Oral Pathology PDF

Oral pathology Dr/ Ala’a Saif Alqhtani BDS , Bachelor of Dental surgery , Ibb University.Yemen M.D.S , Master of Dental medicine - Airlangga University –Indonesia  COURSE CONTENT Introduction of Oral Pathology Development...

Oral pathology Dr/ Ala’a Saif Alqhtani BDS , Bachelor of Dental surgery , Ibb University.Yemen M.D.S , Master of Dental medicine - Airlangga University –Indonesia  COURSE CONTENT Introduction of Oral Pathology Developmental Anomalies of The Oral and Maxillofacial Region. Etiology Of Oral Cancer and Premalignant Lesions Important common syndromes. White Lesions Dental Caries Odontogenic Tumors Pulp Diseases Benign Non-Odontogenic Tumors Periapical Lesions Malignant Non- Odontogenic Tumors Osteomyelitis Malignant Connective Tissue Tumors Orofacial Cysts Salivary Gland Tumors Giant Cell Lesions Salivary Gland Diseases Fibrous Overgrowths of The Oral Cavity Bone tumors Physical, Chemical and Idiopathic Pathology of Teeth Bone diseases Infectious Diseases 2 REFERENCES 3  ORAL PATHOLOGY LECTURE 1 INTRODUCTION Patho : Greek word means Disease ;Logy : science. It is a branch of medical science that studies then disease by specific method. Pathology deals with cause , effective mechanism and nature of the disease. Pathology focuses on 4 aspects of disease: Pathology can answer the following questions? 1. Etiology: Cause of disease. What is the causative agent of the disease ( Etiology ). 2. Pathogenesis: Mechanisms of What are the structural changes ( Morphology ) development of disease. How the structural and functional changes produced. 3. Morphology: The structural alterations What are the consequence of the disease. induced in cell and tissues. Could pathology determine the treatment 4. Functional Consequences: Functional Could pathology help to predict the outcome and final results of the morphologic changes, as 4 prognosis. observed clinically.  INTRODUCTION Pathology branches  Oral Pathology - is the science of abnormal, its etiology, pathogenesis, and histopathology. It Histo-pathology represents the confluence of the basic sciences and Hematology clinical dentistry. Microbiology What is Oral Pathology? Immuno-patholog Pathology can be defined as the scientific Chemical pathology study of disease which include: -The nature Genetics of disease. -Its causes, processes, development, and consequences of disease. Toxicology Forensic pathology. What is the Disease? It is the “State in which an individual Classification of Pathology exhibits an anatomical, physiological, or General pathology - Basic alteration biochemical deviation from the normal” and general characteristic of the major Disease may be defined as : categories of disease. An abnormal alteration of structure or Systemic pathology - Deal with specific function in any part of the body. disease affect organ or system. Oral pathology : Is a branch of systemic pathology that deals with disease affect the soft and hard oral 5 tissue including the teeth.  ETIOLOGY “STUDY OF THE CAUSE OF A DISEASE Knowledge of etiology remains the backbone of: Disease diagnosis. Understanding the nature of diseases. Treatment of diseases. Etiology -The multifactorial and/ or predisposing factors that affect the development of a disease or group of diseases. “Study of the cause of a disease“ An etiologic agent : Is the factor (bacterium, virus, etc.) responsible for lesions or a disease state. Predisposing Causes of Disease: Factors which make an individual more susceptible to a disease (damp weather, poor ventilation, etc.). Exciting Causes of Disease: Factors which are directly responsible for a disease (hypoxia, 6 chemical agents…. etc.).  CLASSIFICATION OF DISEASES A. Developmental – genetic, congenital  Acquired: The genetic feature resulted from an extrinsic factor during development, as infection, trauma, x-ray, or chemicals. B. Acquired:  True: A feature that is truly found (as large tongue) in relation to C. Inflammatory: Trauma, infections, immune, etc. the surrounding normal tissues or organs (normal-size jaws and D. Neoplastic: Tumors cancers. face). E. Degenerative – ageing.  Relative : A feature that is normal in relation to abnormal surrounding tissues or organs. F. Metabolic.  Difference between a syndrome and a disease: A disease is a G. Iatrogenic: Drug induced. condition affecting specific site or organ, while a syndrome is a  Cause of a disease: The only confirmed direct cause or factor group of conditions or lesions involving more than one organ or that gives rise to the disease or abnormal condition. tissue, in the same patient.  