Benign growths and swellings of the oral mucosa



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BENIGN GROWTHS AND SWELLINGS

OF THE ORAL MUCOSA
SLIDE NO. DESCRIPTION

  1. 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, low-grade 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.




  1. 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.


  1. Pyogenic Granuloma – Gingiva

The lesion is fiery red and bleeds readily.


  1. Pyogenic Granuloma – Photomicrograph

The section exhibits immature granulation tissue with a high degree of vascularity. The surface of the lesion is usually ulcerated.

רקמת חיבור ומלאה ועמוסת כלי דם, מדי פעם תאי תסנין דלקתי (תאי פלזמה) - תא עם גרעין אקסנטרי ושק אאוזינופילי, לימפוציטים הם נק' כחולות קטנות.



  1. Pyogenic Granuloma – Gingiva

The present case is an example that pyogenic granuloma may reach large proportions.
SLIDE NO. DESCRIPTION

  1. Pyogenic Granuloma – Lip

א נראה קלאסי, אלא הציפוי בצבע הרירית , נראה כמו איריטשיון פיברומה

  1. Pyogenic Granuloma – Tongue

Note the white sloughy (מתקלף) material on the surface. This represents the necrotic ulcerated surface of the lesion.


  1. 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.

בנשים בהריןו החל מטרימסטר שני, אם יש גורם מקומי מגרה כמו שחזורי םוכד', אבני, כל תגובת החניכיים באובר בגלל השינוי ההורמונלי. לכן סיכוי לפגוש פיוג'ניק גרנולומה.



  1. Pregnancy Gingivitis and Pregnancy Tumor

לא רק החניכיים מודלקות, אלא ממש פפילות נפוחות.

  1. Pregnancy Granuloma

Note the large size that the lesion may achieve.


  1. 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.

כשעקרו את השישית העיפו את השזור שכנראה נכנס לסוקט והפריע לריפוי, יצר רקמת גרעון בעודף.



  1. 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.


  1. Epulis Granulomatosa



SLIDE NO. DESCRIPTION

    1. Peripheral Giant Cell Granuloma

This purple, broad-based sessileבסיס רחב growth 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.

באבחנה מבדלת – ע"פ החניכיים אפשר לרשום פריפרל ג'יינט סל גרנולומה, אבל על הלשון זה לא קיים, לכן זה יהיה פיוג'ניק גרנולומה.




  1. 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.


  1. 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


  1. 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.


  1. 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 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.



SLIDE NO. DESCRIPTION

20 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.


    1. Taumatic Fibroma – Buccal Mucosa

לפעמים יכול להיות עם פסאודו מברנה, אם נושכים את זה. ציפוי שלם עם צבע דומה לרירית הסמוכה, ובדר"כ גם חלק.

    1. 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.

רוב המסה מורכבת מבנדלס של קולגן, לעיתים נק' של תאים אינפלמטוריים




  1. 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.




  1. 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. Compare this tissue with that of the lipoma and consider the differential diagnosis of the two conditions.

ליפומה אם היא מספיק שטחית, הבלק של רקמת שומן יכול להשתקף דרך הרירית האוראלית כנגע צהבהב. בדומה לזה. במראה לא תמיד ניתן להבדיל – אז ממששים. זאת פיברומה פיברוטית, היא תהיה די נוקשה, וצמיגה. ואילו הליפומה – רכה.


SLIDE NO. DESCRIPTION

  1. 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.

פני השטח בצבע די דומה לג'ינג'יבה, לא מכוייב.


    1. 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.

ע"פ מראה לא נוכל להבדיל בינה לבין הקודמים .אלא רק היסטולוגית


    1. 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 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.

בנוסף לקולגן שכאן נראה יותר במערבולות, יש פיברובלסטים שיכולים להיות מולטי נוקלאייקג, וחלר אחרים יכולים להיות בצורת משולש, מנטה ריי.


    1. 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.

