BENIGN GROWTHS AND SWELLINGS
OF THE ORAL MUCOSA
SLIDE NO.
1
DESCRIPTION
Pyogenic Granuloma – Gingiva
A pyogenic granuloma is an epithelialized mass of granulation tissue
that has resulted through accentuation of the reparative phase of the
inflammatory response, usually as an over-reaction to chronic, lowgrade irritation. The term "pyogenic granuloma" is somewhat of a
misnomer in that it is not pus-producing, as "pyogenic" implies. It is,
however, a "tumor" of granulation tissue, as "granulation" implies.
Pyogenic granulomas may occur anywhere in the body, but are very
frequently found in the mouth (and especially the gingiva), possibly
because of the high incidence of chronic irritation in this region
combined with the considerable vascularity and reactive potential of
the oral mucosa.
2
Pyogenic Granuloma – Gingiva
The pyogenic granuloma is most frequently found at sites of chronic
irritation and often develops in association with subgingival calculus,
food impaction, overhanging restorations, implantation of foreign
bodies, and chronic biting of soft tissue.
3
Pyogenic Granuloma – Gingiva
The lesion is fiery red and bleeds readily.
4
Pyogenic Granuloma – Photomicrograph
The section exhibits immature granulation tissue with a high degree of
vascularity. The surface of the lesion is usually ulcerated.
- )‫ מדי פעם תאי תסנין דלקתי (תאי פלזמה‬,‫רקמת חיבור ומלאה ועמוסת כלי דם‬
.‫ לימפוציטים הם נק' כחולות קטנות‬,‫תא עם גרעין אקסנטרי ושק אאוזינופילי‬
5
Pyogenic Granuloma – Gingiva
The present case is an example that pyogenic granuloma may reach
large proportions.
41
SLIDE NO.
6
DESCRIPTION
Pyogenic Granuloma – Lip
‫ נראה כמו איריטשיון פיברומה‬, ‫ אלא הציפוי בצבע הרירית‬,‫א נראה קלאסי‬
7
Pyogenic Granuloma – Tongue
Note the white sloughy )‫ (מתקלף‬material on the surface. This
represents the necrotic ulcerated surface of the lesion.
8
Pregnancy Granuloma (Pregnancy Tumor)
A pregnancy granuloma is essentially pyogenic granuloma that
develops in a pregnant woman. It has been suggested that the hormonal
imbalance coincident with pregnancy heightens the organism's
response to irritation. The causative irritants are usually calculus or
overhanging margins of dental restorations.
‫ אם יש גורם מקומי מגרה כמו שחזורי‬,‫בנשים בהריןו החל מטרימסטר שני‬
‫ לכן סיכוי‬.‫ כל תגובת החניכיים באובר בגלל השינוי ההורמונלי‬,‫ אבני‬,'‫םוכד‬
.‫לפגוש פיוג'ניק גרנולומה‬
9
Pregnancy Gingivitis and Pregnancy Tumor
.‫ אלא ממש פפילות נפוחות‬,‫לא רק החניכיים מודלקות‬
10
Pregnancy Granuloma
Note the large size that the lesion may achieve.
11
Epulis Granulomatosa
The lesion is represented by the tissue that you see arising from the
alveolar process (socket) of a previously extracted tooth. A preparation
immediately adjacent to it would point to a diagnosis of exuberant
overgrowth of granulation tissue from the alveolar socket as a result of
the inclusion into the socket of material from the tooth preparation.
‫ יצר‬,‫כשעקרו את השישית העיפו את השזור שכנראה נכנס לסוקט והפריע לריפוי‬
.‫רקמת גרעון בעודף‬
12
Epulis Granulomatosa
This is the same case as in Slide 11, with a different view showing
more clearly the relationship of the preparation to the overgrowing
tissues.
42
13
Epulis Granulomatosa
SLIDE NO.
DESCRIPTION
14-15 Peripheral Giant Cell Granuloma
This purple, broad-based sessile ‫ בסיס רחב‬growth clinically resembles
pyogenic granuloma. However, on biopsy, it proved to be a giant cell
granuloma. Remember: A giant cell granuloma is always located on
the gingiva or alveolar ridge. Slide 15 is another example of this lesion.
