Developmental Disturbances of the Oral Mucosa, Gingiva and Tongue
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Transcript of Developmental Disturbances of the Oral Mucosa, Gingiva and Tongue
Developmental Disturbances of the Oral
Mucosa, Gingiva and Tongue
GROUP 3:Joyce Ng Siew Siew
Kavinder KaurHarvinder Singh
Kartick Arumugam
Developmental Disturbances of the Oral Mucosa
Fordyce’s GranulesFocal Epithelial Hyperplasia
White Sponge NevusLeukoedema
Caliber-Persistent Artery
FORDYCE’S GRANULES ectopic collections of sebaceous glands upper lip, buccal mucosa, gingiva, anterior pillars of fauces bilaterally symmetrical distribution 60-70% of adult population granules in upper lip increases during puberty; granules in buccal mucosa increases in later stages of life multiple, small, discrete, milia-like, yellowish stuctures; 1-2mm diameter occasionally form slightly raised confluent plaques
HISTOLOGY identical to normal sebaceous glands
found in skin but not associated with hair empty into a duct, which opens directly
onto mucosal surface peripheral cells are flat and darkly stained inner cells are lipid rich and pale
rarely develop into sebaceous cysts or adenomas
FOCAL EPITHELIAL HYPERPLASIA “Heck’s disease” multiple papillary or sessile areas of epithelial
hyperplasia Native Americans, Indians, Northern native people
and other ethnic groups in Europe and Africa caused by Human Papilloma Virus (HIV) type 13
and 32 (?) similar lesions in HIV-seropositive homosexual
males children, 3-18 years old white or pink multiple, small pedunculated,
polypoid or nodular soft tissue growths; 1-5mm diameter
buccal and labial mucosa most common most lesions regress after 4-6months, occasionally
recur
HISTOLOGY hyperparakeratosis of the covering epithelium with extensive acanthosis epithelial cells of the upper spinus layer show enlarged nuclei and vacuolated clear cytoplasms (koilocytes) deeper epithelial layer shows thickening, elongation and fusion of rete-pegs basal cell layer exhibit increased mitotic activity occasional focal areas of liquefaction degeneration of basal layer loose underlying connective tissue, well-vascularized and variable infiltrates of lymphocytes
WHITE SPONGE NEVUS autosomal dominant hereditary disorder mutations in the genes coding for keratins 4 and 13 and cells heap up on epithelial surface some congenital, some adolescence intraoral lesions almost always bilateral buccal mucosa and tongue mostly, sometimes vestibular mucosa asymptomatic, deeply folded white or grey lesion surface is soft, uneven, spongy sometimes can be peeled off by gentle rubbing without bleeding diffused or patchy, translucent opalescence similar to leukoedema
HISTOLOGY epithelial thickening, mild to moderate
hyperparakeratinization from surface until deep into spinus, acanthosis and spongiosis, intra cellular edema of spinus
cells with intracellular edema show vacuolated cytoplasms and shrunken nuclei
“basket weave” appearance – only cell walls and nuclei visible
individual cell keratinization in spinus cell layer, basal cells intact, lamina propria no inflammation
ELECTRON MICROSCOPYSome cells of spinus layer differentiate early and become enriched with tonofilaments
LEUKODEMA more in blacks than whites possibly due to mucosal pigmentation in blacks making edematous changes more noticeable variation of normal rather than disease more common and severe in smokers (?) diffused, gray-white, milky, opalescent mucosa folded surface, wrinkles or whitish streaks lesions do not rub off bilateral, may extend onto labial mucosa easy to diagnose: white appearance diminishes when cheek is stretched
HISTOLOGY increased thickness of epithelium with striking intracellular edema of spinus layer vacuolated cells appear large and have stretched nuclei parakeratinized epithelial surface broad and elongated rete ridges benign condition
CALIBER-PERSISTENT ARTERY “retained caliber labial artery”, “caliber-persistent labial artery” inferior alveolar artery retains its large size and thickened walls even after leaving the bone supplies mucosal aspects of lower lip artery becomes superficial towards midline usually few mm inferior to vermilion border palpable due to size 80% on lower lip, few on upper lip and hard palate 40-88 years old artery sessile, elongated nodule, may be pulsatile may be tender or ulcerated due to recurrent trauma or irritation from teeth
HISTOLOGY large artery with thick smooth muscle walls separated from overlying stratified squamous
epithelium by fibrovascular connective tissue “retained caliber” is obvious vessel somewhat parallel to surface of lesion excess keratin on surface and scattered chronic
inflammatory cells in stroma indicate chronic trauma
TREATMENTNone required unless it becomes tender or excessively enlarged from recurring trauma - simple surgical removal.
