3rd year BDS

(Session-2019-23)

SUBJECT
Oral Pathology
TOPIC
Pre Neoplastic Oral disorders of epithelial origin
SUB TOPIC
Classification and morphological features
DATE
18/2/2021
Presenter
Dr . Abbas Saleem Khan
 Learning objectives
• By the end of this session the participants will
be able to;describe terms like
Neoplasia,Neoplasm ,Malignancy ,Malignant
tumor,Premalignancy,Potentially malignant
Disorders,Atypia,Dysplasia ,Epithelial
dysplasia,Epithelial precursor lesions

 describe various pre neoplastic oral epithelial

lesions.
 Important terms
• 1.Neoplasia
• 2.Neoplasm
• 3.Malignancy
• 4.Malignant tumor
• 5.Premalignancy
• 6.Potentially malignant Disorders
• 7. Atypia
• 8. Dysplasia
• 9. Epithelial dysplasia
• 10. Epithelial precursor lesions
 Origin of the word cancer
• The origin of the word cancer is credited to the Greek physician Hippocrates
(460-370 BC), who is considered the “Father of Medicine.”
• Hippocrates used the terms carcinos and carcinoma to describe non-ulcer
forming and ulcer-forming tumors.
• In Greek, these words refer to a crab, most likely applied to the disease
because the finger-like spreading projections from a cancer called to mind
the shape of a crab.
• The Roman physician, Celsus (28-50 BC), later translated the Greek term into
cancer, the Latin word for crab.
• Galen (130-200 AD), another Greek physician, used the word oncos (Greek
for swelling) to describe tumors.
• Although the crab analogy of Hippocrates and Celsus is still used to describe
malignant tumors, Galen’s term is now used as a part of the name for cancer
specialists – oncologists.
 Tumour vs tumor
• Tumor is the preferred spelling in American
English. 
• Tumour is the standard spelling outside North
America.
• Both are same and means-swelling
• Swelling without inflammation
 Neoplasm -Neoplasia
Neoplasm Neoplasia
• A neoplasm is an abnormal • Formation of a benign or
mass of tissue, the growth malignant tumor
of which exceeds and is
uncoordinated with that of
the surrounding normal
tissues and persists in the
same excessive manner
after cessation of the
stimuli that evoked the
change
 Malignant tumor-malignancy
Malignant tumor/cancer Malignancy
• A tumor that invades • The quality of being
surrounding tissues, is malignant
usually capable of • The state or presence of a
producing metastases, may malignant tumor
recur after attempted • Anaplasia is the hall mark of
removal, and is likely to malignancy
cause death unless
adequately treated
 Types of tumors
Benign tumors Malignant tumors
• non invasive, • tumors=invasive,
• remains localized, • spread via blood
• slow growth rate, lymphatics,
• close histological • relatively rapid growth,
resemblance to parent • variable histological
tissue resemblence
 Premalignancy and potentially malignant
disorders
Premalignancy Potentially malignant disorder
• A precancerous is defined by WHO in 2005 as;
/premalignant condition or “ the risk of malignancy being
precancerous or present in a lesion or
premalignant lesion, with a condition either at time of
state of disordered initial diagnosis or at a
morphology of cells that is future date.”
associated with an
increased risk of cancer
development
 Precancerous lesion VS precancerous
condition
• Precancerous Lesion • Precancerous Condition
can be defined as a can be defined as a
benign lesion with disease or patient’s habit
morphologically altered which does not necessarily
alter the clinical
tissue which has greater
appearance of local tissue
than normal risk of but is associated with a
transforming into greater than normal risk of
malignant lesion (or precancerous lesion or
malignancy).eg., cancer development.eg.,
leukoplakia oral submucous fibrosis
Potentially Malignant Disorders (PMD)
• In a World Health Organization (WHO) workshop,
held in 2005, the terminology, definitions and
classification of oral lesions with a predisposition
to malignant transformation have been discussed.
• It was recommended to abandoned the
distinction between premalignant lesion and
condition and to use PMD instead.
• The term ‘‘potentially malignant” was preferred
above ‘‘premalignant” or ‘‘precancerous”.
 Atypia and dysplasia
Atypia Dysplasia
• Atypia (from Greek, a + typos, • Dysplasia literary means-
without type) disordered growth
• a condition of being irregular • Refers to loss in uniformity
or nonstandard
of the indiviual cells as well
• Cellular atypia is a pathologic
as loss in their architectural
term for a structural
orientation.
abnormality in a cell, i.e. it is
used to describe atypical cells.
• Cellular atypia refers to
cytological change that may or
may not be pre-malignant
 Epithelial dysplasia-Epithelial precursor
lesions
Epithelial dysplasia
A potentially malignant
change in epithelium
characterised by;
i. cellular
and
ii.architectural alterations
Epithelial precursor lesions
• Epithelial Precursor lesions
are defined as altered
epithelium with an
increased likelihood for
progression to squamous
cell carcinoma (SCC).
 3rd year BDS
(Session-2019-23)

