BENIGN AND MALIGNANT TUMORS OF THE ORAL CAVITY

1. banner4-1.jpg

2. CONTENTS
✓ Tumors of so) *ssues
✓ Epithelial
✓ Connec2ve 2ssue
✓ Vascular
✓ Nerve 2ssue
✓ Salivary glands
✓ Tumors of hard *ssues
✓ Nonodontogenic tumors
✓ Diseases of salivary glands

3. • Objec*ves
At the end each students should know
• What do we mean by tumors
• What do we mean by so? and hard 2ssues
• Tumors of so? 2ssues
• Tumors of hard 2ssues
• Some diseases of salivary glands

4. EPITHELIAL TUMORS
• Papilloma…..benign tumor
• carcinoma…...malignant tumor/cancer
• Melanoma…...malignant tumor

5. Epithelial tumors
A.Papilloma
Defini*on
➢ Papilloma is a benign tumor known to grow in an
outward direc*on, it produces frond-like tumors
that can develop anywhere on the body.
➢ Papilloma are also known as neoplasms.
➢ Papilloma can occur in areas throughout the body.
➢ Papilloma on the skin (cutaneous papilloma) are
commonly referred to as warts.

6. Etiology
" Viral
HPV
" Non viral
Tissue injury…... Nasal papilloma

7. CLINICAL FEATURES
• Common benign neoplasm origina*ng
from surface epithelium
• Exophy*c growth made of finger like
projec*ons
• Roughened, Verrucous or cauliflower like
appearance
• Well circumscribed, pedunculated,
• Found on tongue, lips, buccal mucosa,
gingiva & palate
• Few mms in diameter to several cms

9. • Mul*ple papillomas
are seen in focal
dermal hypoplasia
syndrome

10. • Treatment
-Excision through the pedicle

11. carcinoma
squamous cell carcinoma
basal cell carcinoma

12. Squamous Cell Carcinoma
• Defined as a malignant epithelial neoplasm
exhibi*ng squamous differen*a*on as
characterized by the forma*on of kera*n
and/or the presence of intracellular bridges.

13. Epidemiology
• South east Asian scenario-
• 6,44,600 in 19992
• Na*onal cancer Registry Programme

14. E*ology
• Unequivocally associated with Tobacco chewing habits &
usually preceded by premalignant lesions & condi*ons.
• Alcohol
• Syphilis
• Nutri*onal deficiencies
• Sunlight
• Miscellaneous- Trauma, irita*on
• Viruses- HPV,

15. Carcinoma of lip
• Occurs chiefly in elderly men
• Lower lip involved more commonly
• Greatest incidence between 55-75 years

16. E*ology
• Tobacco
• Leukoplakia

17. Clinical features
• Vermillon border of lip
• Small area of indura*on,ulcera*on or
irregularity
• Small crater-like defect
• Slow metastasis to ipsilateral lymph nodes

18. Treatment and prognosis
• Surgical excision
• X-ray radia*on
• Factors affec*ng success of treatment
• Size of lesion
• Dura*on
• Metastases
• Histologic grade

19. Carcinoma of tongue
• Comprises 25-50% of intra oral cancer
• Less common in women
• Average age range 32-87 years

20. E*ology
• Syphilis seen co-existent with carcinoma
• Leukoplakia
• Poor oral hygiene
• Chronic trauma
• Alcohol tobacco

21. Clinical features
• Painless mass or ulcer
• Painful if secondarily infected
• Lateral border or ventral surface of tongue
• If in posterior por*on of tongue-cause early
metastases & poor prognosis

22. Treatment & prognosis
• Judicious combina*on of surgery & X-ray
radia*on

23. Carcinoma of floor of mouth
• Clinical features
• Indurated ulcer
• May or maynot be painful
• Anterior part more o)en involved
• Early extension into lingual mucosa
• Limits mo*on of tongue
• Metastases to submaxillary lymph nodes

24. Treatment & prognosis
• X-ray radia*on
• Use of radium

25. Carcinoma of buccal mucosa
E*ology-
" tobacco chewing & carrying betel nut quid
• Leukoplakia
Clinical features
• Along or inferior to a line opposite occlusal
plane
• High rate of metastases

26. Treatment & prognosis
• Surgery or X-ray radia*on
• Prognosis depends on prescence of
metastases

27. Carcinoma of gingiva
• More common in mandibular gingiva
• An area of ulcera*on,erosion,or exophy*c
growth
Treatment & prognosis
-Surgical excision

28. Carcinoma of palate
• Manifests as a poorly defined,
ulcerated,painful lesion on one side of
midline
Treatment & prognosis
Both surgery & radia*on have been used.

29. MELANOMA
• Aka malignant melanoma
• Is a type of cancer that develops from the pigment
containing cells known as melanocytes which are
located between epidermis and dermis
• Typically occur in the skin but may rarely occur in
the mouth , intes*ne and eyes

30. • Neoplasm of epidermal melanocytes.
• Cutaneous melanomas are increasing in incidence.
• Among dark skinned ethics it 1 per 100,000 and in
light-skinned up to 50 and higher in some areas of the
world.
• Melanoma may occur or near a previously exis*ng
precursor lesion or in healthy appearing skin.