‫ אבל‬,‫באבחנה מבדלת – ע"פ החניכיים אפשר לרשום פריפרל ג'יינט סל גרנולומה‬
.‫ לכן זה יהיה פיוג'ניק גרנולומה‬,‫על הלשון זה לא קיים‬
16
Peripheral Giant Cell Granuloma
The massive bulge on the anterior aspect of the mandible was an
exuberant overgrowth of cellular connective tissue and blood vessels
which contained numerous multinucleated giant cells.
17
Peripheral Giant Cell Granuloma
Although the preceding lesion and this one are both larger, size alone is
not a reliable indicator of the diagnosis. Peripheral giant cell
granuloma is clinically identical to pyogenic granuloma.
‫בחניכיים‬
18
Peripheral Giant Cell Granuloma – Alveolar Ridge
Peripheral giant cell granuloma may arise on both dentulous and
edentulous alveolar ridges and is restricted in location only to these
regions of the mouth. Slide 18 shows the lesion located in an
edentulous area.
19
Peripheral Giant Cell Granuloma – Photomicrograph
Hyperplastic granulation tissue is a basic element of the peripheral
giant cell granuloma. Scattered throughout the granulation tissue are
abundant multinucleated giant cells. Ultrastructural and immunologic
studies have shown that the giant cells are derived from macrophages.
Nevertheless, the giant cells appear to be non-functional in the usual
43
‫‪sense of phagocytosis and bone resorption. Islands of metaplastic bone‬‬
‫‪may occasionally be seen in these lesions.‬‬
‫יש רקע מאוד דומה לפיוג'ניק‪ ,‬מלא כלי דם‪ ,‬נוסף אלמנט של תאי ענק מקובי‬
‫גרעינים‪ ,‬שהם די "אינוסנטיים"‪ ,‬מצד אחד לא סופגים עצם‪ ,‬ומצד שני לא‬
‫פונקציונאליים‪ ,‬כיוון שלא גוייסו לבלוע חומר זר‪ .‬ניתן למצוא לפעמים אזורי‬
‫הסתיידות‪ ,‬נקראת מטה פלסטית כי נוצרת ע"י גורמים מרקמת החיבור‪.‬‬
‫‪44‬‬
SLIDE NO.
20
DESCRIPTION
Traumatic Fibroma (Irritation Fibroma, Focal Fibrous Hyperplasia)
Traumatic fibroma is the most common tumor-like growth of the oral
cavity. It occurs as a response to some local irritation. Clinically, it is
an elevated, pedunculated, or sessile lesion that is typically of normal
color but may appear paler than the normal mucosa. The lesion can be
found virtually anywhere in the oral cavity, but the buccal mucosa,
labial mucosa, and lateral border of the tongue are the sites most
commonly affected. Slide 20 exhibits irritation fibroma of the buccal
mucosa. The next sequence of slides demonstrates varieties of size,
shape and location.
21-22 Taumatic Fibroma – Buccal Mucosa
‫ ציפוי שלם עם צבע דומה לרירית‬.‫ אם נושכים את זה‬,‫לפעמים יכול להיות עם פסאודו מברנה‬
.‫ ובדר"כ גם חלק‬,‫הסמוכה‬
23-24 Traumatic Fibroma – Tongue
25
Traumatic Fibroma – Photomicrograph
Note that the lesion predominantly consists of dense collagen and is
covered with stratified squamous epithelium. The fibroblasts are
mature and widely scattered in dense collagen matrix. Sparse chronic
inflammatory cells may usually be seen in a perivascular distribution.
‫ לעיתים נק' של תאים אינפלמטוריים‬,‫רוב המסה מורכבת מבנדלס של קולגן‬
26
Traumatic Fibroma – Lower Lip
This lesion is associated with a local "irritation", such as lip biting. The
tissue reacts to the trauma with the formation of excessive amounts of
connective tissue.
.‫לאדם בתמונה יש דיפ בייט והוא לוכד את השפה בין השיניים‬
27
Traumatic Fibroma – Commissure
Irritation fibroma ranges in size from a few millimeters to a few
centimeters. Slide 27 shows a rather large lesion at the commissure.
45
Compare this tissue with that of the lipoma and consider the
differential diagnosis of the two conditions.
