Pathology Pathology of the of the

Oral CavityOral Cavity

To learn:To learn: Disorders of the Oral Mucosa and Disorders of the Oral Mucosa and

GingivaGingiva Disorders of the Salivary glandsDisorders of the Salivary glands Disorders of the Teeth and Jaw bonesDisorders of the Teeth and Jaw bones Disorders due to the Systemic DiseasesDisorders due to the Systemic Diseases

Diseases of the Oral CavityDiseases of the Oral Cavity

Disorders of the Oral Mucosa Disorders of the Oral Mucosa and Gingivaand Gingiva

Ulcerative and inflammatory lesionsUlcerative and inflammatory lesions Aphtous ulcersAphtous ulcers Herpes virus infectionsHerpes virus infections Fungal infectionsFungal infections

Hyperkeratotic lesionsHyperkeratotic lesions LeukoplakiaLeukoplakia ErythroplakiaErythroplakia

TumorsTumors Benign tumorsBenign tumors Malignant tumorsMalignant tumors

Aphtous ulcersAphtous ulcers EExtremely common superficial xtremely common superficial

ulcerationsulcerations (erosions) (erosions) of the oral mucosa of the oral mucosa PPainfulainful Single or multipleSingle or multiple ShallowShallow HyperemicHyperemic (erythematous) or yellowish- (erythematous) or yellowish-

graygray Less than 5 mm in diameterLess than 5 mm in diameter

CCovered by a thin exudate and rimmed overed by a thin exudate and rimmed by a narrow zone of erythemaby a narrow zone of erythema

Ulcerative and inflammatory Ulcerative and inflammatory lesionslesions

Location:Location: Soft palateSoft palate Buccolabial mucosaBuccolabial mucosa Floor of the mouthFloor of the mouth Lateral borders of the tongueLateral borders of the tongue

Triggers or Etiology: Triggers or Etiology: Inflammatory bowel diseaseInflammatory bowel diseasess Behçet’s Behçet’s diseasedisease HHypersensitivityypersensitivity reactions reactions EEmotional stressmotional stress Endocrine influences Endocrine influences (pregnancy, (pregnancy,

menstruation) menstruation) Autoimmune reactions Autoimmune reactions ((involving both involving both

cellular and humoral mechanismscellular and humoral mechanisms)) Infectious diseasesInfectious diseases

OOrofacial herpetic infections are rofacial herpetic infections are caused by HSV type 1 (Hcaused by HSV type 1 (HHHV-1)V-1)

HHHHV-2 most often involves the genital tractV-2 most often involves the genital tract Most primary oral infections with Most primary oral infections with

HSV-1 are trivial “cold sores”HSV-1 are trivial “cold sores” AAdults harbor latent Hdults harbor latent HHHV-1V-1: :

upper respiratory tract infections upper respiratory tract infections excessive exposure to cold, wind, or excessive exposure to cold, wind, or

sunlight sunlight allergic reactionsallergic reactions

Herpes virus infectionsHerpes virus infections

HHerpetic gingivostomatitiserpetic gingivostomatitis

Generally acuteGenerally acute Common in AIDS patientsCommon in AIDS patients In severe cases In severe cases

keratoconjunctivitiskeratoconjunctivitis encephalitisencephalitis

Lesions:Lesions:1.1. the oral and pharyngeal mucosathe oral and pharyngeal mucosa

2.2. the tonguethe tongue

3.3. the gingivathe gingivaee

Herpes simplex Herpes simplex HHerpetic gingivostomatitiserpetic gingivostomatitis (HIV-positive patient) (HIV-positive patient)

Fungal infectionsFungal infections

Candida albicansCandida albicans SSuperficial, curdy, gray to white inflammatory uperficial, curdy, gray to white inflammatory

membranemembrane Fibrinosuppurative exudateFibrinosuppurative exudate + + C.albicansC.albicans withwith

an underlying erythematous inflammatory basean underlying erythematous inflammatory base Risk factors: Risk factors:

ddiabetiabetes mellituses mellitus neutropenineutropeniaa iimmunmmune deficiency syndromese deficiency syndromes AIDSAIDS aantibiotic therapyntibiotic therapy