SUBJECT
Oral Pathology
TOPIC
Pre Neoplastic Oral disorders of epithelial origin
SUB TOPIC
Classification and morphological features
DATE
18/2/2021
Presenter
Dr . Abbas Saleem Khan
 Learning objectives
• By the end of this session the participants will
be able to describe the morphology of Oral
epithelial precursor lesions
 Pre Neoplastic epithelial proliferations

• Epithelial precursor lesions

• Oral potentially malignant disorders
 Epithelial precursor lesions
• Precursor lesions are defined as altered
epithelium with an increased likelihood for
progression to squamous cell carcinoma (SCC).
• The altered epithelium shows a variety of
cytological and architectural changes that
have traditionally been grouped under the
term dysplasia.
 Epithelial Dysplasia
• A disordered and disorganized potentially
malignant change in epithelium characterized
by:
A) Cellular
&
B) Architectural alterations
 Epithelial dysplasia-cellular alterations
• Prominent nucleoli
• Hyperchromasia (due to increased DNA content/chromatin in
cell nuclei)
• Nuclear pleomorphism
• Altered nuclear cytoplasm ratio
• Increased mitotic activity
(degree to which a cell population is proliferating)
• Atypical mitotic
figures(the condensed chromosomes by which a cell that is u
ndergoing mitosis can be identified)
• Multinucleation of cells
 Epithelial dysplasia
( cellular alterations )
Mitotic activity-mitotic figures
Cellular or cytological alterations in epithelial
dysplasia
 Epithelial dysplasia
(architectural alterations)
• Formation of bulbous
rete pegs
• Basilar hyperplasia
• Hypercellularity
• Altered maturation
pattern of
keratinocytes-called
dyskeratosis-(indiviual
cell keratinization)
 Mild epithelial dysplasia
• Dysplastic changes
confined to lower 3rd of
epithelium .
• 25% epithelium is
affected by dysplastic
changes above the
basement membrane.
Mild epithelial dysplasia
 Moderate epithelial dysplasia
• Dysplastic changes
confined to middle 3rd
of epithelium .
• 2/3rd epithelium is
affected by dysplastic
changes above the
basement membrane.
Moderate epithelial dysplasia
 Severe epithelial dysplasia
• Dysplastic changes
confined to full
thickness of epithelium
• More than two third
epithelium is affected
by dysplastic changes
above the basement
membrane.
Severe epithelial dysplasia
Carcinoma in situ-CIS
• The most severe form
of epithelial dysplasia
involving the entire
thickness of epithelium,
with the epithelium
basement membrane
remaining intact.
 Epithelial precursor lesions
• Precursor lesions are defined as altered
epithelium with an increased likelihood for
progression to squamous cell carcinoma (SCC).
 Epithelial precursor lesions
• The principal oral lesions which may be precursor lesions
are white patches (leukoplakia) and redpatches
(erythroplasia/erythroplakia) or mixed red and white
lesions.
• The majority of leukoplakias will not show dysplasia and
correspond to the hyperplasia category.
• Red and mixed lesions (speckled leukoplakia) show a higher
frequency of dysplasia, often of higher grade.
• The majority of leukoplakias will not undergo malignant
change and may even regress particularly if apparent
aetiologic factors are removed.
 Histopathology
• Hyperplastic epithelium (basal and parabasal
hyperplasia,acanthosis)
• Can also be atrophic
• Dysplasia
• CIS(Carcinoma in situ)
• By definition, there is no evidence of invasion.
Epithelial precursor lesions
 Epithelial precursor lesions
Hyperplasia
• Hyperplasia describes increased cell numbers.
• This may be in the spinous layer (acanthosis)
and/or in the basal/parabasal cell layers
(progenitor compartment), termed basal cell
hyperplasia.
• The architecture shows regular stratification
without cellular atypia.
 Epithelial precursor lesions
Dysplasia / squamous intraepithelial
neoplasia(SIL) / atypical hyperplasia
• When architectural disturbance is
accompanied by cytologic atypia, the term
dysplasia applies.
• The terms squamous intraepithelial neoplasia
(SIN) and atypical epithelial hyperplasia are
used synonymously.
Epithelial precursor lesions
Acanthosis.
Hyperplastic epithelium
with thickened stratum
spinosum.
 Epithelial precursor lesions
Basal cell hyperplasia.
Increase in progenitor
compartment without
dysplasia.
 Epithelial precursor lesions
• Mild dysplasia.
Basal cell hyperplasia
with relatively mild
cytological change
confined to lower third
of epithelium
 Epithelial precursor lesions
• Severe dysplasia into
upper third of
epithelium with marked
cytological change
 Epithelial precursor lesions
• Carcinoma in-situ. Abnormal
cells seen throughout the full
thickness of epithelium
• Malignant transformation
has occurred but invasion is
not present
• Atypical mitotic figures
and
• abnormal superficial mitoses
are commonly seen in
carcinoma in-situ.
 In Sha Allah
• Next • Potentially malignant
oral disorders
 Learning objectives
• By the end of this session the participants will
be able to describe the morphology of oral
potentially malignant disorders
 3rd year BDS
(Session-2014-18)