Genetic causes: Alteration in a specific gene where its phenotype  Anomality : Is a malformation with its subsequently derived results in a specific feature in the body. It is either inherited or structural changes, where a primary defect sets-off a series of acquired. secondary or tertiary events ,i.e. resulting in multiple anomalies.  Developmental: A genetic change that takes place (i.e. at any developmental stage). during the fetal life.  Inherited: A genetic feature that is developed from one of the parents or ancestors. 7  DEFINITIONS AND TERMS RELATED TO PATHOLOGY AND DIAGNOSIS  Provisional diagnosis - Diagnosis arrived at after history taking and clinical examination but before any investigations.  Differential diagnosis: Process of identifying a particular disease process be differentiating it from all other pathologic processes that may have similar signs and symptoms or clinical course.  Final Diagnosis: Diagnosis arrived after all the data (History, clinical examination and investigations) has been collected, analyzed and subjected to logical thought.  Prognosis - Prediction of the course, duration and termination of a disease and the likelihood of its response to treatment.  Investigations -Steps undertaken to confirm a diagnos.  Inspection- Systematic visual assessment of the patient.  Palpation: Method of examining with the hands using the sense of touch.  Percussion: Technique of striking the tissues with the fingers or an instrument so that the examiner may listen to the resulting sounds or note the response of the patient to such action.  Auscultation: Technique of listening to sounds produced in the body using a stethoscope.  Sign -Any change in the body or its function that is perceptible to a trained observer and may indicate a specific disease. Eg : Tenderness (Development of pain with the application of light touch (palpation) to a specific area).  Symptom: Any change in the body or its function that is perceptibl to the patient and may indicate a disease. Eg : Pain. 8  INDEX FOR SOME SCIENTIFIC TERMS  Palpebral: related to the eye lids.’  Coloboma: absence or defect of some ocular tissues due to failure of part of fetal tissue to close.  Dysostosis: defect in normal ossification of fetal cartilage.  Fontanel: membrane-covered spaces remaining at the junction of sutures in the skull.  Protuberant: a projecting part, or prominence.  Hypertelorism: increase in interorbital distance, usually associated with cleidocranial dysostosis and some mental deficiency.  Strabismus (squint): deviation of the eyes.  Dystopia: malposition or displacement.  Canthus: angles of the eye.  Ecchymosis: non elevated small hemorrhagic spots, larger than petechia, in the skin or mucous membranes.  Glossodynia: pain in the tongue.  Nystagmus: involuntary rapid movement of the eye ball.  Koilonychia: dystrophy of finger nails may be thinned, or concave with raised edges. 9  INDEX FOR SOME SCIENTIFIC TERMS Abscess - Acute inflammatory reaction localized within the tissue and associated with tissue destruction and liquefaction as well as pus formation. Cellulitis- Acute inflammation which spreads diffusely through the tissue spaces and along tissue planes and usually suppurative in nature. Edema- A condition characterized by an excess of watery fluid collecting in the cavities or tissues of the body. Exudate -It is the edema fluid produced by certain inflammatory reactions having a higher specific gravity (1.020 or higher) and a higher protein content (1-6 gm/dl). Erythema- An abnormal redness of the mucosa or gingiva. 10  INDEX FOR SOME SCIENTIFIC TERMS Macule- Well circumscribed flat area of altered coloration varying in size from a pinhead to several centimeters. Papule- Small well circumscribed solid elevated lesion less than 5 mm in diameter. Pustule- Well circumscribed pus filled lesion smaller than 5 mm in diameter. Nodule- Well circumscribed solid, elevated lesion more than 5 mm in diameter. Vesicle- Small well circumscribed fluid filled lesion less than 5 mm in diameter. Bulla- Well circumscribed fluid filled lesion larger than 5 mm in 11 diameter.  INDEX FOR SOME SCIENTIFIC TERMS Erosion- Break in the epithelium extending to but not involving the basal cell layer. Ulcer- Break in the continuity of the entire epithelium with the resultant exposure of the underlying connective tissue. Sinus- Blind tract which connects a cavity lined by granulation tissue to the epithelial surface. Fistul- Communication between two epithelium lined surfaces.- Example: Oro antral fistula. 