Oral trushOral trush

Candida albicansCandida albicans

Hyperkeratotic lesionsHyperkeratotic lesions

LLeukoplakiaeukoplakia ((white plaquewhite plaque) ) WWhite plaque on the oral mucous membranes that hite plaque on the oral mucous membranes that

cannot be removed by scrapingcannot be removed by scraping Precancerous lesionPrecancerous lesion Range from completely benign epithelial thickenings to Range from completely benign epithelial thickenings to

highly atypical lesions with dysplastic changes that highly atypical lesions with dysplastic changes that merge with merge with carcinoma in situcarcinoma in situ (CIS) (CIS)

Etiology:Etiology: TobaccoTobacco

smoking (cigar, cigarette, pipe)smoking (cigar, cigarette, pipe) CChewinghewing tobaco tobaco

Alcohol Alcohol Chronic Chronic irritations (i.e. irritations (i.e. cheek bitecheek bite))

LeukoplakiaLeukoplakia

EErythroplakiarythroplakia (dysplastic leukoplakia) (dysplastic leukoplakia) RRed, velvety, possibly eroded areaed, velvety, possibly eroded area Higher risk of malignant Higher risk of malignant

transformationtransformation more thanmore than 50% 50%

Etiology:Etiology: Tobacco (cigarettes, pipes, cigars, and Tobacco (cigarettes, pipes, cigars, and

particularly chewing tobacco particularly chewing tobacco )) alcoholalcohol Chronic Chronic exposure to persistent irritants exposure to persistent irritants

ill-fitting denturesill-fitting dentures hot hot mealsmeals

HPVHPV

EErythroplakiarythroplakia

TumorsTumors

Benign tumors and tumor-like Benign tumors and tumor-like conditionsconditions

TumorsTumors Papilloma (Papilloma (HPV serotypes 6 and 11HPV serotypes 6 and 11)) Angioma (hemangioma & lymphangioma)Angioma (hemangioma & lymphangioma)

Tumor-like conditionsTumor-like conditions Fordyce spots (ectopic sebaceous glands)Fordyce spots (ectopic sebaceous glands) Mucocele (minor salivary glands – Mucocele (minor salivary glands –

destruction of ductus)destruction of ductus)

Malignant tumorsMalignant tumorsSSquamous cell carcinomaquamous cell carcinoma::

95% of cancers of the oral cavity 95% of cancers of the oral cavity andand the tonguethe tongue The small residual includes The small residual includes

adenocarcinoma (of adenocarcinoma (of salivarysalivary gland origin) gland origin) melanomamelanoma various carcinomasvarious carcinomas

SSquamous cell carcinomaquamous cell carcinoma (Epidermoid (Epidermoid carcinoma)carcinoma)

Location (most predicted):Location (most predicted): Lower lipLower lip Floor of the mouthFloor of the mouth Tongue (lateral borders)Tongue (lateral borders)

Etiology:Etiology: Leukoplakia and Leukoplakia and erythroplakiaerythroplakia Tobacco : Tobacco : alcohol&smoking, tobacco chewingalcohol&smoking, tobacco chewing IIll-fitting denturesll-fitting dentures JJagged teethagged teeth HPVHPV Sunlight Sunlight (lower lip)(lower lip) CChronic infectionshronic infections

MorphologyMorphology In the early stageIn the early stage::

Raised, firm, pearly plaques Raised, firm, pearly plaques irregularirregular - - roughened roughened verrucose areas of mucosal thickeningverrucose areas of mucosal thickening

Differential diagnosis Differential diagnosis : : leukoplakialeukoplakia & & erythroplakiaerythroplakia