SUBJECT
Oral Pathology
TOPIC
Pre Neoplastic Oral disorders of epithelial origin
SUB TOPIC
Oral potentially malignant disorders
DATE
19/12/2016
Presenter
Dr . Abbas Saleem Khan
 Precancerous lesion VS precancerous
condition
• Precancerous Lesion • Precancerous Condition
can be defined as a can be defined as a
benign lesion with disease or patient’s habit
morphologically altered which does not
tissue which has greater necessarily alter the
than normal risk of clinical appearance of
local tissue but is
transforming into
associated with a greater
malignant lesion (or
than normal risk of
malignancy). precancerous lesion or
cancer development.
Precancerous lesion -precancerous condition
Precancerous Lesion Precancerous Condition

• Leukoplakia • Lichen planus

• Erythroplakia • Discoid lupus erythematosis
• Proliferative verrucous • Xeroderma pigmentosum
leukoplakia • Plummer-Vinson syndrome
• Verrucous hyperplasia
• Oral submucous fibrosis
• Snuff dippers keratosis
• Actinic chelosis
• Dyskeratosis congenita
Potentially Malignant Disorders (PMD)
• In a World Health Organization (WHO) workshop,
held in 2005, the terminology, definitions and
classification of oral lesions with a predisposition
to malignant transformation have been discussed.
• It was recommended to abandoned the
distinction between premalignant lesion and
condition and to use PMD instead.
• The term ‘‘potentially malignant” was preferred
above ‘‘premalignant” or ‘‘precancerous”.
Potentially Malignant Disorders (PMD)

Potentially Malignant Disorder is defined by

WHO in 2005 as;
“ the risk of malignancy being present in a
lesion or condition either at time of initial
diagnosis or at a future date.”
 Oral Potentially Malignant Disorders
• Leukoplakia • Lichen planus
• Erythroplakia • Discoid lupus
• Proliferative verrucous erythematosis
leukoplakia • Xeroderma
• Verrucous hyperplasia pigmentosum
• Oral submucous fibrosis • Plummer-Vinson
• Snuff dippers keratosis syndrome
• Actinic chelosis
• Dyskeratosis congenita
 Oral Leukoplakia
• Literary means “white
patch”
• Leuko – white
• Plakia-plaque-
plate/layer
• Plaque= elevated flat
topped lesion,usually
greater than 5 mm
across
 History
• The term "leukoplakia" • In 1877 Schwimmer first
was coined in 1861 by used the term to
Rokintansky, who used describe an oral white
it to describe white lesion.
lesions of the urinary
tract.
 Leukoplakia-definition

WHO definition-1978
 A white patch on oral mucosa that can neither be scraped off nor
classified as any other diagnosible disease.
New definition:
 A white plaque of questionable risk having excluded (other) known
disease or disorders that carry no increased risk for malignancy.
 A predominantly white lesion of the oral mucosa that cannot be
characterized as any other definable lesion

