reactive and neoplastic lesions

• Oral Soft Tissue Tumors

  • Reactive & Neoplastic
  • Muscular Tissue
  • Fibrous Tissue
  • Neural Tissue
  • Fat Tissue
  • Vascular Tissue
• Prof. Natheer Al-Rawi


  February 5th 2024
• Learning Objectives


  • Understand the clinical, histological and the treatment of different oral soft tissue tumors
  • Determine the causes of these lesions
  • Ability to classify these tumors according to their tissue of origin

  
• Swelling & tumors of Oral Cavity

  • Cysts
  • Mucous Extravasation & Retention minor SG lesions
  • Foci of Granulation Tissue & inflammation
  • Abscesses
  • CT proliferation
  • Infiltrative sarcoma
  • Carcinomas
• Clinical Characteristics of any soft tissue swelling

  • Location
  • Coloration
  • Surface texture
  • Palpable nature

  
• Location of Lesions


  • Lip & Buccal Mucosa
  • Gingiva
  • Palate
  • Dorso-lateral tongue
  • Ventral tongue & FOM
• Coloration of Lesions


  • Blue purple
  • Red
  • Brown
  • Black
  • Yellow orange
• Palpation Characteristics


  • Soft, Fluctuant
  • Soft, Non-Fluctuant
  • Firm, movable
  • Firm, Fixed
  • Indurated, Fixed
• Majority of Oral Submucosal masses are Reactive Proliferation (e.g, fibrous hyperplasia, Pyogenic granuloma, Mucous extravasation and retention cysts)
• Uncommon: Mesenchymal & SGT
• Rare: Lymphomas & Sarcomas
• Epulis


  Reactive hyperplastic fibrous tissue lesions

  
• Prerequisites of epulis


  • Periodontium starting from fibrous tissue fibroblast
  • PDL
  • Subgingival calculus is the trigger for such lesions
• Fibroma (Irritation fibroma, Traumatic fibroma, Fibrous Hyperplasia)


  True neoplasm or reactive hyperplasia of fibrous CT in response to local irritation
• Fibroma


  • Smooth-surfaced pink nodule, similar in color to the surrounding mucosa
  • Most fibromas are sessile, some are pedunculated
  • Size: few mm.to several cm. (average 1.5 cm.)
  • Symptomless unless secondary traumatic ulceration of the surface had occurred
  • Age of onset: 4th to 6th. Decades of life

  
• Fibroma Histopathology: Nodular mass of fibrous CT covered by stratified squamous epith. which may show atrophy of the rete ridges, the CT is usually dense & collagenized with scattered chronic inflammatory cells, Lesion is not encapsulated, Collagen bundles arranged in radiating, circular or haphazard fashion

  
• Giant Cell Fibroma


  A mass of fibrous CT which is usually loosely arranged, Presence of numerous large, stellate fibroblasts within the superficial CT, These cells may contain several nuclei, Covering epith. Is thin & atrophic, with some rete ridges that appear narrow & elongated

  
• Epulis Fissuratum (Denture Epulis, Inflammatory Fibrous hyperplasia)


  Tumor-like hyperplasia of fibrous CT that develops in association with the flange of an ill-fitting complete or partial denture
• Epulis Fissuratum


  • Single or multiple folds of hyperplastic tissue in the alveolar vestibule, There are 2 folds of tissue, & the flange of the associated denture fits conveniently into the fissure between the folds of tissue, This tissue is firm & fibrous but sometimes appear erythematous & ulcerated, Site: Facial aspect of the alveolar ridge especially the anterior portion of the jaw, Size: From less than 1cm. to massive lesion that involve most of the length of the vestibule, Age of onset: Middle aged & older adults with ill- fitting dentures. With female predilection

  
• Fibro-epithelial polyp or leaf-like denture fibroma


  Occurs on the hard palate beneath a maxillary denture, as flattened pink mass that is attached to the palate by a narrow stalk, The edge of the lesion is often serrated & resembles a leaf
• Epulis Fissuratum Histopathology: Hyperplasia of fibrous CT, The overlying epith. Is hyperkeratotic & demonstrates irregular hyperplasia of the rete ridges, Pseudo-epitheliomatous hyperplasia may be seen especially at the base of the grooves between the folds, Variable chronic inflammatory cell infiltrate is present, Rarely, osteoid or chondroid tissues is observed (osseous & chondromatous metaplasia)

  
• Inflammatory Papillary Hyperplasia (Denture Papillomatosis)


  Reactive tissue growth that sometimes develops beneath a denture, Related to ill-fitting denture, poor denture hygiene, wearing the denture 24 hours a day, Candida also has been suggested as a cause, but any possible role appears uncertain
• Inflammatory Papillary Hyperplasia