‫ הבלק של רקמת שומן יכול להשתקף דרך‬,‫ליפומה אם היא מספיק שטחית‬
– ‫ במראה לא תמיד ניתן להבדיל‬.‫ בדומה לזה‬.‫הרירית האוראלית כנגע צהבהב‬
‫ ואילו‬.‫ וצמיגה‬,‫ היא תהיה די נוקשה‬,‫ זאת פיברומה פיברוטית‬.‫אז ממששים‬
.‫הליפומה – רכה‬
SLIDE NO.
28
DESCRIPTION
Traumatic Fibroma – Gingiva
This lesion is described by several authors as "fibrous epulis" because
of its location. The normal mucosal color and firm consistency help to
differentiate this lesion from pyogenic granuloma or peripheral giant
cell granuloma.
.‫איריטיישן שמופיעה על החניכיים או על הרכס ייקרא – פיברוס אפוליס‬
.‫ לא מכוייב‬,‫פני השטח בצבע די דומה לג'ינג'יבה‬
29-30 Traumatic Fibroma – Gingiva
Another example of fibrous epulis (Slide 29). Histologically (Slide 30),
it predominantly consists of dense collagen and the entire lesion is
covered by stratified squamous epithelium.
.‫ה אותה יצירה עודפת של קולגן‬
31
Giant Cell Fibroma
Basically, giant cell fibroma is a reactive fibrous lesion proliferation. It
differs from traumatic fibroma because of distinctive microscopic
features. Thus, the differential diagnosis between the two lesions is
made only by microscopic examination. Most of these lesions are
small, normal in color, and located mainly on the attached gingiva of
the mandible. In Slide 31, note the small nodule on the lingual aspect
of the mandibular gingiva. The lesions can also arise on other mucosal
surfaces of the mouth.
‫אלא רק היסטולוגית‬. ‫ע"פ מראה לא נוכל להבדיל בינה לבין הקודמים‬
32-33 Giant Cell Fibroma – Photomicrographs
The lesion is covered by stratified squamous epithelium. The bulk of
the specimen is represented by irregular swirls of collagen fibers with
46
interspersed plump stellate or multinucleated fibroblasts as seen in
Slides 32 and 33. Several cells exhibit a "manta ray" )‫דק (עפיפון‬
appearance. The term "giant cell fibroma" is derived from these "giant"
fibroblasts.
.‫מבחינת התנהגות הנגע וטיפולית לא שונה מאיריטיישן‬
‫ יש פיברובלסטים שיכולים להיות‬,‫בנוסף לקולגן שכאן נראה יותר במערבולות‬
.‫ מנטה ריי‬,‫ וחלר אחרים יכולים להיות בצורת משולש‬,‫מולטי נוקלאייקג‬
34-35 Peripheral Ossifying Fibroma
Peripheral ossifying fibromas appear as pale to red, firm, sessile, or
pedunculated lesions that arise from the interdental papilla. The lesion
is exclusively located on the gingiva and rarely seen on edentulous
ridges. Microscopic sections reveal a tumor consisting of fibroblasts
and collagen fibers in varying proportions. The lesion is more cellular
than the traumatic fibroma and covered by stratified squamous
epithelium. Often the surface is ulcerated. Within the fibrous element,
the lesion contains calcified material in the form of irregular trabeculae
of osteoid or oval cementum-like deposits. Slide 34 is a clinical picture
of peripheral ossifying fibroma. Slide 35 is the histological picture of
the same lesion.
:‫ אבחנות עיקריות‬4( ‫ נראה כמו‬,‫נוצר נגע תגובתי שבסוף מתברר שהוא אוסיפיינג פיהרומה‬
)...1 ‫ ג'יינט סל גרנולומה ועוד‬,‫ פריפרל אוסיפיינג‬,‫פיוג'ניק גרנולומה‬
‫רואים בהיסטולוגיה מעין עיגולים כתמים סגולים של עצם‬
36-38 Peripheral Ossifying Fibroma
Slide 36 exhibits another example of this lesion. In this particular case,
the color is that of the normal gingiva and the consistency is firm. Thus
the clinical appearance is identical with that of fibrous epulis.
Histologically (Slides 37 and 38), it shows ossification.
