Pathology of oral cavaty mucosa

and oral soft tissues.

Tuberculosis
Prof. Kogan E.A.
 STOMATITIS BASIC FORMS
Traumatic stomatitis
Symptomatic - in diseases of the gastrointestinal
tract, endocrine and nervous systems, vasculitis,
leukemia and others.
Infectious - measles, scarlet fever, diphtheria,
malaria, HIV and others.
specific
Drugs
Toxic
Allergic and autoimmune (dermostomatity)


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 Cheilitis
Cheilitis - inflammation of the lips (usually the lower
Duration - acute, chronic
Clinical and morphological forms
exfoliative - epithelial desquamation red border, chronic, with
exacerbations redness, swelling, crusting
glandular - congenital hypertrophy and heterotopia minor
salivary glands (and infection) - the mouth of the gland to 0.1 cm
inside the mouth with saliva secretions (pus), chronic
allergic - Acute
Meteorological and actinic - in response to cold, heat, wind,
ultraviolet irradiation, humidity, dry air, etc. -. redness, itching,
burning, sharp
Abrasive (Manganotti) - in men older than 50 years on the lower
lip - hyperemia, erosion crusts, chronic. obligate precancer
Secondary - eczema, infections, endocrine and other diseases.


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 Exudative erythema multiforme

Exudative erythema multiforme - allergic skin lesions and

mucous membranes
Infectious-allergic form - the link with infection (hr
tonsillitis, caries, chronic apical periodontitis, periodontal
disease..) - Erythema, fever, mioartralgiya.
Permissive factors - overcooling, sore throat, flu, SARS
Chronic, worsening the spring and fall to 3.5 weeks,
perhaps years continuous (continuously recurring)
Toxic-allergic form - on medication
 Characteristics of exudative
erythema
Defeat all areas of the skin (hands extensor surfaces of the forearms),
mucous membranes in the mouth, pharynx, larynx, nose, conjunctiva,
urinary organs
Polymorphism rash - erythematous patches, papules, blisters, blisters,
vesicles to 1.5 cm with a bluish rim. Centrifugal growth (roller retraction
center, cyanosis). In the folds of the skin - the painful bleeding erosion -
does not open his mouth, difficulty swallowing, speech. Annular (of
annular) form. At the confluence - garlands, arcs. Duration - 3 weeks
Micro - swelling, hydropic degeneration of the epithelium, congestion,
lymphohistiocytic infiltration with admixture of neutrophils, eosinophils,
intra- and subepithelial bubbles
VARIANTS - spotted, papular, vesicular, bullous


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 .
,
,

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 GLOSSITES
Duration - acute, chronic, with acute exacerbation

Clinical and morphological forms

Desquamative (exfoliative) - frequent, family, lots of desquamation
and epithelial proliferation folds (geographic tongue)
Romboid - a partial or complete absence of papillae with
papillomatous growths in the form of a rhombus, oval in the middle
of the language (median indurativnyy glossitis). The anomaly of
development? Infection?
Atrophic - lack of B12, B2, B6, PP, iron deficiency anemia (+
hyperkeratosis of skin, conjunctivitis women - Plummer-Vincent
syndrome)
Ulcerative - with caries, syphilis, burns, physical-chemical and
others.
 Necrotizing ulcerative gingivitis
(gingivostomatitis). Vincent's disease,
fuzospirohetoz
Non-communicable infection, usually in 15-30 -year
Pathogenesis - activation of saprophytes in
immunodeficiency, stress. Reduced neutrophil
chemotaxis, violation of the T4 / T8
Risk Factors - gum ischemia (adrenal vasospasm),
smoking, local trauma, unbalanced nutrition, hygiene
non-observance of the mouth and others.
Macro - interdental papillae, then the gingival margin -
necrosis, ulcer with a grayish bloom, bleed, often tartar.
Rarely - the defeat of the soft palate, tonsils (tonsillitis
fusospirochetal Vincent)
Micro - fibrinous-purulent inflammation, necrosis,
bacteria colonies
Complications - nome
 Recurrent aphthous stomatitis
Chronic immune disease (up to 20% of the population). Beginning at 10-30
years, more often in women. Education painful yellowish-gray AFL oral
Etiology - unknown. X-ray film, injection, stress, hypovitaminosis, hormonal
changes (often with menstruation, pregnancy rarely) infection
Micro - lymphohistiocytic infiltration (SD 8-killers with ulceration, CD4 helper
cells in the healing), neutrophils, redness, swelling,
Small sprue (80%) - the front of the mouth Department, erythema 1-2 days,
1-5 sores up to 1 cm in children, boys.. It heals in 1-3 weeks
large aphthae (10%) - Sutton disease. Up to 10 deep ulcers up to 3 cm.
After puberty. Heal in 2-6 weeks scar
herpetic aphthae (10%) - small, up to 0.3 cm at the rear mouth ulcers
division, multiple (up to 100). Normally, in adults
Secondary - the defeat of the mouth in Crohn's disease, ulcerative colitis,
celiac disease