31. Etiology
• A) environmental factors:
• Sun exposure
• Ar*ficial UV sources
• Socioeconomic status
• Fair skin, freckles and red hair
• Number of melanocy*c nevi
• B) gene*c factors:
• Familial melanoma
• Xeroderma pigmentosum

32. Clinical features
Superficial spreading melanoma:
• Common cutaneous melanoma in Caucasians.
• Exists in a radial-growth phase called
premalignant melanosis or pagetoid melanoma
in situ.
• The ver*cal growth phase is characterized by an
increase in size, change in color, nodularity,
ulcera*on.

33. Nodular melanoma:
• Accounts for approximately 13 percent of
cutaneous melanomas.
• No clinically recognizable radial-phase growth,
exists solely in ver*cal-growth phase.
• They may be pink (amelano*c melanoma) or
pink.
• Predilec*on for back and head and neck skin of
men.

34. Len*go maligna melanoma:
• Accounts for 10 per cent of cutaneous
melanomas.
• Exists in a radial-growth phase known as len*go
maligna or melano*c freckle of hutchinson.
• Shows female predilec*on.

35. Acral len*ginous melanomas:
• Melanoma developing on the palms and soles, fingers
and toes.
• The tumor is characterized by macular, len*ginous
pigmented area around a nodule.
Mucosal len*ginous melanomas:
• Develop from mucosal epithelium that lines the
respiratory, gastrointes*nal and genitourinary systems.
Noncutaneous melanomas are common in older age.
• Len*go melanomas have aggressive course.

36. Amelano*c melanomas
• Seen as erythematous or pink, eroded nodule.

37. Oral manifesta*ons:
• Primary oral melanoma twice as common in men.
• Is range between 40-70 years.
• Predilec*on for palate and maxillary alveolar
ridge.
• Appears as deeply pigmented areas.
• Ulcerated and hemorrhagic.
• Increase in size progressively.

38. Treatment
Before it has spread
• surgery
A)er has spread
• Immunotherapy
• Biologic therapy
• Radia*on therapy
• Chemotherapy

39. CONNECTIVE TISSUE
TUMORS
• Fibroma……...benign tumor
• Lipoma……….benign tumor
• fibrosarcoma...malignant tumor

40. Fibroma
" Benign tumors that are composed of fibrous
" Aka irritation fibroma
• They usually emerge in the cheeks, tongue,
palate and gums.
• Fibroids usually grow very slowly

41. Etiology
" Unknown causes
" Tissue rxn to minor injury
" Genetic components

42. Clinical features
• Epulis fissuratum
• Sessile or pedunculated
• Asymptomatic and moderately firm
• Whiteness from the thickened surface keratin
• Ulceration from recurring trauma

43. Differential diagnosis
Pyogenic granuloma
Neurofibroma
frictional keratosis
squamous cell carcinoma

44. Treatment
• Conservative surgical excision
• It may recur a)er surgery if the source of irrita*on
con*nues so manage the source of irritation
• Oral fibromas do not disappear without
treatment.

45. Lipoma
" Benign tumor of fat
" It represents the most mesenchymal
tumor, however most of them occur in the
trunk and extremities – Head and Neck are
less common
✧ Asymptomatic and present for several
years

46. Etiology
" Hereditary condition like familial multiple
lipomatosis( but not hereditary)
" Gardeners syndrome
" Dercum’s syndrome

47. Clinical features
" Buccal mucosa and vestibule are the most
common sites
" >40 years; female = male
" Oral lipomas are soft nodular masses that
is sessile or pedunculated with yellow color
" Soft to the touch, usually movable, and are generally
painless.
" Small (<1 cm) but can enlarge (6cm<)
" Localized, lobular, non-tender
" Semi-fluctuant
" Mobile

48. DDX
Fibrosarcomas
Hernias
papilloma
Neurofibromas
Abscess
Sebaceous cyst
Epidermoid cyts

49. Treatment
• conservative local excision

50. Fibrosarcoma
Is a malignant mesenchymal tumour derived from
fibrous connec*ve *ssue
characterized by the presence of immature
prolifera*ng fibroblasts or undifferen*ated anaplas*c
spindle cells in a storiform palern.
It is usually found in males aged 30 to 40 .
It originates in fibrous *ssues of the bone and invades
long or flat bones such as femur, *bia, and mandible.
It also involves periosteum and overlying muscle

51. Etiology
" Unknown or no define causes
" May be related to genetic mutation
" As complication of other conditions

52. Clinical features
➢ No sex predilec*on
➢ Common tumors of adults, although they can occur in any age group
and even be present as congenital neoplasms.
Microscopic
➢ The cells are arranged in fascicles that intersect each other at acute
angles, resul*ng in a herringbone appearance.
➢ The individual cells resemble normal fibroblasts, and a re*culin stain
demonstrates abundant fibers wrapped around each cell.

