MUCOSAL REACTIONS to INJURIES

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Functions of the Oral Mucosa

1.Protection: Barrier for mechanical trauma and microbiological insults 2.Sensation: Temperature (heat and cold), touch, pain, taste buds, thirst; reflexes such as swallowing, etching, gagging and salivating 3. Secretion: Salivary secretion 4. Thermal regulation: Important in dogs not in humans
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Organization of the Oral Mucosa

3 types according to FUNCTION: 1.Masticatory Mucosa:25% of total mucosa. Gingiva (free, attached and interdental) and hard palate. Primary mucosa to be in contact with food during mastication. MASTOCATORY MUCOSA IS USUALLY KERATINIZED. 2.Lining Mucosa:60% of total mucosa. Covers the floor of mouth, ventral (underside) tongue, alveolar mucosa, cheeks, lips and soft palate. Does not function in mastication and therefore hasminimal attrition. Non-keratinized; soft and pliable. 3.Specialized Mucosa:15% of total mucosa. Covers dorsal tongue and composed of cornifiedepithelial papillae.

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( 25% ) ( 15% )

( 60% )

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Masticatory Mucosa

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Lining Mucosa

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Specialized Mucosa

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General Features of Oral Mucosa

1.Separated from the skin by vermillion zone of the lips which is more deeply colored than rest of the oral mucosa 2.Factors affecting color of the oral mucosa: a. Concentration and state of dilation of the blood vessels in underlying connective tissue b. Thickness of the epithelium c. Degree of keratinization d. Amount of melanin pigmentation Clinically, color of oral mucosa is very important. For example, inflamed oral tissues appear red rather than the normal pale pink
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Injury
An alteration in the environment that causes tissue damage Examples include
Physical Chemical Microorganisms Nutritional deficiencies

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PRODUK MIKROBIAL TRAUMA TERMAL TOKSIN OBAT-OBATAN

MUKOSA

Injury

RESPON

RADIASIPENGION

REVERSIBEL

IREVERSIBEL
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Natural (Innate) Defenses Against Injury Intact skin or mucosa is a physical barrier. Saliva have an antibacterial activity. Flushing action of saliva..

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Inflammation
A nonspecific response to injury
Occurs in the same manner regardless of the nature of the injury May be local and limited to the area of injury, or may be extensive if the injury is extensive May be acute or chronic

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Manifestasi Radang / Inflamasi

Manifestasi Klinis
RUBOR

Perubahan Mikroskopik

Hiperemi - Vasodilatasi mikrovaskularisasi Hiperemi metabolisme meningkat Eksudasi - cairan keluar dari pembuluh masuk ke jaringan Tekanan eksudasi pada saraf dan stimulasi mediator kimia radang Dampak lanjut pembengkakan dan nyeri
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KALOR

TUMOR

DOLOR

FUNGSIO LESA

Sikatan mudah berdarah?

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Manifestasi Radang / Inflamasi

Manifestasi Systemik FEVER Perubahan Mikroskopik

Pyrogen hypothalamus demam Jml leukosit meningkat Protein yang dihasilkan hati meningkat dalam sirkulasi Hiperplasi dan hipertrofi limfosit

LEUKOSITOSIS C-REAKTIF PROTEIN MENINGKAT LIMFADENOPATI

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Microscopic Events and Clinical Signs of Inflammation

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Lymphadenopathy

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Sequence of Microscopic Events

Injury to tissue Constriction of microcirculation Dilation of microcirculation Increase in permeability Exudate leaves microcirculation. Increased blood viscosity Decreased blood flow Margination and pavementing of white blood cells (WBCs) WBCs enter tissue. WBCs ingest foreign material.
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White Blood Cells and Their Involvement in the Inflammatory Response

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Sequence of Microscopic Events

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Regeneration and Repair

Regeneration
If the inflamed area returns to normal structure and function

Repair
Occurs when the damage is too great for the tissue to return to normal Functioning cells and tissue often are replaced with nonfunctioning scar tissue.