.‫ זה מראה יצירת עצם לכל דבר‬,‫לעומת הגלובולות הקטנות של הרקמה הקודמת‬
.‫זו עצם מטפלסטית כי אין אוסטאובלסטים‬
39
Epulis Fissuratum (Denture-Induced Fibrous Hyperplasia)
47
Note the extra tissue in the maxilla. Occasionally, one must palpate to
find the original alveolar ridge. The excess tissue is anterior to the
ridge in this case.
40
Epulis Fissuratum
The mass of tissue in the maxillary vestibule is a response to an illfitting denture.
41-42 Epulis Fissuratum
The lesion represents an extensive inflammatory hyperplasia as a
response to the overextended flange of the denture.
‫ כתגובה לחוסר התאמה‬,‫יש מעין תוספת של רקמת חיבור בשוליים של התותבת‬
.‫שלה‬
43
Epulis Fissuratum
Elongated mass of pink or red tissue resulting from ill-fitting dentures.
44-46 Papillary Hyperplasia of the Palate (Inflammatory Papillary Hyperplasia)
The grape-like clusters or raspberry-like red lesions on the palate of an
edentulous patient are associated with an ill-fitting denture and poor
oral hygiene. Slides 44, 45 and 46 demonstrate other examples of this
same condition.
– ‫ מלווה בצבע אדמדם‬,‫פני השטח של החיך בנויים מבליטות נודולריות קטנות‬
‫ ולא נורידים‬,‫ ועם הגיינה אוראלית לא טובה‬,‫בדר"כ כשהתותבות לא מתאימות‬
.‫ יש פה גם גורם מזהם – קנדידה‬.‫אותם‬
47-49 Papillary Hyperplasia of the Palate – Macro- and Microscopic Pictures
The lesion was excised (Slide 47) and the microscopic sections show
numerous papillary growths covered by hyperplastic stratified
squamous epithelium (Slide 48). ‫הנודולות – רואים במיקרוסקופ –פני שטח‬
‫פילריים ואפיתל מאוד מעובה עם מרכיס תסנין דלקתי באזור הבזל מצד רקמת‬
‫החיבור‬
The latter may extend deep into the underlying connective tissue. The
connective tissue shows diffused plasma cell and lymphocytic
48
infiltration (Slide 49). In certain cases, pseudoepitheliomatous
hyperplasia is present. The lesion is not premalignant.
‫ לעיתים‬.‫ תסנים דלקתי ואפיתל מעובה‬,‫יבמקרה זה הרקמה מגיבה בעודך קולגן‬
‫ חלק מהרטה פגס נראים בעומק לכאורה כמו איים של אפיתל‬,‫בגלל החתך‬
.‫ אך זה בגלל החיתוך‬,)‫(=קרצינומה‬
.‫ ואז שונה לפסאודו אפיתליומאטוס‬,‫פעם נקרא פסאודו קרצינומטוס‬
...‫מכאן – הגדלת חניכיים באופן כללי‬
50
Fibromatosis Gingivae – Generalized Gingival Fibromatosis
The condition demonstrated here is a classic picture of the form of
hyperplasia of gingival tissue seen under a variety of etiologies. This
particular one is of idiopathic etiology. (A similar enlargement also
occurs with the ingestion of Dilantin.)
‫ יחד עם צמיחת השיניים יש צמיחה מיותרת של‬,‫ שמסיבה לא ידועה‬,‫זהו ילד‬
.‫רקמת החיבור של החניכיים – דומה לנטילת דילנטין‬
51
Fibromatosis Gingivae (Elephantiasis Gingiva)
This condition is a congenital malformation, which clinically produces
the condition of anodontia. In this particular case, the patient was
found to have teeth in situ. The gingival tissue has covered these
completely. Rarely, is it associated with other forms of epithelial
malformations, such as hypertrichosis.
‫ פיגור‬,‫ ובא יחד עם למשל צמיחת יתר של שערותעל כל הגוף‬,‫לפעצים זה תורשתי‬
.‫שכלי וכל מיני סיבוים נוספים‬
52-53 Fibromatosis Gingivae – Study Casts
Note the generalized enlargement of the gingiva in this hereditary case.