53. Differential diagnosis
" Monophasic synovial sarcoma,
" Liposarcoma,
" Malignant fibrous histiocytoma,
Diagnosis
• Incisional or excisional biopsy

54. Treatment
" Genetic and immunohistochemical testing
" Surgical resection(standard tx)
" chemotherapy( not been encouraged)

55. VASCULAR TUMORS
• Heamangioma…...benign tumor
• Lymphangioma…..benign tumor

56. Hemangioma
" Benign tumors of mesenchymal cells
➢ Hemangiomas are the most common tumors of
the head and neck in infancy and childhood,
➢ Comprising approximately 7% of all benign so)
*ssue tumors .
" Etiology…..congenital

57. classification
congenital hemangioma
cavernous hemangioma
capillary hemangioma
central hemangioma

58. Clinical features
➢ Most common tumors of infancy
➢ More common in females (3:1)
➢ Most common in Head and Neck (60% of
cases)
➢ Mostly occurs as single lesions
➢ Red/blue lesions that occur in skin, lips,
tongue and buccal mucosa;
➢ The lesion blanches when compressed
➢ Intraosseous lesions also occur – Mandible >
Maxilla and occurs as multilocular

59. DDX
Macular stains
Vascular malformation
Pyogenic granuloma

60. Investigation
➢ Imaging techniques(CT scan and MRI) are
used as diagnos*c aids to document the
extent of the deep hemangioma.
➢ Arteriography is rarely indicated for the
diagnosis of a hemangioma.

61. Treatment
" Most congenital lesions will involute
(“Watchful Neglect”)
➢ Surgical removal and sclerotherapy with 95%
ethanol
➢ Corticosteroid medication
➢ Laser treatment
➢ Medicated gel

62. Lymphangioma
Definition
• Benign hamartomatous tumors of lymphatic
vessels
• Most frequent site in the oral cavity - anterior
2/3 of the tongue where it causes
MACROGLOSSIA
• Pebbly surface resembling cluster of
translucent vesicles (similar to frog eggs)

63. Etiology
" Lympha*c system blockage
- maternal alcohol, viral infec*on
" Gene*c disorder

64. Classification:
• Capillary lymphangioma
-Capillary lymphangioma are composed of small,
capillary-sized lympha*c vessels and are
characteris*cally located in the epidermis.
• Cavernous lymphangioma
- Composed of dilated lympha*c channels
- Characteris*cally invade surrounding *ssues.

65. ✓ Cys*c hygromas
✓ Cys*c hygromas are large, macrocys*c
lymphangiomas filled with straw-colored,
protein-rich fluid.
✓ Hemangiolymphangioma
✓ Hemangiolymphangioma are lymphangioma
with a vascular component.
.

66. Cyst’s size based
classification According to the size of their cysts.
➢ Microcys*c lymphangioma
➢ Microcys*c lymphangioma are composed of cysts,
each of which measures less than 2 cm3 in volume.
➢ Macrocys*c lymphangioma
➢ Macrocys*c lymphangioma contain cysts measuring
more than 2 cm3 in volume.
➢ Mixed lymphangioma
➢ Lymphangioma of the mixed type contain both
microcys*c and macrocys*c components

67. Clinical features
" Predilection to the head and neck with 50 –
75% occurring
" Cavernous lymphangiomas are most
common in oral cavity
" These malformations can occur at any age and
may involve any part of the body
" But, 90% occur in children less than 2 years of age
and involve the head and neck.

68. Vascular tumors
✓ Lymphangioma of so) *ssue showing dilated
spaces lined by flalened endothelium.
✓ A scalering of lymphocytes is present in stroma

69. Vascular tumors
Treatment
• surgery
• sclerotherapy

70. TUMORS OF NERVE
TISSUES
• Neurofibroma
• Neurofibromatosis
• Trauma2c neuroma

71. Tumors of nerve *ssues
A.Neurofibroma
Definition
o Benign tumor arising from CT of nerve sheath.
o Horizontal mobility only.
o Most common

72. Tumors of nerve *ssues…ctd..
o Consists of neural (ectodermal) &
fibrous(mesodermal) elements.
o Benign
o Single/ mul*ple
o Fusiform swelling in the direc*on of nerve

73. Tumors of nerve *ssues…ctd..
• Sites
• Cranial
• Spinal
• peripheral

74. Tumors of nerve *ssues…ctd..
Types of neurofibroma
• Nodular
• Plexiform
• Generalised
• Elephan*a*c
• Pachy dermatocoele

75. Tumors of nerve *ssues..ctd..
Nodular
o Commonly affects peripheral
nerves
o Adults
o Single , smooth, firm
o Moves perpendicular to the direc*on of the nerve.
o Presents as painful subcutaneous nodule.
o Skin can be li)ed up.

76. Tumors of nerve *ssues…ctd..
Plexiform
• Can grow from nerves in the skin or
• From more internal nerve bundles,& can be large
• Skin can be li)ed up.
• Tingling paresthesia
• Obstructs vision
• Erodes into bone, orbit & deeper structures
• Myxomatous degenera*on

77. Tumors of nerve *ssues…ctd..

78. Tumors of nerve *ssues…ctd..
Generalized
✓ Aka von Recklinghausen’s disease
✓ Inherited autosomal disease
✓ 1 in 4000 births
✓ 2 types-
– Type 1- chr.17 muta*on
– Type 2- chr.22 muta*on

79. Tumors of nerve *ssues…ctd..
• So), non-tender, mul*ple
• Skeletal deformi*es
• Neurological disturbance
• Café au lait spots
• Lisch nodules
• May be associated with MEN type2b

80. Tumors of nerve *ssues…ctd..

81. Tumors of nerve *ssues…ctd..

82. Tumors of nerve *ssues…ctd..
Elephan2a2c
❖ Advanced stage of plexiform variety
❖ Involves limbs
❖ Dry, coarse, thick skin
❖ Congenital origin