12 13 INDEX FOR SOME SCIENTIFIC TERMS Hamartoma- Tumor like malformation characterized by the presence of particular histologic tissues in improper proportions or distribution with a prominent excess of one type of tissue. Eg: Haemangioma Neoplasm- Abnormal mass of tissue, the growth of which exceeds and is uncoordinated with that of the normal tissue and persists in the same excessive manner even after the cessation of the stimulus that evoked the change. Hypertrophy -Increase in the size of an organ or tissue due to an increase in the size of the cells. -Example: Masseteric hypertrophy. Hyperplasia -Increase in the size of an organ or tissue due to an increase in the number of the cells. -Example: Gingival 14 INDEX FOR SOME SCIENTIFIC TERMS Anaplasia- Reversal of highly differentiated cells into a less differentiated type. Metaplasis- Is the reversible replacement of one differentiated cell type with another maturedifferentiated cell type. Aplasia- Complete failure of formation of organ/tissue.Example: Condylar aplasia. Hypoplasia- Incomplete development of 15 an organ or tissue. Example: Enamel 16  INDEX FOR SOME SCIENTIFIC TERMS Atrophy- Decrease in the size of an organ or tissue after complete formation.- Example: Papillary atrophy. Hyperkeratosis- Thickening of the stratum corneum. Acanthosis- Thickening /Widening of the stratum spinosum. Spongiosis- Intercellular edema. Acantholysis- Separation of cells in stratum spinosum resulting in intraepithelial split. 17 INDEX FOR SOME SCIENTIFIC TERMS Pedunculated- Attached by a stemlike or stalk base similar to that of a mushroom. Sessile- Describing the base of a lesion that is flat or broad instead of stemlike. Diffuse- Describes a lesion with borders that are not well defined, making it impossible to detect the exact parameters of thelesion; this may make treatment more difficult and, depending on the biopsy results, moreradical. Exophytic 18  INDEX FOR SOME SCIENTIFIC TERMS Firm- strongly felt and unlikely to change. Cheesy- like cheese in consistency. Hard- not easily broken or bent. Metastasis- Metastasis is a complex process that involves the spread of a tumor or cancer to distant parts of the body from its original site.  Mutation: A relatively permanent change in hereditary material involving either a physical change in chromosome relations or a biochemical change in the codons that make up genes. 19 20  ORAL PATHOLOGY L EC T U R E 2 DEVELOPMENTAL ANOMALIES ASSOCIATED WITH ASYMMETRIC GROWTH Asymmetric overgrowth of one or more body parts, mostly represents a hyperplasia of the tissues rather than a hypertrophy. It can be isolate (sporadic) or associated with syndromes. The etiology is obscure, however, various the opries include: - Vascular or lymphatic abnormalities. - CNS disturbances. -Endocrine dysfunction. - Aberrant twinning mechanisms. - Occasionally chromosomal anomalies have been documented. When the condition involves one entire side of the body (complex hemi 21  DEVELOPMENTAL DISTURBANCES OF THE FACE Orofacial clefts I- Oblique facial cleft - This is a developmental cleft start from the inner canthus of the eye to the ala of the nose or upper lip. - It is due to failure of fusion between maxillary and lateral and medial nasal processes. - It is usually unilateral but may be bilateral in about 20% of cases. II- Transverse facial cleft: - This is a cleft running from the angle of the mouth towards the ear. - It is due to failure of fusion between the maxillary and mandibular processes. - unilateral or bilateral, partial or complete (rare). 22  DEVELOPMENTAL DISTURBANCES OF THE FACE Facial hemi- hypertrophy or –atrophy - 2:1 in females, more on the right side, often noted at birth, or later in childhood. - 20% are mentally retarded. - Unilateral macroglossia, increased size of the mandibular canal, crowns of permanent cuspids, premolars& first molars can be larger, and malocclusion with open bite is a usual finding. - Macro- and microstomia, true or relative.  Macro stomia and Microstomia: Macro stomia: it is an excessively large mouth. - It is due to premature arrest of fusion between maxillary and mandibular processes bilaterally. Microstomia: it is an abnormally small mouth. 23 - It is due to excessive fusion between maxillary and mandibular  DEVELOPMENTAL ANOMALIES OF THE JAWS Agnathia: Complete or partial absence of either jaw, very rare. Micrognathia: Either jaw, true or relative, familial or acquired. Macrognathia: Hereditary or associated with other conditions as Paget's disease of bone, or acromegaly. - True or relative. 