  • Asymptomatc, erythematous & has a papillary surface, Site: hard palate beneath the denture base
• Inflammatory Papillary Hyperplasia Histopathology: Numerous papillary growths on the surface that are covered by hyperplastic stratified squamous epith., In advanced cases, pseudoepitheliomatous hyperplasia(mistaken for carcinoma), The CT can vary from loose & edematous to densely collagenized, Chronic inflammatory cells infiltrate

  
• Treatment of Inflammatory Papillary Hyperplasia

  1. Very early lesion: removal of the denture to let the condition subside & tissue resume a normal appearance

  2. Topical & systemic antifungal therapy

  3. Advanced lesions: Excision of the hyperplastic tissue before fabricating a new denture
• Pyogenic Granuloma


  Common tumor-like growth of the oral cavity that is considered to be non-neoplastic in nature, It represents an exuberant tissue response to local irritation or trauma
• Pyogenic Granuloma

  • Smooth or lobulated mass that is usually pedunculated, although some lesions are sessile, The surface is characteristically ulcerated& ranges from pink to red to purple, depending on the age of the lesion, Young pyogenic granulomas are highly vascular in appearance, Older lesions tend to become more collagenized & pink

  
• Sites of Pyogenic Granuloma

  • Gingival inflammation & irritation due to poor oral hygiene
  • Lip, tongue & buccal mucosa
  • Maxillary gingiva more than mandibular gingiva
  • Anterior areas more than posterior areas
  • Facial aspects of gingival more than lingual aspect
  • May extend between teeth & involve both facial & lingual gingiva
• Pyogenic Granuloma


  • Size: vary from small growths of only a few mm. in size to larger lesions that may measure several cm. in diameter, Painless, but bleeds easily because of extreme vascularity, May exhibit rapid growth, which may create alarm for both the patient & clinician, who may fear that the lesion might be malignant, Age of onset: Any age, but most common in young adults & children with female predilection
• Pregnancy tumor or granuloma gravidarum


  Pyogenic granulomas of the gingiva that frequently develop in pregnant women, Develops during the first trimester & their incidence increases up through the 7th. Month of pregnancy, The gradual rise of theses lesions throughout pregnancy may be related to the increasing levels of estrogen & progesterone as the pregnancy progresses, After pregnancy & the return of normal hormone levels, some of these pyogenic granulomas resolve without treatment or undergo fibrous maturation & resemble a fibroma
• Epulis granulomatosa


  Hyperplastic growths of granulation tissue that sometimes arise in healing sockets, It resemble pyogenic granulomas & usually represent a granulation tissue reaction to bony sequestra in the socket
• Pyogenic Granuloma Histopathology: Highly vascular proliferation that resemble granulation tissue, Numerous small & larger endothelium-lined channels are formed that are engorged with r.b.c., Sometimes these vessels are organized in lobular aggregates (lobular capillary hemangioma), Mixed inflammatory cell infiltrate, PMNs are more prevalent near the ulcerated surfaces while plasma cells & lymphocytes are more in deeper areas of the specimen, Older lesion may have areas with more fibrous appearance

  
• Treatment of Pyogenic Granuloma


  Conservative surgical excision, Occasionally the lesion recurred & re excision is necessary, For Pregnancy tumor, treatment is usually deferred unless significant functional or esthetic problems develop, High recurrence rate for pyogenic granuloma removed during pregnancy
• Peripheral Giant Cell Granuloma (Giant Cell Epulis)


  Common tumor-like growth of the oral cavity, Does not represent a true neoplasm but rather a reactive lesion caused by local irritation or trauma, It may represents a soft tissue counterpart of Central giant cell granuloma
• Peripheral Giant Cell Granuloma


  • Sessile or pedunculated, may or may not ulcerated, Resemble pyogenic granuloma but it is more bluish-purple compared with bright red of typical pyogenic granuloma, It may develop in anterior or posterior region of the gingival or alveolar mucosa, Mandible is slightly more affected than maxilla, Cupping resorption of the underlying alveolar bone sometimes seen, Site: Exclusively in gingival or edentulous alveolar ridge

  
• Pregnancy tumor


  Treatment is usually deferred unless significant functional or esthetic problems develop
• High recurrence rate for pyogenic granuloma removed during pregnancy
• Peripheral Giant Cell Granuloma (Giant Cell Epulis)


  • Common tumor-like growth of the oral cavity
  • Does not represent a true neoplasm but rather a reactive lesion caused by local irritation or trauma
  • May represent a soft tissue counterpart of Central giant cell granuloma

  
• Peripheral Giant Cell Granuloma


  • Sessile or pedunculated, may or may not be ulcerated
  • Resemble pyogenic granuloma but more bluish-purple compared with bright red of typical pyogenic granuloma
  • Develops in anterior or posterior region of the gingival or alveolar mucosa
  • Mandible is slightly more affected than maxilla
  • Cupping resorption of the underlying alveolar bone sometimes seen
• Site


  Exclusively in gingival or edentulous alveolar ridge