נוצר נגע תגובתי שבסוף מתברר שהוא אוסיפיינג פיהרומה, נראה כמו (4 אבחנות עיקריות: פיוג'ניק גרנולומה, פריפרל אוסיפיינג, ג'יינט סל גרנולומה ועוד 1...)

רואים בהיסטולוגיה מעין עיגולים כתמים סגולים של עצם




    1. 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.

לעומת הגלובולות הקטנות של הרקמה הקודמת, זה מראה יצירת עצם לכל דבר.

זו עצם מטפלסטית כי אין אוסטאובלסטים.


  1. Epulis Fissuratum (Denture-Induced Fibrous Hyperplasia)

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.


  1. Epulis Fissuratum

The mass of tissue in the maxillary vestibule is a response to an ill-fitting denture.


    1. Epulis Fissuratum

The lesion represents an extensive inflammatory hyperplasia as a response to the overextended flange of the denture.

יש מעין תוספת של רקמת חיבור בשוליים של התותבת, כתגובה לחוסר התאמה 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.

פני השטח של החיך בנויים מבליטות נודולריות קטנות, מלווה בצבע אדמדם – בדר"כ כשהתותבות לא מתאימות, ועם הגיינה אוראלית לא טובה, ולא נורידים אותם. יש פה גם גורם מזהם – קנדידה.


    1. 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 infiltration (Slide 49). In certain cases, pseudoepitheliomatous hyperplasia is present. The lesion is not premalignant.

יבמקרה זה הרקמה מגיבה בעודך קולגן, תסנים דלקתי ואפיתל מעובה. לעיתים בגלל החתך, חלק מהרטה פגס נראים בעומק לכאורה כמו איים של אפיתל (=קרצינומה), אך זה בגלל החיתוך.

פעם נקרא פסאודו קרצינומטוס, ואז שונה לפסאודו אפיתליומאטוס.


מכאן – הגדלת חניכיים באופן כללי...


  1. 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.)

זהו ילד, שמסיבה לא ידועה, יחד עם צמיחת השיניים יש צמיחה מיותרת של רקמת החיבור של החניכיים – דומה לנטילת דילנטין.




  1. 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.

לפעצים זה תורשתי, ובא יחד עם למשל צמיחת יתר של שערותעל כל הגוף, פיגור שכלי וכל מיני סיבוים נוספים.



    1. Fibromatosis Gingivae – Study Casts

Note the generalized enlargement of the gingiva in this hereditary case.


    1. 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 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




    1. 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.


  1. 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.

דילנטין – ההיפרפלזיה תישאר אחרי ההפסקה, לעומת זאת ציקלוספורין וניפדיפין – יש סיכוי שזה יסוג אחרי הפסקה




  1. Localized Gingival Fibromatosis – Palate

This case represents an idiopathic hyperplasia of the gingiva in the area of the tuberosities.

בחלק הפלטינלי של השיניים, זה אידיופטי.




  1. Congenital Epulis of the Newborn – Mandible

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




  1. Congenital Epulis of the Newborn – Maxilla

Congenital epulis is more common on the maxillary anterior alveolar ridge. Note how large the lesion may reach.


    1. 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.

יש המתייחסים אליהם כהמרטומות – רקמה שנוצרה בעודף. או שנולדים עם זה או שמתפתח בשנה ראשונה לחיים. דווקא על השפה, יש כאלה שמופיעות מאוחר יותר בחיים. אחת הדרכיים לאבחן אם זה וסקולרי או פיגמנטוזי – ללחות. אם וסקולרי – בעת לחיצה, בהרפייה עדיין יהיה לבן. אם פיגמנטוזי – לא ילבין.

הנגעים כחלחלים, סגולים.


  1. 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.

כלי דם גדולים, בחלקם יש אריתרוציטים.

אלו כלי דם אמיתיים


  1. 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 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.

אם זה קפילרי שמורכב מכלי דם קטנים, ולכן לא יעבור בליצ'ינג.




    1. 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 (בליטות) on the tongue.

