the exophaytic lesions in oral mucosa .pptx

exophytic lesions that need biopsy to be diagnosed

1. Peripheral Oral Exophytic Lesions Dr.Kareman Elsoudany

2. Any pathologic growth that projects above the normal contours of the oral surface." Hypertrophy, hyperplasia, neoplasia, and the pooling of fluid are four mechanisms by which exophytic lesions may be produced. Hypertrophy refers to an enlargement caused by an increase in the size but not in the number of cells. Hyperplasia is generally defined as an enlargement caused by an increase in the number of normal cells. Combinations of these two processes occur with some frequency. Neoplasia is defined as the formation of a neoplasm, which is identical to a tumor and may be benign or malignant.

3. The specific shapes of exophytic lesions are papillomatous, verrucous, papular , nodular , dome shaped, poly- poid and bosselated. Exo­phytic lesions with a papillomatous or verrucous shape originate in the surface epithelium (e.g., verrucae vulgaris, papillomas , squainous cell and verrucous carcinomas, and keratoacanthomas Nodular, dome shaped, poly- poid and bosselated with a smoothly contoured shape originate in the deeper tissues and are be­neath and separate from the stratified squamous epithelium (e.g., tori, fibromas, lipomas, and early malignant mesenchymal tumors.

4. The surfaces of the lesions may become eroded (red), keratinized (white), necrotic (white), or ulcerated, de­pending on the reaction of the epithelial surface to varying degrees of trauma. Mild trauma may cause the epithelial surface to become eroded or keratinized, whereas severe trauma may cause the surface to become ulcerated. When an exophytic lesion is found on an area of oral mucosa that is overlying bone, it must be identified as originating in the soft tissues or the bone by care­ful visual, digital, and radiographic examinations If the lesion and accompanying soft tissues can be moved over the underlying bone and a radiograph fails to show bony changes, the lesion probably originated in the soft tissue.

5. Anatomical lesions have been known by: Knowledge of normal structure as parotid papilla, which appear in buccal mucosa opposite to upper six and seven. Most is bilateral Specific site No change by time Exophytic anatomic structures: Accessory tonsillar, tissue Buccal fat pads, Circumvallate papillae Foliate papillae, Genial tubercles, Lingual tonsillar tissue Palatine rugae , Palatine tonsils , Palatine papillae Retrocuspid papillae , Retromolar papillae Stensen's papillae , Sublingual caruncles

6. I) Developmental Lesions Tori and Exostoses Lingual thyroid Hemangioma Tori and exostoses are the most common oral exophytic lesions . Tori and exostoses are peripheral, benign, slow-growing bony protuberances of the jaws. They appear symmetrically as nodular or bosselated lesions that have smooth contours and are covered with normal mucosa. They are hard on palpation and are attached by a broad bony base to the underlying jaw. Growth occurs mainly during the first 30 years of life. It may be single, double or multiple.

7. Palatine tori are located on the hard palate, usually in the midline and are twice as common in female as in male patients. Mandibular tori are located on lingual aspect of mandible above the mylohyoid ridge, most often bilaterally in the premolar region. No differences in occurrence between genders. Similar bony protuberances that occur in other locations around the jawbones are termed exostoses.

8. Differential Diagnosis The following lesions may resemble a torus or exostosis on clinical and radiologic examinations: A mature cementifying or ossifying fibroma Ossified subperiosteal hematoma A non-resolved bony callus An osteoma An early osteosarcoma An early chondrosarcoma. Management -Removal is unnecessary unless prompted by psychologic, prosthetic, phonetic or trau­matic considerations.

9. Hemangioma It appears at birth or shortly after birth, Some of them may undergo regression. They are flat or raised soft lesions of blue to red color that blanch on pressure and the color returns shortly after releasing the pressure. They are usually asymptomatic but may bleed when traumatized. It occurs anywhere in the oral cavity Histopathology Proliferating endothelial cells and depending on the size of the vessel hemangiomas are divided into capillary and cavernous types. Capillary hemangioma is similar to pyogenic granuloma but there is no accumulation of inflammatory cells. Treatment Small lesions: cryosurgery if there are episodes of bleeding on eating or brushing. Conventional surgery gives rise to severe bleeding. Large lesions: they are not suitable for surgery and may be injected with sclerosing agent to induce fibrosis.