54-55 Drug-Induced Gingival Hyperplasia – Dilantin Hyperplasia
Phenytoin (Dilantin), the drug used to control seizure disorders, is a
well-known etiologic factor in generalized gingival enlargement. Note
that the gingiva shows bulbous fibrotic firm nodules emanating from
the papillar regions. In certain cases, the hyperplasia may be severe
enough to obscure the crown of the teeth. The extent or severity of the
so-called Dilantin hyperplasia is dependent on the presence of local
49
factors. The condition is worsened when oral hygiene is poor and
dental plaque accumulates. This drug-induced gingival enlargement
may be indistinguishable from fibromatosis gingiva and may resemble
that seen in leukemia.
‫לשאול את הפציינט‬
56-58 Drug-Induced Gingival Hyperplasia – Nifedipine Hyperplasia
Use of Nifedipine, a calcium channel blocker agent for treatment of
angina and arrhythmias, is known to contribute to gingival hyperplasia
(Slide 56). The process mimics Dilantin-related hyperplasia, but
appears to be reversible. Slides 57 and 58 are other examples of
Nifedipine-related gingival hyperplasia. In these cases, the gingival
enlargement appears more pronounced. This is probably due to the
poor oral hygiene of these patients.
59
Drug-Induced Gingival Hyperplasia – Cyclosporine Hyperplasia
Hyperplasia of the gingiva can be a side effect of another drug,
Cyclosporine (Slide 59). Cyclosporine is an immunosuppressive drug
used to suppress T-lymphocyte function in transplant patients and in
patients with various auto-immune diseases. Although the drug is
chemically unrelated to Dilantin, there are many clinical gingival
parallels. Not all patients treated with Cyclosporine are affected and
local factors play a synergistic role. Unlike Dilantin hyperplasia,
Cyclosporine-induced hyperplasia has been reported to be reversible
after discontinuing the drug.
‫ לעומת זאת ציקלוספורין‬,‫דילנטין – ההיפרפלזיה תישאר אחרי ההפסקה‬
‫וניפדיפין – יש סיכוי שזה יסוג אחרי הפסקה‬
60
Localized Gingival Fibromatosis – Palate
This case represents an idiopathic hyperplasia of the gingiva in the area
of the tuberosities.
.‫ זה אידיופטי‬,‫בחלק הפלטינלי של השיניים‬
61
Congenital Epulis of the Newborn – Mandible
50
This lesion is seen only in newborn infants. It arises from the maxillary
or mandibular alveolar mucosa and histologically resembles granular
cell tumor (except for the pseudoepitheliomatous hyperplasia).
‫תינוק שרואים על הרכס התחתון תפיחות‬
62
Congenital Epulis of the Newborn – Maxilla
Congenital epulis is more common on the maxillary anterior alveolar
ridge. Note how large the lesion may reach.
63-66 Hemangioma
This lesion in the oral cavity may be seen at any age. However, most
are congenital and become clinically apparent at an early age. They are
usually soft and compressible to palpation and may blanch on pressure
(provided a thrombus is not present within the vascular lumen). Slide
63 is hemangioma of the lip; Slide 64 of the buccal mucosa; Slide 65
of the palate; and Slide 66 of the tongue.
‫ או שנולדים עם זה‬.‫יש המתייחסים אליהם כהמרטומות – רקמה שנוצרה בעודף‬
‫ יש כאלה שמופיעות מאוחר‬,‫ דווקא על השפה‬.‫או שמתפתח בשנה ראשונה לחיים‬
‫ אם‬.‫ אחת הדרכיים לאבחן אם זה וסקולרי או פיגמנטוזי – ללחות‬.‫יותר בחיים‬
.‫ אם פיגמנטוזי – לא ילבין‬.‫ בהרפייה עדיין יהיה לבן‬,‫וסקולרי – בעת לחיצה‬
.‫ סגולים‬,‫הנגעים כחלחלים‬
67
Cavernous Hemangioma – Photomicrograph
Note the large, thin-walled blood-containing spaces lined by flattened
endothelial cells. Finger pressure on this type of hemangioma would
force the blood from the spaces, causing a momentary blanching of the
lesion until the vessels fill up again.
.‫ בחלקם יש אריתרוציטים‬,‫כלי דם גדולים‬
‫אלו כלי דם אמיתיים‬
68
Capillary Hemangioma – Photomicrograph
This type of hemangioma consists of numerous blood-containing,
endothelium-lined capillaries. While cavernous hemangioma can be
readily emptied into the afferent and efferent vessels by digital
pressure, the capillary hemangioma cannot be as readily emptied
51
beecause the vascular spaces and the afferent and efferent vessels are
so small that they may be immediately sealed when pressure is applied
to the lesion.
