" "

Before starting Dr.RIMA assigned that there will be an AVG by 5 marks

on labs lec.s, so you have to be ready to answer any Q related to lectures
and you may asked more than one Q during the whole sem.
Firstly, Dr.Rima whishes for us all the luck for this course, and she wishes
that ORAL PATHOLOGY 2 will be easier than ORAL PATHOLOGY 1
according to us.
Unfortunately, Dr didn't give full lec. Because of having meeting on
12:00 and she promised us that this shortage will be compensated later
on.
So let's start the first lec. Which is about hyperplasia this lec. Covers
the slides ( 2-27)


Hyperplasia, Neoplasia and related disorders of oral
mucosa.

Slide #2
What's the difference between hyperplasia and neoplasia?
increasing in cells number but under control of Hyperplasia :
normal cell cycle proteins due to stimulus, but the hyperplastic
tissue will regress after stimulus removal.
loss of normal control of cell cycle due to mutation, Neoplasia:
so in this process there will be proliferation for ever ( abnormal
control of cell cycle).

Slide # 3
Hyperplasia of oral mucosa is usually localized. -
-How does localized hyperplastic oral mucosa will be clinically?
Will it be flat?
It will not be flat; it will look like increasing-sized exophitic
mass.
Note: most of the localized hyperplastic lesions in oral mucosa
, which is caused by chronic inflammation are caused by
1-chronic mechanical trauma like in case of over-extended
denture; which causes non-sever trauma (NO ulceration, NO
bleeding, but it's CONTINOUS)
Friction. 2-
Heat. 3-
Plaque and calculus accumulation of food debris on gingiva , 4-
( kinds of irritants to gingival, deposit on tooth surface and
induce chronic inflammation so lead to hyperplasia ).
-Inflammation and repair together will produce hyperplasia of
oral mucosa.
Dr. said that we studied inflammation process, inflammatory
mediators, production of granulation tissue, proliferation of
endothelial cells and increasing of fibroblastic nom.
-Excessive production of granulation tissue will cause exophilic
mass .
-Usually the hyperplasia of oral mucosa due to over growth of
granulation tissue is relatively avascular , because this
granulation tissue varies in cellualrity and vascularity which
could be a scar-like due to decreased in cellularity and
vascularity.
-We conclude that hyperplasia of oral mucosa is caused by
chronic inflammation of variable sources.
any where in the mouth but if it's Location of hyperplasia:
epulis. it's called gingiva occurred in the
Epulis :non-neoplastic localized, reactive over-growth mass in
gingiva . the oral mucosa specifically
Slide # 4
Kinds of epulis:
Fibrous epulis. -
-Vascular epulis
Peripheral giant cell granuloma. -
What are the differential diagnosis of hyperplasia in the oral
mucosa? What could the epulis be?
Pyogenic granuloma vascular epulis. -
but it's , separated entity Peripheral giant cell granuloma -
vascular lesion because of high capillary content.
Peripheral ossifying fibroma considerd as fibrous epulis -
irritation fibroma -
-Giant cell fibroma
Retrocuspid papilla -
All these may enter the differential diagnosis of epulis.
Slide # 6
Epulides ( plural of epulis )
Again, epulis is hyperplastic growth of the gingiva which has in
these lesions are lesion, its differential diagnosis more than one
divided into vascular and fibrous and PGCG.
In general comparison between vascular and fibrous epulis *
-Vascular epulis : red, soft, edentulous and easily bleeding
mass.
-Fibrous epulis : not easily bleeding mass, like adjacent
epithelial color.
Look at this pic. This is localized
mass on gingiva, slightly pinkish.
This lesion is firstly described
until proving its clinically as epulis
microscopically. diagnosis

Slide # 7 :
Epulides :
More common on females.
More common on max. than mand. ( with some exceptions).
Occur mainly anteriorly to molars, rarely present posteriorly to
molars.
Recurrence is possible when: 1- causative factors are not
removed (when the plaque and calculus are not controlled ,
and teeth are not clean ;for example )
ell c iant g eripheral p as in PGCG ( Or in incompletely excision - 2
) ranuloma g
Slide # 8
Firstly, what is the difference between pedunculated and
sessile?
Pedunculated: constructed base of the lesion.
Sessile: broad base of the lesion.
of fibrous epulis? atures clinical fe What are the *
-Pedunculated or sessile.
-Firm.
-Similar on color to adjacent gingiva.
Presence / absence e of ulceration according to a trauma. -
Bleeding is NOT a feature, unless secondarily trauma occurred.

