Oral Pathology

Olga A.C. Ibsen

Dental hygienists perform comprehensive extraoral and intraoral examinations, identify pathologic conditions, and communicate these findings to the dentist for diagnosis, treatment, or referral. Knowledge of oral pathology affects infection control, managing the risk of emergencies, and developing dental hygiene care plans congruent with the patient’s health status and needs. The dental hygienist differentiates between normal and abnormal findings and relates significant health, dental, and cultural histories to clinical, radiographic, and histologic findings. Although the dental hygienist is not responsible for the dental diagnosis, skill in the use of the diagnostic process is essential for the dental hygiene diagnosis and collaborative practice.

Benign Lesions of Soft Tissue Origin

Inflammatory Tumors (Granulomas)

General Characteristics

A Growth or enlargement of tissue composed mainly of inflammatory cells

B Account for the major portion of all oral tumors

C Benign tumors

Pyogenic Granuloma

A Etiology—an exuberant tissue response to chronic irritants or trauma (i.e., plaque biofilm, calculus, poor restorative margins, hormonal levels)

B Age and gender related—children and young adults; more common in females (3 : 1), perhaps related to an increase in estrogen levels

C Location—much more common on the maxillary labial gingiva than mandibular gingiva; can occur on the lips, tongue, and buccal mucosa

D Clinical features (Figure 8-6)

FIGURE 8-6 Pyogenic granuloma. (From Ibsen OAC, Phelan JA: Oral pathology for the dental hygienist, ed 5, Philadelphia, 2009, Saunders.)

1. Protrusive mass; pedunculated, sessile, or lobulated base

2. Deep red rather than pink surface

3. Soft and spongy; freely movable; ulcerated, bleeds easily

4. Lesions are a few millimeters to several centimeters

5. In pregnancy, these lesions were formerly called pregnancy tumors

E Histologic characteristics

1. The epithelium, if present, is thin

2. Rich in capillaries with proliferation of connective tissue; inflammatory cells

3. The lesion contains polymorphonuclear leukocytes (PMNLs), acute and chronic inflammatory cells, plasma cells, and lymphocytes

F Treatment and prognosis

1. Removal of the irritant

2. Surgical excision of the lesion

3. These lesions can recur if the irritant remains (e.g., calculus)

4. The lesions that occur during pregnancy may resolve spontaneously

Papillary Hyperplasia of the Palate (Palatal Papillomatosis)

A Etiology—type of denture stomatitis; chronic irritation to the vault of the hard palate related to an ill-fitting denture (full or partial); excessive pressure of an ill-fitting denture; poor denture hygiene (secondary); can also be associated with an orthodontic appliance; wearing the prosthetic device 24 hours a day

B Age and gender related—no gender predilection

C Location—especially—in vault of the hard palate in maxillary denture wearers (suction chamber area)

D Clinical features (Figure 8-7)

FIGURE 8-7 Papillary hyperplasia of the palate. (Courtesy of Dr. Edward V. Zegarelli; from Ibsen OAC, Phelan JA: Oral pathology for the dental hygienist, ed 5, Philadelphia, 2009, Saunders.)

1. Closely clustered erythematous papillary projections, 1 to 4 mm in diameter

2. Round, smooth, glistening red surface; granular appearance

3. Varying degrees of inflammation present

E Histologic characteristics

1. Small vertical projections, each composed of stratified squamous epithelium and a central core of connective tissue

2. Epithelial proliferation

3. Infiltrated with inflammatory cells

F Treatment

1. Surgical excision of the hyperplastic tissue prior to construction of a new denture or a reline

2. After surgery, emphasize denture care and removing the denture at night to rest the tissues

G Prognosis—good

Denture-Induced Fibrous Hyperplasia (Epulis Fissuratum, Inflamatory hyperplasia)

A Etiology—irritation caused by a denture flange, which produces a proliferation of tissue in the vestibule along the denture boarder

B Age and gender related—denture wearers; no gender predilection

C Location—vestibule along denture border; alveolar ridge in regions along the denture border

D Clinical features (Figure 8-8)

FIGURE 8-8 A, Denture-induced fibrous hyperplasia (epulis fissuratum) (arrows), shown with denture in place, and B, denture removed. (From Ibsen OAC, Phelan JA: Oral pathology for the dental hygienist, ed 5, Philadelphia, 2009, Saunders.)