10. Lingual thyroid It is a developmental anomaly characterized by ectopic aggregate of thyroid tissue in the substance of the tongue. Failure of the thyroid analog to migrate to its predestined position. Hence lingual thyroid is the only thyroid tissue in the body Detached thyroid analog remnants that were left behind . Hence lingual thyroid is not the only thyroid tissue in the body Clinical features Asymptomatic Symptomatic Smooth, vascular, nodular mass in or near the base of the tongue in the general vicinity of the foramen caecum. More common in female during puberty and adolescence. The increase in size gives a feeling of fullness in the throat, change in voice, dysphagia, dyspnea or hemorrhage.

11. Diagnosis Scanning of the thyroid tissue using radioactive iodine & Thyroid function tests. N.B. Biopsy is contraindicated as: * It may induce hemorrhage and infection. Lingual thyroid may be the only thyroid tissue in the body, so biopsy may lead to hypothyroidism. Treatment Asymptomatic: requires no treatment. Symptomatic: Surgical excision especially when malignant transformation is suspected. Replacement thyroid therapy after the surgical excision if it is the only thyroid tissue in the body

12. II) Inflammatory hyperplasia An oral inflammatory hyperplastic lesion is defined as "an increase in the size of an organ or tissue due to an increase in the number of its constituent cells as a local response of tissue to injury ". Types of Inflammatory hyperplasia Fibrous hyperplasia (FH) 2. Pyogenic granuloma 3. Hormonal tumor 4. Epulis fissuratum 5. Parulis 6. Papillary hyperplasia of the palate 7. Epulis granulomatosum 8- Acquired hemangioma 9- Peripheral fibroma with calcification 10- Peripheral giant cell lesions 11. Pulp polyp

13. Granulation tissue (stage I) : The initiating chronic injury produces an inflammation, which in turn stimulates the proliferating endothelial cells ; a very rich, patent capillary bed ; chronic inflammatory cells and a few fibroblasts. The granulation tissue (granuloma) soon becomes covered with stratified squamous epithelium. Clinically at this stage the lesion is asymptomatic and smooth contoured or lobulated with a very red appearance because of the rich vascularity and transparency of the non-keratinized epithelial covering. It is moderately soft and spongy and blanches on careful digital pressure. If the recurring insult is eliminated at this stage , the lesion shrinks markedly as the inflammation subsides and the vascularity is reduced .

14. Granulomatous lesion (stage II) If the insult is permitted to continue, the continues to i ncrease in size, although some fibrosis may occur in the regions farthest from the areas being irritated. These fibrotic areas appear as pale pink patches on the reddish surface of the lesion . If the irritating factor is eliminated at the mixed stage , the decrease in the size of the lesion is directly proportional to the amount of inflammation present . if the lesion is composed mostly of fibrous tissue, there is little shrinkage, but if considerable granulation tissue and inflammation exist, there is marked shrinkage. Stage III : the complete lesion may fibrose resulting in a pale pinkish, smooth or lobulated, firm lesion: fibrous hyperplasia (traumatic or irritating fibroma.

15. Management The management of IH lesions is determined by the clinical appearance of the lesion and the microstructure: The lesion is red and soft and the irritating cause can be eliminated, a significant reduction in size may be observed, eliminating the need for excision. When excision is required, less blood is lost if the lesion is permitted to regress before it is removed. When the lesion is pale pink and firm, no reduction can be expected because its bulk is predominantly fibrous tissue. Excision followed by microscopic examination of the specimen is the procedure indicated .

