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Common benign mucosal swellings

FIBROUS POLYPS, EPULIDES AND DENTURE-INDUCED GRANULOMAS • Fibrous nodules are the most common soft-tissue swellings of the

mouth. They are not neoplasms but hyperplastic swellings that develop in sites subject to chronic minor injury and/or lowgrade infection . Fibromas are not recognised as an entity and in any case cannot be distinguished from fibrous hyperplasia. The term epulis (literally, 'on the gingiva') refers only to the site. It has no implications for the histology but in practice most epulides are fibrous.

• Irritation of the gingival margin by the sharp edge of a carious cavity or by calculus may lead to the formation of a fibrous epulis; irritation of alveolar or palatal mucosa by a rough area on a denture may provoke development of a denture granuloma. Though different names are given to these lesions they are similar in origin and structure.

Fibrous nodules: practical points • The most common oral tumour-like swellings

• Most frequently form at gingival margins (fibrous epulis) or in relation to a denture

• They are hyperplastic responses to chronic irritation

• Should be excised complete and sent for histological examination

Clinical features • A fibrous epulis is most common near the front of the mouth on the

gingiva between two teeth . Fibrous polyps can also form on the buccal mucosa .

• Denture-induced hyperplasias ('denture granulomas') often form at the edge of dentures .

• These swellings are pale and firm but may be abraded and ulcerated, and then inflamed.

• 'Leaf fibroma'' is another fibrous overgrowth which forms under a denture but has become flattened against the palate

Fibrous epulis and polyp

Leaf fibroma

Pathology

• These nodules consist of irregular interlacing connective tissue

• fibres without encapsulation but covered by epithelium, which

• is usually hyperplastic

Giant-cell fibroma

• This variant is distinguished microscopically by large, mononucleate,

• stellate, darkly-staining cells (quite unlike the multi-nucleate cells of a giant-cell granuloma) and less conspicuous multinucleate cells, scattered between short, coarse fibrous tissue bundles.

• Clinically, giant-cell fibromas are typically pedunculated

• and usually arise from the gingivae.

• The surface is frequently verrucous.

• The treatment is the same as for a fibrous epulis.

PAPILLARY HYPERPLASIA OF THE PALATE

• Nodular overgrowth of the palatal mucosa is occasionally seen,

• particularly under dentures in older persons in whom low-grade

• trauma or infection exacerbates the proliferation

• Candidosis is sometimes superimposed but is not the cause.

• Mild palatal papillary hyperplasia is also occasionally seen in

• non-denture wearers

PAPILLARY HYPERPLASIA OF THE PALATE

• Histologically, palatal papillary hyperplasia shows close-set

• nodules of vascular fibrous tissue with a variable chronic inflammatory infiltrate and a covering of hyperplastic epithelium

PYOGENIC GRANULOMA AND PREGNANCY EPULIS • Microsopically, it consists of many dilated blood vessels in a loose

oedematous connective tissue stroma.

• There is typically a dense acute inflammatory infiltrate but this may be scanty or absent.

• A pregnancy epulis has the same histological appearances and can

• only be distinguished by the nature of the patient and usually,

• an associated pregnancy gingivitis .

Pyogenic granuloma

GIANT-CELL EPULIS

• The giant-cell epulis, like the fibrous epulis

• is probably hyperplastic

• less common

• Clinically, a giant cell epulis is usually found on the gingival

• margin between teeth anterior to the permanent molars

• Histologically, numerous multinucleate cells lie in a vascular

• stroma of plump spindle-shaped cells. The appearance is similar to that of a giant-cell granuloma of the jaw, but for the fact that

• the epulis has a covering of stratified squamous epithelium

• A giant cell epulis should be excised, together with its

• gingival base, and the underlying bone curetted

• Adjacent teeth need not be extracted if they are healthy

GIANT-CELL EPULIS

BENIGN EPITHELIAL TUMOURS AND TUMOUR-LIKE LESIONS

• Squamous cell papilloma

• Histologically, the papillae consist of stratified squamous

• epithelium supported by a vascular connective tissue core

• Histologically, the papillae consist of stratified squamous

• epithelium supported by a vascular connective tissue core

Infective warts (verruca vulgaris)

• Oral warts are uncommon but seen particularly in children and

• frequently result from autoinoculation from warts on the hands

• Histologically, the structure is generally similar to that of

• papillomas but there are typically large clear cells (koilocytes)

• with pyknotic nuclei and prominent keratohyaline granules in

• the superficial layers of the prickle cells. There is also positive

• staining of the nuclei with peroxidase-labelled antiserum to

• HPV. IMMUNODEFICIENCY

Soft tissue neoplasms

• BENIGN NEOPLASMS

• Neurofibromas

• Neurilemmomas/Neurinomas

• Lipoma and fibrolipoma

• Granular cell tumour

• Congenital (granular cell) epulis

• Haemangiomas

• Lymphangiomas

• MALIGNANT CONNECTIVE-TISSUE TUMOURS

• Rhabdomyosarcomas

• Fibrosarcomas

• Kaposi's sarcoma

• LYMPHOMAS

• Neurofibromas

• These uncommon tumours arise from nerve sheaths.

• They form smooth, painless lumps but are particularly rare in the mouth

• Neurofibromatosis should be suspected- MEN 2

• Neurofibromas are cellular with plump nuclei separated by fine, sinuous collagen fibres, among which mast cells can usually be found. Excision is curative.

