HAND WRITTEN STUDY NOTES FOR ORAL MEDICINE AND ORAL PATHOLOGY, Study notes of Oral Medicine

Download HAND WRITTEN STUDY NOTES FOR ORAL MEDICINE AND ORAL PATHOLOGY and more Study notes Oral Medicine in PDF only on Docsity! BENIGN EPITHELIAL LESIONS SQUAMOUS PAPILLOMA A benign exophytic papillary growth of SSE. Unisex HPV Young adults-adults Most common CLINICAL FEATURES Soft, painless, exophytic papillary lesion - <1cm. Sessile - pedunculated - keratinized (white) or non-keratinized (pink). Cauliflower-like projections. Soft-palate, Uvula, ventral/dorsal surfaces of tongue, gingiva and buccal mucosa. HISTOPATHOLOGY A thick papillary layer of keratinized/non-keratinized SE + central core of fibrovascular CT. Papillary projections - long and finger-like or short, rounded and blunt. Epithelium - normal maturation pattern + mild degree of basilar hyperplasia. Koilocytes - virus altered clear epithelial cells with dark pyknotic nuclei. TREATMENT Surgical excision. Recurrence uncommon. KERATOACANTHOMA A benign endophytic epithelial growth appearing as a well-circumscribed keratin filled crater or sun-exposed skin, often mistaken for SCC. Sun-exposed skin 50 years age M-F 2:1 CLINICAL FEATURES Cheek, nose, eyelids,ear. Lower lip - arises from the superficial epithelium of sebaceous ducts or from hair follicle epithelium of adjacent skin. Small, red macule that becomes a firm papule with a fine scale over its highest point. Rapid enlargement over 1-2 months - hemispheric, firm, elevated, asymptomatic nodule. Core of keratin surrounded by a concentric collar of raised skin or mucosa. HISTOPATHOLOGY Resembles a well-differentiated SCC. Central keratin plug with an overhanging lip or marginal buttress of epithelium. Marked pseudoepitheliomatous hyperplasia + intense mixed inflammatory infiltrate. TREATMENT Surgical excision. No recurrence. MELANOCYTIC NEVI A benign, exophytic, pigmented, congenital lesion of skin or mucosa composed of focal collections of rounded melanocytes. CLINICAL FEATURES e MN of skin are common acquired papular lesions that appear after birth and throughout childhood. e Intraoral are rare. e Oral lesions are < 0.5 cm, elevated papules or nodules and non-pigmented (20%). e Palate most common, buccal mucosa, labial mucosa, gingiva, alveolar ridge and vermilion. HISTOPATHOLOGY INTRADERMAL NEVUS JUNCTIONAL NEVUS COMPOUND NEVUS Cells are located in connective tissue. Cells are located in epithelium - CT | Cells are located ina junction. combination of these zones. Young patients, most common in skin ( mole). CF CF Uncommon in the oral cavity. | Benign, brown to black lesion, Nevus cells in the basal region of occurs on skin and oral mucosa. epithelium and in adjacent CT. Asymptomatic, pigmented, brown to black, slightly Less common. More common on skin than oral elevated papule or flat mucosa. macule on hard palate or Pigmented macular lesion on hard gingiva. < 1cm. palate or gingiva. Pigmented papule or macule on hard palate or gingiva. Contains more hair than HISTOPATHOLOGY surrounding normal skin. Excisional biopsy. Nevus cell nests in the basilar HISTOPATHOLOGY region of epithelium, at tios of Nests, cords or sheets of epithelial rete pegs. nevus cells confined to CT. Epithelioid, lymphocyte-like, | No nevus cells in CT. spindle and multinucleated cells. Focal proliferation similar to early Mitotic figures absent. phases of melanoma. BLUE NEVUS Benign pigmented lesion that presents as dark blue dome-shaped papule or as a flat macule on skin or mucosa. e Spindled, fusiform, dendritic cells deep in CT. e Separated and parallel to normal overlying epithelium. PEUTZ-JEGHERS SYNDROME Uncommon autosomal dominant disorder characterized by multiple intestinal polyp and freckle-like pigmentation of skin in periorificial areas. e Skin of fingers, genital areas and oral mucosa. e Apparent in early childhood as small, brown to blue-gray macules 1-4mm in diameter. e Intestinal polyp are capable of causing intussusception that can lead to ischemic bowel damage. e 2-3% patients develop intestinal adenocarcinoma. MELASMA Or mask of pregnancy, is a