83. Tumors of nerve *ssues…ctd..
Pachydermatocele
• Variant of plexiform NF
• Neck is involved

84. Tumors of nerve *ssues…ctd..
Treatment
Excision-
❑ Symptoma*c
❑ Cosme*c
❑ Recent increase in size
❑ Malignant transforma*on

85. Tumors of nerve *ssues…ctd..
B.NEUROFIBROMATOSIS
Definition
A Neurofibromatosis is an autosomal dominant
gene9cally-inherited disorder in which the nerve
9ssue grows abnormally to form tumors
(neurofibromas) that may be benign or may cause
serious damage by compressing nerves and other
9ssues

86. Tumors of nerve *ssues…ctd..
• Affects all neural crest cells (Schwann
cells, melanocytes and endoneurial fibroblasts).
• Melanocytes also func*on abnormally in this
disease, resul*ng in disordered skin pigmenta*on
and café au lait spots.
• Approximately half of cases are due to de
novo muta*ons and no other affected family
members are seen.
• It affects males and females equally.

87. Tumors of nerve *ssues…ctd..
NEUROFIBROMATOSIS TYPE1
( von Recklinghausen disease)
• Mul*system neurocutaneous disorder
• Most common phakomatosis
• Most common inherited CNS disorder, autosomal
dominated disorder
• 1:3000, M:F
• 50% inherited, 50% spontaneous

88. Tumors of nerve *ssues…ctd..
• The diagnosis of NF1 is made if any two of the
following 7 criteria are met:
• 1. Two or more neurofibromas on or under the
skin, or one plexiform neurofibroma (a large
cluster of tumors involving mul*ple nerves)

89. Tumors of nerve *ssues…ctd..
• 2.Freckling(crowe sign) of the groin or
the axilla 2-3mm in diam .
3 .Café au lait spots:(Hallmark of NF1)
- Six or more measuring
5 mm in greatest diameter
in prepubertal individuals
and over 15 mm in greatest
diameter in postpubertal
individuals.

90. Tumors of nerve *ssues…ctd..
• 4. Lisch nodules
(hamartomas of iris),
freckling in the iris-
2 or more
5. Tumors on the op*c nerve,
also known as an op*c glioma

91. Tumors of nerve *ssues…ctd..
• 6. A dis*nc*ve osseous lesion
such as sphenoid dysplasia or
cor*cal thinning of
long bones with or
without pseudoarthrosis.
• 7. A first degree rela*ve with NF 1 whose
diagnosis was based upon these criteria.

92. Tumors of nerve *ssues…ctd..
Sign and syndrome
• Macrocephaly in 30-50% of the pediatric
popula*on without any hydrocephalus
• Epilepsy (seizures)
• Juvenile posterior len*cular opacity
• Scoliosis with or without kyphosis
• Hydrocoele
• Early puberty

93. Tumors of nerve *ssues…ctd..
Neurofibromatosis type 2 (NF 2)
• Also called "central neurofibromatosis“
• Is results from muta*on of the merlin (also known
as "schwannomin") in chromosome 22q12.i.e NF2
gene
• It accounts for only 10% of all cases of NF

94. Tumors of nerve *ssues…ctd..
The disorder manifests in the following fashion:
1. Bilateral acous9c neuromas :
❖ Tumors of the ves*bulocochlear nerve or cranial
nerve 8 (CN VIII) also known as schwannoma)
❖ The hallmark of NF 2 is hearing loss due
to acous*c schwanoma.

95. Tumors of nerve *ssues…ctd..
2.
– headache
– balance problems, and peripheral ver*go due
to schwannoma and involvement of the inner ear
– facial weakness/paralysis due to involvement or
compression of the facial nerve.
– brain tumors, as well as spinal tumors.
– deafness and *nnitus

96. Tumors of nerve *ssues…ctd..
Diagnosis
• Fetus
Chorionic villus sampling or
amniocentesis can be used
• MRI
• Slit lamp

97. Tumors of nerve *ssues…ctd..
Treatment
• There is no cure for the condi9on so the only therapy
for pa9ents with neurofibromatosis is to manage
symptoms or complica9ons.
• Surgery may be needed when the tumors compress
organs or other structures.
• Less than 10% of people with neurofibromatosis
develop cancerous growths; in these cases,
chemotherapy may be successful.
• Gene9c screening and counselling for families with
neurofibromatosis.

98. Tumors of nerve *ssues…ctd..
C. Trauma2c neuroma
➢ Aka amputa*on trauma or pseudotrauma
➢ Is a type of neuroma which results from
damage to the nerve, usually during surgical
procedures
➢ More than 50% of these lesions are related to
tooth extrac*on
The most common oral loca*on:
➢ Tongue &
➢ Close to mental foramen of the mouth

99. " Reactive proliferation of neural tissue after damage to
nerve bundle
" Smooth nodules most common in mental foramen,
tongue and lower lip with a history of trauma;
intraosseous lesions appear as radiolucencies
" Any age but mostly middle-age, with F>M
" Hallmark is PAIN which could be intermittent or constant
and mild or severe;
" Mental nerve neuromas are painful especially with denture
flange impingement