1. Exophytic folds of hyperplastic tissue in the vestibule under or around the denture flange

2. Pink to red color (can have ulcerated areas)

3. Firm to palpation

E Histologic characteristics

1. Dense fibrous connective tissue covered by stratified squamous epithelium

2. Connective tissue composed of coarse bundles of collagen fibers

3. Same type of tissue as seen in irritation fibroma

F Treatment and prognosis

1. Surgical removal of the excess tissue

2. Construction of a new denture

3. Prognosis is excellent

Peripheral Giant Cell Granuloma

A Etiology—a reactive lesion caused by local irritants

B Age and gender related—40 to 60 years; more common in females (2 : 1)

C Location—gingiva or alveolar process, anterior to molars

D Clinical features (Figure 8-9, A)

FIGURE 8-9 A, Peripheral giant cell granuloma. B, Microscopic appearance of a peripheral giant cell granuloma showing multi-nucleated giant cells (M), capillaries, and fibroblasts. (From Ibsen OAC, Phelan JA: Oral pathology for the dental hygienist, ed 5, Philadelphia, 2009, Saunders.)

1. Exophytic lesion 0.5 to 2.0 cm in diameter

2. Deep red to bluish color

3. Pedunculated or sessile base

4. Arises from a deeper area in tissue than does a pyogenic granuloma or fibroma

E Radiographic appearance—this soft tissue lesion can cause superficial destruction of alveolar bone

F Histologic characteristics (see Figure 8-9, B)

1. Composed of a delicate reticular and fibrillar connective tissue stroma containing a large number of ovoid or spindle-shaped, young, connective tissue cells

2. Multi-nucleated giant cells

3. Proliferation of blood vessels

4. Appears to originate from the periodontal ligament or mucoperiosteum

G Treatment and prognosis

1. Surgical removal of the entire base to eliminate recurrence

2. Usually does not recur

Central Giant Cell Granuloma

A Etiology—occurs within bone; trauma caused by a fall, blow, or tooth extraction

B Age and gender related—children and young adults; more common in females (2 : 1) age 10–30 years

C Location—75% in the anterior segment of the mandible; also found in the maxilla

D Clinical features

1. Appears as a swelling or bulge resulting from the expansion of cortical plates

2. No symptoms, so may be discovered by chance

3. A similar lesion, often called “brown tumor,” occurs in persons with hyperparathyroidism; resolves without treatment

E Radiographic appearance (Figure 8-10, A and B)

FIGURE 8-10 Radiographs of central giant cell granulomas showing multi-locular radiolucencies. A, The mandible. B, The maxilla. (From Ibsen OAC, Phelan JA: Oral pathology for the dental hygienist, ed 5, Philadelphia, 2009, Saunders.)

1. Usually a large radiolucent area with diffuse margins that are ill defined with faint trabeculae

2. Displacement of teeth; divergence of the roots of teeth adjacent to the lesion

3. Root resorption

F Histologic characteristics

1. Loose fibrillar connective tissue with many fibroblasts

2. Rich vascularity

3. Foreign-body multi-nucleated giant cells

G Treatment and prognosis

1. Curettage (perhaps more than one treatment)

2. Surgical removal

3. Radiotherapy is contraindicated

4. Occasionally recurs

Chronic Hyperplastic Pulpitis (Pulpal Granuloma, Pulp Polyp)

A Etiology—excessive proliferation of inflamed pulp tissue found in teeth with large open carious lesions; rapid caries; lesion projects from the pulp chamber

B Age and gender related—children and young adults; no gender predilection

C Location

1. Usually in primary molars or permanent molars

2. Can occur in any tooth with a large carious lesion

D Clinical features (Figure 8-11)

FIGURE 8-11 Chronic hyperplastic pulpitis (pulp polyp) (arrow). (From Ibsen OAC, Phelan JA: Oral pathology for the dental hygienist, ed 5, Philadelphia, 2009, Saunders.)