symmetrical hyperpigmentation of sun exposed skin of face and neck. e Unknown cause. e Associated with pregnancy and oral contraceptives containing estrogen and progesterone. e Increase in melanin within basal keratinocytes. e Topical treatment with 3% hydroquinone and tretinoin. LEUKOPLAKIA ( WHITE PATCH } Clinical term used to denote mucosal conditions that produce a either than normal coloration of mucous membrane. White Patch on the oral mucosa that can neither be scraped off nor classified as any other diagnosable disease. CLINICAL FEATURES Occurence rate 1.5-12% - 5.8% eventuate in squamous cell carcinoma. Flat, smooth, slightly translucent macular areas to thick, firm, rough surfaced and fissured, raised plaques. Buccal mucosa, floor of mouth, labial commissures and lateral borders of tongue and mandibular and maxillary alveolar ridges. Occurs in non-smokers, smoking increases risk upto 16%. (box 6-1 page 175). HISTOPATHOLOGY Increase in thickness of keratin layer (hyperorthokeratosis - most common finding , hyperparakeratosis ). Increase in thickness of spinous layer ( acanthosis ). Changes in underlying CT impart whitish appearance to oral mucosa - due to dec in vascularity and inc in collagen content of CT. DIAGNOSIS Biopsy - removal of a sample of living tissue for laboratory examination. Incisional biopsy - large lesion, small portion of lesion is removed and submitted for microscopic examination. Excisional biopsy - small lesion, entire lesion is removed and submitted for microscopic examination. TREATMENT Benign lesion - remove local predisposing factors that cause lesion. Premalignant lesion - completely remove lesion. Proliferative verrucous leukoplakia Leukoplakia Relatively uncommon Common Women > men (4:1) Men > women (2:1) Lower correlation with tobacco and alcohol | Higher correlation with tobacco and use alcohol use High rate of malignant transformation Moderate rate of malignant (7026 to 8084) transformation (3% to 25%) High mortality Moderate mortality EPITHELIAL HYPERPLASIA Reduction in normal thickness of epithelium that involves less than entire thickness of epithelium. ORAL SUBMUCOUS FIBROSIS Diffuse whitish areas of the submucosal scarring caused by frequent and prolonged contact with betel nut quids, tobacco or hot Chili Peppers; lesions have higher than normal risk of developing squamous cell carcinoma. e Disorder that resembles scleroderma, limited to oral cavity. CLINICAL FEATURES e Affects oral tissues of buccal mucosa, lips, soft palate and pharynx. e Tissue is symmetrically affected and becomes firm and pale. e Progressive stiffness of cheeks, which inhibits ability to open mouth. e Oral mucosa appears pale and atrophic. HISTOPATHOLOGY e Chronic inflammation of submucosal CT (earliest sign). e Diffuse progressive fibrosis and atrophy of overlying epithelium. e Atrophic epithelium has a greater chance to develop hyperkeratosis and epithelial dysplasia which can progress to SCC. TREATMENT Systemic and intralesional injections of corticosteroids. EPITHELIAL DYSPLASIA A premalignant change in epithelium characterized by combination of cellular and architectural alterations. Individual cell alterations in epithelial cell dysplasia NOMsRoONS Prominent nucleoli Hyperchromatic nuclei (Hyperchromasia) Nuclear pleomorphism Altered N:C ratio Increased mitotic activity Abnormal mitotic figures Multinucleation of cells (p0ikilocarynosis) Architectural alterations RoONe Formation of bulbous rete pegs Basilar hyperplasia Hypercellularity Altered maturation pattern of keratinocytes Mild-moderate-severe - ED of floor of mouth or lateral border of tongue in cigarette smoker with time and continued smoking will increase. Mildest-most severe - vary among individuals and range from months to years. Some mild and incipient forms may reverse and epithelium will revert to normal when the inciting factor is removed. HISTOPATHOLOGY Areas of ED exhibit chronic lymphocytic infiltrate in adjacent CT, lymphocytes extend into deeper layers of dysplastic epithelium. Resembles lichen planus. Lichenoid dysplasia - ED having multiple histologic features