Slide # 9 and 10
Histopathology of fibrous epulis:
1-Cellular variability: according to number of cells;
-If there is cellular fibrous stroma (if you can see the nuclei of
fibroblasts) so it's peripheral ossifying fibroma.
: bone ng ossifyi outside the bone; in gingiva, (peripheral:
: cellularity of fibrous fibroma matrix, formation in fibrous
tissue. )
-If the number of nuclei is small by the presence or absence of
calcification then it's acellular fibrous tissue so it's hyperplastic
gingivitis.
Mature collagen. 2-
3-Inflammatory infiltration is present in most of the gingival
biopsies, because gingiva is exposed to plaque and calculus
accumulation ( the source of bacteria) , the main infiltration is
plasma cells. the
-Hyperplastic lesion reacts with plaque and calculus on gingival
specifically, so it's common to have inflammatory infilteratation
on epulides.
Bone formation. 4-
5-Stroma could be less cellular and less vascular so it's called
hyperplastic gingivitis.
this image in the slide is cellular fibrous tissue ( see the black
dots ) contains calcified material in the center, so it's peripheral
ossifying fibroma.
This biopsy could be from gingiva because black dots indicate
plasma cells which are the main infiltration of inflammation ,
which is most occurred on gingiva.



Slide # 11

(2) ) 1 (
Which one of these epulides is sessile and which one is
pedunculated?
(1)is pedunculated lesion because of base construction.
(2) is sessile because the base is flat or broad.
ulcerated vascular epulis. secondarily emage (1) is Note :

Slide # 15 :
Clinical features of vascular epulis:
-Dark red-purple: because of high vascularity so having
different color of adjacent tissue.
-It may secondarily ulcerated.
Easily bleeding. -
-Soft, because of having a lot of blood vessels, unlike
fibrous epulis which is fibrous tissue having a lot of
collagen ( firm tissue ).
-Rapidly growth specifically pyogenic granuloma, so it
may reach a big size even in one week, and the clinician
may think that it's malignant tumor.
Usually there is a history of trauma. -

but it pyogenic granuloma is common on gingiva , Imp. Note:
this may occur in any part of the mouth such as lip and skin ,
point is very important to distinguish it from other lesions
not on , only which occur just in gingiva and alveolar mucosa
buccal mucosa or soft palate.
What is the difference between gingiva and alveolar mucosa? -
Alveolar mucosa: in case of teeth absence or extracted teeth.
Gingiva : in case of teeth presence.
Both seen on slide # 21.
Slide # 16
If pyogenic granuloma occurs in pregnancy on gingiva then it's
pregnancy epulis. called
Pregnancy epulis = pyogenic granuloma=lobular capillary
hemangioma.
Why does pyogenic granuloma occur usually on pregnancy? -
endothelial cells in gingiva are responsive to Pregnancy
hormones such as estrogen and progesterone because of
having receptors for these hormones, so these hormones
stimulate endothelial cells proliferation, so pyogenic granuloma
reach a big size during pregnancy.
removal of pyogenic granuloma in pregnancy surgical Note:
should be delayed because if it's removed it will recur again,
because she(pregnant pt.) still have the same receptors and the
same hormones, so the treatment should be delayed after
except in some cases. delivery