 A potentially malignant disorder

Leukoplakia-Differential diagnosis
 Leukoplakia-definition

 A potentially malignant disorder

 Purely a clinical term
 Histologically it is reported as
hyperkeratosis,acanthosis with or without
dysplasia.
 Aetiology -leukoplakia
ETIOLOGY -MULTIFACTORIAL
• Use of smoked and smokeless tobacco - strong
causative factor.
• Other factors may include;
 Alcohol-synergistic effect with tobacco use
 Viruses ;HPV,EBV in AIDS
 Chronic infection by candida albican
 Chronic irritation / Ill fitted denture
 Genetic causes ( p53 gene mutation )
Leukoplakia-clinical presentation
• Lesions can vary from
thin, flat , smooth
surfaced areas to thick ,
firm ,rough surfaced
fissured raised plaques.
 leukoplakia
Epidemiology
• Occurs more commonly in
middle aged or elderly
males.
• Females also affected
• 5-20 % of these lesions
undergo malignant
transformation( i.e ., into
squamous cell carcinoma or
verrucous carcinoma)
Localization
• Can affect any intraoral site
• Most commonly intra oral
locations are;
• Buccal mucosa, floor of the
mouth, labial commissures,
Lateral border of
tongue,maxillary and
mandibular alveolar ridges.
 classification
1.Homogenous leukoplakia
2.Non-homogenous leukoplakia
 Erythroleukoplakia (speckled leukoplakia)
 Nodular leukoplakia
 Verrucous leukoplakia
 Proliferative verroucous leukoplakia
3.Idiopathic leukoplakia (with no known
aetiology)
 Homogenous leukoplakia
• Charcterized by flat
,thin uniform white
coloured plaques.
 Non homogenous leukoplakia
 Erythroleukoplakia (speckled leukoplakia)-characterized
by erythroplasic and leukoplasic component
 Nodular leukoplakia- characterised by rough nodular
surface
 Verrucous leukoplakia (VL)- characterised by uniform
white appearance with verrucous texture.
 Proliferative verrucous leukoplakia (PVL)- a sub type of
VL characterised by multifocal presentation,resistant to
treatment and increase rate of malignant transformation.
 Non homogenous leukoplakia
Erythroleukoplakia/speckled Leukoplakia Nodular leukoplakia
 Non homogenous leukoplakia
Verruciform leukoplakia
PVL
Non homogenous leukoplakia-PVL
Idiopathic leukoplakia
 Leukoplakia-Microscopic features
• Hyperkeratosis
• Acanthosis
• Dysplasia may or may not be present
• If dysplasia present –inflammatory cell
infiltrate present in lamina propria
Oral leukoplakia
Oral leukoplakia
Oral leukoplakia
 Reported risk factors for malignant
transformation in leukoplakia
• Female gender
• Long duration of leukoplakia
• Idiopathic leukoplakia-especially in non
smokers
• Lesion location at tongue or floor of mouth
• Non homogenous type
• Presence of Candida albican
• Histologically presence of dysplasia
Reported frequency of development of OSCC
in oral leukoplakia
• Thin leukoplakia often becomes malignant
without clinical changes.
• The frequency of malignant changes in
verruciform ranges from 4% to 15%
• In Speckled leukoplakia ranges from and 18%
to 51%
• PVL-63-100%
 3rd year BDS
(Session-2014-18)

SUBJECT
Oral Pathology
TOPIC
Pre Neoplastic Oral disorders of epithelial origin
SUB TOPIC
Oral potentially malignant disorders
(erythroplakia,VX,DC)
DATE
23/2/2021
Presenter
Dr . Abbas Saleem Khan
 Learning objectives
• By the end of this session the students would
be able to define and explain
erythroplakia,verruciform
xanthoma,dyskeratosis congenita
 Erythroplakia/erythroplasia
• Any lesion of the oral
2 Greek words; mucosa that presents as
• erythro = red bright red velvety
• Plakia = plate plaques which cannot
be characterized
• Red patch/plaque/plate
clinically or
2 greek words; pathologically as any
 Erythro=red other recognizable
 Plasia=growth,formation condition
 Red growth
 Erythroplakia
Etiology Age and gender
• Not known • 60-70 yrs
• Tobacco and alcohol are • No apparent sex
predisposing factors predilection
 Erythroplakia
Localization/site Clinical features
• floor of the mouth, tongue, • Asymptomatic lesion.
soft palate, buccal mucosa. • The surface is frequently
velvety in texture and
margins may be sharply
defined.
 Erythroplakia
Risk for conversion into pre malignancy
Variants or malignancy
• Homogenous • In 80-90% cases present as
• Granular form severe dysplasia or CIS or
• Speckled erythroplakia microinvasive or even
invasive carcinoma
Erythroplakia/erythroplasia
Speckled Erythroplakia

• Lesion that is primarily red but

exhibit interspersed white
focal plaques
• Lesion should always be
viewed with high degree of
suspicion because it has high
incidence of development of
malignancy
• While obtaining biopsy of such
lesions both red and white
areas should be sampled
 Erythroplakia