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 Thrush
Risk Factors - immunodeficiency (primary, HIV, cancer,
chemotherapy, hormone therapy, diabetes, and others.)
Thrush - sharp, more often in children with HIV infection,
chemotherapy. White patches on the cheeks, the oropharynx, the side
edges of the tongue, mushrooms, desquamated epithelium, keratin,
fibrin with an admixture of neutrophils. Pseudomembranous removed
- a painful ulcer, erosion
Atrophic, hypertrophic - chronic. Median rhomboid glossitis - actinic
atrophy with papillomatous growths in the middle of the tongue back,
acanthosis.
Called dentures - chronic under tight unremovable prosthetic.
Erythema, inflammation, swelling, fungi
Angular - in the corners of the mouth. Chronic. Erythema, cracks,
peeling

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 Mucocutaneous THRUSH (Oral,
extraoral)
Clinical and anatomical forms
Diffuse - a heavy defeat of the skin, oral
mucous membranes, respiratory tract
Family - a hereditary disease. In children,
thrush becomes chronic leykoplakichesky
candidiasis. easy for with endocrine
disorders - DiGeorge syndrome, MEN type 1
Late - rare, combined with thymoma,
myasthenia gravis, red cell aplasia, a cellular
immune deficiency

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 HIV STOMATITIS
Etiology - secondary infections (fungi, bacteria,
viruses)
Symptoms:
Persistent thrush cheeks and palate, hyperplastic
candidiasis, sky erythema, tongue
Acute necrotizing ulcerative gingivitis
Heavy widespread herpes of the lips, mouth
Hairy (fleecy) leukoplakia - soft white rough spots on
the sides of the tongue, the cheeks less.
Hyperkeratosis, acanthosis, vacuolar degeneration of
epithelial cells with karyopyknosis (koylotsity)
Kaposi's sarcoma - soft palate, gums
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 FORMS OF TUBERCULOSIS
Tuberculosis orofacial erythematosus (lupus vulgaris) -
children, young men. The yellowish-red spots up to 0.5 cm, rise
above the skin (rarely vovyshayutsya) from lyupom - granulomas
deep dermis. Variety - flat, hypertrophic (warty), peptic ulcer.
Forms - plain, mutiliruyuschaya (deep ulcers in the tissue, the
cartilage of the nose, ears, followed by disfigurement), lupus-
carcinoma.
Oral lupus - the gums, palate (uvula), lips - red soft spots, then
papillary growths, ulcers, scars
Papules necrotic tuberculosis skin - often in zhenschin15-40 years.
Pink tight knot to 0.5 cm, followed by necrosis, brown crust, white
scar. Occasionally abscesses
Skrofuloderma (kollikvativ tuberculosis) ulcers of tongue,
cheeks, up to 3 cm, dense, painless, movable, then there is
(spayanie with surrounding tissues)
Ulcerative tuberculosis - at the open secondary tuberculosis - a
small single (rarely multiple) ulcer tongue, lips, palate. Can
milliarno-ulcerative form

