EPULIS

Epulis:

👉 Epulis means “upon the gum”. It refers to a solid swelling situated on the gingiva.

👉 It arises from the alveolar margin of the jaw.

👉 The swelling is usually painless.

Classification of Epulis ➡️ Based on it’s consistency:

⚫ Soft Epulis – Granulomatous

⚫ Firm Epulis – Fibrous, Giant cell

⚫ Hard Epulis – Carcinomatous

⚫ Malignant Epulis – Carcinomatous

⚫ Dangerous Epulis – Fibrosarcomatous

Granulomatous Epulis:

🔼 Consistency: Soft to firm fleshy mass

🔼 Clinical Presentation: Manifests as a mass of granulation tissue around the teeth on the gums. It bleeds on touch.

🔼 Example: Pregnancy Epulis (gingivitis gravidarum)

Fibrous Epulis: (⭐ most common)

🔼 Consistency: Firm polypoidal mass

🔼 Clinical Presentation: Slow growing, non tender, a simple fibroma arising from the periodontal membrane, presents on the gum. May undergo sarcomatous change.

Giant Cell Epulis: (⭐ AKA Myeloid Epulis)

🔼 Consistency: Soft to firm gums with indurated underlying mass due to expansion of bone.

🔼 Clinical Presentation: It is an osteoclastoma arising in the jaw. Presents as hyperaemic vascular, oedematous, may ulcerate and result in haemorrhage. X ray shows pseudo trabeculation.

🔼 Treatment: Small tumours are treated by currettage; Large tumours are treated by radical excision.

Carcinomatous Epulis:

🔼 Consistency: Hard or malignant in consistency.

🔼 Clinical Presentation: This is an epithelioma arising from mucous membrane of the alveolar margin. Presents as a non healing, painless ulcer slowly infiltrating the bone. Hard regional lymph nodes are due to metastasis.

🔼 Treatment: Wide excision which includes removal of segment of the bone.

SOURCE: Manipal Manual of Surgery (3rd edition)


~Sunantha✍️

FRACTURE

FACTS ABOUT FRACTURE:

Broken Bone Fact #1: It’s no secret that smoking is bad for you, but did you realize that it can also have a negative impact on your ability to heal from broken bones?

Broken Bone Fact #2: If you aren’t sure you have a fracture, you can always try treating your injury at home with the “RICE” treatment: Rest, Ice, Compression and Elevation.

Broken Bone Fact #3: Ability to move isn’t a sure indicator of a broken bone, as the only way to confidently identify a fracture is with an X-ray. Infact, broken bones are almost always movable!

Broken Bone Fact #4: Fractures happen more easily as you get older. If you are over 85, your chance of breaking a bone is four times higher than if you are between the ages of 65 and 75.

Broken Bone Fact #5: At the end of the day, it’s better to see a doctor for your concerns. If you take too long to speak to your doctor about your possible broken bone, your bone could begin healing on its own in a crooked, painful and uncomfortable fashion!

STUDY NOTES ⚕️

Fracture:

A fracture is a structural break in the normal continuity of bone. This also includes hairline fractures.

Mechanism of Injury:

Direct violence ➡️ Fracture of tibia or mandible can occur due to a fall.

Indirect violence ➡️ Fracture of clavicle due to fall on outstretched hand.

Traction injuries ➡️ Traction of the ligament attached to the medial malleolus may lead to its fracture.

Compression fracture ➡️ It may occur due to fall from a height. May also be associated with impacted fracture of the vertebral body.

Types of Bones:

🔸Tubular bone

🔸Cancellous bone

Types of Fracture:

• Closed or Simple: There is no communication between the site of Fracture and the exterior.

• Open or Compound: There is a wound leading to the site of Fracture or communication between the Fracture site and the exterior.

Classification:

I. Depending on etiology of Fractures

II. Depending upon the plane of Fracture surface

III. Special Fractures

I. Depending on the etiology of Fractures

1️⃣ Traumatic Fractures

2️⃣ Pathological Fractures:

2a) Tumours 👉 Giant cell tumours, Secondaries in bone, bone cysts.

2b) Infections 👉 Acute osteomyelitis

2c) Metabolic bone diseases 👉 Hyperparathyroidism, Osteoporosis, Paget’s disease, Multiple myeloma, etc.

3️⃣ Stress Fractures:

Commonly seen in metatarsal bones (particularly in the second metatarsal due to prolonged marching).

Hence it is also called as ‘march fracture’.

II. Depending upon the plane of Fracture surface

• Transverse

• Spiral

• Oblique

• Comminuted

• Compression

III. Special Fractures

📍 Depressed Fractures

• Results due to sharp localised blow because of which a cortical bone segment is depressed.

• That needs to be treated with elevation of bone outwards.

• This type of Fracture is commonly seen in the skull.

📍 Fracture-Dislocation

• Fracture-Dislocation gives rise to severe pain and the continues till the dislocation is reduced.

• Classic example: Anterior dislocation of shoulder with Fracture of neck of humerus.

📍 Fracture involving a joint

• These Fractures should be treated with care OTHERWISE joint stiffness and late osteoarthritis can occur.

📍 Complex Fractures

• These Fractures involve major vessels or nerves.

• Example: Fracture of humerus associated with radial nerve injury or fracture of lower femur associated with popliteal artery injury.

