Oral & Maxillofacial Pathology II                    DB 3702       Topic: Soft Tissue Tumors    Course Director: Dr. J. E....
This presentation created by          Dr. J. E. BouquotThis presentation is intended for students of Dr. Jerry Bouquot.Des...
For More Information: The Neville BookUsed in almost all U.S. dental schools; one of most popular books in dentistry,     ...
Mars’ Rule:                  An expert is anyone from out of town.Neville at Home                                         ...
Brad Neville @ West Virginia University  1973                       1977
Bouquot at Lilly Pharmaceuticals, with his University of Minnesota class
White Water in West Virginia           The New River    Arrow points to Dr. Bouquot
Interpretation of                                         Lumps and Bumps     Mr. Big Mouth                               ...
Interpretation of Lumps and Bumps       Peripheral Ossifying Fibroma
Basic Objectives for Individual LesionsIdentify the cause-- Etiology; pathoetiology-- Pathogenesis-- Cell or tissue of ori...
Basic Objectives for Individual LesionsDescribe the basic microscopic featuresDescribe the biologic behavior (pathophysiol...
Differential Diagnosis    of Oral Masses
Mucosal Masses – Look at Base       Hyperplastic lingual tonsil                                         Duration          ...
Mucosal Masses – Look at Location                                  Location   Granular Cell Epulis                        ...
Mucosal Masses – Look at Surface IntegrityMetastatic Adenocarcinoma                                     Duration          ...
Mucosal Masses – Look at Surface Irregularities      Irritation Fibroma                                 Duration          ...
Mucosal Masses – Look at Surface Irregularities    Condyloma Acuminatum                     Duration                      ...
Mucosal Masses – Look at Color                    Lipoma                                             Duration             ...
Mucosal Masses – Feel (Palpate) It       Hemangioma                    Duration                                     Rate o...
Mucosal Masses – Look at Moveability     Thyroglossal Duct Cyst                                     Duration              ...
Mucosal Masses – Look at Pain        Pericoronitis                                     Duration                           ...
Mucosal Masses – Look at Underlying Bone                                  LocationMetastatic Esophageal Carcinoma         ...
Mucosal Masses – Look at it All!   Crohn’s Disease                    Location                                      Multip...
Irritation Fibroma
Irritation Fibroma     Reactive Fibrous Hyperplasia;          Traumatic FibromaFrom acute or repeated trauma  -- Poor heal...
Irritation FibromaReactive Fibrous Hyperplasia;     Traumatic FibromaSmooth-surfaceNormal colorPainless noduleMay be pigme...
Irritation Fibroma    Histopathology & TreatmentPedunculated or sessileDense, avascular fibrous stromaNo capsuleEpithelium...
FibrolipomaRule out herniated buccal fat pad (Is it moveable?)
Look-alike Lesion: Scar TissuePrevalence (# Lesions/1,000) = 2.4 for Males, 1.9 for Females, 2.1 Total                    ...
Leaf-Shaped Fibroma        Variant of Irritation FibromaGrows under a denture baseFlat, often with small papules along edg...
Epulis Fissuratum
Epulis Fissuratum      Variant of Irritation Fibroma?Reactive fibrous hyperplasia; inflammatoryfibrous hyperplasia; dentur...
Epulis Fissuratum       Variant of Irritation Fibroma?Linear, often lobulatedPainless fibrous massBase parallels alveolusM...
Epulis Fissuratum     HistopathologyLike irritation fibromaMore chronic inflammatorycellsAcanthosis/degenerationMay have s...
Epulis FissuratumMaybe: pseudoepitheliomatous Hyperplasia-- “Islands” of epithelium if cut tangentially or in cross sectio...
Epulis Fissuratum     Pathophysiology & Treatment Continues to elongate over time (and continued trauma)– New parallel mas...
InflammatoryPapillary Hyperplasia
Inflammatory Papillary Hyperplasia    Papillary Hyperplasia of the Palate          Denture PapillomatosisRepeated trauma f...
Inflammatory Papillary      Hyperplasia       Clinical FeaturesMultiple painless fibrous papules-- Scattered across hard p...
Inflammatory Papillary Hyperplasia             Histopathology  Old papules: like small irritation fibroma  Early: edematou...
Inflammatory Papillary       Hyperplasia   Pathophysiology & TreatmentContinues indefinitely-- Even with new denture-- Ede...
Giant Cell Fibroma
Giant Cell FibromaVariant of Irritation Fibroma       Etiology: unknown       -- Not related to trauma        GALP:       ...
Giant Cell FibromaHistopathology, Pathophysiology,           Treatment   Like irritation fibroma   Large, stellate, subepi...
Retrocuspid PapillaVariant of Giant Cell Fibroma?      Small fibrous gingival nodule      More frequent in children (25%) ...