Histopathology Clinical presentation

 Erythroplakia DD’s
• Inflammatory
conditions due to local
infection
• Chronic stomatitis
associated with denture
• Tuberculosis
• Fungal infections
• Early squamous cell
carcinoma
 Tobacco pouch keratosis:

• It is a distinct form of OPMD specifically associated with with SLT products, mostly
develops in the area of placement of SLT product and the lesion usually vanish with
in 2-6 weeks after quiting the ST product
• It has been reported that the lesion develops after 5 years of snuff dipping or
tobacco chewing habit.
• The disease is prevalent in male and female individuals of any age group with the
habit of SLT product use
• The most commonly affected area are the mucobuccal folds of maxillary or
mandibular region in incisors or molars area
• Clinically it present as a chronic white or gray wrinkled or fissured lesion which
usually seems to disappear when stretched.
• Micrscopically it present as hyperplasia of stratum corneum or spinosum with
parakeratin chevrons.
• Dysplasia may or may not be recorded and if present usually, mild type of OED is
identified
 Tobacco pouch keratosis:
(Snuff Dipper’s Lesion, Spit tobacco keratosis,
Smokeless tobacco keratosis)
 Dyskeratosis congenita
• 3 Gr words • Congenital= a disease or
• dys =disordered/disorganiz physical abnormality
ed present from birth
•  keras= horn
• Osis= condition
• abnormal,disordered/disor
ganized , premature,or imp
erfect development of the 
KERATINOCYTES
• A disorder of keratinization
 Dyskeratosis congenita
• Also called; Cole-Engman
Syndrome or Zinsser-Cole-
Engman Syndrome)

• Dyskeratosis congenita (DC)

is a rare inherited disease,
which is characterized by
the classic triad of ;
• nail dystrophy,
• reticular skin pigmentation,
• and oral leukoplakia.
 Dyskeratosis congenita
• DC may affect one in
1,000,000 of the population.
• It mainly occurs in men (male-
to-female ratio of 13:1) and
manifests between 5 and 13
years of age.
• Oral lesions, as white
keratotic patches, occur in
about 80% of cases.
• Typically, the buccal mucosa,
tongue and oropharynx are
affected.
• DC has an increased potential
of malignant transformation.
• There is no effective
treatment for DC.
• However, surgery and
treatment with bleomycin,
vitamin A, steroids and
testosterone have been
recommended for the man-
agement of this condition
 Verruciform Xanthoma

• Latin word •  Greek  word xanthos,

.Verruca=wart means "yellow",
• Forma=like • Refers to deposition of
• Resembling ,shaped like yellowish cholesterol
wart rich material that can
appear anywhere in the
body in various disease
states
 Verruciform Xanthoma
• Verruciform xanthoma
(VX) is a rare lesion first
described by Shafer in
1971.
• Unknown etiology
• Some reported role of
HPV
• Common in 5th and sixth
decade of life
• More common in females
• It mainly occurs in the
oral mucosa.
• The gingiva is the most
commonly affected site,
followed by tongue,
buccal mucosa,
vestibular mucosa, floor
of the mouth, soft
palate and lower lip.
•  
 Verruciform Xanthoma

• The lesions appear as a  

well-defined,
asymptomatic, slightly
elevated mass with a
yellow-white or red
color and a papillary or
verruciform surface.
Verruciform Xanthoma
VX
• Parakeratinized
papillomatous
epthelium
• Elongated rete pegs
• Xanthoma cells (foamy
histiocytes) in the
lamina propria
VX
 Verruciform Xanthoma

• There is limited information about malignant

transformation of VX.
• Some researchers described association of VX
with SCC and carcinoma in situ, respectively.
• Verruciform xanthoma is treated with
conservative surgical excision.
• Recurrence after removal of the lesion is rare.
Palatal lesion associated with reverse
smoking
 MTR
Malignant Transformation Rate
• Malignant transformation • OL-15-40%
may be defined as • PVL-70%
• OE-14-50%
development of oral
• TPK-0.6% to 2.8%
malignancy at the same
• OLP-0-10%
and previous site of OPMD • XP-50%
specified by time between • DC-8%
the onset of initial • hyperplasia and mild dysplasia are
diagnosis and progression less than 5%,
to malignancy confirmed • 3-15% for moderate dysplasia and
histopathologically on • 7-50% for both CIS and severe
biopsy dysplasia and 16% for CIS
Thankyou