in common with lichen planus. CARCINOMA IN SITU The most severe stage of ED, involving entire thickness of epithelium with epithelial basement membrane remaining intact. e No invasion into CT, when DE cells breach basement membrane and invade CT, metastasis occurs and CIS become SCC. ERYTHROPLAKIA/ERYTHROPLASIA A clinical term for a red patch of oral mucosa, caused by epithelial dysplasia, CIS or SCC. CLINICAL FEATURES Asymptomatic Older males who smoke cigarette Floor of mouth, lateral and ventral surfaces of tongue, soft palate and buccal mucosa. e Speckled erythroplakia - lesion primarily red but exhibits interspersed focal white plaques. HISTOPATHOLOGY e 60-90% epithelial dysplasia, CIS or SCC. e It lacks the surface layer of keratin that diffuses redness emanating from underlying vasculature. e The remaining epithelial layers that cover the CT papillae b/w rete pegs are reduced in thickness. e Thesize and number of vascular structures increase in response to inflammation associated with thinned and neoplastic epithelium. TREATMENT e Alllesions are biopsied to determine exact nature. e Dysplasia and CIS treated by local incsion. e SCC treated more aggressively depending on staging of lesions. to keratin. deviation from normal. cellular abnormalities. SSC of lower lip. SSC on lateral border of SSC that involve tonsillar tongue. region. 1. Lower lip 35 2. Lateral/ventral tongue 25 3. Floor of mouth 20 4. Soft palate 15 5. FGingival/alveolar ridge 4 6. Buccal mucosa 1 1. LOWER LIP e 30-40% of all oral carcinomas. e@ M>F e Sth-8th decade e Right or left vermillion border e Prolonged period of actinic cheilitis, followed by recurring ulceration and encrustation. Ulcer fails to heal and develops a rolled border surrounded by indurated tissues. Well-differentiated and slowly metastasize.. 100% curable if metastasis does not occur. TONGUE 25% of all oral carcinomas. Lateral borders, anterior, right and left floor of mouth and retromolar pad and adjacent areas of soft palate. Lesions appear as an area of leukoplakia that ulcerate and develop raised or rolled borders. Pain, immobility and altered speech. Metastasis extends to mandibular and deep cervical lymph nodes. Partial glossectomy followed by radiotherapy TOC. FLOOR OF MOUTH 20% of all OC. 3rd most common site of all intraoral SSC. Lesions located in the anterior areas adjacent to caruncles containing the orifice of wharton ducts. Lesions appear as an area of erythroplakia or speckled erythroplakia that gradually develops into an irregularly shaped central ulcer. Area becomes nodular and indurated as the lesion progresses. Metastasis to submandibular triangle and upper jugular chain of lymph nodes. Surgery + removal of adjacent lymph nodes TOC. . SOFT PALATE 15% of intraoral carcinomo-lateral posterior regions adjacent to anterior faucial pillars. Lesions are erythroplakic or a mixture of red and white plaque like areas. Invasion occurs before surface ulceration is visible. Metastasizes to cervical and jugular lymph nodes. . GINGIVA/ALVEOLAR RIDGE 4-6% of intraoral carcinomas. Initial appearance of a verrucous leukoplakia or an ulceration with rolled borders. Mandible affected more than maxilla- lesions more on posterior areas. Lesions invade underlying bone via periodontal ligament. Extensive tooth mobility + early tooth loss. Metastasis usually to the submandibular and cervical lymph nodes in the mandible. Surgical excision TOC. . BUCCAL MUCOSA 1-2% - ulcers along the occlusal line. Associated with surrounding induration caused by rapid invasion of deeper structures. Metastasis to submandibular lymph nodes. Surgical excision + radiotherapy. VERRUCOUS CARCINOMA A diffuse, largely exophytic superficial spreading highly keratinized warty form of well-differentiated SCC that is unlikely to metastasize. CLINICAL FEATURES e Males-60 years e@ Gingiva, alveolar mucosa, buccal mucosa, hard palate and floor of mouth. e Exophytic, warty pattern. HISTOPATHOLOGY e Surface is papillary and covered by a thick layer of parakeratin, occurring between elongated surface projections. e Epithelium is dysplastic. e