Developmental Disturbances of the Gingiva
Fibromatosis Gingivae
• Definition :Benign diffuse infiltrative proliferations of
fibroblast and mature collagen fibers within gingival tissues
Hereditary condition – transmitted as an autosomal dominant trait
Result of developmental abnormality of fibroblast function
• Clinical features : Localized / generalized
fibrous enlargement of gingiva
Mostly appears in young children but maybe present at birth / even may not be noticed until adult life
Both sexes equally effected Multinodular enlargements
especially in the inter dental papilla regions
Hyperplastic tissue is firm, painless, and gingiva is coral pink
Sometimes markedly enlarged gingiva may cover entire crown of erupted teeth (Eruption normal)
Associated with hypertrichosis, epilepsy, and mental retardation
Associated with syndromes, e.g. Cowden’s Syndrome and Rutherfords Syndrome
Can be a feature of “ Laband Syndrome”
• Histopathology : Covering epithelium is
hyperplastic and rete-pegs elongated
Fibrous connective tissue consists bundles of collagen fibers with scattered mature spindle shaped few multinucleated fibroblasts
Mucoid changes in gingival connective tissue
Significant number of mast cells
• Differential Diagnosis : Phenytonin sodium
induced gingival hyperplasia
Generalized hyperplastic gingivitis
Leukemic infiltration of gingiva
• Treatment : Periodic gingivectomy
with placement of gingival acrylic splints for cosmetic and functional reasons
• Slightly raised area of mandibular alveolar mucosa
• Commonly located lingual to the cuspids• Structure measures abt 2-4mm • Often present bilaterally between marginal
gingiva and mucogingival junctions• Common among children• Structural resemblance to incisive papilla• Histological – papilla represents a focus of fibro-
vascular tissue with an orthokeratinized / parakeratinized surface and usually covers an osseous foramen of nutrient blood vessel.
Retrocuspid Papilla
Retrocuspid papilla; here, a reddish, slightly-raised sessile small nodule behind or lingual to the lower cuspid tooth.
Retrocuspid papillae in two patients. They are bilateral, green arrows. They may be mistaken for disease.
Developmental Disturbances of the Tongue
AGLOSIA What is it?Its a rare birth defect where the tongue is missing or underdeveloped
Symptoms ? •Missing tongue, •Feeding problems •Breathing, Speech & Swallowing •problems•Missing teeth• Tooth enamel defects •Missing or abnormally small tongue(two thirds of the tongue is missing)
Treatment ?•Orthodontics.•Breathing assistance may be needed •early in life if airway is compromised•Speech Therapy
MICROGLOSSIA
This is a condition where the size of the tongue is abnormally small. Cases of complete absence of the tongue have been reported.
Difficulties in SpeechDifficulties in Swallowing
NO TREATMENTaffected person will have to train their tongue to the best of their abilities.
MACROGLOSSIAWhat is it? • The presence of an excessively large
tongue, which may be congenital or may develop as a result of a tumor or edema due to obstruction of lymphatic vessels,or it may occur in association with hyperpituitarism or acromegaly. It also may be associated with malocclusion because of pressure of the tongue on the teeth.
Causes ?• Cystic hygroma • I-cell disease • Alpha-mannosidase deficiency • Opitz-Frias syndrome • Wiedemann-Beckwith syndrome • Pituitary tumour (growth hormone
secreting) • Amyloidosis • Tongue cancer • Gangliosidosis GM3 • Generalized gangliosidosis GM1 • Alpha-L-iduronidase deficiency • Hypothyroidism, congenital • Down syndrome
ComplicationsFeeding difficulty Speech problems Jaw development abnormalities Dental abnormalities Ulcerated tongue tip Necrotic tongue tip
Treatment•Get the correct diagnosis 1st !
•Tongue reduction surgery protect the airway & allow normal mastication it may also help optimize dental & oral cavity development.
•Beckwith-Wiedemann: Intractable neonatal hypoglycemia requires immediate recognition •and ICU management.
•Down syndrome: patients should be followed at a comprehensive Down syndrome care center; ( genetics referral )
•Hypothyroidism: Thyroxine replacement with careful tracking to keep levels therapeutic as patient grows .
ANKYLOGLOSSIAWhat is ?
term for tongue tied which is an anomaly present from birth. The severity of the anomaly is variable with the tongue
completed joined to the floor of the mouth in severe cases.
Symptoms•Reduced mobility of tip of tongue •Short frenulum•Impaired feeding ability •Impaired speech •Impaired oral hygiene
Usually seen in patients with ?Chromosome 9 trisomy syndrome
Treatment No treatment is usually required but
Surgery can be done in problematic cases
BIFID TONGUEA tongue with a groove or split
running lengthwise along the tip of the tongue. Also called cleft tongue.