Fibromatosis
FibromatosisJuvenile Aggressive Fibromatosis    Extraabdominal DesmoidEtiology: unknown (neoplasm?)GALP:– None– Children a...
FibromatosisHistopathology, Pathophysiology, Treatment     Fibrous stroma many spindle cells     -- Streaming fascicles   ...
Gingival Fibrous HyperplasiaPrevalence (# Lesions/1,000) = 0.1 for Males, 0.1 for Females, 0.1 Total              This is ...
Soft tissue tumors 1 2007
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  1. 1. Oral & Maxillofacial Pathology II DB 3702 Topic: Soft Tissue Tumors Course Director: Dr. J. E. Bouquot Room 3.094b; 713-500-4420 Jerry.Bouquot@uth.tmc.edu Thursdays, 10:00 – 11:50 am Room DB 132
  2. 2. This presentation created by Dr. J. E. BouquotThis presentation is intended for students of Dr. Jerry Bouquot.Designated owners of the photographic images in this lectureretain the copyrights for those images but have agreed to allowtheir photos to be used for teaching. You are welcome to use thispresentation or portions thereof for your own teaching withoutpermission from the Maxillofacial Center, but permission is notgiven for the publication of these photos in electronic or otherformats. Disclaimer: Dr. Bouquot is Professor & Chair, Department of Diagnostic Sciences, University of Texas Dental Branch at Houston. The information and opinions provided herein are, however, his own and do not represent official opinion or policy of the University of Texas.
  3. 3. For More Information: The Neville BookUsed in almost all U.S. dental schools; one of most popular books in dentistry, 1,100+ pictures (in color), published by W. B. Saunders An unusual view of the authors. Brad Neville (South Carolina), Douglas Damm (Kentucky) Carl Allen (Ohio), Jerry Bouquot (University of Texas, Houston)
  4. 4. Mars’ Rule: An expert is anyone from out of town.Neville at Home West Virginia Neville in London Weber’s Definition An expert is one who knows more and moreabout less and less until he knows absolutely everything about nothing. West Virginia
  5. 5. Brad Neville @ West Virginia University 1973 1977
  6. 6. Bouquot at Lilly Pharmaceuticals, with his University of Minnesota class
  7. 7. White Water in West Virginia The New River Arrow points to Dr. Bouquot
  8. 8. Interpretation of Lumps and Bumps Mr. Big Mouth Mario the Mouth DetectiveLaw of Revelation: The hidden flaw never remains hiddenMuir’s Law: When we try to pick out anything by itself, we find ithitched to everything else in the universe
  9. 9. Interpretation of Lumps and Bumps Peripheral Ossifying Fibroma
  10. 10. Basic Objectives for Individual LesionsIdentify the cause-- Etiology; pathoetiology-- Pathogenesis-- Cell or tissue of originList the GALP-- Gender predilection-- Age predilection Gingival Fibrous Hyperplasia-- Location predilection-- Prevalence (frequency)Describe the typical clinical appearance-- Unusual clinical variants-- Look-alike lesions (differential diagnosis)-- Systemic associations-- Genetic associations-- Drug, foreign material, etc.
  11. 11. Basic Objectives for Individual LesionsDescribe the basic microscopic featuresDescribe the biologic behavior (pathophysiology)-- Rate and pattern of growth-- Prognosis without treatmentTypical treatment(s) and the prognosisof such treatment(s)Describe unique variants or features-- Microscopic-- Physiologic-- Clinical -- Biological behavior Peripheral Ossifying Fibroma
  12. 12. Differential Diagnosis of Oral Masses
  13. 13. Mucosal Masses – Look at Base Hyperplastic lingual tonsil Duration Rate of enlargement Constancy of enlargement Uniformity of expansion Size Pedunculated (on a stalk) Irritation fibromaSessile (broad based), lobulated Base Surface integrity Surface irregularities Color/Blanching Firmness/Fluctuation Moveability Pain/Tenderness
  14. 14. Mucosal Masses – Look at Location Location Granular Cell Epulis Multiplicity Skin/Other mucosa lesions Patient age Gender Family history Gingiva Peripheral Giant Cell GranulomaAnterior maxillary alveolusBaseSurface IntegritySurface irregularitiesColorFirmnessMoveabilityPain/Tenderness