1. Red to pink outgrowth of pulp tissue protruding from the occlusal surface of the crown of a tooth that has a large, open, carious lesion

2. Lesion is not painful because hyperplastic tissue contains few nerves

E Histologic characteristics

1. Originates from pulpal tissue

2. Contains acute and chronic inflammatory cells, plasma cells, and lymphocytes

3. Granulation tissue

F Treatment and prognosis

1. Extraction of the involved tooth

2. Endodontic therapy

3. Prognosis is good

Internal Resorption

A Etiology—not clear; theories include:

1. Inflammatory response in the pulp

2. Trauma

3. Caries-related pulpitis

B Age and gender related—any age; no gender predilection

C Location—usually found within a tooth in the permanent dentition

D Clinical features

1. Dentin immediately surrounding the pulp in the area of resorption is destroyed

2. The crown may appear pink (“pink tooth”) because of the vascularity of the lesion within (this is not easily observable on posterior teeth)

E Radiographic appearance well defined, but radiolucent lesion in close proximity to the pulp canal (Figure 8-12)

FIGURE 8-12 Radiograph showing an area of internal resorption on the maxillary first molar (arrow). (From Ibsen OAC, Phelan JA: Oral pathology for the dental hygienist, ed 5, Philadelphia, 2009, Saunders.)

F Histologic characteristics—highly vascularized chronic inflammatory tissue

G Treatment—endodontic therapy if perforation of the root has not occurred; otherwise, extraction of the tooth is performed

Periapical Granuloma

A Etiology—dental caries or deep restorations

B Age and gender related—any age; no gender predilection

C Location—apex of a nonvital tooth

D Clinical features

1. Nonvital tooth; asymptomatic

2. Fistula or parulis may be present if the condition has been chronic

3. The affected tooth can be sensitive to percussion

E Radiographic appearance—varies from a well-defined, circular, radiolucent lesion at the apex of the involved tooth to a diffuse radiolucency or thickening of the periodontal ligament space (Figure 8-13, A)

FIGURE 8-13 A, Radiograph of a periapical granuloma. B, Low-power microscopic appearance of a periapical granuloma. (From Ibsen OAC, Phelan JA: Oral pathology for the dental hygienist, ed 5, Philadelphia, 2009, Saunders.)

F Histologic characteristics (see Figure 8-13, B)

1. Lymphocytes, plasma cells, macrophages

2. Dense fibrous connective tissue

3. Epithelial (Malassez) rests

G Treatment—endodontic therapy or extraction of the affected tooth

Benign Intraosseous Neoplasms

General Characteristics

A Etiology—generally unknown

B Onset—gradual, with slow development or enlargement

C Early stages—asymptomatic

D With expansion of the lesion, malocclusion may occur; bone tenderness on palpation; cortical bone may become thin

Osteoma

A Etiology—asymptomatic benign tumor of compact bone; etiology generally unknown, but the cause may be irritation or inflammation; associated with a genetic condition called Gardner syndrome

B Age and gender related—more common in young adults but can be found at any age; no gender predilection

C Location—most common posterior mandible; mandibular condyle; craniofacial skeleton

D Clinical features—the affected individual may be unaware of the lesion because it grows slowly; considerable growth must occur before cortical plates expand

E Radiographic appearance—well-circumscribed radiopaque mass that is indistinguishable from scar bone; panoramic or lateral plate radiograph may be needed to view the lesion in its entirety (Figure 8-14)

FIGURE 8-14 Radiograph of an osteoma showing a radiopacity (arrow) of the posterior mandible. (Courtesy of Dr. Sidney Eisig; from Ibsen OAC, Phelan JA: Oral pathology for the dental hygienist, ed 5, Philadelphia, 2009, Saunders.)

F Histologic characteristics—extremely dense, compact bone or coarse, cancellous bone

G Treatment and prognosis

1. Surgical excision

2. Does not recur

Chondroma

A Etiology—benign tumors of hyaline cartilage; cause unknown

B Age and gender related—ages 30 to 40 years; no gender predilection

C Location

1. Maxilla—anterior area

2. Mandible—posterior to canines

3. May involve the body of the mandible or the coronoid or condylar process

D Clinical features

1. Painless

2. Slow, progressive swelling of the jaw may loosen or malposition teeth

3. Tendency to become malignant

E Radiographic appearance—irregular radiolucent or mottled area in bone; may displace surrounding teeth or cause root resorption

F Histologic characteristics

1. Mass of hyaline cartilage with areas of calcification or necrosis

2. Cartilage cells are small, and each has one nucleus

3. Large biopsy sample must be obtained because the lesion is similar to a malignant chondrosarcoma (more common in men)

G Treatment and prognosis

1. Nonconservative surgical removal; tumor may be resistant to radiation therapy

2. Periodic follow-up evaluation is necessary to detect recurrence or possibility of a chondrosarcoma

Odontogenic Myxoma

A Etiology—unknown; benign; originates from mesenchymal tissue of the tooth germ

B Age and gender related—most often in young adults (ages 10 to 30 years); no gender predilection

C Location—mandible more often than maxilla

D Clinical features—deeply situated lesion; small lesions asymptomatic

E Radiographic appearance (Figure 8-15)

FIGURE 8-15 Radiograph of a myxoma showing multi-locular, honeycombed radiolucency. (From Ibsen OAC, Phelan JA: Oral pathology for the dental hygienist, ed 5, Philadelphia, 2009, Saunders.)