16. Fibrous Hyperplasia (FH) Definition : Fibrous hyperplasia (traumatic or irritation fibroma) is the healed end product of an IH lesion and is not a true neoplasm. FH is the second most common oral exophytic lesion. Differential Diagnosis: Benign tumors such as minor salivary gland neoplasms, neurofibroma, neurilemoma, rhabdomyoma, leiomyoma and giant cell fibroma. The giant cell fibroma

17. Giant cell fibroma Fibroma small not more than 1 cm in diameter Large Size firm, papular sessile with a smooth contour, pale pink and firm to palpation Clinical Features gingiva, tongue, buccal mucosa and palate. gingiva, tongue, buccal mucosa and palate. Sites large, multinucleated giant cell, active fibroblasts . hyperplastic collagenous tissue covered with a smooth layer of stratified squamous epithelium. Histological An excisional biopsy is the indicated treatment Removal of any source of irritation. An excisional biopsy is the indicated treatment Management

18. 2-Pyogenic Granuloma 3-Pregnancy Tumor Pregnancy tumor Pyogenic Granuloma Source of irritation higher levels of sex hormones (increased levels of estrogen and progesterone). Source of irritation Causes Female only Female > Male Sex Clinical features are similar to pyogenic granuloma Asymptomatic reddish papule, nodule or polyp shows at least part of its surface to be rough, ulcerated and necrotic. This necrotic white material clinically resembles pus prompted clinicians to refer to the lesion as a pyogenic granuloma. Teeth may be separated due to pressure from the lesion. The most common site is the gingival. Clinical Features Scaling and home care excised after delivery Removal of any source of irritation. An excisional biopsy is the indicated treatment. Management

19. 4-Epulis Fissuratum Definition lesion observed at the borders of ill-fitting dentures . In most instances the dental flanges overextend secondary to alveolar bone resorption and settling of the denture. Clinical Features The exophytic, often elongated lesion has at least one cleft into which the denture flange fits with a proliferation of tissue on each side. Most of these lesions are asymptomatic. Sites: there is a greater incidence in the maxilla than in the mandible and the anterior regions of both jaws are more often affected than the posterior regions . The lesions occur under the buccal and labial flanges and are seen predominantly in female patients. Management Small red lesions composed mostly of inflamed tissue and some hyperplasia may subside in 2 or 3 weeks if the denture flange is reduced without further treatment. Larger, more fibrosed lesions will require excision, perhaps combined with a sulcus-deepening procedure. In either case, a new, well-adapted denture should be fabricated or at least the current appliance should be adjusted and rebased. Microscopic examination of excised tissue is mandatory.

20. 5- Parulis Definition A parulis is a small IH type of lesion that develops on the alveolar mucosa at the oral terminus of a draining sinus . This lesion accompanies a draining chronic alveolar abscess in children. Clinical Features Slight digital pressure on the periphery of a parulis may force a drop of pus from the sinus opening. Sites: The upper labial and buccal mucosa are the most frequent sites but the lower mucosa and palate may also be involved. Differential Diagnosis Rarely, a draining osteomyelitis or infected malignant tumor may produce a similar appearance. Management The lesion usually regresses spontaneously after the chronic odontogenic infection has been eliminated.

21. 6- Papillary Hyperplasia of the Palate (PHP)   Papillary Hyperplasia of the Palate Nicotine stomatitis. Clinical features numerous small, painless papular or polypoid masses that are seldom over 0.3 cm in diameter. No red dot in centre linear and angular and the segments are flatter and broader but less elevated. red dot in centre Causes 1- Frictional irritation produced by loose-fitting dentures on the palatine tissues. 2-Candida albicans pipe smokers   Treatment New denture and antifungal Stop smoking

22. 7- Epulis Granulomatosum Definition Epulis granulomatbsum is the specific IH type of lesion that grows from a tooth socket after the tooth is extracted or lost . Etiology The precipitating cause in most cases is a sharp spicule of bone left in the walls of the socket. Clinical Features The growth may become apparent in a week or two after the loss of the tooth and the clinical characteristics are similar to those of other IH lesions. Differential Diagnosis Antral polyp protruding into the oral cavity through a maxillary molar or premolar socket . Radiograph examination reveals well-defined loss of bone from the antral floor. If antral polyps are present, the patient should be referred to a surgical specialist for management and for confirmation that the "polyp" is not an antral malignancy. Malignant tumor growing from a recent extraction. A radiograph usually shows bony destruction or a combined radio lucent radiopaque lesion. Herniation of the antral membrane through an extraction site is reported.