  15. 15. Mucosal Masses – Look at Surface IntegrityMetastatic Adenocarcinoma Duration Rate of enlargement Constancy of enlargement Uniformity of expansion Size Fungating (ulcerated, lobulated mass) UlceratedBaseSurface IntegritySurface irregularitiesColor/BlanchingFirmness/FluctuationMoveability Squamous Cell CarcinomaPain/Tenderness
  16. 16. Mucosal Masses – Look at Surface Irregularities Irritation Fibroma Duration Rate of enlargement Constancy of enlargement Uniformity of expansion Size Lobulated Torus Palatinus Smooth surfaceBaseSurface IntegritySurface irregularitiesColor/BlanchingFirmness/FluctuationMoveabilityPain/Tenderness
  17. 17. Mucosal Masses – Look at Surface Irregularities Condyloma Acuminatum Duration Rate of enlargement Constancy of enlargement Uniformity of expansion Size Verruciform (pointed projections)Papillary (finger-like projections) Base Surface Integrity Surface irregularities Color/Blanching Firmness/Fluctuation Moveability Verruca Vulgaris (Wart) Pain/Tenderness
  18. 18. Mucosal Masses – Look at Color Lipoma Duration Rate of enlargement Constancy of enlargement Uniformity of expansion Size Red (vascular)Yellow (fat, keratin, pus, lymphocytes) Base Surface Integrity Surface irregularities Color/Blanching Firmness/Fluctuation Moveability Hemangioma Pain/Tenderness
  19. 19. Mucosal Masses – Feel (Palpate) It Hemangioma Duration Rate of enlargement Constancy of enlargement Uniformity of expansion Size Soft, nonfluctuant Soft, blanchingBaseSurface IntegritySurface irregularitiesColor/BlanchingFirmness/FluctuationMoveabilityPain/Tenderness Lipoma
  20. 20. Mucosal Masses – Look at Moveability Thyroglossal Duct Cyst Duration Rate of enlargement Constancy of enlargement Uniformity of expansion Size Immovable Freely movableBaseSurface IntegritySurface irregularitiesColor/BlanchingFirmness/FluctuationMoveabilityPain/Tenderness Squamous Cell Carcinoma
  21. 21. Mucosal Masses – Look at Pain Pericoronitis Duration Rate of enlargement Constancy of enlargement Uniformity of expansion Size Aching, tender to palpation Sharp pain on palpationBaseSurface IntegritySurface irregularitiesColor/BlanchingFirmness/FluctuationMoveabilityPain/Tenderness Masseter Hypertrophy
  22. 22. Mucosal Masses – Look at Underlying Bone LocationMetastatic Esophageal Carcinoma Multiplicity Skin/Other mucosa lesions Patient age Gender Family history Underlying bone change
  23. 23. Mucosal Masses – Look at it All! Crohn’s Disease Location Multiplicity Skin/Other mucosa lesions Patient age Gender Family history Underlying bone changeBaseSurface IntegritySurface irregularitiesColor/BlanchingFirmness/FluctuationMoveability Multiple Mucosal Neuroma SyndromePain/Tenderness
  24. 24. Irritation Fibroma
  25. 25. Irritation Fibroma Reactive Fibrous Hyperplasia; Traumatic FibromaFrom acute or repeated trauma -- Poor healing -- “Exuberant scar tissue” – May develop from pyogenic granuloma -- Similar skin lesion: keloidGALP: – None (but 2x females for biopsied cases) – 4th-6th decades = usual age – Buccal > lip > tongue > gingiva -- Most common soft tissue mass -- 3rd most common mucosal lesion in adults -- 3rd most common oral lesion – Prevalence: 12/1,000 adults
  26. 26. Irritation FibromaReactive Fibrous Hyperplasia; Traumatic FibromaSmooth-surfaceNormal colorPainless noduleMay be pigmented-- Melanosis of epitheliumMaybe: frictional keratosisMay be ulcerated (trauma)Usually sessile-- May be pedunculatedUsually <1 cm.– May become 3-4 cm.Full size within 6 months-- Minimal increase after-- Does not go away– No malignancy risk
  27. 27. Irritation Fibroma Histopathology & TreatmentPedunculated or sessileDense, avascular fibrous stromaNo capsuleEpithelium often atrophicSmall numbers of lymphocytes in fibrous stroma, maybeTreat: conservative excision, otherwise lasts forever
  28. 28. FibrolipomaRule out herniated buccal fat pad (Is it moveable?)
