheese-like plaques any where in oral cavity.
Pseudomembrane ( composed of myriad of fungi ) : may scrapped off to reveals underlying erythematous inflamed base .
Minimal- marked ulceration with inflammatory exudate and fungal microorganisms (pseudohyphae)
In vulnerable patients, disease may spread .
ULCERATIVE & INFLAMMAT ORY LESIONS OF THE ORAL CAVITY
ACQUIRED IMMUNODEFICIENCY SYNDROME (AIDS)
HIV infection is associated with different lesions in the oral cavity
Candidiasis
Herpetic vesicles
Other oppurtunistic infections
Kaposi’s sarcoma: multifocal vascular tumor, present in 25% of AIDS patients; related to HSV8.
Hairy leukoplakia: white patches with hairy surface:
Caused by EBV
Rare, but seen mainly in AIDS
The patches may look hairy
Histology shows acanthosis, hyperkeratosis
PRE-MALIGNANT LESIONS OF THE ORAL CAVITY
LEUKOPLAKIA A clinical term used to describe a whitish well- defined
mucosal patch or plaque caused by epidermal thickening or
hyperkeratosis .
C/P :Older men; associated with tobacco, chronic friction
(dentures), alcohol & irritant foods; HPV link.
Microscopically, they vary from hyperkeratosis without
dysplasia to mild to severe dysplasia or CIS.
Only histologic examination distinguishes these changes (
impossible to distinguish on visual inspection ).
3-6% transform into squamous cell carcinoma
PRE-MALIGNANT LESIONS OF THE ORAL CAVITY
ERYTHROPLAKIA
Red velvety areas which may remain at level with or slightly depressed in relation to surrounding mucosa
Have greater tendency for epithelial cell atypia and marked dysplasia than leukoplakia.
M/E :Hyperkeratosis is less frequent; red color is due to intense inflammation and vascular congestion
Higher risk (50%) of malignant transformation (the risk corresponds to the degree of atypia)
Erythroleukoplakia: speckled leukoplakia; mixture of erythroplasia and leukoplakia
SQUAMOUS CELL CARCINOMA
Represent 90% of oral cavity malignancies (3% of all malignant
tumors); M>F
Site : Lip > ant. floor of mouth > tongue >palate .
Etiology: Smoking, smokeless tobacco, protracted irritation (e.g.
dentures), chronic dental & oral infections, sunlight, heat, alcohol,
atrophy, HPV.
Gross appearance :Plaque, mucosal thickening or ulcer.
M/E :Invasive &/or in situ carcinoma; well differentiated to
undifferentiated.
Spread to local drained LN (submandibular, high jugular…)
Prognosis: depends on location (e.g. lip), grade, stage.
Mortality :50% lead to death in 5 years ;overall 5 YS without L.N
mets is 40% after chemo & radio ;and 20% with L.N mets
DISEASES OF THESALIVARY GLANDS
Inflammation Viral sialadenitis
Bacterial sialadenitis
Autoimmune sialadenitis
Sialolithiasis
Tumors Benign
Pleomorhpic adnoma (mixed tumor)
Warthin’s tumor
Malignant Carcinoma ex-pleomorphic adenoma
Mucoepidermoid carcinoma
Adenoid cystic carcinoma
Mickulicz’s syndrome
VIRAL SIALADENITIS
Most common cause is mumps, which usually affects the parotid gland (epidemic parotitis) .
70% bilateral parotid; 20% unilateral; 10% others .
Mumps is an acute contagious childhood disease .
Pathogen :Paramyxovirus, acquired by respiratory droplets.
Usually self limited, but may lead to complications, which are commoner in adults:
Pancreatitis
Orchitis: usually unilateral; rarely leads to infertility
CNS inflammation: rare but serious
AUTOIMMUNE SIALADENITIS
Sjogren’s syndrome: Inflammation of salivary glands &
mucus-secreting salivary glands of oral mucosa (resulting in
dry mouth or xerostomia) and lacrimal glands (resulting in
dry eyes or keratoconjunctivitis sicca)
90% are females; Parotid enlargement in 50% (bilateral ).
May be primary or secondary (60%) to other autoimmune
disease (RA, SLE, polymyositis ..)
M/E : Lymphocytic infiltration & fibrosis.
DX:RF, ANAs +/-; anti-ribonucleoprotein SS-A & B Abs
High risk to develop lymphomas
SIALOLITHIASIS & NONSPECIFIC SIALADENITIS
Etiology :Bacterial & usually chronic course.
Secondary to ductal obstruction by stones (sialolithiasis) in major
excretory duct .
Usually unilateral .
Pathogenesis: impacted food debris & edema around orifice
following injury and secondary bacterial invasion .
M/E :Ductal dilatation, periductal inflammation, & suppuration
Predisposing factors: Hx of major surgery, dehydration, long-
term phenothiazines Rx.
SALIVERAY GLANDS TUMORS
Relatively uncommon; 2% of tumors in humans.
80% of tumors occur in parotid gland .
Equal M:F ratio; all ages [6th - 7th decade]
Most of these neoplasms are benign: 70-80% of parotid tumors and only 50% of submandibular tumors .
C/P: mass at angle of jaw
Wide histologic variations:
Benign: Pleomorphic adenoma, Warthin’s tumor
Malignant: Carcinoma ex-pleomorphic adenoma, Mucoepidermoid carcinoma .
Adenoid cystic carcinoma: The most aggressive & locally invasive salivary gland carcinoma.
PLEOMORPHIC ADENOMA aka: benign mixed tumor: Most common tumor (65-80%) of the
salivary glands.
C/P: Slowly growing painless well-demarcated, encapsulated swelling, mostly arising from superficial lobe of parotid gland.
Pathology: heterogeneous histology with epithelial elements, myxoid stroma, often containing chondroid foci or, rarely, bone.
Despite its capsulation microscopic examination reveals multiple site where tumor penetrate the capsule .
Adequate margins of surgical resection are necessary to prevent recurrence.
Prognosis: Recurrence after surgery: 10%.
Malignant transformation: 15% in parotid, 40% in submandibular gland.
S TUMOR’WARTHIN
aka: Papillary cystadenoma lymphomatosum
Benign slowly growing tumors
5-10% of all parotid tumors; extremely rare in other salivary glands
Pathology: Composed of cystic spaces lined by tall columnar cells overlying abundant lymphoid tissue
Histogenesis: vestigial embryonic remnants of branchial cleft origin?&also :thought to represent hetrotopic salivary tissue trapped within a regional lymph node during embryogenesis .
Prognosis : rare malignant transformation .
Rx: cured by surgical excision .