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Oral Mucosa

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Oral Mucosa
The oral cavitiy is lined by a mucous membrane that consists of:
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A mucosa { Epithelium { Lamina propria A submucosa, which is not always present

There is considerable variabilty in the type of epithelium present, as well as in the characteristics of the connective tissue. As a consequence, several regions are usually distinguished from one another:
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Lining mucosa Masticatory mucosa (mucoperiosteum) Specialized mucosa A transitional zone (vermilion zone)

Clinically, your ability to detection pathological changes will be directly dependent on your understanding of these normal variations. Lining Mucosa The epithelium of lining mucosa is a non-keratinized stratified squamous epithelium, which has a:
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A basal layer An intermediate layer (similar to spinous layer) A superficial layer

The thickness of the epithelium is variable. For example, in the buccal mucosa the the epithelium is relative thick, whereas on the floor of the mouth it is quite thin. As in the skin,"immigrant" cells (Langerhans cells, Merkel cells and melanocytes) are also present within the basal and suprabasal layers of the mucosal epithelium. Recall that Langerhans cells are derived from bone marrow an have an immune function, Merkel cells are associated with intraeipthelial nerve endings and and melanocytes (neural crest origin) synthesize melanin pigment. The underlying connective tissue (lamina propria) is separated from the epithelium by a basement membrane. The lamina propria is similar in structure and composition to the dermis of the skin. In the papillary layer there are connective tissue papillae and epithlial ridges. However, the interface between the mucosal epithelium and connective tissue is fairly "flat" compared to that in either skin or masticatory mucosa. The deeper submucosa is analagous to the hypodermis or subcutus of the skin, and it contains glands and adipose tissue. As with other connective tissues, the most common cell type in both the lamina propria and the submucosa is the fibroblast. Other cells, particularly macrophages and mast cells, are also present, and under conditions of inflammation, neutrophils, lymphocytes and plasma cells may also be seen. Collagen type I is the predominant fiber component of the extracellular matrix. Both collagen type III and elastic fibers are found in the lamina propria and submucosa, but their proportions vary depending on

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the region. Clinically, the relatively "loose" nature of the connective tissue in lining mucosa allows for the easy and relatively painless injection of local anesthetic solutions. Masticatory Mucosa In contrast to lining mucosa, masticatory mucosa has a keratinized stratified squamous epithelium:
z z z z

Basal layer Spinous layer Granular layer Cornified layer { Orthokeratinized -- no nuclei present { Parakeratinized -- pyknotic nuclei retained

The epithelial ridges and connective tissue papillae are long and numerous. Presumably this is related to the need to withstand the abrasive forces during mastication. In addition to a keratinized epithelium and the complex epithelial-connective tissue junction, the lamina propria of masticatory mucosa is often directly attached to the periosteum of the underlying alveolar or palatal bone, i.e. there is no submucosa. This arrangement is also called a "mucoperiosteum". There are exceptions to this generalization, however. In the posterior lateral region of the hard palate, for example, there is a submucosa containing adipose tissue and numerous minor salivary glands. Specific Regional Variation Differences in both the epithelium and the underlying connective tissue contribute to regional variation within the oral cavity.

REGION

EPITHELIUM

LAMINA PROPRIA

SUBMUCOSA

SOFT PALATE

Thin, nonkeratinized; taste buds present Thin, nonkeratinized

Thick with numerous short papillae

Loose connective tissue; minor salivary glands

VENTRAL TONGUE

Thin with short papillae; extensive capillary network Short papillae; extensive vascular supply Short papillae

Thin and irregular

FLOOR OF MOUTH

Very thin, nonkeratinized

Loose connective tissue

ALVEOLAR MUCOSA LABIAL & BUCCAL MUCOSA

Thin, nonkeratinized Very thick, nonkeratinized

Loose connective tissue containing elastic fibers Mucosa attached to underlying muscle; minor salivary glands

Long slender papillae but wide rete ridges, dense connective tissue with elastic fibers Numerous papillae and extensive capillaries Long, narrow papillae and rete ridges, dense connective tissue

VERMILLION ZONE GINGIVA

Thin, keratinized

Mucosa attached to underlying muscle Mucoperiosteum

Thick, ortho- or parakeratinized epithelium

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HARD PALATE

Thick, ortho- or parakeratinized epithelium

Long, narrow papillae, dense connective tissue

Mucoperiosteum, except over neurovascular bundles in posterior lateral region; minor salivary glands

One of the most important functional aspects of this regional variation is the effects on permeability. The oral mucosa acts as a permeability barrier, much like the lining of the intestine. However, in certain areas (floor of the mouth, ventral surface of the tongue) both the epithelium and the underlying connective tissue are thin, and there is an extensive capillary network in the lamina propria. Transmucosal adsorption of drugs, for example, occurs rapidly across these surfaces. The Mucogingival and Mucocutaneous Junctions The boundaries between lining mucosa and masticatory mucosa, as well as between the skin and labial mucosa, are relatively sharply defined.
z z

The mucogingival junction is the border between the alveolar mucosa and the gingiva. The mucocutaneous junction is found at the vermilion zone where the skin is continuous with the labial mucosa. The line separating the skin from the red vermilion zone is sometimes called the vermilion border.

Epithelial differentiation: Metaplasia and Dysplasia The differentiation of epithelium in the oral cavity is regulated by growth factors and retinoids, as in the skin. In addition, the underlying connective tissue plays a significant role in epithelial differentiation. Following wounding, epithelium at the edges of the wound proliferate to reepithelkialize the surface. The phenotype of the epithelium (keratinized versus non-keratinized) is determined largely by the connective tissue. Thus, gingiva regains keratinized epithelium, and alveolar mucosa will have its non-keratinized epithelium restored. This is of considerable clinical significance when doing gingival and other grafts within the oral cavity. Epithelial differentiation can also be influenced by functional stresses and other factors (e.g. smoking). The linea alba, for example, is a region of lining mucosa that changes to a keratinizing phenotype. This is an example of metaplasia. In metaplasia, the terminal differentiation of the epithelium is altered, but the basic architecture of is maintained. In "premalignant lesions", however, you start to see mitotic activity in the suprabasal layers, and there may be considerable variability in nuclear morphology. This is referred to as dysplasia.

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