Slide # 17, 18
Pyogenic granuloma could occur on lip or skin due to trauma,
and it's vascular and bleeds easily.
In the tongue as in the image it could be pale because this
chronic lesion ( pyogenic granuloma) will have less vessels and
more fibrous so color is more pale and bleeding is decreased.
Although it looks pale and firm but it's pyogenic granuloma that
happens when it's mature and become chronic so become
more fibrous.
any reactive tissue could have mineralized tissue Note:
formation such as gingivitis.
may be a bone formation on the tongue as an : there Note
ectopic lesion.
Slide # 19
Histopathology of pyogenic granuloma:
Look at the image in this slide, look at the spaces which are
capillaries and there are fibrous septa.
1-This represent pyogenic granuloma as lobular capillary
: lobules separated by fibrous septa, lobular hemangioma (
use of having small blood vessels not : beca capillary
having a lot of vascular spaces). : hemangioma *cavernous,
Cavernous : dilated blood vessel.
This term (lobular capillary hemangioma) is the 2
nd
name of
pyogenic granuloma but it's more descriptive.
2- Highly vascular proliferation.
Presence / absence of ulceration due to trauma. 3-
4-Older lesions are getting more fibrous and pale as seen on
the tongue image.
Slide # 20
Treatment of pyogenic granuloma:
Surgical removal of the irritant or the cause to avoid
recurrence.
But in pregnancy it's delayed.
Slide # 21
Peripheral giant cell granuloma





Slide # 22
-So when having central giant cell granuloma we should
measure parathyroid hormone level to rule out
hyperparathyroidism.
Both PGCG and CGCG are non-neoplastic, both look like each
other clinically because CGCG perforate the bone and PGCG
occur on gingival and alveolar mucosa, and in both cases we
should ask about parathyroid hormone level, but they could be
distinguished radiographically.
Remember: central giant cell granuloma: bony lesion occur ant. To
mand. Contain multi nucleated giant cells and stroma of fibroblast like
cells, and (?) and it's vascular because of having plenty of capillary.
And it looks like brown tumor of hyperparathyroidism.
So PGCG occur on gingiva and alveolar mucosa and CGCG occur
inside the bone so when it perforates the bone it will be appear
on gingiva and alveolar mucosa.
-There maybe superficial bone erosin in peripheral type, like (
for example ) when taking radiograph and find soserization (
not sure) in alveolar bone crest that doesn't mean that this
lesion is CGCG.
What's the origin of giant cell? (From where it arises)? -
Macrophages or osteeoclat or periosteum.
So the sources of PGCG are: macrophages, osteocalst and
periosteum.
and alveolar mucosa. : PGCG occurs only on gingiva Note

Slide # 23, 24
-PGCG is usually red because of having a lot of capillaries and
RBC's such the case in CGCG,and there maybe hemosidren
presence due to RBC's destruction.
-It's commonly ulcerated.
If PGCG occurs on interdental papilla it will look like hour-glass,
so named because it's squeezed between teeth.
And it protrudes buccally and lingually and constructed in the
middle as in slide # 25.
So in PGCG diagnosis we have to rule out both CGCG and
in NOT hyperparathyroidism, but this ruling out is just on PGCG
pyogenic granuloma.
Look how vascular it is, due to these congested capillary y3ni
and by RBC's destruction hemosidren is with RBC's, full
produced that gives the lesion its brown color.
What does stromal cells mean?
Stromal cells are spindle or ovoid cells( which have capillary ,
fibroblast, macrophages, endothelial cells and inflammatory
mediators ) which are extended between these multinucleated
giant cells as seen in these slides.
Most of the reactive lesions due to a certain cause will have
bone formation and it could be found in more than one place.
slide # 25
-this is a lingual mass on gingiva ( and it could be buccally but
it's not obvious)
-this mass may occur buccally or lingually or both, it may start
buccally and then protrude lingually.
-Because most of the calculus occurs lingually, so the masses
could occur lingually.
Slide # 26
we should rule out multiple PGCG In case of
hyperparathyroidism mainly, and in rare cases
neurofibromatosis 1.
Slide # 27
Treatment of PGCG:
-Local excision and removal or correction of underlying cause to
prevent recurrence.
-If PGCG not treated well or not completely removed it will
recur by 60% that means more than half of the cases will recur
and Dr. said that the AVG is 10%!!
- -
I have changed the order of some points to ease its studying.
Special thanks to my twin.
Bone by Nays }aiauat