As these lesions enlargeAs these lesions enlarge:: protruding massesprotruding masses undergo central necrosisundergo central necrosis irregular, shaggy ulcer rimmed by irregular, shaggy ulcer rimmed by

elevated, firm, rolled borderselevated, firm, rolled borders

MicroscopyMicroscopy

with lwith leukoplakia and erythroplakia eukoplakia and erythroplakia well-differentiated keratinizing neoplasmswell-differentiated keratinizing neoplasms

or or anaplasticanaplastic or or sometimes sometimes undifferentiated (undifferentiated (sarcomatoidsarcomatoid))

tumorstumors Metastases:Metastases:

regional and regional and mediastinal lymph nodesmediastinal lymph nodes lungslungs liverliver bonesbones

SSquamous cell carcinomaquamous cell carcinoma

Disorders of the Salivary Disorders of the Salivary glandsglands

Inflammatory disordersInflammatory disorders SialadenitisSialadenitis Sjögren syndromeSjögren syndrome Mikulicz syndromeMikulicz syndrome

TumorsTumors Benign tumorsBenign tumors

Plemorphic adenomaPlemorphic adenoma Warthin tumorWarthin tumor

Malignant tumorsMalignant tumors Mucoepidermoid carcinomaMucoepidermoid carcinoma Adenoid cystic carcinomaAdenoid cystic carcinoma

Inflammatory Disorders of the Salivary Inflammatory Disorders of the Salivary glandsglands

VViraliral (mumps) (mumps) BBacterialacterial (complication of sialolithiasis) (complication of sialolithiasis) AAutoimmune originutoimmune origin

Sjögren’s syndromeSjögren’s syndrome:: involvement of the salivary glands involvement of the salivary glands xerostomiaxerostomia

((dry mouthdry mouth)) involvement lacrimal glands involvement lacrimal glands

keratoconjunctivitis sicca keratoconjunctivitis sicca ((dry eyesdry eyes))

Sarcoidosis :Sarcoidosis : bbilateral sarcoidosis of the parotid, ilateral sarcoidosis of the parotid,

submaxillary, and sublingual glands submaxillary, and sublingual glands uveuveaa involvement involvement

Mikulicz Mikulicz syndromesyndrome

Sjögren’s Sjögren’s syndromesyndrome

Tumors of the Salivary Tumors of the Salivary glandsglands

Benign tumorsBenign tumors

Plemorphic adenomaPlemorphic adenoma

Mostly parotid glandMostly parotid gland Painless swelling at the angle of the jawPainless swelling at the angle of the jaw Excision; may recur (10%)Excision; may recur (10%)

MicroscopyMicroscopy Composed of epithelial elements Composed of epithelial elements and and

myoepithelial cells myoepithelial cells dispersed dispersed throughout a matrix of throughout a matrix of mucoid, mucoid, myxoid, myxoid, chondroid tissuechondroid tissue

a mixed tumor a mixed tumor

Warthin TumorWarthin Tumor ((PPapillary Cystadenoma apillary Cystadenoma Lymphomatosum)Lymphomatosum)

Almost always in the parotid glandAlmost always in the parotid gland Small, Small, round to oval, encapsulated mass round to oval, encapsulated mass Excision; may recur (10%)Excision; may recur (10%) MicroscopyMicroscopy::

(1) (1) spaces are lined by a double layer of spaces are lined by a double layer of epithelial cellsepithelial cells

(2)(2) dense lymphoid stroma sometimes dense lymphoid stroma sometimes formforming ing germinal centersgerminal centers

Malignant tumorsMalignant tumors

Mucoepidermoid carcinomaMucoepidermoid carcinoma- Particularly the minor salivary glandsParticularly the minor salivary glands- Radiation-induced neoplasmRadiation-induced neoplasm - Mixture of squamous cells, mucus-secreting Mixture of squamous cells, mucus-secreting

cellscells- May May recur recur (( 30% 30%))- Disseminate to distant sitesDisseminate to distant sites (30%) (30%)