24  DEVELOPMENTAL ANOMALIES OF THE PALATE:  Failure of normal fusion of the palatal shelves, due to lack of force, interference by the tongue, or a disparity in size of the parts involved, will lead to the different forms of cleft palate and lip. The following arches and processes are involved in the development of the palate and upper lip: Maxillary processes of the first branchial arch, and the medial nasal process. Cleft of the soft palate and uvula appears to be formed as aEnumerate result ofthe a complications posterior extension of clefts ? of the palatal processes. 25  DEVELOPMENTAL ANOMALIES OF THE PALATE Clinically: -It may involve both the hard and soft palate, or the hard palate and upper lip, or the hard palate only where it exhibits a large defect in the roof of palate (with a direct opening into the nasal cavity). -The midline defect continues anteriorly to the premaxilla, where it deviates to either the right or left ridges (between lateral incisor and cuspid teeth, or between the central and lateral incisors). 26 - The teeth in the area may be missing, deformed, displaced, or divided.  DEVELOPMENTAL ANOMALIES OF THE LIPS 1- Congenital lip &commissural pit and fistula: -Uni- or bilateral depression or pit on the vermilion surface of either lip (more on the lower lip), with mucous secretion.  Commissural pit or fistula appears at the corners.  Mostly they are hereditary, and develop from notching of the lip at an early stage of development, with fixation of the tissue at the notch base.  Or failure of complete union of the lateral sulci of the lip. 2- Double lip: -A fold of excess tissue on the inner mucosal aspect, congenital or acquire due to trauma to the lip during development. 3- Cheilitis glandularis:. - Mostly affect adult males, lower lip is enlarged, firm and everted. - Unknown etiology but may be due to exposure to the sun, dust or smoking. Emotional and familial occurrence suggests hereditary factors. 27  DEVELOPMENTAL ANOMALIES OF THE LIPS  4- Cheilitis granulomatosa: -occurs in both children and adults, soft enlargement of both lips (more in the lower), and painless.  Histologically: -Tissue composed of peri and para-vascular chronic inflammatory cellular infiltrate and histiocytes.  5- Cleft lip:  Cleft of the lower lip -Is very rare, on the midline, due to failure of the copulas (that gives rise to the mandibular arch), or persistence of the central groove of the mandibular process. -It may occur alone or with midline mandibular cleft.  Maxillary cleft lip -Is more common, intimately related to cleft palate, genetically, embryologically, and functionally. -It was thought to be due to failure of globular portion of the median nasal process to unite properly with lateral nasal and maxillary processes, but recently suggested to be due to failure of mesodermal penetration and obliteration of the ectodermal grooves separating these mesodermal masses constituting the facial 28 processes. DEVELOPMENTAL ANOMALIES OF THE ORAL MUCOSA Fordyce Granules: - This is an ECTOPIC condition in which sebaceous glands develop in the oral mucosa which is normally devoid of them as sebaceous glands normally develop in skin in relation to hair follicles.  Clinical appearance: - Single or multiple pinhead-sized spots appear symmetrically located most frequently in the buccal mucosa in the molar region, but they have been observed also on the mucous side of the lips. The covering mucosa may be smooth or slightly elevated.  Histopathology: Normal sebaceous glands without hair follicles. White Spongy Naevus (white folded gingivostomatitis): - Naevus is hamartoma in skin or mucous membrane. This is a hereditary condition of the oral mucosa which is sometimes congenital, appears in early childhood and persists for life.  Clinical appearance: - It is grayish-white spongy areas of the oral mucosa with folds and it is soft upon palpation. - It often exhibits a symmetric wavy pattern. The entire oral mucosa may be involved, but the most frequently affected regions are the buccal mucosa, the floor of the mouth and the ventral surface of the tongue.  Histopathology: - Prickle cell layer shows acanthosis (increase in number of layers) with inter- and intracellular oedema or 29 vacuolation giving the basket-weave appearance with surface hyperkeratosis.  DEVELOPMENTAL ANOMALIES OF THE ORAL MUCOSA Bohn’s nodules - These are small, discrete, whitish swellings occurring in the gingivae of infants representing small cysts that arise from degeneration of remnants of the dental lamina. - are keratin cysts derived from remnants of odontogenic epithelium over the dental lamina or may be remnants of minor salivary glands. - They occur on the alveolar ridge, more commonly on the maxillary than mandibular. 