ORAL PATHOLOGY Outline White lesions Red lesions Ulcerative

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ORAL PATHOLOGY

ORAL PATHOLOGY

Outline ● ● White lesions Red lesions Ulcerative lesions Pigmented lesions

Outline ● ● White lesions Red lesions Ulcerative lesions Pigmented lesions

Categories ● Inflammatory ● Infective (bacterial, fungal, viral) ○ ○ Candida albicans EBV +

Categories ● Inflammatory ● Infective (bacterial, fungal, viral) ○ ○ Candida albicans EBV + HIV - oral hairy leukoplakia ● Developmental ○ ○ Epithelial: Leukodema, white sponge naevus CT: gingival fibromatosis, haemangioma, lymphangioma Ectopic tissue: fordyce spots Pigmented: normal, focal melanosis, naevus, amalgam tattoo ● Hyperplastic ○ ○ ○ Epithelial: Frictional hyperkeratosis, linea alba, morsicatio buccarum, smoker’s keratosis CT: Fibro-epithelial hyperplasia, pyogenic granuloma, peripheral giant cell granuloma, calcifying fibroblastic granuloma, gingival hyperplasia Miscellaneous

Categories ● Ulcerations ○ ○ ○ Reactive: traumatic ulcer (acute vs chronic) Immune-mediated: aphthous

Categories ● Ulcerations ○ ○ ○ Reactive: traumatic ulcer (acute vs chronic) Immune-mediated: aphthous ulcers Drug-induced ● Dysplasia and Neoplasm ○ Clinical descriptions: leukoplakia, proliferative verrucous leukoplakia, speckled leukoplakia, erythroplakia

Descriptions Ying’s 5 C’s and 5 S’s Colour Red, white, mixed, pink, normal Site

Descriptions Ying’s 5 C’s and 5 S’s Colour Red, white, mixed, pink, normal Site Be specific Contour Pedunculated, sessile, exophytic, raised Size Use relative to teeth, fairly lenient Consistency Indurated, fluctuant, hard (not known, check clincally) Shape Circular, irregular, patchy, lacey Circumscription Well-defined, diffuse Surface Ulcerated, intact, wrinkley Chronology Take a hx Symptoms Take a hx

White Lesions Developmental

White Lesions Developmental

White Lesions Infective

White Lesions Infective

White Lesions Hyperplastic

White Lesions Hyperplastic

White Lesions Hyperplastic

White Lesions Hyperplastic

White Lesions Idiopathic

White Lesions Idiopathic

Red Lesions: Infective (bacterial) Leprosy ● ● Don’t need to know much Red macules,

Red Lesions: Infective (bacterial) Leprosy ● ● Don’t need to know much Red macules, purple papules Nodules and ulceration Keep in mind for differential diagnosis

Red lesions: Infective (fungal) Candida Hypertrophic/hyperplastic ● White patch ● If can remove= acute

Red lesions: Infective (fungal) Candida Hypertrophic/hyperplastic ● White patch ● If can remove= acute ● If can’t remove= chronic Atrophic ● ● Red patch (generally denture related) Acute= symptomatic (burning pain), sudden onset Chronic= generally asymptomatic, been there a while Two can interchange

Red Lesions: Infective (viral) Kaposi’s Sarcoma ● ● Herpes Virus 8 Most frequent on

Red Lesions: Infective (viral) Kaposi’s Sarcoma ● ● Herpes Virus 8 Most frequent on palate Vascular: purplish area or nodule Easily bleeds

Red Lesions: Developmental? ? Haemangioma ● ● Not a true red patch Localised proliferation

Red Lesions: Developmental? ? Haemangioma ● ● Not a true red patch Localised proliferation of endothelial cells Can press blood out→ goes white Capillary or cavernous, clinical behaviour the same

Red Lesions: hyperplastic? ● Pretty much don’t exist ● Remember red lesions are thinning

Red Lesions: hyperplastic? ● Pretty much don’t exist ● Remember red lesions are thinning of tissue ● However, can get ulcerated surface on hyperplastic tissue

SCC - Epithelial Neoplasia Aetiology ● ● Tobacco use Betel nut chewing Alcohol HPV

SCC - Epithelial Neoplasia Aetiology ● ● Tobacco use Betel nut chewing Alcohol HPV infection (16 and 18)

SCC Clinical Appearance ● Variable ○ ○ ○ red/white speckled patches Raised (HPV) Non-healing

SCC Clinical Appearance ● Variable ○ ○ ○ red/white speckled patches Raised (HPV) Non-healing ulcers Common sites in order of frequency · Vestibule > buccal mucosa > palate > alveolar ridge > lip > tongue > floor of mouth High-risk sites for malignant transformation · Floor of mouth > tongue > lip > palate > buccal mucosa > vestibule > retromolar The least likely spots are the highest risk

SCC Histology ● Epithelial Dysplasia ○ Atypical changes to epithelium ● Malignant epithelial cells

SCC Histology ● Epithelial Dysplasia ○ Atypical changes to epithelium ● Malignant epithelial cells broken through basement membrane

Dysplasia ** Know your definitions ** Definition ○ A collection of atypia involving epithelium

Dysplasia ** Know your definitions ** Definition ○ A collection of atypia involving epithelium Cellular ➔ Nuclear and cellular pleomorphism ➔ Hyperchromasia Architectural Drop-shaped rete pegs Irregular epithelial stratification Dyskeratosis Suprabasal Mitoses (will see increased number of mitotic figures above basal layer) ➔ Loss of polarity of basal cells ➔ ➔

Dysplasia grading Mild Dysplasia ● ● ● Basal 1/3 rd of epithelium Slight nuclear

Dysplasia grading Mild Dysplasia ● ● ● Basal 1/3 rd of epithelium Slight nuclear pleomorphism Normal maturation and stratification in upper layers Moderate Dysplasia ● ● Basal 2/3 rds of epithelium Evident nuclear pleomorphism Suprabasal mitoses (but no abnormality) Normal cell maturation and stratification Severe Dysplasia ● ● ● More than 2/3 rds of epithelium Loss of maturation and normal stratification Abnormal suprabasal mitoses

Tumour Grading Carcinoma In Situ ● ● ● **exam** Pre-invasive SCC Has not broken

Tumour Grading Carcinoma In Situ ● ● ● **exam** Pre-invasive SCC Has not broken through basement membrane yet Significantly better prognosis as it has not invaded CT Grade 1 ● ● Well differentiated More “normal” thus less dangerous Grade 2 ● Moderately differentiated Grade 3 ● Poorly differentiated Grade 4 ● Anaplastic (complete lack of differentiation)

TNM Staging

TNM Staging

Pathologist’s report (exam question) Question: The lesion is SCC. What histological features does the

Pathologist’s report (exam question) Question: The lesion is SCC. What histological features does the pathologist need to describe for the surgeon that may give an indication of the lesion’s clinical behaviour and assist in clinical management? (10 mins) Translation: What histological features would affect the prognosis and management of the lesion; ie. focus more on the malignancy 1. Is the lesion benign or malignant? 2. Has the lesion invaded beyond the basement membrane into the underlying CT 3. Is the lesion well encapsulated? 4. Is the invasion pattern Infiltrative or cohesive? 5. How well differentiated are the lesional cells (e. g. keratin pearls indicate normal differentiation) 6. Lesion thickness; i. e. the depth of infiltration 7. Does the lesion involve vital structures? 8. Is there necrosis? 9. Is there considerable chronic inflammatory cellular infiltrate surrounding the invading front of the lesion? 10. Surgical margins: +ve or -ve? 11. Finally, what is the most likely diagnosis for the lesion given the histopathology?