Healing of a Fracture:

✔️ Stage of haematoma formation

✔️ Cellular stage

✔️ Stage of callus formation

✔️ Stage of new bone formation

✔️ Stage of remodelling


~Sunantha✍️

HISTOPATHOLOGICAL FEATURES OF COMMON ODONTOGENIC CYSTS

DENTIGEROUS CYST

• The lining epithelium is derived from reduced enamel epithelium and hence appears as uniformly thin non-keratinized epithelium.

• The epithelium comprises of 2-3 layers of flattened cells and is characteristically devoid of rete ridges.

Connective tissue capsule is derived from dental follicle, consists of young fibroblasts widely separated by ground substance rich in mucopolysaccharide.

• Connective tissue capsule may show odontogenic epithelial remnants.

• Cystic lumen contains cystic fluid which is thin, watery or may be blood tinged.

ODONTOGENIC KERATOCYST

• Typically shows a thin friable wall which is often difficult to enucleate from the bone in one piece.

• Cystic lumen may contain a clear liquid that is similar to a transidase of serum or it may be filled with a cheesy material, that on microscopic examination consists of keratinaceous debris.

• Microscopically, thin fibrous wall is essentially derated of any inflammatory infiltrate.

• Epithelium may show infoldings into the connective tissue capsule and may be separated from capsule in some areas.

CALCIFYING ODONTOGENIC CYST

• The lining epithelium is of variable thickness commonly around 5-10 layers.

• Spinous cells are loosely arranged.

• Presence of Ghost cells.

• Ghost cells are degenerating cells that appear as void, eosinophilic cells with nucleus showing different stages of degeneration.

• These cells are seen in thickened areas of lining epithelium.

• Connective tissue capsule is often scanty and sometimes contain discrete islands of odontogenic cells.

RADICULAR CYST

• The epithelial lining of the radicular cyst is stratified squamous in type of variable thickness.

• Epithelium shows spongiogenesis and inflammatory cell infiltration.

• Epithelium may show arc-shaped structures called Rushton bodies.

• The surrounding connective tissue shows granulomatous reaction due to the presence of Cholesterol clefts.

Source: Maji Jose

HISTOPATHOLOGICAL FEATURES OF COMMON SALIVARY GLAND TUMOURS

PLEOMORPHIC ADENOMA

• It is a well circumscribed tumour with complete or partial encapsulation with dense fibrous tissue.

• Epithelial components include proliferating ductal and myoepithelial cells forming ductal structures containing eosinophilic material.

• These cells also may form sheets, strands or islands.

• Ductal cells are cuboidal in shape with scanty cytoplasm.

WARTHIN TUMOUR

• Warthin tumour is made up of epithelial component and lymphoid component.

• Cystic formation, papillary projections are seen, showing germinal centres.

• The cyst are lined by papillary proliferation of bilayered oncocytic epithelium.

• The epithelial cells are abundant, finely granular, eosinophilic and are arranged in two layers.

• The inner luminal layer consists of tall columnar cells with centrally placed, palisaded and slightly hyper-chromatic nuclei.

• The outer luminal layer consists of cuboidal or polygonal cells with more vesicular nuclei.

MUCOEPIDERMOID CARCINOMA

• Microscopically, three types of cells are seen, dispersed in the connective tissue stroma.

• First type is Epidermoid cells which are squamous with distinct intercellular bridges, rarely with evidence of keratin formation.

• Second type is mucous secreting cells which are ovoid, filled with mucin and peripherally placed nucleus (clear cells)

• Intermediate cells are another type of cells, ovoid with darkly staining nucleus and scanty eosinophilic cytoplasm.

ADENOID CYSTIC CARCINOMA

• The tumour is composed of uniform cells resembling basal cells arranged in anastamosing whorls or duct like pattern.

• Some of these duct like areas contain mucoid material.

• This feature gives rise to the characteristic appearance described as “cribriform”, “honeycomb” or “swiss cheese” pattern.

• There may be areas where the cells are tubular or more solid

• The connective tissue components is often hyalinized and surrounding the tumour cells, forming a structural pattern of cylinders (ACC aka cylindroma).

Source: Maji Jose

HISTOPATHOLOGICAL FEATURES OF MAJOR EPITHELIAL LESIONS

SQUAMOUS PAPILLOMA

• Papilloma is characterized by finger-like projections lined by hyperplastic stratified squamous keratinized epithelium.

• Each finger like projection has a central thin connective tissue core carrying the blood vessels.

LEUKOPLAKIA

• Histopathologically, leukoplakia is characterized by Hyperkeratosis, Acanthosis and Dysplastic features.

• Dysplastic features include bulbous or drop shaped rete ridges, basal cell hyperplasia, loss of polarity of basal cells, irregular epithelial stratification, cellular pleomorphism, alteration in nuclear cytoplasmic ratio, nuclear hyper chromatism and increased mitosis.

ORAL SUBMUCOUS FIBROSIS

• The epithelium is atrophic with short or flat rete ridges.

• Connective tissue shows juxta epithelial hyalinization and exhibits fibrosis with dense bundles of collagen fibres.

• Focal collections of chronic inflammatory cells are present.

• In severe cases, muscles undergo degenerative changes.

SQUAMOUS CELL CARCINOMA

• The most significant microscopic feature of squamous cell carcinoma is dysplastic epithelial cells invading connective tissue.

• These cells may be arranged in the form of cords, sheets or islands.

• Dysplastic features seen are hyperchromatism of nuclei, alteration of nuclear cytoplasmic ratio, pleomorphism of cells and nuclei, prominent nucleoli, many normal and abnormal mitotic figures, individual cell keratinization and keratin pearl formation.

Source: Maji Jose