100. Tumors of nerve *ssues…ctd.
Classifica*on
Two major categories:
(i) Spindle neuromas
are internal, focal, fusiform swellings secondary to
chronic fric*on or irrita*on to a non
disrupted, injured but intact nerve trunk.
• ii) Lateral or terminal neuromas
are the result of severe trauma with disrup*on or
total transec*on of a nerve

101. Tumors of nerve *ssues…ctd.
Clinical features
• Trauma*c neuromas appear grossly as firm, oval,
whi*sh nodules that are rarely larger than 2 cm .
• At sec*oning, they have a dense fibrous appearance
with lille vascularity.
• A nerve may terminate at the upper pole of the
mass .
• Although not encapsulated, the outer layer of
fibrous *ssue is o)en in separable from the
surrounding scar, and microscopically, an outer
layer of connec*ve *ssue is con*nuous with the
perineurium of the intact nerve trunk

102. Tumors of nerve *ssues…ctd.
Differen*al diagnosis
Palisaded encapsulated neuroma

103. Tumors of nerve *ssues…ctd.
Treatment
Lymphadenectomy
• Neck dissec*on, or cervical lymphadenectomy, is a
procedure for eradica*ng metastases to the regional
lymph nodes

104. • SALIVARY GLAND
DISEASES &
TUMORS

105. ✧ Salivary gland
diseases
-Developmental
-Func*onal
-Inflammatory
-Cysts and tumors
-Miscellaneous
SALIVARY GLAND TUMORS
✧ Pleomorphic adenoma
✧ Adenocarcinoma
✧ Warthin’s tumor
✧ Adenoid cys2c carcinoma
✧ Mucoepidermoid
carcinoma

106. Salivary gland diseases
A) Developmental disorders
• Aberrancy
• Aplasia & Hypoplasia
• Hyperplasia
• Atresia
• Accessory ducts
• Diver*culi
• Congenital fistula

107. B) Functional disorders
• Sialorrhoea
• Xerostomia

108. C) Obstructive disorders
• Sialolithiasis
• Mucus plug
• Stricture & stenosis
• Foreign bodies
• Extra ductal causes

109. D) Cyst
• Mucocele
• Ranula
E) Asymptoma*c enlargement
• Sialosis
• Allergic
• Associated with malnutri*on and
alcoholism

110. Inflammatory
F) Infec*on
• Viral
• Bacterial
• Myco*c
G) Autoimmune disorders
• Sjogren’s syndrome
• Mikulicz’s disease
• Uveoparo*d fever
• Recurrent non specific paro**s

111. Developmental anomalies
Aberrant salivary glands
• An aberrant or ectopic is salivary gland *ssue
that develops at a site where it is not normally
found.

112. Clinical features
" Site – cervical region near the parotid gland or body
of mandible.
Posterior to first molar
" Clinical signifance
-Site for development of retention cyst or neoplasm

113. Aplasia & hypoplasia
It is congenitally absence of salivary gland.
• Aplasia occurs in combina*on with congenital
anomalies.
• Hypoplasia in pa*ent with Melkersen Rosenthal
syndrome.

114. Clinical features
" One or group of glands missing unilaterally or
bilaterally.
" Xerostomia
" Dental caries
" Early loss of teeth
" Dry & smooth oral mucosa
" Cracking & Fissuring at corner of mouth.

115. Management
" Good oral hygiene.

116. Functional disorders
Sialorrhoea or ptyalism
It is increase salivary secre*on.
S*mula*on of parasympathe*c causes
profuse secre*on of watery saliva.

117. Etiology
Drugs like sialogogues
" Local factors ANUG,erythema multiforme
" Systemic like paralysis
" Misc. like metal poisoning

118. Clinical features
Drooling from mouth
• Lip chapping
• Infec*on from constant exposure to saliva
• Cheek scarring.

119. Management
" Oral motor draining
" Biofeed
" Removal of local factors
" Anti cholinergic drugs (atropine sulphate
0.4 mg in adults
.01 mg / kg in children upto 0.4
" Surgery

121. Sialadenitis
(sialoadenitis)
ü is inflamma*on of a salivary gland.
• It may be subdivided temporally into
acute, chronic and recurrent forms

122. Acute
Predisposing factors
• sialolithiasis
• decreased flow (dehydra*on, post-opera*ve,
drugs)
• poor oral hygiene
• exacerba*on of low grade chronic sialoadeni*s

123. Clinical features
• Painful swelling
• Reddened skin
• Edema of the cheek, Periorbital region and neck
• low grade fever
• malaise
• raised ESR, CRP, leucocytosis
• purulent exudate from duct punctum

124. chronic
Chronic sclerosing
sialadenitis
Clinical Features
• unilateral
• mild pain / swelling
• common a)er meals
• duct orifice is reddened and flow decreases
• may or may not have visible/palpable stone.
• Paro*d gland
Recurrent painful swellings
• Submandibular gland
• Usually secondary to sialolithiasis or stricture

125. Treatment
• In chronic recurrent sialadeni*s or chronic sclerosing
sialadeni*s, acute alacks are managed with conserva*ve
therapies such as hydra*on, analgesics (mainly NSAIDs),
sialogogues to s*mulate salivary secre*on, and regular,
gentle gland massage.
• If infec*on is present, appropriate cultures should be
obtained, followed by empirical an*bio*c therapy ini*ally,
for example amoxicillin/clavulanate or clindamycin which
cover oral flora.
• If there are alacks more than approximately 3 *mes per
year or severe alacks, surgical excision of the affected
gland should be considered

126. Viral Infections
Mumps
Contagious viral infec*on caused by para myxo virus

127. Clinical features
Unilateral & bilateral swelling of salivary gland
" Fever, malaise, anorexia.
" Tender & pain on eating sore food
" Involved gland continues to enlarge for 2-3 days &
comes back to normal.
Complication
oophritis, orchitis, meningitis, encephalitis.