Takes about 2-3 weeks

Occurs almost simultaneously in both epithelium and connective tissue
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Chronic Inflammation
Due to persistent injuries Cells involved include macrophages, lymphocytes, and plasma cells as well as neutrophils and monocytes present in acute inflammation. May include proliferation of fibroblasts and formation of granulomas

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Chronic Inflammation
Granuloma
Microscopic groupings of macrophages surrounded by lymphocytes and plasma cells Usually contain multinucleated giant cells Large macrophages with multiple nuclei Associated with foreign body reactions and some infections such as tuberculosis

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Hyperplasia, Hypertrophy, and Atrophy

Hyperplasia An increase in the number of cells often in response to chronic irritation or abrasion May return to normal if the insult subsides, or may persist following removal of the irritant Hypertrophy An increase in the size of cells May be seen in cardiac muscle as a response to hypertension Atrophy A decrease in size or function of a cell, tissue, organ, or entire body
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PRODUK MIKROBIAL TRAUMA TERMAL TOKSIN OBAT-OBATAN

MUKOSA

Injury

RESPON

RADIASIPENGION

REVERSIBEL

IREVERSIBEL
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Aspirin Burn
Topical application is a common misuse of this product. The tissue becomes necrotic and white. The surface may slough off leaving a painful ulcer. The ulcer usually heals in 7 to 21 days.

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Aspirin burn

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Perhatikan ciri-ciri klinis.

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Phenol Burn
Used in dentistry as a cavity sterilizing agent and a cauterizing agent Will cause whitening and sloughing of the area as a result of tissue destruction

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Erosions on the dorsum of the tongue, caused by very hot food

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Electric Burn
May be seen in infants or young children who have chewed an electrical cord May be quite extensive, damaging oral tissue and even tooth buds May cause constriction of the commissure

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Electrical and Thermal Burns

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Other Burns
Hot food burns
From soup or cheese on pizza

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Other Burns

Trichloroacetic acid
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Physical and Chemical Injury

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Lesions from Self-Induced Injuries

A factitious injury
Due to a habit such as chronic lip, cheek or tongue biting, or trauma to the teeth from a fingernail Lesions may range from ulceration to epithelial hyperplasia and hyperkeratosis.

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Morsicatio buccarum (chronic cheek chewing)

Morsicatio buccarum Morsicatio linguarum Morsicatio labiorum

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Hematoma
A bruise inside the mouth Blood in an extravascular space Appears as a red to purple to bluishgray mass Most frequently seen on labial or buccal mucosa

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Traumatic Haematoma on lower lip

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Traumatic Ulcer
May be due to such events as biting the cheek, lip, or tongue, irritation from a complete or partial denture, mucosal injury from sharp edges of food, or removal of a dry cotton roll after a dental procedure (some patients are sensitive to the starch in a cotton roll) Persistent trauma may cause a hard (indurated), raised traumatic granuloma. Treatment Usually heals within 7 to 14 days unless the trauma persists, May require a biopsy
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Traumatic Ulcer

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Frictional Keratosis
Due to chronic rubbing or friction against an oral mucosal surface A form of hyperkeratosis
Resembles a callus on skin

Results in a opaque white appearance Treatment

Identify the traumatic cause of the lesion whether it be an opposing third molar, chronic cheek or tongue chewing, or some other entity. Eliminate the cause.

Must be differentiated from idiopathic leukoplakia because leukoplakia may be premalignant

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Frictional Keratosis

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Linea Alba
A white, raised line most commonly on the buccal mucosa at the occlusal plane May be the result of a teeth clenching habit Sometimes the pattern of the teeth can be seen in the lesion. Due to epithelial hyperplasia and hyperkeratosis Treatment None
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Linea alba

Hiperorthokeratotik Edema intrasel Radang kronis (sedikit)

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Linea Alba

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Nicotinic Stomatitis
A benign lesion typically associated with pipe and/or cigar smoking; may also occur with cigarette smoking Initially, erythema is seen, but over time keratinization takes place, resulting in increased opacity. Raised red areas may be seen at the openings of ducts of minor salivary glands on the palatal surface. This is due to obstruction by keratin at the mucosal openings of the ducts.
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Nicotinic Stomatitis

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Tobacco Pouch Keratosis

A white lesion located where chewing tobacco is placed, most often in the mucobuccal fold
Early lesions may have a granular or wrinkled appearance. Long standing lesions may be more opaquely white and have a corrugated surface.