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Formes of tuberculosis (Robbins et
al..,1999)

1. Primary Tuberculosis
2. Secondary Tuberculosis (Post-
primary, adult of reinfection tbc)
3. Disseminated tuberculosis
Formes of tuberculosis (Strukov A.I.,
Serov V.V.,1999)

1. Primary Tuberculosis
2. Secondary Tuberculosis
(Post-primary)
3. Heamatogeneus tuberculosis
The initial focus of primary infection
(Primary complex, Ghons complex)
The fate of the primary
complex
 Major characteristics of the Heamatogeneous
Tuberculosis (Disseminated):

1. 1. The source of infection - heamatogeneous foci after primary tbc

2. 2. Presence of healed primary infectious tbc complex with
calcification, fibrosis and bone formation
3. 3. Adults (30-40 year old)
4. 4. Repeated contact with infect with the presence of antytub.
Immunity
5. 5. Productive tissue reaction with granuloma formation
6. 6. Spread by blood
7. 7. Possible systemic spread (Systemic disease)
8. 8. Possible organ pathology (Local disease - lung or other
organs)
 Variants of the
Heamatogeneous Tuberculosis
(Disseminated):
1. Generilized
# Acute tbc sepsis
( Landusi's
typhobacilleousis)
# Acute systemic
miliari tbc
# Acute
grossfocal tbc
 Variants of the
Heamatogeneous Tuberculosis
(Disseminated):
2. Lung
# Acute miliari tbc
# Chronic miliari
tbc
# Chronic
grossfocal tbc
(described by
Strukov)
 Variants of the Heamatogeneous
Tuberculosis (Disseminated):
3. Organ
# Focal - acute
and chronic
# Cavitary
(Destructive) - acute
and chronic
 Forms of secondary tbc.

1. Acute focal secondary tbc. (Abrikosov's focus)

2. Healed focus of secondary tbc (Ashoff-Pull's focus)
3. Chronic focal second. tbc. (fibrocaseous, described by
Strukov )
4. Progressive Secondary Pulmonary Tuberculosis
Infiltrative (Assmann's focus)
Caseous Bronchopneumonia
Tuberculoma
Cavitary tbc (acute and chronic, fibrocavitary)
5. Cirrhotic
Abricosovs focus
Caseous pneumonia and
cavernous tuberculosis
 Orofacial Syphilis
Primary - chancre lips, tongue, regional
lymphadenitis, polyadenylation
Secondary - syphilides - roseolous, papular, pustular
rash rarely on the skin, mucous membranes (soft
palate, tonsils). Syphilitic Zayed
Tertiary - papulose - single or multiple bumps up to
1.5 cm, quickly ulcerate. Scarring in a few months
- Gumma - solitary gumma formation with a dense
rounded ulcers
- Interstitial glossitis (Fibroplastic, sclerosing) -
proliferation of fibrous tissue, syphilitic cirrhosis
Late congenital - triad Hetchinsona (teeth, keratitis,
deafness), syphilitic glossitis

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 Benign epithelial tumors of the oral
cavity and skin mucous membranes

Papilloma
acanthoma verrucosum
Keratoacanthoma
Cutaneous horn
Calcifying epithelioma Malerba
Acanthoma adenoides cysticum
Adenoma (arises from sweat or sebaceous
glands)
 Papilloma
Definition: Broad-based superficial tumor of branching
villous vascular stroma covered by neoplastic epithelium.
Two forms are differentiated according to the
predominant direction of growth:

Exophytic papillomas are the commonest

form. The tumor ( A1) primarily grows
above the plane of the epithelial surface ( A2).