23. Management Careful inspection of the socket and removal of any bony spicules at the time of extraction prevent the formation of an epulis granulomatosum . Treatment requires the excision of the lesion and a careful curettage of the alveolus to ensure the elimination of irritating bony spicules. Because the growth might be malignant, the excised tissue should be examined microscopically.

24. 8- Acquired Hemangioma Definition A majority of hemangiomas are congenital but some are acquired later in life. Some of the acquired capillary hemangiomas of the oral cavity may develop from IH le­sions mostly on the gingiva. Clinical Features The conditions may be right for certain IH lesions with many patent capillaries to develop significant blood flow during the IH stage. Such capillary systems remain after the irritant is eliminated and the inflammation subsides. The resultant lesion is usually nodular and bluish-red, usually bleeds easily and may blanch on pressure. Management Indicated treatment is sclerosis, excision or perhaps a combination of these modalities after determination of the blood supply to the lesion.

25. III) Mucocele, Ranula and Eruption cyst The mucocele and ranula are retention phenomena of the minor salivary glands and the sublingual (major) salivary glands, respectively. Clinical Features If the mucocele and ranula is covered by thin overlying mucosa as located near the surface, it appears as bluish mass (the thin mucosa permits the pool of mucous fluid to absorb most of the visible wavelengths of light except the blue which is reflected). If it is deep, it appears pink in color, not bluish because of the thickness of covering mucosa. It is soft to rubbery in consistency and is fluctuant, soft elevation that moves freely over the underlying tissue. If aspiration of the lesion produces a sticky, viscous, clear mucus like fluid

26. Sites: 80% of the time of mucoceles on the lower lip and rarely on the palate. An induration at the base of a retention phenomenon may be just fibrous tissue, but it should alert the clinician to the possibility of a malignant tumor. Ranula is a mucous retention cyst in the sublingual salivary gland that appears in the floor of the mouth. Etiology: Truman 2. Obstructed minor salivary gland duct Differential Diagnosis: Superficial cyst , lipoma Neurofibroma Deep cavernous hemangioma, Lymphangioma Mucus producing salivary gland tumor. Management If the conservative approach of marsupialization is followed, the base of the lesion must be examined carefully for pathosis and cautious periodic follow-up must be maintained. Clinicians may choose complete excision . Specimens must be examined microscopically .

27. Eruption cyst It appears as bluish grey swelling of the mucosa over an erupting tooth, it may enlarge and submerge the erupting tooth if untreated. It is a cyst within the oral mucosa arising by the separation of the follicle from around the anatomical crown of an erupting tooth. Treatment is by surgical excision of a wedge of the mucosa to expose the tooth crown.

28. IV) Specific Infectious Lesions Verruca vulgaris Features Verruca vulgaris, the common wart of the skin, is not a common oral lesion , it is white. The superior surface is a firm, horny, white, rough plateau. Oral mucosal lesion develops as a result of autoinoculation with warts on the finger in children. The lesion is associated with human papilloma virus (HPV ). Most common sites Lip, palate and commissures . Mean age is approximately 15 years. Histopathology The epithelium shows elongated rete pegs with hyperkeratinization . At the margins, the rete pegs bend inward toward the center below the main lesion.