Treatment
May require biopsy
Long-term exposure to chewing tobacco has been associated with increased risk of squamous cell carcinoma.

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Tobacco Pouch Keratosis

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Amalgam Tattoo
A flat, bluish-gray lesion of oral mucosa due to the introduction of amalgam into tissue
May occur during placement or removal of an amalgam restoration or during an extraction May be seen in any location in the oral cavity, most commonly on gingiva or alveolar ridge Amalgam particles may be seen on radiograph, aiding in diagnosis.

Diagnosis
Patient history and radiographs may help. Must be differentiated from malignant melanoma

Treatment
None providing melanoma has been ruled out
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Amalgam Tattoo

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Solar Cheilitis (Actinic Cheilitis)

A degeneration of the tissue of the lips due to exposure to the sun Occurs particularly in fair-skinned individuals The lower lip is usually more involved than the upper lip. The epithelium is thinner than normal; the vermilion appears pale pink and mottled. The interface between lips and skin is indistinct. Treatment No specific treatment

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Solar Cheilitis (Actinic Cheilitis)

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Mucocele
A lesion that forms when a minor salivary gland duct is damaged Not a true cyst The mucous salivary gland secretion is walled off by granulation tissue to form a cystlike structure lined by compressed granulation tissue. Most commonly found in the lower lip It may increase or decrease in size over time. May appear bluish if near the surface Treatment If persistent, they are surgically removed.
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Mucocele (cont.)

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Necrotizing Sialometaplasia
A benign condition of salivary glands Moderately painful swelling and ulceration Thought to result from blockage of the blood supply to the affected area Necrosis of the salivary glands is seen histologically. Salivary gland epithelium is replaced by squamous epithelium (metaplasia). The ulcer usually heals by secondary intention.

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Necrotizing Sialometaplasia

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Reactive Connective Tissue Hyperplasia

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Reactive Connective Tissue Hyperplasia

Pyogenic Granuloma Giant Cell Granuloma Irritation Fibroma Denture-Induced Fibrous Hyperplasia Papillary Hyperplasia of the Palate Gingival Enlargement Chronic Hyperplastic Pulpitis

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Reactive Connective Tissue Hyperplasia

Proliferating, exuberant granulation tissue and dense fibrous connective tissue resulting from overzealous repair
May be a response to a single event or chronic low-grade injury

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Connective Tissue Hyperplasia ()

chronic inflammation or irritation

exuberant production of granulation tissue in chronic inflammatory reactions

Reactive Hyperplasia

Tumor like Lesions

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Pyogenic Granuloma

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Pyogenic Granuloma
A proliferation of connective tissue containing numerous blood vessels and inflammatory cells occurring as a response to injury
The name is a misnomer; the lesion is neither pyogenic (pus forming) nor a true granuloma.

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Pyogenic Granuloma

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Gingival Swelling
Epulis (epulides)
non-specific term for any solid growth arising from the gingiva or alveolar ridge area

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Pyogenic Granuloma
(pregnancy tumor)
It is deep red to purple. Generally elevated, may be sessile or pedunculated Most commonly on the gingiva, it may be seen on other intraoral areas Usually develop rapidly and then remain static If seen in a pregnant female, it is called a pregnancy tumor.
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PEDUNCULATED

EXOPHYTIC GROWTH

SESSILE

ENDOPHYTIC GROWTH
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Pregnancy Tumor
A pyogenic granuloma seen in a pregnant woman
The lesions are identical to those seen in men and nonpregnant women. May be caused by hormonal changes and increased response to plaque They often regress after delivery.

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Pregnancy Tumor

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Peripheral Giant Cell Granuloma

A lesion that contains many multinucleated giant cells, wellvascularized connective tissue, RBCs, and chronic inflammatory cells.