128. Management
" Self limiting
" MMR vaccine
" Systemic corticosteroids

130. Sarcoidosis heerdfordt syndrome
• Aka uveoparo*d fever
• A rare manifesta*on of sarcoidosis

131. symptoms:
Include inflammation of the eye (uveitis), swelling of the
parotid gland, chronic fever, and in some cases, palsy of
the facial nerves.

132. Causes
• The exact cause of Heerfordt's syndrome has not
yet been defini*vely determined.
• Of those pa*ents who have been diagnosed with
Heerfordt's syndrome, 15% have a close rela*ve
who also has the syndrome.
• One possible explana*on is that the syndrome
results from a combina*on of an environmental
agent and a hereditary predisposi*on.
• Mycobacterium and Propionibacteria species have
both been suggested as the environmental agent,
though the evidence for this is inconclusive.

133. Diagnosis
• In pa*ents that have already been diagnosed with
sarcoidosis, Heerfordt's syndrome can be inferred
from the major symptoms of the syndrome,
which include paro**s, fever, and facial nerve
palsy.
• In cases of paro**s, ultrasound-guided biopsy is
used to exclude the possibility of lymphoma.
• There are many possible causes of facial nerve
palsy, including Lyme disease, HIV, Melkersson–
Rosenthal syndrome, schwannoma, and Bell's
palsy.
• Heerfordt's syndrome exhibits spontaneous

134. Treatments
• Cor*costeroids and immunosuppressive
drugs.

135. Necrotizing
Sialometaplasia
• Uncommon locally destruc*ve
inflammatory condi2on of the salivary
glands.
Cause:
• unknown but they believe it is the
result of ischemia of the salivary *ssue
that leads to local infac2on.

136. ISCHEM
IA
OXYGE
N

137. Predisposing factors:
– Trauma*c injuries
– Dental injec*ons
– Ill firng dentures
– Upper respiratory infec*ons
– Adjacent tumors
– Previous tumors ***However many cases occur without any
known predisposing factors.

138. CLINICAL FEATURES
✓ Most frequently develops in the
palatal salivary glands
✓ Hard palate > so) palate
✓ 2/3 of palatal cases are
unilateral, with the rest being
bilateral or midline in loca2on

139. CLINICAL FEATURES
• Has also been reported in
other minor salivary gland
sites and occasionally in the
paro*d gland.
• Submandibular and sublingual
glands are rarely affected.

140. CLINICAL FEATURES
• Most common in adults and in
men
• The condi*on appears ini*ally as
a non-ulcerated swelling o)en
associated with pain or
paresthesia with crater-like ulcer
that can range from less than 1cm
to more than 5cm in diameter

141. CLINICAL FEATURES

142. Bilateral
Midline
in loca*on

143. Unilateral

144. Treatment
• The lesion is self-limi*ng in
most instances and heals
unevenuully.

145. autoimmune diseases
Sjorgen’s syndrome
• Chronic inflammatory disease that predominantly affects
salivary, lacrimal & other exocrine glands
• It was first described by HENNIK SJOGREN in 1933.

146. Types
primary – dry eyes, dry mouth.
secondary – dry eyes , dry mouth ,
collagen disorders
usually rheumatoid
arthritis & SLE.

147. Salivary gland diseases

148. Clinical Features
• Middle aged and female are commonly
infected
• Xerostomia
• Soreness and difficulty in controlling dentures
• Pus from duct
• Difficulty in ea2ng and unpleasant taste
• Unilateral and bilateral enlargement of paro2d
gland
• Frothy saliva
• Severe dental caries
• Depapilla2on of tongue
• Dry eyes
• Vaginal dryness
• Connec2ve 2ssue disorder
• Enlargement of lymph nodes

149. Radiographic Findings
" Snow storm appearance
" In some cases cherry blossom appearance

150. MANAGEMENT
SYMTOMATIC TREATMENT
" Occular lubricant- artificial tears coating methyl
cellulose
" Saliva substitute
" Oral hygiene
" Surgery for enlargement of glands

151. MIKULICZ’S DISEASE
• Symmetric or bilateral chronic painless
enlargement
of lacrimal or salivary gland has inflammatory
characteris*cs.