.‫ ולכן לא יעבור בליצ'ינג‬,‫אם זה קפילרי שמורכב מכלי דם קטנים‬
69-70 Varix – Lip
Hemangiomas begin in childhood, while focal venous dilatation
(varices) is found in adults and the elderly. Trauma may play a role in
the induction of a varix.
Slide 69 shows a varix appearing as a reddish-brown swelling. Slide 70
exhibits the microscopic appearance of a large dilated erythrocyte –
engorged blood vessels. Occasionally, varix and macular hemangiomas
require differential diagnosis from focal pigmentation, such as tattoos,
nevi, melanotic macule, and hematoma. This may be accomplished
clinically, provided blanching can be induced, as only vascular lesions
behave in this manner.
.‫יש לעיתים טרומבוסים בתוך כלי הדם המורחבים – וגם הם לא ילבינו‬
71
Lymphangioma – Tongue
Note the cluster of colorless, thin-walled, soft excrescences )‫ (בליטות‬on
the tongue.
‫ והם נותנים מעין מראה בועתי‬,‫כלי הלימפה נמצאים ממש מתחת לאפיתל בלשון‬
.‫לאפיתל הלשון‬
‫ חלק מהגידול יכול להיות עמוק יותר – ואז‬,‫היווצרות עודפת של כלי לימפה‬
.‫ והחלק החיצוני לפני השטח –נותן מראה בועיות‬,‫הגדלה של הלשון‬
72
Lymphangioma – Tongue
This aspect of the tongue presents the usual bubbly appearance of
lymphangioma. The difference between this lesion and hemangioma is
that the endothelial channels contain lymph instead of blood.
‫ העולים ממש עד לפני שטח‬,‫ כל הורוד בהיר הם כלים לימפטיים‬:‫היסטולוגיה‬
‫ הגדלה של הלשון – בגלל ריבוי‬.‫האפיתל – וזה מה שנותן את המראה הבועתי‬
.‫כלי לימפה‬
73
Lymphangioma – Photomicrograph
52
Note the large, thin-walled, lymph-containing spaces.
74-77 Squamous Papilloma
Oral squamous papilloma is a benign neoplasm of the epithelium. Most
of these lesions, but not all, were identified to consist of human
papilloma virus Types 6 and 11. Clinically, it may be pedunculated or
sessile and show a cauliflower-like surface with finger-like projections.
It can occur anywhere in the oral cavity (Slides 74 and 75).
‫ באזור הקומיסורה – רירית לחה לורמיליון‬,‫ פני שטח דמויי כרובית‬,‫נגע לבן‬
.‫ פני שטל נודולריים עם שלוחות‬.‫ אחר – בחיך‬,‫בורדר‬
Slide 76 (same case as Slide 75) demonstrates that the base of this
lesion is in the form of a narrow peduncle. Slide 77 (very low power
photo-micrograph), shows the papilloma to be a pedunculated mass of
proliferating stratified squamous epithelium with a thin core of
connective tissue.
‫נמצא קוילוציטים באפיתל‬
78
Squamous Papilloma
Compare the surface of this lesion with that of the traumatic fibroma.
You will find that the papilloma has a rough, verrucous or
"cauliflower-like" surface, whereas the traumatic fibroma generally
represents a very smooth mucosal surface contiguous with that of the
tissue immediately surrounding it. Name other papillary-verrucous
lesions that should be included in the differential diagnosis of
squamous papilloma.
.‫ורוקה וולגריס‬
79-80 Squamous Papilloma – Lower Lip
Both papilloma and verruca vulgaris are benign exophytic growths of
surface epithelium, as their rough surface would indicate. Because their
surfaces often retain a significant amount of keratin, these lesions were
also discussed with the white lesions. Slide 79 shows squamous
papilloma of the lower lip. Slide 80 is the photomicrograph of the same
lesion.
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.‫ באפיתל יהיו קוילוציטים‬,‫נגרם מאותו וירוס‬
81
Squamous Papilloma – Lower Lip
.‫ בעור יש פלט פפילומה‬.‫ פני שטח נודולריים‬,‫נגע זה פחות פפיליר‬
82
Squamous Papilloma – Gingiva
Occasionally, keratinization will not be a feature and the papilloma
will appear pink. However, note the cauliflower-like, pebbly ‫ רך‬surface
of the lesion.