BMremains intact, intense chronic inflammatory cell infiltrate present in CT Apoptosis is common. Fibrous stroma is cellular and exhibits large amounts of acid mucopolysaccharides. Dehydration causes mucopolysaccharides to shrink causing formation of retraction spaces (clefts) that seperate stroma from tumor islands. Increase in elastic tissue content and focal deposits of amyloid in stroma. Excisional surgery + Radiation + electrocautery. MELANOMA Malignant neoplasm of melanocytes occurring on skin and mucosal surfaces, commonly has a radial and superficial initial growth period before it extends into deeper underlying tissues and metastasizes. RoONe Superficial spreading Lentigo maligna Acral lentiginous Nodular Risk factors a fair complexion and light hair. a tendency to sunburn easily. a history of painful or blistering sunburns in childhood. an indoor occupation with outdoor recreational habits. a personal history of melanoma. a personal history of dysplastic or congenital nevus. oakhONs Oral melanoma (rare) arise on hard palate and maxillary gingiva. 3rd most common skin cancer. CLINICAL FEATURES 50-55 years, 2nd-3rd decade. Asymmetry (because of its uncontrolled growth pattern). Border irregularity (often with notching). e Color variegation (which varies from shades of brown to black, white, red, and blue, depending on the amount and depth of melanin pigmentation). e Diameter greater than 6 mm (which is the diameter of a pencil eraser). e Evolving (lesions that have changed with respect to size, shape, color, surface, or symptoms over time). e Dark brown, blusih-black or black. e Amelanotic melanoma - reddish, non-pigmented. e Melanomas grow in 2 phases 1. Radial-growth phase - neoplastic cells spread laterally in all directiosn but remain confined to the surface epithelium. 2. Vertical-growth phase - begins when neoplastic cells invade and populate CT. SUPERFICIAL SPREADING MELANOMA Most common form of melanoma, initally appearing as an irregularly shaped brown-black macular area with jagged borders and satellite lesions in which areas of nodular melanoma develop. e Most common type of melanoma (70%). e Middle-aged patients. e interscapular area of males and the back of the legs of females. CLINICAL FEATURES e Radial-growth phase - tan, brown or black variegated macule or plaque that exhibits an irregular outline. e lesion is smaller than 3 cm. e Satellite macules or nodules of malignant cells may develop around the primary lesion. HISTOPATHOLOGY e Large typical melanocytes within epithelial layer that exhibit abundant pale cytoplasm, arranged in small round clusters at epithelial CT interface. Pagetoid - clear cells in the unique intraepithelial gorwth pattern in superfical spreading melanoma. Nodular/ulceration stage - frank invasion of the CT by tumor cells which are arranged in an alveolar pattern. Individual tumor cells - abundant, pale cytoplasm containing variable amount of fine, powdery melanin that imparts a dusty appearance to cytoplasm. Significant pseudoepitheliomatous hyperplasia. Diagnosis is confirmed with positive immunohistochemical stains, melanin-A, HMB-45. LENTIGO MALIGNA MELANOMA Slowly evolving melanoma that develops within a pre-existing pigmented macular lesion on sun-exposed skin of older patients. CLINICAL FEATURES Cheeks and temples of older white men and women - 5%.(over 15 years). Arises in a pre-existing pigmented lesion - Hutchinson melanotic freckle. Large, irregular and asymmetrical, variegated macular lesion. Light tan to black. Central area of pale scarring. HISTOPATHOLOGY Atrophic epithelium, increased no. of cytologically atypical melanocytes with variable amounts of coarse melanin granules. Intraepithelial spreading of tumor cells present. Neoplastic melanocytes are spindle shaped and exhibit desmoplasia or neurotropism. ACRAL LENTIGINOUS MELANOMA Brown, irregularly shaped macular lesion of skin and palms of hands and soles of feet that undergo progression to nodular melanoma. palms of the hands, soles of the feet, subungual area, and mucous membranes. Most common form of oral melanoma. 8% of melanomas.