Endophytic papillomas are rare. Here, the tumor

primarily grows beneath the surface of the epithelium as
an inverted papilloma and remains largely covered by
the epithelium.
 Papilloma take origin from an epithelial
surface and may be derivied from
squamous cell epithelium or transitional
cell epithelium:
Squamous cell papilloma
Transitional cell papilloma
Malignant epithelial tumors of the oral cavity
and skin mucous membranes

Basal cell carcinoma (basal cell carcinoma)

Squamous (epidermoid) carcinoma with or
without orgoveniem
Bowen's disease (intraepithelial carcinoma)
Adenocarcinoma (arises from sweat or
sebaceous glands)
 Basalcell carcinoma
Superficial
- Nodal
- micronodular
- infiltrative
Metatipical
keratotic
fibroepithelial
With pridatkovoy differentiation
other forms of
sclerosing
Adenoid
Pigmentary
cystic
 - ,

10% 30%
.


,

 - ,


60% 80%
,
:
.

, ,

,
.
- ,

-

 Squamous Cell Carcinoma

Definition: A collective term for carcinomas

that mimic squamous epithelium,
exhibiting filamentous eosinophilic
cytoplasm, sharply demarcated cell
borders, and often keratinization.



57






 Carcinoima grading
Well differentiated/low grade
closely resembles tissue of origin
Moderately differentiated/intermediate
grade
Poorly differentiated/high grade
difficult to recognise the tissue of
origin

(- )
 Localization
Sguamous carcinoma
Language 40%
The bottom of the cavity 30%
Gums and rather palate, cheeks and
red border of the cancer of the lower lip
by 10%
 PREMALIGNANCY

It is frequently possible to recognise

precursor lesions of malignant tumours.
Often these are benign tumours such as
colorectal adenomas which precede
colorectal adenocarcinomas. In other
situations a benign tumour is not present
but morphological abnormalities may still
be identified. These abnormalities are
called dysplasia.
 Dysplasia intraepithelial
neoplasia

A pre-malignant disturbance of cell proliferation

and maturation. It is generally assumed that
once initiated dysplasia will inevitably progress
(through increasing grades of severity) to an
invasive malignant tumour. However, it must be
said that evidence is accumulating that dysplasia
can remain static or regress. The most severe
end of the dysplasia spectrum can be
synonymous with intra-epithelial carcinoma or
carcinoma-in-situ.
 Dysplasia is recognised by:

Pleomorphism of cells (excessive

variation in shape and size)
Hyperchromatic nuclei and increased
mitotic activity
Loss of polarity (orientation) of cells
Disordered maturation
5. Absence of invasion
 CARCINOMA IN SITU

This represent an intermediate stage in the

production of cancer. All the cytological features
of malignancy are present, but the cell have not
invaded the surrounding tissues.
There are two speculations about the
biological nature of carcinoma in situ:
It doesn't develop the molecular genetic base
for invasion into basal membrane
It doesn't produce enough angiogenetic growth
factors to induce stroma formation

Carcinoma in situ
 in situ
( )
 Adenomas

Definition: Tumor arising from glandular

parenchymal, or mucosal epithelium and
consisting of proliferative epithelial folds or
tubules in or on a stroma. Stasis of
secretion leads to development of
chambers.
 99
(-)

, ,
.
,
, .
()
.
 Carcinoima grading
Well differentiated/low grade
closely resembles tissue of origin
Moderately differentiated/intermediate
grade
Poorly differentiated/high grade
difficult to recognise the tissue of
origin
 Adenocarcinoma

Definition: Collective term for carcinomas

of the mucosa or exocrine or endocrine
glandular epithelium with formation of
lumina within the tumor cell complex or
lumina within the tumor cells themselves in
the form of inner surfaces.
Endometrial adenocarcinoma presenting as
a fungating mass in the fundus of the uterus.
 Mesenchymal Tumors

These tumors consist of tissues that originate in

the middle germ layer or mesoderm, primarily
from the pluripotential supporting tissue of the
embryo (mesenchyma). This definition applies
to tumors of connective tissue, supporting tissue,
and muscle.
For this reason, the World Health
Organization introduced the definition of
an additional tumor group,
soft tissue tumors.
 Soft Tissue Tumors