1. May be unilocular or multilocular

2. Several small radiolucencies occurring in groups, giving a “honeycomb” appearance

3. May show displaced teeth, mandibular canal, and antrum (may also invade the antrum)

4. Peripheral borders are irregular, diffuse, and not well defined

F Histologic characteristics

1. Loosely textured tissue containing delicate reticulin fibers and mucoid material

2. Contains stellate, spindle-shaped cells

3. The tumor is not encapsulated and may invade surrounding tissues

4. Does not metastasize

G Treatment and prognosis

1. Complete surgical excision

2. Recurrence is common (25%)

Exostosis

Torus Palatinus

A Etiology—inherited, autosomal dominant; some believe the cause to be genetic or environmental factors

B Age and gender related—usually seen by the age of puberty; rarely observed in children, but peak incidence occurs before 30 years; more common in females (2 : 1)

C Location—midline of the hard palate

D Clinical features (Figure 8-16, A)

FIGURE 8-16 A, Clinical appearance of a lobulated torus palatinus. B, Clinical appearance of bilateral mandibular tori. (From Ibsen OAC, Phelan JA: Oral pathology for the dental hygienist, ed 5, Philadelphia, 2009, Saunders.)

1. Bony, hard protuberance in the midline in a variety of shapes—nodular; lobulated; smooth; spindle

2. Occurs in 20% to 35% of the U.S. population

3. Torus may appear ulcerated because of trauma to the thin overlying mucosa

E Radiographic appearance—dense radiopaque area

F Histologic characteristics—dense cortical bone

G Treatment—usually none, but surgical removal if the lesion interferes with a prosthodontic appliance

Torus Mandibularis

A Etiology—inherited, autosomal dominant; possibly genetic or environmental

B Age and gender related—first observed in early teen years; slightly more common in males

C Location—lingual surface of the mandible above the mylohyoid line in the area of premolars

D Clinical features (see Figure 8-16, B)

1. Bony, hard protuberance varying in size and shape; common exostosis

2. Slow growing—usually unnoticed

3. Bilateral incidence more common (90%)

E Radiographic appearance—dense radiopaque area

F Histologic characteristics—dense cortical bone

G Treatment—surgical excision if the lesion interferes with a prosthodontic appliance

Odontoma

A Etiology—most common odontogenic tumor composed of all tooth structure and pulp but not considered a neoplasm

B Age and gender related—usually seen in adolescents and young adults (mean age 14 years); no gender predilection

C Location—more frequently seen in the maxilla (especially the anterior maxilla for the compound type) than in the mandible; usually between the roots of teeth or near apices; complex odontomas seen more often in the posterior of the mandible

D Clinical features

1. Failure of a permanent tooth to erupt

2. Asymptomatic

E Radiographic appearance—irregular mass of radiopacities (“tooth-like structures”) surrounded by a narrow radiolucent halo

1. Two types

a. Compound—tooth structures are identified radiographically (Figure 8-17)

FIGURE 8-17 Radiograph of a compound odontoma, showing a collection of numerous, small, tooth-like radiopacities (arrows) surrounded by a radiolucent halo. (From Ibsen OAC, Phelan JA: Oral pathology for the dental hygienist, ed 5, Philadelphia, 2009, Saunders.)

b. Complex—appears as a radiopaque mass (can be confused with other lesions in bone) (Figure 8-18)

FIGURE 8-18 Radiograph of a complex odontoma showing a radiopaque mass surrounded by a radiolucent halo (arrow). (From Ibsen OAC, Phelan JA: Oral pathology for the dental hygienist, ed 5, Philadelphia, 2009, Saunders.)

