boards’ fodder #1

Oral Disease, Part 2

by Helena Pasieka, MD

CLINICAL PATHOLOGY TREATMENT ASSOCIATIONS

SALIVARY GLAND DISEASES

Mucocele Painless submucosal swelling. Collection of mucus surrounded Superficial mucoceles often
Color ranges from clear/blue/ by macrophages and granula- resolve w/o intervention
colorless depending on depth of tion tissue. Look for the inflamed by spontaneous rupture.
lesion. Lower labial mucosa most minor salivary gland as a clue. However, most require surgi-
common, but can occur anywhere cal excision.
where there are minor salivary
glands.

Cheilitis Ranges from slight hypertrophy of Localized dense accumulations Vermilionectomy of the lower
glandularis lower lip to nodular enlargement of inflammatory cells within and lip, with or without cosmetic
with eversion. Most commonly in around the mucous glands in a debulking is the standard of
adult men. background of actinic chelitis. care. Injections of cortico-
steroids can provide symp-
tomatic relief..

Sjögren’s Slow onset of variable degrees of Salivary glands with focal aggre- Symptomatic care and
syndrome eye and oral dryness. Increased gates of >50 lymphocytes adja- management of the associ-
dental carries and difficulty wearing cent to normal-appearing acini. ated complications. Salivary
dentures. Increased candidiasis. In the parotid gland characteristic stimulation (sugarless gum,
epimyoepithelial islands are seen. hard candies, pilocarpine)
or artificial saliva.

Salivary gland Submucosal, painless, rubbery Varies depending on the specific Benign salivary gland tumors
tumors firm swelling often noted on the type of salivary tumor. are conservatively excised.
posterior hard palate or anterior Malignant tumors are more
soft palate. extensively removed +/-
radiotherapy as adjunct.

HEMATOLOGIC/ONCOLOGIC DISEASE

Chemotherapy- Multiple oval or irregularly shaped Lichenoid mucositis. Usually resolves in 2-3
induced ulcers, usually on the gingivae, weeks cessation of chemo-
mucositis lateral tongue, or buccal mucosa. therapy. Palifermin (kerati-
Usually appear 4-7 days after che- nocyte growth factor) may
motherapy administered. reduce severity for those on
high-dose chemotherapy.
Meticulous oral hygiene and
symptom management.

Leukemia Many oral manifestations, most Infiltration of leukemic cells into Multi-agent chemotherapy
commonly bruising or hemorrhage gingival connective tissue (most and peripheral blood stem
related to thrombocytopenia. Also, commonly with monocytic or cell or bone marrow trans-
pallor of anemia, increased viral, myelomonocytic leukemias). plantation are most com-
fungal and bacterial infections monly used to treat acute
related to leukopenia. Diffuse, firm, leukemia.
non-tender gingival enlargement
can be caused by infiltration of
the gingival connective tissue by
leukemic cells.

Lymphoma Slow growing, painless, soft or Infiltration of atypical lympho- Chemotherapy and/or HIV, other iImmuno-
rubbery, with purplish swelling. cytes, usually of B-cell type. monoclonal antibodies (e.g. suppression, older
Most commonly on the palate and rituximab). age.
the buccal vestibule. Overlying
telangiectasia sometimes seen.
Ulceration possible, mimicking
SCC.

Melanoma Most commonly on hard palate, Proliferation in epithelium and Wide surgical excision with
maxillary attached gingiva. Has infiltration of the connective tissue (-) margins. Sentinel lymph
same features as cutaneous mela- by atypical melanocytes, with or node biopsy for prognosti-
noma. without melanin production. Can cation. Minimal radial growth
Helena Pasieka, MD, is use Melan-A or S100 to stain. phase on mucosa, so they
a second year resident differ from cutaneous mela-
nomas in that they present
in the department of
in the vertical growth phase.
dermatology at Johns Chemotherapy and XRT of
Hopkins University. little utility. Worse prognosis
than cutaneous lesions,
w/5year survival rate of
~15%, and median from dx
of < 2 years.

D­Rirections
in
esidency p. 2 • Fall 2012
 boards’ fodder #1
Oral Disease, Part 2 (continued)
by Helena Pasieka, MD

CLINICAL PATHOLOGY TREATMENT ASSOCIATIONS

MANIFESTATIONS OF SYSTEMIC DISEASE

Amyloidosis Firm macroglossia, often with scal- Homogeneous eosinophilic accu-

loped edge. Xerostomia or dysgeu- mulation. (+) congo red stain.
sia can be seen before the onset
of tongue enlargement.

