Pathology of the alimentary

system
Lecture 1:
Prepared by:
Dr. Savan Saeed Azeez
M.B.Ch.B, FKBMS (Pathology)
 PATHOLOGY OF THE ORAL CAVITY &
SALIVARY GLANDS

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 Infections of the Oral Cavity
• Commensal microorganisms of oral
cavity are normal, numerous, different
types and are usually harmless.

• they can become pathogenic If the

mucosa is injured or immunity impaired.

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 Infections of the Oral Cavity
The following terms are used to describe
localized inflammation of the oral cavity:
• Cheilitis (lips)
• Gingivitis (gum)
• Glossitis (tongue)
• Stomatitis (oral mucosa)
• Sialadenitis ( SG )
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 Infections of the Oral Cavity
• Viral e.g. HSV, EBV, HPV
• Bacterial e.g. Ludwig angina, diphtheria,
syphilis
• Fungal Infections e.g. candidiasis.

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 Herpes Simplex Virus (HSV) Infections
• Most orofacial herpetic infections are caused
by (HSV-1), with the remainder being caused
by HSV-2 (genital herpes).
• oral HSV-2 is becoming increasingly common 
bcz of changing sexual practices.
• Primary infections:
occur in children ( 2-4y)
are often asymptomatic,
in 10%-20% of cases it manifests as acute
herpetic gingivostomatitis.
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 HSV Infections
• Recurrent herpetic stomatitis:
occur in adults who harbor latent HSV-1, and the
virus can be reactivated, resulting in “cold sore” or
recurrent herpetic stomatitis.

• The recurrent lesions occur at 

1- the site of primary inoculation
2- in adjacent mucosa innervated by the same
ganglion.
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• Recurrent herpetic stomatitis:
• It appear as groups of small (1-3 mm) vesicles
on
lips (herpes labialis),
nasal orifices,
buccal mucosa,
gingiva & hard palate.
• lesions typically resolve within 7 to 10 days,
they can persist in immuno-compromised
patients.

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 orofacial herpetic infections

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 Factors associated with HSV reactivation
include:
• Trauma.
• Allergies.
• Immunosuppression.
• Upper respiratory tract infections ( influenza-
common cold) .
• Exposure to ultraviolet light.
• Exposure to extremes of temperature.
• Pregnancy & menstruation.
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 • The infected cells
become ballooned and
have large eosinophilic
intranuclear inclusions.
• Adjacent cells commonly
fuse to form  large
multinucleated
polykaryons.

herpesvirus infection
A, Herpesvirus blister in
mucosa.
B, cells from blister in A,
showing glassy intranuclear
HSV inclusion bodies.

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 INFLAMMATORY/REACTIVE LESIONS

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 Aphthous Ulcers (Canker Sores)
• Are common, often recurrent, painful,
superficial oral mucosal ulcerations of
unknown etiology.
• It tend to be prevalent within certain
families
• May also be associated with immunologic
disorders. ( such as celiac disease, IBD & behçet disease.)

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 Aphthous Ulcers / Presentation:
• More common in the first 2 decades of
life.
• They appear as single or multiple ,
typically, they are shallow, with a
hyperemic base covered by a thin
exudate (a yellowish fibrino-purulent membrane )and
rimmed by a narrow zone of erythema.
• Typically resolve spontaneously in 7 to 10
days, but may persist for weeks.
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 Aphthous Ulcers / Predisposing factors:
• Cessation of smoking.
• Stress: ulcers appear to exacerbate during school or
university examination times.
• Fever
• Trauma.
• Endocrine factors in some women increase in the luteal
phase of the menstrual cycle, and may regress in
pregnancy.
• Allergies to food.
• Sodium lauryl sulphate (SLS), a detergent in some oral
healthcare products.
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 Aphthous ulcer:
Single ulceration with an
erythematous halo
surrounding a yellowish
fibrinopurulent membrane.

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 Pyogenic Granuloma
• Is an inflammatory lesion typically found on
the gingiva of children, young adults, and
pregnant women (pregnancy tumor).
• The etiology is unknown, though it is
believed to be a possible response of tissues
to minor trauma and/or chronic irritation.
• The lesion may grow alarmingly rapid.
• It may regress spontaneously.

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• These lesions are richly vascular and typically ulcerated, which
gives them a red to purple color.
• In some cases, growth can be rapid and raise fear of a malignant
neoplasm.
• However, histologic examination demonstrates 
a proliferation of immature vessels similar to that seen in
granulation tissue.
• The term pyogenic granuloma is a misnomer as it is not filled
with pus or granulomatous tissue histologically.
• Fate of Pyogenic granulomas :
1. may regress
2. mature into dense fibrous masses
3. develop into a peripheral ossifying fibroma.
• Complete surgical excision is definitive treatment.