כלי הלימפה נמצאים ממש מתחת לאפיתל בלשון, והם נותנים מעין מראה בועתי לאפיתל הלשון.

היווצרות עודפת של כלי לימפה, חלק מהגידול יכול להיות עמוק יותר – ואז הגדלה של הלשון, והחלק החיצוני לפני השטח –נותן מראה בועיות.




  1. 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.

היסטולוגיה: כל הורוד בהיר הם כלים לימפטיים, העולים ממש עד לפני שטח האפיתל – וזה מה שנותן את המראה הבועתי. הגדלה של הלשון – בגלל ריבוי כלי לימפה.




  1. Lymphangioma – Photomicrograph

Note the large, thin-walled, lymph-containing spaces.


    1. 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).

נגע לבן, פני שטח דמויי כרובית, באזור הקומיסורה – רירית לחה לורמיליון בורדר, אחר – בחיך. פני שטל נודולריים עם שלוחות.

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




  1. 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.




    1. 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.

נגרם מאותו וירוס, באפיתל יהיו קוילוציטים.


81 Squamous Papilloma – Lower Lip

נגע זה פחות פפיליר, פני שטח נודולריים. בעור יש פלט פפילומה.





  1. Squamous Papilloma – Gingiva

Occasionally, keratinization will not be a feature and the papilloma will appear pink. However, note the cauliflower-like, pebbly רך surface of the lesion.


    1. 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 auto-inoculation. The lesions appeared suddenly with rapid growth.




  1. Verruca Vulgaris – Palate

This is a rare instance of intraoral verruca vulgaris.


    1. 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.

בורוקה – האפיתל מאוד מעובה. אם מעבירים קו דמיוני בין עומק האפיתל הנורמלי לורוקה – הוא אחיד – כל הצמיחה של הורוקה היא החוצה. התעבות האפיתל נוסעת מ- 2 גורמים: היפרקרטוזיה (פארא קרטין) ואקנטוזיס – התעבות ניכרת ומרשימה של השכבה הספינוזית. לפי הספר (לא כולם בקליניקה), מבדילים בינה לבין פפילומה ע"י כך שאם נעביר נעביר קו דמיוני באמצע, כל הרטה ריג'ס מתכנסים לכיוון הנגע, מעין סל.




    1. 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.

לפי איך שנראה בתמונה, יש 2 נגעים פפילריים שנראים כמו ורוקות או וירוס פפילומה.




    1. 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.

האנסטמוזות הן רטה ריג'ס שמחוברות ביניהם, נראות כגוש ולא כ"אצבעות", חלק מהתאים נראים כנמצאים במיטוזה -אלו תאים מיטוזואידיים.




    1. 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).

מחקה קלינית והיסטולוגית סקוומוס סל קרצינומה. יש ויכוח בספרות מה לעשות – בספרי עור – חושבים שאין קרטו קנטומה, אלא מתייחסים אלז ה כוון דיפרנשיאייטד אקנטומה ומתייחסים בהתאם. אופייני פלאק של קרטין הממלא 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.


  1. 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.

כשליפומה מספיק שטחית – מקבלים תפיחות צהבהבה רכה, ואם היא בעומק – מקבלים תפיחות רכה שניתן למשש בי-מנואלית.

תאי השומן יהיו ברקמת החיבור.

100 Lipoma – Buccal Mucosa


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).תאים שהציטו/ אאוזינופילית, אבל היא מנוקבת, גרנולרית, גידול מזנכימלי. The 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.

חוץ ממרכיב התאים הגרנולריים של רקמת החיבור, יש היפרפלזיה של פיתל שיכולה להיות כ"כ מודגשת שזה דומה ממש לקרצינומה. יש איים חתוכים הנראים בעומק הרקמה, יכולים אפילו להיות פניני קרן. לא קרצינומה כי הציטולוגיה שפירה, אין מיטוזות, או היפרכרומטיזם, וברקמת החיבור – אם מלווה בצמיחה של התאים הגרנולריים זה לא קרצינומה.









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