Pernicious Gradual onset of smooth, ‘beefy- Absence of filiform papillae. Vitamin B12 injections pro-
anemia red’ tongue, w/ill-defined areas vide rapid improvement.
of erythema which can coalesce
into diffuse dorsal tongue involve-
ment causing a smooth, beefy-red
appearance.

Crohn’s dis- Linear fissures +/- ulcers of the Non-necrotizing granulomatous Respond to therapy for
ease vestibule or “cobblestone” ulcers inflammation. bowel lesions. Topical or
of the buccal mucosa. Sometimes intralesional corticosteroids
scarring. Can also have cheilitis also effective.
granulomatosa both clinically and
histologically.
Pyostomatitis “Snail track” arrangement of mul- Intra- or subepithelial microab- Management of the underly- Inflammatory bowel
vegetans tiple tiny, creamy-yellow pustules scesses containing eosinophils ing GI disease often results in disease.
set against a bright erythematous and neutrophils. improvement of oral lesions.
background. Fragile pustules lead
to shallow erosions and ulcerations.
Labial, gingival and buccal mucosa
are most commonly involved;
tongue is usually spared.
HIV
Kaposi’s sar- Multiple violaceous macules, Infiltration of the dermis w/slit-like May improve or resolve with
coma plaques, or nodules. Most common- vascular spaces, and dilated ves- improved immune status (i.e.,
ly on palate, but can be anywhere sels. Many extravasated RBCs and initiation of HAART).
in mouth. proliferating spindle cells seen.
Oral hairy White, shaggy, corrugated protru- Irregular keratin projections, para- Antiretroviral therapy may Epstein-Barr virus
leukoplakia sions on lateral tongue. Cannot be keratosis, acanthosis, and groups lead to regression. in HIV. Predictor of
dislodged with tongue depressor. of pale epithelial cells. rapid decline and
progression to AIDS.
Candidiasis Thick white or cream-colored Pseudohyphae and budding yeast Improvement of immune sta-
deposits on tongue or posterior oro- sometimes seen in H&E. More tus. Anti-candidal treatment,
pharynx with “cottage cheese-like” easily seen with PAS or GMS stain. such as clotrimazole troches
appearance. Can be dislodged with or PO fluconazole.
tongue depressor. Also can have fis-
suring at the corners of the mouth.
HSV Grouped vesicles on erythematous Epidermal necrosis and ballooning Suppressive therapy with
base, becoming ulcerated. Can degeneration. Infected cells are antiviral medications.
coalesce into larger lesions. Look multinucleated w/glassy nuclear Severely immunosuppressed
for scalloped border. contents, marginalized nuclear may need IV acyclovir.
chromatin, and nuclear molding.
CMV Ulcerations anywhere in mouth. Vascular dilation with large cytome- Antiviral drugs (ganciclovir Development on
Appear like aphthae, may be slightly galic endothelial cells. “Owls eye” and valganciclovir). mucosal surface
larger. appearance due to halo around usually a sign of dis-
intranuclear inclusion bodies. seminated disease.
SYNDROME ASSOCIATIONS
Odontogenic Often incidentally noted radiolu- Lining of stratified squamous epi- Opinions differ and range Nevoid basal cell
keratocysts of cent or mixed radiolucent/radi- thelium with basal layer of the epi- from wide local excision to carcinoma syndrome
the jaw opaque lesions of the mandible. thelium exhibiting palisaded cuboi- marsupialization to curettage. w/mutations in PTCH
Asymptomatic; rarely mild facial dal to columnar cells. The luminal (Hedgehog signaling
swelling and discomfort. surface often with a corrugated pathway).
morphology and parakeratosis.
Multiple Asymptomatic facial deformity. Same as typical solitary osteomas. Surgical removal, screening Often the earliest
osteomas of for malignancy. marker of Garner
the jaw syndrome occur-
ring >80% around
puberty.
Multiple Multiple mucosal neuromas involv- “Plexiform neuromas” of hyper- Screening for malignancy:
endocrine ing lips and tongue are often the plastic bundles of nerves sur- Medullary thyroid carcinoma
neoplasia first dermatologic manifestation. rounded by a thickened perineu- with pheochromocytoma in
syndrome type rium. 50% of cases, and digestive
2B neurofibromatosis.
Sources:
1. Bolognia JL, Jorizzo JL, Rapini RP eds. Dermatology. 2nd ed. Mosby; 2007.
2. Rapini R. Practical Dermatopathology. Mosby; 2005.

D­Rirections
Special thanks to Dr. Gary Warnock.
in
Fall 2012 • p. 3 esidency