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 The pyogenic granuloma

Grossly it appear as polypoidal Histologically it composed of

nondual that usually ulcerate highly vascular proliferation of
organizing granulation tissue.

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07/03/2020 JUST TO REMIND YOU THE DIFFERENCEE BW 22
GRANULATION TISSUE AND GRANULOMA
Neoplastic lesion of the oral cavity
1. Benign lesion: e.g. hemangioma,
chondroma, …….
2. Precancerous and Cancerous Lesions:
Leukoplakia And Erythroplakia.
3. Malignant lesion Of The Oral Cavity
And Tongue. The commonest is SCC.

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 Leukoplakia
• It is a white patch or plaque
that cannot be scraped off
& cannot be characterized clinically or
pathologically as any other disease.
• This is present in the oral cavity for no apparent
reason.
• About 3% of the world’s population have
leukoplakia , of which 5% to 25% are dsyplastic
and at risk for progression to squamous cell
carcinoma.
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 Leukoplakia
• white patches caused by obvious irritation or
diseases as lichen planus & candidiasis are not
considered to be leukoplakias.
• 5% to 25% of these lesions are premalignant.
• Thus, until proven otherwise by means of
histologic evaluation,
all leukoplakias must be considered precancerous.

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 Leukoplakia

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 Erythroplakia
• Is a red, velvety, possibly eroded area that is
flat or slightly depressed relative to the
surrounding mucosa.
• Erythroplakia is associated with a much
greater risk of malignant transformation than
leukoplakia.

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 Erythroplakia

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 leukoplakia and erythroplakia
• May be seen in adults typically between the
ages of 40 & 70 years.

• Although the etiology is multifactorial,

tobacco use (cigarettes, pipes, cigars, and
chewing tobacco) is the most common risk
factors.

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 Histopathology
• Erythroplakia is commonly associated with
ominous alterations, including:
– Severe dysplasia
– Carcinoma in situ, or
– Invasive carcinoma.
• By contrast, leukoplakia may show a
spectrum of changes, from increased surface
keratinization without dysplasia to invasive
keratinizing SCC.
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Leukplakia show a hyperkeratosis and acanthosis without dysplasia

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Neoplastic lesion of the oral cavity
1. Benign lesion: e.g. hemangioma,
chondroma, …….
2. Precancerous and Cancerous Lesions:
Leukoplakia And Erythroplakia.
3. Malignant lesion Of The Oral Cavity
And Tongue. The commonest is SCC.

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 Squamous Cell Carcinoma (SCC)
• It is the sixth common malignancy
• Account for about 95% of oral cavity cancers .
• It is aggressive tumor with poor survival.
• oral cancer often is diagnosed at an advanced stage.
• The cervical LN are the most common sites of
regional metastasis; frequent sites of distant
metastases include the mediastinal LN, lungs, and
liver.
• Multiple primary tumors may be present at initial
diagnosis but more often are detected later
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 Pathogenesis
• Squamous cancers of the oropharynx arise through two distinct
pathogenic pathways, one involving exposure to carcinogens, and
the other related to infection with high risk variants of human
papilloma virus (HPV).
 1)- Carcinogen exposure
• mainly stems from chronic alcohol and tobacco (both smoked and
chewed) use.
• In India and Southeast Asia, chewing of betel quid and paan are
impor-tant predisposing factors.
• Betel quid is a “witch’s brew” containing araca nut, slaked lime, and
tobacco, all wrapped in betel nut leaf. It is likely that these tumors
arise by a pathway similar to that characterized for tobacco use–
associated tumors in the West.
• The mutations involved in sequencing of these cancers frequently
involve TP53 and genes that regulate cell proliferation, such as RAS.
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 2)- HPV:
• It is predicted that the incidence of HPV-associated
oropharyngeal squamous cell carcinoma will surpass
that of cervical cancer by 2020, in part because the
anatomic sites of origin—tonsillar crypts, base of tongue,
and oropharynx—are not readily accessible or amenable
to cytologic screening (unlike the cervix).
• The prognosis for patients with HPV-positive tumors is
better than for those with HPV-negative tumors.
• The HPV vaccine, which is protective against cervical
cancer, offers hope to limit the increasing frequency of
HPV-associated oropharyngeal squamous cell carcinoma.

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 3)-Unknown pathogenesis :
• The incidence of oral cavity squamous cell
carcinoma (particularly in the tongue) has been
on the rise in individuals younger than 40 years
of age who have no known risk factors.
• The pathogenesis in this group of patients, who
are nonsmokers and are not infected with HPV,
is unknown

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 SCC / etiology
• Is multifactorial:
1. Within North America and Europe, it is
classically a disease of middle-aged
individuals who have been chronic
abusers of smoked tobacco and alcohol.