54
83-85 Verruca Vulgaris – Lip
Verruca vulgaris, the common wart, is a virus-induced growth of the
skin caused by human papillomavirus. It is usually seen on the
vermilion border. Lesions showing microscopic features
indistinguishable from those of the skin verrucae have been identified
in the mouth. Human papillomavirus Types 2 and 4 are consistently
identifiable in labial verruca; however, viral genomes of these types are
rarely seen in intraoral examples.
Most oral pathologists claim that verruca vulgaris is distinctive on the
vermilion border or skin. Yet intraorally, it is clinically identical to
squamous papilloma. The clinical distinction between verruca and
papilloma, however, is not critical since both are managed identically.
Slide 83 is an example of verruca vulgaris on the vermilion and labial
mucosa. Most oral warts are seen in patients who also have warts on
their fingers (Slide 84).
A patient who chews on skin warts can transmit the virus to the oral
mucosa. Lesions may be single or multiple and show rapid growth.
Slide 85 exhibits multiple lesions which represent examples of autoinoculation. The lesions appeared suddenly with rapid growth.
86
Verruca Vulgaris – Palate
This is a rare instance of intraoral verruca vulgaris.
87-89 Verruca Vulgaris – Photomicrographs
In Slide 87, note that the epithelium exhibits papillary projections
covered by keratin superficial to the normal tissue surface. In Slide 88,
observe that the tips of the elongated rete ridges at the margin of the
verruca are bent inward toward the center. In Slide 89, try to identify
the vacuolated epithelial cells (koilocytes) in the upper level epithelial
cells.
‫ אם מעבירים קו דמיוני בין עומק האפיתל‬.‫בורוקה – האפיתל מאוד מעובה‬
‫ התעבות‬.‫הנורמלי לורוקה – הוא אחיד – כל הצמיחה של הורוקה היא החוצה‬
– ‫ היפרקרטוזיה (פארא קרטין) ואקנטוזיס‬:‫ גורמים‬2 -‫האפיתל נוסעת מ‬
55
‫ לפי הספר (לא כולם‬.‫התעבות ניכרת ומרשימה של השכבה הספינוזית‬
‫ מבדילים בינה לבין פפילומה ע"י כך שאם נעביר נעביר קו דמיוני‬,)‫בקליניקה‬
.‫ מעין סל‬,‫ כל הרטה ריג'ס מתכנסים לכיוון הנגע‬,‫באמצע‬
90-91 Condyloma Acuminatum
Condyloma acuminatum is an infectious lesion that is characteristically
located in the anogenital region, but may also involve the oral mucosa.
A history of sexual contact as a source of transmission can usually be
obtained. The lesion is a verrucous papillary growth that has been
etiologically related to human papillomavirus Types 6 and 11.
Characteristic of early condyloma acuminatum formation is a group of
multiple pink nodules that grow and ultimately coalesce. The result is a
soft, broad-based, exophytic cauliflower growth as shown in Slides 90
and 91. Discuss the differential diagnosis of condyloma acuminatum.
‫ נגעים פפילריים שנראים כמו ורוקות או וירוס‬2 ‫ יש‬,‫לפי איך שנראה בתמונה‬
.‫פפילומה‬
92-95 Focal Epithelial Hyperplasia (Heck's Disease)
Focal epithelial hyperplasia is an unusual hyperplastic reaction
characterized clinically by multiple, soft papules and nodules of the
oral mucosa. The lower lip is always involved. Other common sites are
the buccal mucosa and the upper lip. In Slide 92, note the multiple
lesions on the buccal mucosa. Similar lesions were present on the
lower lip (Slide 93).‫נגעים מפושטים‬
Although the condition was originally described in North American
Indians and Eskimos, it has since been reported in a wide variety of
other ethnic groups. In Israel, it was described mainly in Jews of
Libyan origin.
The histologic picture exhibits acanthosis of the epithelium and
elongation with anastomosis of the rete ridges (Slide 94). Enlarged
ballooning cells with abnormal chromatin pattern are often seen within
the spinous layer (Slide 95). Recently, it was suggested that the
hyperplasia is caused by human papillomavirus Types 13 and 32.