• Neurilemmomas

• Arise from axon sheaths and, though uncommon,

• are more frequently found in the mouth than neurofibromas

• Antoni A and B

• Excision is curative

• Lipoma and fibrolipoma

• Lipomas can occasionally grow, particularly from the buccal fat

• pad, as soft, sometimes yellowish, swellings, which may be

• pedunculated

• Granular cell tumour

• Clinically, granular cell tumours typically form painless

• smooth swellings. The tongue is the most common site.

• Large granular cells form the bulk of the lesion but

• pseudoepitheliomatous hyperplasia of the overlying epithelium

• may be conspicuous .

• Electron microscopy suggests that the granular cells originate from Schwann cells.

Granular cell tumour

• Congenital (granular cell) epulis

• The rare congenital epulis is typically present at birth as a

• smooth but prominent soft nodule, usually on the alveolar ridge

Females are predominantly affected and occasionally

• the mass is so large as to obstruct respiration.

• Large pale granular cells with sharply-defined cell membranes are covered by epithelium which lacks pseudoepitheliomatous hyperplasia.

• Immunohistochemistry suggests that the origin is myogenous.

• Excision is curative but spontaneous regression is also seen.

• Haemangiomas

• Lymphangioma

• Consist of thin-walled vascular spaces sometimes containing pinkish amorphous material as a result of fixation of lymph

MALIGNANT CONNECTIVE-TISSUE TUMOURS

• Rhabdomyosarcoma

• Rhabdomyosarcomas can affect children or young adults and

• form rapidly growing soft swellings.

• Histologically The embryonal type, which more frequently affects children, consists of cells of variable shape and size. Some are strap or tadpole-shaped, while muscle-like cells with cross striations may be difficult to find.

• The alveolar type consists of slit-like spaces into which hang

• tear-shaped, darkly-staining cells attached to the walls. These

• alveoli are separated by a fibrous stroma.

• Treatment is by excision and combination chemotherapy but

• the prognosis is poor.

• Fibrosarcoma

• Fibrosarcomas consist of broad interlacing bands of fibroblasts

• with a streaming or herring-bone pattern .

• Some produce abundant collagen, others are highly cellular with

• close-packed nuclei, among which there are often mitoses.

• Treatment is by radical excision. Local recurrence and spread

• are common but metastasis is rare.

Fbrosarcoma

• Kaposi's sarcoma

• Kaposi's sarcoma is occasionally the first manifestation of HIV infection but is usually associated with a low CD4 count and opportunistic infections

• Kaposi's sarcoma is a vascular tumour in which factor VIII antigen (a marker for endothelial cells) can be identified but is not the most sensitive marker. Immunoreactivity for CD34 antigen is also positive in most spindle cells

Kaposi's sarcoma

• LYMPHOMAS

• Lymphomas can arise from any type of lymphocyte, but more

• frequently from B cells. They are all malignant.

• They comprise Hodgkin's disease and the more common non-Hodgkin lymphoma.

• Lymphomas relatively frequently involve the cervical

• lymph nodes but are rare in the mouth.

• However, in AIDS, lymphomas may account for 2% of oral neoplasms.

Melanoma and other pigmented lesions

• Malignant melanoma

• Pigmented naevi

• Amalgam tattoo

• Addison's disease

• Peutz-Jeghers syndrome

• Racial pigmentation

• Lichen planus rarely

• Amalgam tattoo

• Fragments of amalgam frequently become embedded in the

• oral mucosa and form the most common pigmented patches

• which may simulate melanomas clinically.

• They are usually close to the dental arch and typically 5 mm or more across .

Amalgam tattoo

• Oral melanotic naevi

• Pigmented naevi are benign lesions of melanocytes which form

• circumscribed brown to black patches about 5 or 6 mm across.

They are asymptomatic but should be excised .

• The main features are modest numbers of pigmented melanocytes

• in the basal cell layer but many clumps of melanocytes in

• the corium

Melanocytic naevi

• ORAL MELANOTIC MACULES ASSOCIATED WITH HIV

• INFECTION

• Oral and labial melanotic macules may be seen in up to 6% of

• patients with HIV infection. This is approximately twice the

• frequency seen in HIV negative persons. Also, oral melanotic

• macules appear to become more numerous as HIV infection

• advances. Increasing numbers of oral melanotic macules may

• appear long before HIV infection is detected.

• Histologically, there is vacuolation of the spinous cells which

• are either in large clusters or spread throughout the epithelium.

• Excess melanin deposition is present in the basal cell layer and

• upper part of the lamina propria.

• MALIGNANT MELANOMA

• They are usually dark brown or black but 15% of oral melanomas are

• non-pigmented and typically, red.

• The peak age incidence is between 40 and 60.

• They are macular or nodular and may ulcerate: the palate is most frequently affected .

• They are typically firm and rubbery but asymptomatic at first.

• Melanomas consist of neoplastic melanocytes often surrounded

• by clear halos, both within the epithelium and invading deeper

• tissues.

• These cells are round to spindle-shaped and typically

• speckled or intensely pigmented with melanin.

• Melanomas are typically S-100, MMA (melanoma-associated

• antigen) positive, but HMB-45 and NKI/C3 are currently

• regarded as being more specific.

Primary cause of alveolar osteitis is:

• Infection

• Destruction of clot

• Trauma

• None correct