2. Cyst involvement may occur with an odontoma

F Histologic characteristics—tumor in which epithelial and mesenchymal cells show differentiation, resulting in abnormal enamel and dentin formation

G Treatment and prognosis

1. Complete surgical removal (both forms are well encapsulated)

2. Prognosis is good

Gingival Fibromatosis

General Characteristics

A Enlargement of gingival tissue, sometimes covering teeth

B Contains a proliferation of dense fibrous connective tissue

C Classification includes

1. Irritative fibromatosis—localized areas associated with extraneous irritants

2. Hereditary fibromatosis—generalized enlargement of gingival tissue

3. Chemical fibromatosis—caused by certain medications (drug-influenced gingival enlargement)

Irritative Fibromatosis

A Etiology—irritant such as mouth breathing, orthodontic appliances, bacterial plaque biofilm, dental calculus, debris, overhanging restorations, or ill-fitting dental appliances

B Age and gender related—any age; no gender predilection

C Location—localized areas on interproximal papillae; in mouth breathers, on maxillary and mandibular anterior labial gingivae

D Clinical features—solitary round, smooth-surfaced, pink enlargement of papillae; well attached to surrounding structures

E Histologic characteristics—proliferation of dense, fibrous connective tissue with an increase in the number of fibroblasts

F Treatment and prognosis

1. Removal of the irritant

2. Improved oral hygiene

3. Gingivectomy in severe cases

4. Prognosis is excellent

Hereditary Gingival Fibromatosis (Gingival Lesions of Genetic Origin)

A Etiology (see the section on “Genetics” in Chapter 7)

1. Hereditary; believed to have genetic or developmental involvement or to be related to hormonal imbalances; a component of several syndromes (e.g., Zimmerman-Laband, Cross, Rutherfurd, Murray-Puretic-Drescher, and Cowden’s syndromes)

2. Contributing factors include poor oral hygiene, food impaction, calculus, malocclusion

3. Other conditions associated with gingival fibromatosis may include growth hormone deficiency, hypothyroidism, epilepsy, and intellectual and developmental disabilities (IDD)

B Age and gender related—appears during the eruption of primary or permanent teeth; slightly more common in females

C Location—excessive enlargement of interproximal gingival tissues; can be localized

D Clinical features

1. Gingival enlargement may be generalized or localized

2. Diffuse, smooth-surfaced, pink, firm tissue involving the interproximal papillae

3. Multiple protruding pink, stippled, firm masses; labial and buccal areas are most affected; teeth may be displaced; delays eruption of teeth

E Histologic characteristics—bundles of fibrous connective tissue with fibroblasts and fibrocytes (depending on the formative stage)

F Treatment and prognosis

1. Gingivectomy

2. Rigid adherence to home care

3. Recurrence is common

Chemical Fibromatosis (Drug-influenced Gingival Enlargement)

A Etiology—reaction to drugs, specifically phenytoin (Dilantin); calcium channel blockers including nifedipine (Procardia), amlodipine (Norvasc), diltiazem (Cardizem), and verapamil (Calan); cyclosporin, an immunosuppressant drug given in association with organ transplants

B Age and gender—no gender predilection

C Location—papillae and gingivae

D Clinical features—smooth, pink, firm enlargement of the papillae (Figure 8-19)

FIGURE 8-19 Drug-influenced gingival enlargement. A, Gingival enlargement caused by phenytoin (Dilantin). B and C, Gingival hyperplasia caused by nifedipine (Procardia). (A, Courtesy of Dr. Edward V. Zegarelli; B and C, Courtesy of Dr. Victor M. Sternberg; A to C, from Ibsen OAC, Phelan JA: Oral pathology for the dental hygienist, ed 5, Philadelphia, 2009, Saunders.)

E Histologic characteristics—extensive proliferation of connective tissue

F Treatment

1. Change in the prescribed medication, if possible

2. Gingivectomy

3. Improved oral self-care

Ulcerative Diseases

General Characteristics

A Ulcer—formed by the destruction of the epithelium and some underlying tissue

B Factors aiding in the diagnosis of ulcers occurring in the oral cavity

5. Patient history (personal, health, cultural, and pharmacologic)

C Etiology—not always known

D Can be classified as an acute or chronic condition

1. Acute ulcerative conditions include traumatic ulcers, aphthous ulcers, allergic reactions, and viral ulcerations

2. Chronic/>

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Tags: Mosbys Comprehensive Review of Dental Hygiene

Jan 1, 2015 | Posted by mrzezo in Dental Hygiene | Comments Off

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8: Oral Pathology

Oral Pathology

Irritative Fibroma (or Traumatic Fibroma) (see Figure 8-1)

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