152. Clinical Features
Women in middle and later life
" Site- unilateral or bilateral enlargement of parotid or
submandibular gland
" Fever
" Upper respiratory tract infection
" Occasional pain
" Xerostomia
" Diffuse poorly outline and enlargement of gland

153. Management
Surgical excision

154. Investigations
Non-invasive inves*ga*ons
• Radiographs
• Computerized Tomography
• Ultrasound scanning
• Magne*c resonance imaging
• Single Photon emission Computed Tomography
Invasive Inves*ga*ons
• Biopsy
• Fine needle Aspira*on cytology
Sialography

155. SALIVARY GLAND
TUMORS

156. SALIVARY GLAND TUMORS
Classifica*on of tumors
Benign
✧ Pleomorphic adenoma
✧ Warthin’s tumor
✧ Ductal papillomas
✧ Basal cell adenoma
✧ Canalicular adenoma
✧ oncocytoma

157. Benign tumors
✓ Painless
✓ Slow growing
✓ No facial palsy

158. Epidemiology
• Rule of 80’s
• Mucoepidermoid – MC
malignancy1.2% of all neoplasms

159. Malignant
Mucoepidermoid carcinoma
Adenocarcinoma
Adenoid cys*c carcinoma
Acinic cell carcinoma
Squamous cell carcinoma

160. Indications of malignancy
• Facial nerve involvement
• Indurations / ulceration of skin ,
mucous membrane
• Lymph node metastasis
• Rapid tumor growth

161. Investigations
o FNAC
o Open biopsy
o CT
o MRI

162. Pleomorphic adenoma
• Commonest benign tr
• Pseudocapsule
• Pseudopodal extensions
• Not multicentric

163. Clinical features
Age—any age but more common
b/n 30-50 yrs
Sex --women
Site –post. hard palate & ant. soft
palate mucosa followed by upper
lip & buccal mucosa

164. • Mixed tumor
• Consists of cartilage besides
epithelial cells
• Cartilage not of mesodermal
origin
• Derived from mucin secreted by
epithelial cells

165. Diagnosis
• Lobulated , painless swelling
• Long dura*on
• Neither adherent to skin/ masseter
muscle
• Generally firm / variable consistency

166. DDx
Other benign and malignant salivary gland tumors
Ø Necrotising sialadenometaplasia
Ø Lipoma

167. Malignant transformation
• 3 – 5 % of cases
• Pain
• Rapid growth
• Hard
• Fixed to masseter
• Fixity to skin
• Lymph nodes
• Restricted jaw movements

168. Tx
• Superficial parotidectmy
• Total parotidectomy

169. Warthin’s tumor
(Papillary cystadenoma lymphamatosum)
• A benign cys2c tumor
• contains abundant lymphocytes & germinal centers(LN-
like stroma)
• 5 – 15 % of parotid trs
• Always at the lower pole of the parotid
• Overlies the angle of mandible
Etiology
unknown ,smoking

170. Clinical features
• More in white races
• Not seen in negroes
• Encapsulated lesions
• No malignant transformation

171. Clinical features
• Only salivary neoplasm more in
males
• Elderly males
• Slow growing
• painless

172. • Surface is smooth
• Well defined
• Distinct margins
• Soft in consistency with
fluctuation
• Not tansilluminant

173. Investigation
• FNAC
Tc99 scan – hot spot
DDX
• Sebaceous lymphadenoma
• oncocytoma

174. SALIVARY GLAND TUMORS
Tx
• Superficial parotidectmy
• Enucleation

175. Malignant tumors
• Commonest site –minor glands
• Palate
• MC in females
• 7th decade
• Previous irradiation

176. Mucoepidermoid carcinoma
• MC
• The tumor made up of 3 types of cell
(mucous,epidermoid,inter.)
• Parotid &minor gland
• Slow growing tr
• Lung, bone, brain -15%

177. epidemiology
" Occurs in adult
" Peak incidence—20-40 yrs
" Causal link with CMV has been strongly implicated

178. Clinical features
" Present as :
Ø painless ,
Ø slow-growing mass,
Ø w/c firm/hard
Ø most appear clinically as mixed tumors

179. Tx
✓ Determined by the tumor:
grade
Loca*on
Clinical presenta*on

180. Adenoid cystic carcinoma
• Malignant cylindroma
• The third MC
• Rare in parotid
• 60% in sublingual gland
• Generally,slow growing and
well defferentiated

181. • Perineural invasion
• Nerve palsy even before mass
• Also spread along haversian system and
• neural canals of bone
• Mets LN –direct spread

182. Tx
" Surgical removal
" Fast neuron therapy
" chemotherapy

183. Adenocarcinoma
is a type of cancer that forms in mucus secreting glands
throughout the body.

184. Clinical features
" Rare
" Mainly parotid
" 80% as adherent masses
" 5th to 8th decades
" F >M
" Parotid and minor salivary glands
" Presentation:
– Enlarging mass
– 25% with pain or facial weakness

185. Dx
Boipsy
CT scan
MRI

186. Tx
Surgery
Radiation therapy
Chemotherapy

187. HARD TISSUE TUMORS

188. NON ODONTOGENIC TUMORS

189. • Non odontogenic tumors of the jaw
origina*ng from bone and its
mesenchymal *ssue represent a large
group of diverse diseases.