Adenoid cystic carcinomaAdenoid cystic carcinoma- Particularly the minor salivary glandsParticularly the minor salivary glands- Frank pain due to Frank pain due to neural invasionneural invasion- Microscopy: round-cystic spaces filled by mucusMicroscopy: round-cystic spaces filled by mucus

Tumors of the Salivary glandsTumors of the Salivary glands

Disorders of the Teeth and Jaw Disorders of the Teeth and Jaw bonesbones

TeethTeeth CariesCaries Inflammation (pulpitis, apical granuloma & Inflammation (pulpitis, apical granuloma &

cyst)cyst) Jaw bonesJaw bones

FracturesFractures Inflammation (osteomyelitis)Inflammation (osteomyelitis) Cysts (odontogenic; non-odontogenic)Cysts (odontogenic; non-odontogenic) TumorsTumors

Soft tissuesSoft tissues Bone & CartilageBone & Cartilage OdontogenicOdontogenic

Odontogeic cysts & tumorsOdontogeic cysts & tumors

Disorders due to the Disorders due to the Systemic DiseasesSystemic Diseases

INFECTIOUS DISEASESINFECTIOUS DISEASES Measles:Measles: Koplik’s spots Koplik’s spots Infectious mononucleosis:Infectious mononucleosis: acute acute

tonsillitis/pharyngitis, cervical tonsillitis/pharyngitis, cervical lymphadenopathylymphadenopathy

Diphtheria:Diphtheria: pseudomembrane pseudomembrane (tonsils/retropharynx)(tonsils/retropharynx)

AIDS:AIDS: Herpesvirus infection Herpesvirus infection (gingivostomatitis), (gingivostomatitis), Candida albicansCandida albicans, , Kaposi sarcomaKaposi sarcoma

DERMATOLOGIC DISORDERSDERMATOLOGIC DISORDERS

Lichen planus:Lichen planus: reticulate, white (keratotic) reticulate, white (keratotic) lesionslesions

Pemphigus:Pemphigus: vesicles and erosions vesicles and erosions Bullous pemphigoid:Bullous pemphigoid: bullae and erosions bullae and erosions Erythema multiforme Erythema multiforme (Stevens-Johnson (Stevens-Johnson

syndrome):syndrome): maculopapular-vesiculobullous maculopapular-vesiculobullous lesionslesions

follows an infectionfollows an infection drugdrug cancercancer auto-immune disorderauto-immune disorder

Pemphigus vulgarisPemphigus vulgaris

HEMATOLOGIC HEMATOLOGIC DISORDERSDISORDERS

Pancytopenia and/or LeukemiaPancytopenia and/or Leukemia gingivitisgingivitis pharyngitispharyngitis tonsillitistonsillitis neck cellulitis (Ludwig’s angina)neck cellulitis (Ludwig’s angina)

Monocytic leukemiaMonocytic leukemia gingival infiltrationgingival infiltration

MISCELLANEOUSMISCELLANEOUS Melanotic pigmentation:Melanotic pigmentation:

Albright’s syndromeAlbright’s syndrome Peutz-Jegher’s syndromePeutz-Jegher’s syndrome

Dilantin (phenytoin):Dilantin (phenytoin): gingival hyperplasia gingival hyperplasia Pregnancy:Pregnancy: granuloma gravidarum granuloma gravidarum Other Syndromes:Other Syndromes: oral manifestations can oral manifestations can

be found in the hereditary or acquired be found in the hereditary or acquired syndromessyndromes Teeth anomaliesTeeth anomalies MacroglossiaMacroglossia Bifid palate/tongue/lipBifid palate/tongue/lip Hemangiomas, ect.Hemangiomas, ect.

Peutz-Jegher’s syndrome; Gingival Peutz-Jegher’s syndrome; Gingival hyperplasiahyperplasia