  29. 29. Look-alike Lesion: Scar TissuePrevalence (# Lesions/1,000) = 2.4 for Males, 1.9 for Females, 2.1 Total © Photo: Dr. Richard Hart, West Virginia University, Morgantown, West Virginia
  30. 30. Leaf-Shaped Fibroma Variant of Irritation FibromaGrows under a denture baseFlat, often with small papules along edges6th most common mucosal lesion-- Prevalence = 7/1,000, with strong female predilectionProblems: Cortical erosion; infarction (stalk gets twisted)Treat same as for regular irritation fibroma
  31. 31. Epulis Fissuratum
  32. 32. Epulis Fissuratum Variant of Irritation Fibroma?Reactive fibrous hyperplasia; inflammatoryfibrous hyperplasia; denture injury tumor;denture epulis; redundant tissue Etiology: repeating trauma from denture flange GALP: – None (but strong female in biopsied cases) -- Middle-aged and older – Anterior vestibule > posterior vestibule > anterior oral floor -- 11th most common oral lesion -- Prevalence = 4/1,000 adults
  33. 33. Epulis Fissuratum Variant of Irritation Fibroma?Linear, often lobulatedPainless fibrous massBase parallels alveolusMay have traumatic ulcer in depth of a fissureMay have multiple parallel masses (“redundant tissue”)May have areas of papillary hyperplasia along edges
  34. 34. Epulis Fissuratum HistopathologyLike irritation fibromaMore chronic inflammatorycellsAcanthosis/degenerationMay have surface ulcer (traumatic ulcer)May have inflammatory papillary hyperplasia of surface
  35. 35. Epulis FissuratumMaybe: pseudoepitheliomatous Hyperplasia-- “Islands” of epithelium if cut tangentially or in cross section-- Can look like: Squamous cell carcinoma
  36. 36. Epulis Fissuratum Pathophysiology & Treatment Continues to elongate over time (and continued trauma)– New parallel masses develop, may ulcerated– No malignant transformation-- Although it was once thought to be premalignantDual treatment:-- Surgical excision-- Replace/repair denture-- Low recurrence
  37. 37. InflammatoryPapillary Hyperplasia
  38. 38. Inflammatory Papillary Hyperplasia Papillary Hyperplasia of the Palate Denture PapillomatosisRepeated trauma from denture base-- Especially in persons who sleep with denture in place-- Edema of connective tissue papillaeMay be seen in non-denture patients with:-- High arched palate-- Immune deficiency (e.g. AIDS)GALP:– 2x female– Middle-age and older– Hard palate, under denture-- 15th most common mucosal lesion-- Prevalence = 3/1,000 adults
  39. 39. Inflammatory Papillary Hyperplasia Clinical FeaturesMultiple painless fibrous papules-- Scattered across hard palate-- Concentrated in the midline-- Burning? CandidiasisEarly lesions are: -- Edematous -- Erythematous
  40. 40. Inflammatory Papillary Hyperplasia Histopathology Old papules: like small irritation fibroma Early: edematous granulation tissue -- With chronic inflammatory cells Pseudoepitheliomatous hyperplasia: -- Can look like squamous cell carcinoma
  41. 41. Inflammatory Papillary Hyperplasia Pathophysiology & TreatmentContinues indefinitely-- Even with new denture-- Edematous lesions may disappearNo malignant potential-- Although once considered premalignantDual treatment: -- Conservative surgical excision or laser/electrosurgical removal – And replace or repair denture -- Take denture out overnightTreat early (edematous) case: Keep denture out (2+ weeks)Antifungals, if burningAntibiotics, maybe?
  42. 42. Giant Cell Fibroma
  43. 43. Giant Cell FibromaVariant of Irritation Fibroma Etiology: unknown -- Not related to trauma GALP: – Slight female – Younger persons -- 2-5% of fibrous oral masses – 50% on gingiva Small, often lobulated Smooth or pebbled Painless nodule < 5 mm in size
  44. 44. Giant Cell FibromaHistopathology, Pathophysiology, Treatment Like irritation fibroma Large, stellate, subepithelial fibroblasts Sometimes multiple nuclei Remains indefinitely Treat: conservative surgical excision
  45. 45. Retrocuspid PapillaVariant of Giant Cell Fibroma? Small fibrous gingival nodule More frequent in children (25%) -- 6% of adults Behind mandibular cuspid Often bilateral Same giant fibroblasts as giant cell fibroma
  46. 46. Fibromatosis
  47. 47. FibromatosisJuvenile Aggressive Fibromatosis Extraabdominal DesmoidEtiology: unknown (neoplasm?)GALP:– None– Children and young adults– Mandibular gingiva-- Rare in mouthPainless, firm mass-- Often lobulatedMay destroy underlying boneMay be ulcerated
  48. 48. FibromatosisHistopathology, Pathophysiology, Treatment Fibrous stroma many spindle cells -- Streaming fascicles – Not encapsulated – Cells are mature -- Cells more numerous than normal Can grow to considerable size May destroy underlying bone Maybe great local disfigurement No metastasis Aggressive fibromatosis Treat: wide excision -- Including affected bone – 1/4 recur with this treatment
  49. 49. Gingival Fibrous HyperplasiaPrevalence (# Lesions/1,000) = 0.1 for Males, 0.1 for Females, 0.1 Total This is NOT an aggressive fibromatosis! © Photos Dr. Thomas Wilcko, Erie, Pennsylvania

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