Occurs only in the jaws Seems to originate from periodontal ligament or periosteum in response to injury Peripheral OF Central OF
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Peripheral Giant Cell Granuloma

Occurs on gingiva or alveolar process, usually anterior to the molars Vary in size from 0.5 to 1.5 cm Usually dark red from vascularization Most frequent in people from 40 to 60 years of age More common in women than in men
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Irritation Fibroma
The most common mass on the gingiva A broad-based, persistent exophytic lesion composed of dense, scarlike connective tissue with few blood vessels The result of trauma such as cheek chewing or cheek biting Usually a small lesion, less than 1 cm in diameter Most often occurs on buccal mucosa, may occur on tongue, lips, and palate

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Irritation Fibroma
Usually lighter than surrounding mucosa The surface is covered by stratified squamous epithelium. May be opaque if thick or ulcerated due to local secondary trauma Treatment Surgically removed Must be differentiated from many soft tissue tumors
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Denture-Induced Lesions

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Mucosal Pathologies of Oral Prostheses

Mucosal Lesions Burning Mouth Syndrome

Allergic response Fungal Infection

Trauma (metallic clasps)
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Denture stomatitis

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Denture-Induced Fibrous Hyperplasia (Epulis fissuratum)

Observed in the vestibule as elongated folds of tissue into which of an ill-fitting denture fits Composed of dense, fibrous connective tissue with a surface of stratified squamous epithelium The surface may be ulcerated. Treatment Surgical removal of excess tissue and construction of a new denture

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Denture-Induced Fibrous Hyperplasia (Epulis fissuratum) (Inflammatory hyperplasia)

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Papillary Hyperplasia of the Palate (Palatal papillomatosis)

Almost always associated with a removable full or partial denture The palatal vault is covered by multiple papillary projections. Each projection consists of fibrous connective tissue, usually chronically inflamed and surfaced by stratified squamous epithelium.
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Papillary Hyperplasia of the Palate (Palatal papillomatosis)

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Gingival Enlargement
An increase in the bulk of free and attached gingiva, especially the interdental papillae Gingival margins are rounded. Color may vary from normal pink to pale or erythematous depending upon the degree of inflammation and vascularity. May be generalized or localized

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Gingival Enlargement
Usually an unusual tissue response to chronic inflammation associated with local irritants such as plaque or calculus

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Gingival Enlargement
May be from an increased response to local tissue factors due to Hormonal changes during pregnancy or puberty Certain drugs such as phenytoin, Ca channel blockers, and cyclosporine

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Oral Complications of Antineoplastic Therapy

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Oral Mucositis?
Inflammatory lesion of oral mucosa in cancer patients receiving high-dose chemotherapy or head and neck radiation therapy up to 80% of patient receiving radiotherapy for head and neck tumors develop OM Characterized by:
Erythema Ulceration Pain

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Oral mucositis (OM) in head and neck cancer

week 2 of radiation therapy: patients experience clinically evident OM from week 5-6 of radiation therapy, symptoms peak and may last several weeks following radiotherapy

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Significance
Cancer therapy dose reductions interruptions Difficulty swallowing Weight loss Increased infection Prolonged hospital stays Increased healthcare costs
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The effect on symptoms of OM

Erythema Oedema Ulceration Pain Bleeding Partial/absent taste sensations Xerostomia Local infection Malnutrition Fatigue Dental caries Abdominal disturbances

SHORT TERM

Quality of Life
LONG TERM

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WHO Grade 1 2 Mucositis

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WHO Grade 2 3 Mucositis

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WHO Grade 4 Mucositis

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White Lesions Associated with Smokeless Tobacco: Treatment

Discontinue habit; biopsy suspicious areas

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Actinic Cheilosis

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Actinic Cheilosis

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Actinic Cheilosis

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Oral Trauma from Sexual Practice

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Fibrous hyperplasia - cunnilingus

Palatal petechiae - fellatio

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White Lesions Associated with Smokeless Tobacco

Asymptomatic white folds surrounding area where tobacco is held; usually found in labial and buccal vestibules; a common oral lesion. Increased risk for development of verrucous and squamous cell carcinoma after many years.
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Smoker melanosis

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