29. Oral papilloma It is benign, rough-surfaced exophytic hyperplasias of epithelial tissue caused by human papillomavirus (HPV) that belong to the papovavirus group. The oral papilloma is recognized as a relatively common oral lesion. Oral papillomas are papillomatous in shape, it have a pebbled surface with prominent clefting . The oral papilloma is seldom larger than 1 cm in diameter. Approximately a third of these lesions occur on the tongue; the remaining sites are the palate, buccal mucosa, gingiva, lips, mandible ridge and floor of the mouth. Most cases occur in patient’s ages 21 through 50 years with an average age of 38 years. Oral papillomas do not show a tendency for malignant change .

30. Condyloma Acuminatum (CA) CA is known as the common venereal wart that is seen in the oral cavity. Oral CAs are particularly common in HIV-positive in­dividuals . It is caused by human papillomavirus (HPV). Clinically and microscopically oral papillomas and oral CAs cannot be differentiated, although if genital warts are present this would suggest that oral lesion is probably a CA. N .B.: Papillomas , verrucae vulgaris and CAs are symmetric lesions that have a uniform pattern, whether the surface is hornified , is tight pebbly or has longer fronds with deeper recesses.

31. Management of Papillomas , verrucae vulgaris and CAs: Single lesions are best removed by surgery including blade excision, laser, heat cautery or cryosurgery. Any excised tissue must be submitted for microscopic study. Podophyllin resin can be used to manage multiple lesions. One or two topical applications may be given per week over 4 to 8 weeks. Although interferon is very effective against HPV with intralesional injection, this costly and painful procedure should be used only as a last treatment .

32. Focal epithelial hyperplasia (Heck's disease) Soft, well-circumscribed, flat, sessile (non-papillomatous) papules, common in Eskimo and rare in Caucasians. Anywhere in the oral mucous membrane. It caused by caused by human papilloma virus . Histopathology Nodular acanthosis that forms the papule. Subepithelial lymphocytic inflammation. Treatment The lesion requires no treatment. Fungal granulomatous lesion In chronic mucocutaneous candidosis , the fungus penetrates to the connective tissue and results in both hyperplastic and inflammatory response that appear as multiple granulomatous reaction affecting the skin, mucous membrane and nail folds.

33. V) Neoplasms Lipomas Myomas (rhabdomyoma and leiomyoma) Peripheral nerve tumors (neurofibroma, plexiform type of neurofibroma schwannoma, traumatic neuroma) 2-Oral Nevus 1- Peripheral benign mesenchymal tumors A) Benign Neoplasm

34. Features All the peripheral benign mesenchymal tumors are oval, nodular, polypoid or dome shaped with smooth contours and are covered with normal mucosa unless chronically traumatized. They may be located on the tongue, buccal mucosa, lips, hard and soft palates, floor of the mouth and vestibule. They are asymptomatic, grow slowly and can be moved over the deeper tissue. The benign mesenchymal tumors seldom occur in the oral cavity. Oral papilloma is pedunculated cauliflower lesions with normal or whitish color that occur in the third to fifth decade. Management The recommended treatment for peripheral benign mesenchymal tumors is excision, microscopic examination of the tumor tissue and postoperative surveillance . 1- Peripheral benign mesenchymal tumors

35. A nevus is a benign tumor of the melanocytes that occurs on the skin but seldom intraorally. It is pigmented ranging from gray to light brown to blue to black. There are four types of oral nevi: intramucosal, junctional, compound and blue. The most common location for oral nevi is the hard palate (40%), followed by the buccal mucosa (19%). The vermillion border, gingiva, labial mucosa, soft palate, and retromolar pad are next in order of frequency. Almost two thirds of the cases are found in women. The mean age is 32 years, and the highest incidence is in the third and fourth decades. More than half of the le­sions are very small, measuring from 0.1 to 0.6 cm. 2-Oral Nevus

36. B) Malignant neoplasms 1- Squamous cell carcinoma (SCC) Features: SCC clinically appear as, red indurated lesion, white indurated lesion, red and white lesion, exophytic lesion, indurated ulcer and crust (lower lip). Approximately 55% of all the SCCs of the tongue are exophytic-type lesions . SCC is the most common oral malignancy. Exophytic carcinoma occurs most often on the lateral borders of the tongue, the floor of the mouth and the soft palate. All exophytic SCCs have a rough surface. They are usually irregular in shape and, if not totally white, are usually pink to red with possibly some white. However, SCC is not, symmetric and the surface pattern is not uniform but rather varies considerably. Ulceration may be present especially in larger fungating lesions in which the surface may be necrotic and multicolored. The lesions are painless and firm on palpation and bleeding is not an early characteristic. Cervical lymph node involvement is the usual route of metastasis.