This is a collective term for nonepithelial

tumors that arise exclusively from cells of
nonskeletal tissue including peripheral
nerve tissue.
 Benign Nonepithelial Tumors

General morphology: These tumors exhibit striking

similarity to their physiologic tissue of origin.
For this reason, the names of these neoplasms
include the tissue of origin with the suffix
-oma (for example, a tumor of fatty tissue
is a lipoma).
 Benign

These tumors are composed of

differentiated connective tissue of the
body - fibrous tissue, cartilage, bone,
muscle, fatty tissue. They are tend to
be rounded or lobulated, well-
encapsulated and merely compress the
surrounding tissues.
 Benign Nonepithelial Tumors
Fibromas (derive from connective tissue)
Neurofibroma (derive from connective tissue of the
peripheral nerves)
Single
Multiple
Lipoma
Chondroma
Osteoma
Leiomyoma (FIBROIDS -with large fibrous
component)
Angioma
Malignant Nonepithelial Tumors

General morphology: Because of fleshy

appearance of their cut surface, these tumors are
known as sarcomas (from Greek sarx, flesh).

Next to leukaemia, they are the most common

malignant tumors in children and young adults. In
older age groups, 90% of malignant tumors are
carcinomas.

Clinical presentation: These tumors grow rapidly

with extensive tissue destruction and produce
primarily hematogenous metastases.
 Sarcomas
Fibrosarcoma
Spindle cell sarcoma (well differentiated)
Pleomorphic of anaplastic sarcoma (poor
differentiated)
Malignant fibrous histiocytoma
Osteogenic sarcoma
Chondrosarcoma
Liposarcoma
Myosarcoma
Leiomyosarcoma
Rhabdomyosarcoma
Mixed tumors

Secondary changes -
haemorages and necrosis are
frequent in sarcomas
Ki-67
SMA
Desmin
 Rule of thumb:
In grading sarcomas, malignancy increases
with decreasing similarity to the tissue of
origin, and in direct proportion to the
mitosis count (10 or more mitoses in the
visual field at 40-power magnification), and
the extent of tumor necroses.
 TUMOR-LIKE GROWTHS

Keloid
Palmar fibromatosis - flexion deformities of
fingers
Juvenile aponeurotic fibroma of palms and
soles in children
Nodular fasciitis of the subcutaneous tissue of
adults
Musculoaponeurotic fibromatosis (desmoid
formation) It grows progressively infiltrating
sur.tisssue
 Melanocytic tumors
Benign pigmented naevus or lentigo
(Melanotonic naevus or mole)
Junctional (proliferation is local in the
dermoepidermal junction)
Compound (proliferation is found in the
dermis as well as in the junctional area)
Intradermal (proliferation is wholly in the
dermis)
Displastic pigmented naevus
 Malignant Melanoma

Definition: A highly malignant tumor in the

skin or mucosa adjacent to the skin, eye
and CNS.
 Sites of melanoma

Skin of face, soles of feet, palms of hand,

snail beds, legs, trunk
Mucous membranes of mouth, arms and
genitalia
Eye and meningeas
 Four types of growth may occur

Lentigo maligna
Superficial spread melanoma
Acral lentigous melanoma
Nodular malignant melanoma
 Classification of melanoma
Superficially spreading melanoma 8743/3
Nodal Melanoma 8721/3
Lentigo melanoma 8742/2
Acral lentiginous melanoma 8744/3
Desmoplastic melanoma 8745/3
Melanoma arising in a blue nevus 8780/3
Melanoma arising in a giant congenital nevus 8761/3
Melanoma in children
Nevoid melanoma 8720/3
Recurrent melanoma or local
 The essential features of
malignant melanoma are:

Abnormal melanocytes
Invasion of epidermis
Invasion down into dermis
 The prognosis depends on depth of
invasion, measured as follows:

1,5mm or less- good prognosis

1,5-3 mm - fair prognosis
Metastasis - blood and lympatic spread
3mm - poor prognosis

Metastasis - blood and lympatic spread