2. In India and Asia, the chewing of betel

quid and paan is a major risk.
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 SCC / etiology
3. Actinic radiation (sunlight) and pipe
smoking can predispose to cancer of the
lower lip.
4. no risk factors may be identified
particularly in SCC of the tongue in
individuals younger than age 40.

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Factor Risk of transformation

Leukoplakia 3% to 25%

Erythroplakia More than 50%

Tobacco use Best-established influence, particularly pipe

smoking and smokeless tobacco

Human papillomavirus Identified in 30% to 50% of cases; probably

types 16 and 18 have a role in a subset of cases

Alcohol abuse Weaker influence than tobacco use, but the

two habits interact to greatly increase risk

Protracted irritation Weakly associated

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 SCC / morphology
• They appear as raised, firm, pearly plaques or
as irregular, roughened, or verrucous
mucosal thickenings.
• Then they typically form ulcerated and
protruding masses that have irregular and
indurated or rolled borders.
• They may be superimposed on a background
of a leukoplakia or erythroplakia.

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 SCC / morphology

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 Diseases Of Salivary Glands (SG)

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 Classification of diseases affecting the
Salivary glands
• Inflammatory conditions and their
aetiologies.
• Mucocele
• Neoplastic lesions of salivary glands.

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 Diseases Of Salivary Glands
Sialadenitis: is inflammation of the SG, may be
induced by:
• Trauma
• Viral infection e.g. mumps
• Bacterial infection: by staph or strept in case
of duct obstruction by stone or food particles
or due to dehydration.
• Autoimmune disease e.g. Sjögren syndrome.

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 Mucocele
• Is the most common lesion of the minor SG.
• Is a cystic lesion filled with mucous and
lined by granulation tissue.
• It results from:
– Either blockage of a SG duct (retension mucocele)
– or rupture of a SG duct (extravasation mucocele)
• with consequent leakage of saliva into the
surrounding CT stroma.

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 blockage of a SG duct

Accumulation of the saliva in duct

With time the duct will rupture

Release of high contents of saliva ( which contain high concetrations

of a-amylase and protases ) into the surrounding CT stroma

digestion of the tissue and formation of a cyst

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 Mucocele

• typically manifests as a fluctuant swelling of the lower

lip that may change in size, particularly in association
with meals
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 Mucocele.
• (A) Fluctuant fluid-filled 
lesion on the lower lip
subsequent to trauma.
• (B) Cystlike cavity 
(right) filled with 
mucinous material and 
lined by organizing
granulation tissue. 
The normal gland acini 
are seen on the left. 

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 Neoplasms Of Salivary Glands

• Diverse histopathology
• Relatively uncommon 2% of head and neck neoplasms
• Distribution
– Parotid: 80% overall; 80% benign
– Submandibular: 15% overall; 50% benign
– Sublingual/Minor: 5% overall; 40% benign
• The smaller the SG involved, the more likely the tumor
in it will be malignant.

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 Pleomorphic Adenoma PA

• ALSO called benign mixed tumor of SG.

Because of their remarkable histologic diversity.
• PA exhibit both epithelial and mesenchymal
differentiation & consists of a mixture of
– epithelial (ductal) cells.
– myoepithelial cells
• it is common (about 60% of) tumors in the
parotid gland.

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 Pleomorphic Adenoma PA
– Epithelial elements are dispersed
throughout the matrix

– mesenchymal elements which may contain

variable mixtures of myxoid, hyaline,
chondroid (cartilaginous), and even
osseous tissue.

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 Pleomorphic Adenoma
• It is more common in middle aged females
• Present as painless, slow-growing, rounded,
well demarcated masses.
• Although they are encapsulated, but the
capsule is not fully developed, and some growth
may extend into the surrounding tissues.

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 Pleomorphic Adenoma
• PA recur if incompletely excised.
• Complete surgical resection is difficult because of
the tumor’s proximity to the facial nerve, and,
thus, recurrence is frequent.
• Carcinoma arising in a pleomorphic adenoma is
referred to variously as a carcinoma ex
pleomorphic adenoma or malignant mixed tumor.

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 Pleomorphic Adenoma

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 Pleomorphic Adenoma

Bone cells
Epithelial cells

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 Mucoepidermoid Carcinoma MEC
• is the most common form of primary
malignant tumor of the SGs.
• Is composed of variable mixtures of
squamous cells,
mucus-secreting cells,
and intermediate cells.

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 Mucoepidermoid Carcinoma MEC

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 References
• Robbins & Cotran Pathologic Basis of Disease
- 9th edition -2015.
• Robbins Basic Pathology - 9th edition 2013.
• Muirs Textbook of Pathology 15th edition –
2014.
• Rubin’s Pathology, Clinicopathologic
Foundations of Medicine – 6th edition -2012.
• WEBSITE

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 Questions?

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