190. The following primary tumors
belong to this group;
1. Bone tumors
a) Benign;osteoma,osteoblastoma and
osteoid osteoma
b) Malignant;osteosarcoma
2.car*lage tumors
a) Benign;chondroma,chondroblastoma,cho
ndromyxoid fibroma,osteochondroma
b) Malignant;chondrosarcoma

191. 3.Fibroplas*c tumors
• Desmoplas*c fibroma
• Fibrosarcoma
4.Ewing sarcoma
5.Plasmocytoma and malignant lymphoma
6.Vascular tumors
• Haemangioma
• Malignant vascular tumors

192. • Osteogenic Tumor
Osteoma
• (Also reffered to as exostosis ) almost
uniquely occurs in the cranial bones.
• It represents a hamartomatous new growth
consis*ng of medullary or compact bone,and
presen*ng on the surface of the bone from
which it arises.
• Women affected most frequently

193. Clinical & Radiographic Features
• slow growing,usually asymptoma2c
tumor
• periosteal or endosteal osteomas
• radiographically: presen2ng as a
Circumscribed sclero2c mass consistent
with bone density depending on the
tumors component
• can be associated with Gardners
syndrome(mul2ple osteoma, intes2nal
polyposis leading to colon CA)

194. Mul*ple osteoma associated with gardner’s
syndrome

196. HistopathologicFeatures
• Compact osteoma:dense bone with Minimal
marrow 2ssue
• Cancellous osteoma:trabeculae with fibro-
facy marrow

197. Differen*al diagnosis
• Cementoblastoma and cemen*fying
fibroma
Treatment&Prognosis
Do not need to be
treated,if no symptom

198. Osteosarcoma
• Malignant,osteoid producing
mesenchymal tumor;it is the most
frequent primary malignant bone tumor
• The distal femur and proximal *bia;the
most frequent sites; 7% occuring in the
jaws
• Men are affected most frequently

199. Clinical & Radiographic Features
• most o)en occurring in the third and
fourth decades of life
males > females,swelling and pain
loosening of teeth, paresthesia, and nasal
obstruc*on
young children to the elderly varying
from dense sclerosis to admixed sclero*c
and radiolucent lesion, to an en*rely
radiolucent process, ill defined and
indis*nct margin

200. Histopathologic Features
• Direct proof of tumor osteoid forma2on by
atypical mesenchymal cells is important for
diagnosis
• the tumor otherwise appears with both chondroid
differen*ated (‘chondroblas*c sarcoma),or
fibroblas*c forms in the same tumor.
differen*al diagnosis
• Osteoma
• Osteoblastoma
• Ossifying fibroma

201. Treatment & Prognosis
• radical surgical excision
• supplemented : chemotherapy,
• radia2on therapy or both

202. Car*lage tumors
A. Chondroma(benign)
B. Chondrosarcoma(malignant)

203. 1. Chondroma
• Benign tumors of hyaline car*lage with a
tendency for malignant growth.
• most o)en located in the short tubular
bones of the hand and the feet.
• rarely been reported in the jaws.
Histopathological Features
mature car*lage,very difficult to
dis*nguish from low grade
chondrosarcoma

205. Treatment and Prognosis
• Total surgical removal of the tumor
Differen*al diagnosis
chondrosarcoma

206. Chondrosarcoma
• Malignant neoplasm of hyaline car*lage.
• most commonly located in the
metaphyseal region of the long bones.
• rarely involving in the jaws

207. Clinical and Radiographic Feature
• wide age range
• average age: 33years
• the most common presen2ng as painless or
swelling mass
• the maxilla and mandible involved with
about equal frequency
• a radiolucent process with poorly defined
borders
• containing scacered and variable amounts
of radiopaque foci

208. Histopathological Features
• Consists of car2lage with varying degree
of matura2on and cellurarity,and
showing lobulated growth pacern
• ossifica2on,calcifica2on and chondroid
matrix

209. Differen2al diagnosis
• Radiologically;It is hardly possible to
clearly dis*ngush these tumors ronm any
other benign or malignant growth.
• The most important histological
differen*a*on is from osteosarcoma since
this may show extensive chondroid
differen*ated parts

210. Treatment and Prognosis
• Radical surgical excision
• Poorer prognosis than osteosarcoma of
the jaws

212. Vasculr tumors
• Both benign and malignant vascular tumors
rarely occur in the jaw
central haemangioma
• is a benign vascular tumor rarely occuring in
the jaw.
• it occurs more frequently in women and in
the maxilla.

213. Clinical features
• Asymptoma*c swelling,occasional
loosening of the teeth and haemorrhage
from around the neck of the tooth.
diagnosis/histological findings
• Poorly demarcated osteolysis
• Usually capillary haemangiomas,some
with cavernous spread

214. Differen*al diagnosis
• Other osteoly*c lesion
treatment and prognosis
• Tooth extrac*on may causesevere
haemorrhage;angiography in case of
suspicion
• resec*on

215. Central giant cell tumor
• It is rela*vely uncommon tumor of bone.
• It is characterized by the prescence of
mul*-nucleated giant cells(osteoclast like
cells).
• In most pa*ents ,the tumors are slow to
develop,but may recur locally in as many
as 50% of the cases.

216. Clinical features
• Pain and limited range of mo*on caused
by tumor’s proximity to the joint space
• Swelling
• Muscular aches and pain in arms,legs and
abdominal pain

217. Diagnosis
• Presence of mul*nucleated giant cells
• Surrounding mononuclear and small
mul*nucleated cells have nuclei similar to
those in the giant cells
• Soap bubble appearance
Treatment
• Surgery
• curelage

218. Differen*al diagnosis
• Aneurysmal bone cyst
• Chondroblastoma
• Simple bone cyst
• Osteoid osteoma
• Osteoblastoma
• osteosarcoma

219. THANK YOU