37. Differential Diagnosis: Verrucous carcinoma: less common and slower growing than SCC. Pyogenic granuloma: It is softer on palpation and bleeds readily and usually its instigating irritant can be found. Papilloma and condyloma acuminatum: is an uncommon oral lesion and its small size and characteristic verrucous appearance with a horny "crown" distinguishes it from SCC. Amelanotic melanoma Peripheral malignant mesenchymal tumors (e.g., fibrosarcoma, myosarcoma, neurosarcoma , liposarcoma) are also rare oral lesions. Peripheral metastatic tumors Many rare oral exophytic lesions, including syphilis, fungal diseases, sarcoidosis and tuberculosis, may be confused with exophytic SCC. Malignant salivary gland tumors ( SGTs): The following clues, however, are helpful

38. 2-Verrucous Carcinoma Verrucous carcinoma has a white keratotic surface. On occasion, verrucous carcinoma develops as a nodular lesion or may present with a reddish, pinkish and whitish surface. Most common site is alveolar mucosa since it occurs in person who uses snuff ( oral snuff keratosis) or chewing tobacco (tobacco chewer keratosis). It is slowly growing and metastasis occurs rarely (on the contrary exophytic squamous cell carcinoma is rapidly growing and metastasis involves cervical lymph nodes). Verrucous carcinoma can transform into squamous cell carcinoma and adapt a more aggressive behavior.

39. 3-Malignant Melanoma Malignant melanoma is a malignant tumor of nevus cells and is an increasingly common neoplasm of the skin. It is more common in male patients and occurs most frequently be­tween the ages of 40 and 70. 80% occur on the maxilloalveolar ridge and palate . The oral melanoma may present as one of four enlarg­ing lesions: a pigmented macule (various shapes, possibly linear); a pigmented nodule; a large, pigmented exophytic lesion perhaps associated with macular pigmentation; or an amelanotic (nonpigmented). Melanoma may vary from a mucosal pink through brown and blue to black. It is usually firm on palpation but not as firm as a squamous cell carcinoma.

40. VI) Minor salivary gland tumors (SGTs) Features Minor SGTs are fully movable, spherical or ovoid masses when they occur in the lining mucosa. Irregular, fixed masses in these locations suggest fibrosis or malig­nancy. Minor SGTs are nodular or dome shaped and immobile when situated in masticatory mucosa . The posterior palate is the most common site of minor SGTs. Most of the remainder occurred in the buccal mucosa or retromolar region and the upper lip whereas a few were located on the gingiva, bone, lower lip and floor of the mouth. The upper lip is 10 times more likely to be involved than the lower lip. Female patients are affected more frequently than male patients. Benign tumors are more common. The mixed tumor is the most common benign type. The majority of malignant tumors are of these types: mucoepidermoid carcinoma , adenoid cystic carcinoma and adenocarcinom .

41. Management The recurrence rates for minor SGTs vary are high even in the case of benign tumors because the original tumor was incompletely excised and residual tumor cells left. Consequently, it is expedient to include a wide margin of normal tissue in the removal of benign or malignant lesions. Frozen sections completed at surgery indi­cate whether the margins are free of tumor and whether a wider excision should be undertaken. Magnetic resonance imaging yields a better picture of the margins of the adenoid cystic carcinomas and their characteristics than computed tomography. Benign tu­mors have well-defined margins, whereas malignant neoplasms (minor SGT) usually have irregular ones