A congenital structural defect of the tongue in which its anterior
part is divided longitudinally for a greater or lesser distance
SURGERY for treatment
FISSURED TONGUE Characterized by grooves that vary in depth and are noted along the
dorsal and lateral aspects of the tongue. The lesions are usually asymptomatic unless debris is entrapped within the fissure .
PhysicalUpon clinical examination, fissured tongue affects the dorsum and often extends to the lateral borders of the tongue. The depth of the fissures varies but has been noted to be up to 6 mm in diameter. When particularly prominent, the fissures or grooves may be interconnected, separating the tongue dorsum into what may appear to be several lobules.
Fissured tongue is seen in Melkersson-Rosenthal syndrome, in most patients with Down syndrome, and in association with geographic tongue
MEDIAN RHOMBOID GLOSSITIS
Smooth-surfaced red area in posterior midline (large arrow) is slightly nodular. Patient also has midline fissure of anterior dorsum of tongue (small arrow).
Previously median rhomboid glossitis was thought to represent DEVELOPMENTAL DEFECT OF THE TONGUE due to tuberculum impar on the surface of the dorsum of the tongue
during normal embryogenesis however the tuberculum impar should retrude and is overgrown by the lateral lingual swellings.
now investigators believe median rhomboid glossitis is due to chronic infection of candida albicans
ETIOPATHOGENESIS
The embryonic tongue is formed by two lateral processes (lingual tubercles) meeting in the midline and fusing above a central structure from the first and second branchial arches, the tuberculum impar
The posterior dorsal point of fusion is occasionally defective, leaving a rhomboid-shaped, smooth erythematous mucosa lacking in papillae or taste buds
This median rhomboid glossitis (central papillary atrophy, posterior lingual papillary atrophy) is a focal area of susceptibility to recurring or chronic atrophic candidiasis, prompting a recent movement toward the use of posterior midline atrophic candidiasis as a more appropriate diagnostic term.
ETIOPATHOGENESIS
CLINICAL FEATURES
Median rhomboid glossitis presents in the posterior midline of the dorsum of the tongue, just anterior to the V-shaped grouping of the circumvalate papillae. The long axis of the rhomboid or oval area of red depapillation is in the anterior-posterior direction. Most cases are not diagnosed until the middle age of the affected patient, but the entity is, of course, present in childhood. There appears to be a 3:1 male predilection.
Those lesions with atrophic candidiasis are usually more erythematous but some respond with excess keratin production and, therefore, show a white surface change. Infected cases may also demonstrate a midline soft palate erythema in the area of routine contact with the underlying tongue involvement; this is euphemistically referred to as a kissing lesion.
Lesions are typically less than 2 cm. in greatest dimension and most demonstrate a smooth, flat surface, although it is not unusual for the surface to be lobulated. Occasional lesions have surface mamillations raised more than 5 mm. above the tongue surface, and occasional lesions are located somewhat anterior to the usual location. None have been reported posterior to the circumvallate papillae.
Prior to biopsy, the clinician should be certain that the midline lesion does not represent a lingual thyroid, as it may be the only thyroid tissue present in the patient's body. Additional clinical look-alike lesions include the gumma of tertiary syphilis, the granuloma of tuberculosis, deep fungal infections, and granular cell tumor.
Starts as a narrow,mildly erythematous area located along the median fissure of tongue
Lession is asymptomatic and enlarges for years
Developped lession appears as a diamond or lozenge shaped area devoid papilla
Colour of lesion varies from pale pink to bright red , ocasionally presence of white halo
Some patient even develop a similar lesion on the midline of the palate just opposite the tongue lesion
Asymptomatic but cause slight soreness or burning sensation
shows a smooth or nodular surface covered by atrophic stratified squamous epithelium overlying a moderately fibrosed stroma with somewhat dilated capillaries.
PATHOLOGY AND DIFFERENTIAL DIAGNOSIS
Chronic candida infection may result in excess surface keratin or extreme elongation of rete processes and premature keratin production with individual cells or as epithelial pearls (dyskeratosis) deep in the processes. Silver staining for fungus will often reveal candida hyphae and spores in the superficial layers of the epithelium. This pseudoepitheliomatous hyperplasia may be quite pronounced, and the tangential cutting of such a specimen may result in the artifactual appearance of cut rete processes as unconnected islands of squamous epithelium, leading to a mistaken diagnosis of well differentiated squamous cell carcinoma. Because of this difficulty, it is recommended that the patient be treated with topical antifungals prior to biopsy of a suspected median rhomboid glossitis.