,"‫ נראות כגוש ולא כ"אצבעות‬,‫האנסטמוזות הן רטה ריג'ס שמחוברות ביניהם‬
.‫אלו תאים מיטוזואידיים‬- ‫חלק מהתאים נראים כנמצאים במיטוזה‬
56
96-97 Keratoacanthoma – Lip
Keratoacanthoma is a benign lesion of the skin of unknown cause.
Only rarely does keratoacanthoma involve the mucocutaneous junction
or vermilion border of the lip, usually the lower. Characteristically, it
forms a rapidly growing exophytic mass, which reaches a diameter of
1-2 cm within a few weeks and then remains static. Within 6 to 12
months, it spontaneously regresses. Clinically, the lesion is
characterized by an elevation with rolled margins and a central
keratotic core. The margins are sharply delineated. Slide 96 presents a
piled-up mass of extremely firm tissue. The microscopic picture is
similar to that of well-differentiated squamous cell carcinoma, but in
reality it represents pseudoepitheliomatous hyperplasia (Slide 97).
‫ יש ויכוח בספרות מה‬.‫מחקה קלינית והיסטולוגית סקוומוס סל קרצינומה‬
‫ אלא מתייחסים אלז ה כוון‬,‫לעשות – בספרי עור – חושבים שאין קרטו קנטומה‬
‫ אופייני פלאק של קרטין הממלא‬.‫דיפרנשיאייטד אקנטומה ומתייחסים בהתאם‬
.‫את ליבת הגידול – ולכן זה נגע מאוד קשה למישוש‬
98
Keratoacanthoma – Lip
Note the crater-like lesion containing mass of keratin. Remember:
keratoacanthoma may mimic both clinically and microscopically,
squamous cell carcinoma.
.‫מעצם המיקום והמראה – עדיין מיידים לו את היישות של קרטואקנטומה‬
99
Lipoma – Tongue
Lipomas are uncommon in the oral cavity. However, when they occur,
they usually present as a soft, very smooth, raised lesion. The color is
often yellow, but it depends on the thickness of the overlying mucosa.
Lipomas may also present as a submerged lesion and be found by
palpation.
– ‫ ואם היא בעומק‬,‫כשליפומה מספיק שטחית – מקבלים תפיחות צהבהבה רכה‬
.‫מנואלית‬-‫מקבלים תפיחות רכה שניתן למשש בי‬
.‫תאי השומן יהיו ברקמת החיבור‬
100
Lipoma – Buccal Mucosa
57
101
Granular Cell Tumor – Tongue
The granular cell tumor was formerly known as granular cell
myoblastoma. This is a benign soft tissue tumor, the exact nature of
which is unknown. Note the elevated, smooth-surfaced growth on the
tongue. The tongue is the most common location in the oral cavity.
102-103 Granular Cell Tumor – Photomicrographs
The clinical tumescence of granular cell tumors is due to the presence
of unencapsulated sheets of large polygonal cells with pale, granular
cytoplasm (Slide 102). ,‫ אבל היא מנוקבת‬,‫ אאוזינופילית‬/‫תאים שהציטו‬
.‫ גידול מזנכימלי‬,‫ גרנולרית‬The nuclei are small and compact. As seen in
Slide 103, pseudo-epitheliomatous hyperplasia of the overlying oral
epithelium appears in about half of the cases. This may be such a
prominent feature that subjacent granular cells are overlooked,
resulting in an over-diagnosis of squamous cell carcinoma. The
pseudoepitheliomatous hyperplasia of granular cell tumor represents a
completely benign process. It is not known to have malignant potential.
‫ יש היפרפלזיה של פיתל‬,‫חוץ ממרכיב התאים הגרנולריים של רקמת החיבור‬
‫ יש איים חתוכים‬.‫שיכולה להיות כ"כ מודגשת שזה דומה ממש לקרצינומה‬
‫ לא קרצינומה כי‬.‫ יכולים אפילו להיות פניני קרן‬,‫הנראים בעומק הרקמה‬
‫ וברקמת החיבור – אם‬,‫ או היפרכרומטיזם‬,‫ אין מיטוזות‬,‫הציטולוגיה שפירה‬
.‫מלווה בצמיחה של התאים הגרנולריים זה לא קרצינומה‬
58