30 DEVELOPMENTAL ANOMALIES OF THE TONGUE 1- Aglossia: complete absence of the tongue; very rare, may be associated with agnathia. 2- Microglossia: small tongue ; true or relative. 3- Macroglossia: true or relative, primary or secondary (congenital or acquired). -Congenital as in mongolism, cretinism or arteriovenous malformations. -Acquired as in myxedema, acromegaly, amyloidosis, or any tumor of the tongue tissue or infiltrating the tongue. 4: Ankyloglossia or tongue tie (complete or partial): -Fusion between the tongue and floor of the mouth, or short lingual frenum, or one which is attached too near the tongue tip. Complications:- 31 Restricted tongue movements lead to dyspnea, difficulties in speech, and eating.  DEVELOPMENTAL ANOMALIES OF THE TONGUE 5- Cleft or bifid tongue: -Complete cleft is very rare, due to lack of merging of the lateral lingual swellings. -Partial cleft is more common, as a deep groove in the midline of the dorsum, due to incomplete merging and failure of groove obliteration by the underlying mesenchymal proliferation.  Complications: -Collection of food debris and micro-organisms causing irritation. 6- Fissured tongue: (scrotal tongue): -Numerous small furrows or grooves on the dorsal surface, radiating out from a central groove along the midline. -Usually painless except when food debris tend to collect in the grooves and cause irritation. 7- Median rhomboid glossitis: -Now it is suggested to be due to a localized chronic fungal infection specifically Candida albicans, resulting in a structure devoid of papillae between them -It appears as an ovoid, diamond, or rhomboid shaped depapillated, reddish patch or plaque on the dorsal surface, immediately anterior to the circumvallate papillae, flat or slightly raised area.  D.D.: lingual thyroid nodule, geographic tongue, or a neoplasm.  Histologically: -loss of papillae with hyper parakeratosis, acanthosis with elongation of the rete processes that may branch. Lymphocytic infiltration within the connective tissue, numerous blood vessels& lymphatics, with hyaline degeneration of underlying muscles. 32 - Fungal hyphae are usually found in the superficial epithelial layers.  DEVELOPMENTAL ANOMALIES OF THE TONGUE 8- Geographic tongue: (benign migratory glossitis): -Unknown etiology may be related to emotional stress, immunosuppression, and Candidal infection.  Clinically: -It affects mostly pregnant women, and debilitated children. -Appear as multiple, irregular or circular, depapillated areas,(fungiform papillae persist as small elevated red dots). -The areas may be outlined by a thin, yellowish-white line or band. -The depapillated areas remain for a short time, in one location, then heal to reappear in another location. -The condition may persist for weeks or months then regress spontaneously, only to recur at a later date.  Histologically: -Filliform papillae are lost, at the margins hyperparakeratosis and some acanthosis. -At the center polymorphs. and lymphocytes are seen within the epithelium. producing epithelial degeneration and micro abscess formation. -Special stains reveal Candidal hyphae within the epithelium. 9- Hairy tongue: will be covered later (white , black lesions). 10- Thyroglossal tract cyst: will be covered later (cysts lecture ). 33  DEVELOPMENTAL ANOMALIES OF THE TONGUE 11- Lingual thyroid nodule: -Follicles of thyroid tissue are found in the substance of the tongue, possibly arising from thyroid anlage that failed to migrate to its predestined position, or detached remnants that are left behind. -Its enlargement is thought to be due, in part, to functional insufficiency of the main gland. -It has been suggested to be related to hormonal factors, as it is common in females during puberty, adolescence, pregnancy, or menopause.  Clinically: -A nodular, smooth surfaced mass, in or near the tongue base (area of the foramen caecum), however, not always in the midline. -Dysphagia, dysphonia, dyspnea, hemorrhage with pain.  D.D.: Accessory salivary glands, thyroglossal duct cyst, median rhomboid glossitis, or tumor.  Management: -If a normally located, functioning thyroid gland is present or not, before surgery, using C.T. scan with a-tracer dose of radioactive iodine. -A trial of thyroid hormone replacement, before excision, since this will often decrease its size and make surgery unnecessary. 12- Lingual varices: -Dilated, tortuous veins, appearing as red or purple clusters of vessels on the ventral surface and lateral border of tongue, as well as floor of the mouth.  -It has been suggested to be an age change and related to leg varicosis. *Thrombosis is a 34 frequent occurrence. 35