GEOGRAPHIC TONGUEIs the multifocal, patchy irregular area of depapillation of tongue characterized by frequent remission and recurrences.
ETIOLOGY
EXACT ETIOLOGY NOT KNOWN
POSITIVE FAMILY HISTORY
EMOTIONAL PROBLEM
Signs and symptoms of geographic tongue include:
Map-like, or geographic, appearance of your tongue
Smooth, bright red patches of various shapes and sizes on the top surface of your tongue
Tongue discomfort
Soreness or a burning sensation that may worsen with hot, spicy or acidic foods
Factors that may be associated with or that may increase the risk of geographic tongue include:
Having relatives with geographic tongue Having a fissured tongue, a condition in which deep grooves form on your tongue's surface Psoriasis Excessive stress Hormonal changes Allergies Systemic steroid use Atopic dermatitis
However, research studies about the risk factors for geographic tongue have been contradictory, and the connection between geographic tongue and other conditions is uncertain. Geographic tongue can occur at any age. Geographic tongue affects about 1 to 3 percent of people. Some evidence suggests that it's more common in women than in men.
Irregular areas of dekeratinized and desquamated filiform papillae (red in color) are surrounded by elevated whitish or yellow margins due to acantholysis and hyperkeratosis. Neutrophils migrate into the epithelial layer, creating what are termed Munro's abscesses.
HISTOPATHOLOGY
TREATMENTNO SPECIFIC TREATMENT , BUT HEAVY DOSES OF VITAMIN MAY PRODUCE SOME RESULT , Eg: VITAMIN B
LINGUAL VARICES
A varix is a dilated,tortuous vein, which is often subjected to increased hydrostatic pressure but is poorly supported by the surrounding tissue
CLINICAL FEATURES
Varicosities can be observed in many oral location: Ventral surface of tongueFloor of the mouthLipsBuccal mucosa Commissures
Ventral surface of the tongue and floor of the mouth are most common sites for oral varices.
Clinically lingual varices appears small roundPurplish nodules lateral to the sublingual vein
Lingual Varices are common among people > 50 and become more conspicuous with advancing age
Presence of lingual varices < 50 indicates premature ageing
Lingual Varices may occur with leg varicosities, however there is no relationship between cardiopulmonary disorder and lingual varices
Lingual varices can be indistinguishable from hereditary hemorrhagic telangiectasia, however the absence of skin and mucosal lession and absence of bleeding tendency in lingual varices usually helps to establish the proper diagnosis.
Hairy Tongue• Definition :Hypertrophy of the filliform papilla of tongue
along with loss of normal desquamation process which eventually leads to formation of pigmented, thick, matted layer on the tongue surface heavily coated with bacteria and fungi
Filiform papillae
• Clinical Features : Commonly affects mid dorsum of
tongue Hypertrophy of filliform papilla
produces thick matted layer on dorsal surface
In extreme case may produce a thick, leathery coating on the tongue surface, known as earthy or encrusted tongue
Brushes soft palate and produce gagging sensations
Produces halitosis Can be irritation due to
accumulation of food debris and microorganisms
Often associated with various systemic diseases
Extension of the tongue with a gauze, showing the dorsal surface with elongated filiform papillae (hairy tongue).
• Treatment : Cleaning and scrapping
of tongueApplication of topical
keratolytic agentsConsumption of yogurtThe affected tongue
papilla often rapidly returns to normal when long-term antibiotics or other drugs are discontinued
• Definition : Accessory accumulation of functional thyroid gland
tissues within the body of the tongue.
• Clinical Features : seen in females during puberty or adolescence In the tongue, thyroid tissue appears as nodular exophytic
mass, measuring abt 2-3mm in diameter and located posterior to foramen caecum
Can also be present as smooth cystic swelling Symptoms – change of voice(dysphonia) , bleeding , pain ,
difficulty in swallowing (dysphagia), respiratory obstruction (dyspnea) and feeling of tightness in the throat
Lingual Thyroid Nodule
• Histopathology : Normal mature thyroid
tissues, although embryonic or fetal thyroid gland tissues may also be seen
Occasionally, thyroid nodules may exhibit colloid degeneration or goiter
• Differential Diagnosis : Thyroglossal tract cyst Neoplasms
• Diagnosis : Diagnostic procedures
include1. Iodine-131 and
technetium scans2. Preoperative biopsy
from the thyroid nodule• Treatment : Surgical excision
Thyroglossal Tract Cyst
• Definition :An uncommon developmental cystic lesion
arising frm the embryonic remnants of the thyroglossal tract and it develops in the midline of the neck, anywhere between the base of the tongue above and the thyroid gland below
The End…