Oral mucous membrane

Dr. Kush Pathak

 CONTENTS
 Introduction
 Definition
 Classification
 Development of oral mucosa
 Functions
 Clinical features
 Components of oral mucosa
 Oral epithelium/ Epidermis
 Epithelial proliferation
 Epithelial maturation
 Non keratinocytes
 Ultra Structure of Epithelial cell
 Lamina Propria/ Dermis

 Submucosa
 Arterial blood supply of oral mucosa
 Nerve supply of oral mucosa
 Tongue
 Junctions in oral mucosa
 Gingiva
 Fibers of gingiva
 Age changes in oral mucous membrane
 Clinical considerations
 Conclusion
 Introduction
 The skin, oral mucosa and intestinal lining, all consist
of two separate tissue components, which are, the
covering epithelium and an underlying connective
tissue. As these tissues, together perform a common
function, the oral mucosa must be considered as an
organ.
 Understanding the complex structure of a tissue or
organ often is easier, when it’s function is known. The
structure of oral mucosa reflects a variety of
functional adaptations. Any change in these functional
adaptations, leads to pathology.
 Definition :

 “The term moist membrane is used to describe moist

lining of GIT, nasal passages and other body
cavities that communicate with exterior. In the
oral cavity this lining is called oral mucous
membrane.”
 Classification
( A ) Based on functional criteria :
 (1) Masticatory mucosa : Gingiva and hard palate


 (2) Lining / reflecting mucosa : lip, cheek, soft

palate, floor of mouth.


 (3) Specialized mucosa : Dorsum of tongue



( B ) Based on structure of surface layers :

(C )
 ( 1 ) Keratinized mucosa : Hard palate and gingiva


 (2) Non keratinized mucosa : Cheek, soft palate,

vestibule, floor of mouth etc.

 Development of oral mucosa
 At about 26 days of gestation - Primitive oral cavity
develops by fusion of embryonic stomatodeum with foregut,
after rupture of buccopharyngeal membrane and thus gets
lined by epithelium derived from ectoderm and endoderm.

 Tongue, epiglottis and pharynx are covered by epithelium
derived from endoderm, whereas epithelium covering the
palate, cheeks, and gingiva is derived from ectodermal
origin.

 By 5 to 6 weeks of gestation – single layer of cells
lining the primitive oral cavity, has formed 2 cell
layers.

 Initially ectomesenchyme consists of widely spaced
stellate cells in an amorphous matrix, but by 6 to
8 weeks, extra cellular reticular fibers begin to
accumulate.





 At about 7weeks- Circumvallate, foliate and

fungiform papillae develop on the lingual
epithelia.


 By 8 weeks – Thickening occurs in the region of

vestibular dental lamina complex.

 At about 8 to 11 weeks.- palatal shelves devate
and close.

 By 8 to 12 weeks, capillary buds and collagen
fibers can be detected.


  By 10 to 12 weeks - future lining of masticatory
mucosa show some stratification of epithelium.

 By 10 to 14 weeks -Cellular degeneration occurs
in central region of the thickening of
vestibular dental lamina complex.


 Between 13 to 20 weeks - all oral epithelium

thicken and with the appearance of keratohyalin
granules, so a distinction between prickle and
granular layer can be made.

 Between 17 to 20 weeks – elastic fibers become
prominent only in connective tissue of lining
mucosa.

 Functions :
 Protection : Separates and protects deeper tissues
and organs from mechanical stresses/ forces, and
external environment.

 Sensation : Temperature, touch and pain sensation.
 Tongue has taste buds. Reflexes like swallowing,
gagging, salivating, also are initiated by receptors in
oral mucosa.

 Secretion : Saliva is secreted by salivary glands and
contributes to the maintenance of a moist surface.

 Thermal regulation : In some animals (dog),
considerable body heat is dissipated through oral
mucosa by panting. For these animals, oral mucosa
plays a major role in regulating of body
temperature. This function is not active in humans.

 Absorption : Certain substances like nitrates are
absorbed from sublingual region.

 Excretion : Excretes metabolites.

 Aesthetics : Gingiva and lip mucosa enhance
facial esthetics.
 Clinical features of oral
mucosa:
 Deeply colored, most obviously at the lips.

 Contains only minor salivary glands in comparison to
skin that contains hair follicles, sebaceous glands
and sweat glands.

 Surface of oral mucosa tends to be smoother and have
fewer folds or wrinkles than skin.

 Healthy gingiva shows fine surface stippling (small
indentations on mucosa surface).

 Slight whitish ridge present on the buccal surface is
called linea alba (white line). It is a keratinized
region and may represent the effect of abrasion from
rough tooth restorations or cheek biting.
 Components of oral mucosa
 Oral mucosa consists of 2 separate tissue components :


 (1) Epidermis - Stratified squamous epithelium,

called oral epithelium.
 (2) Dermis – Underlying connective tissue , called
lamina propria.
 Upward projections of connective tissue into
epithelium, are called connective tissue papilla.
 Epithelium is formed into ridges that protrude
towards lamina propria. These ridges are called
epithelial ridges.
 At their junction there are 2 different structures
with very similar names :
 (1)Basal lamina
 (2)Basement membrane
 (1) Basal lamina : It is evident at the electron
microscopic level and is epithelial in origin. It has
two parts : lamina lucida and lamina densa.
 (2) Basement membrane : It is evident at light
microscopic level and is found at the interface of
epithelial and connective tissue within the connective
tissue.
 - It is 1 to 4 µm wide.
 - It is cell free.
 -Stains positively with PAS, indicating that it
contains neutral mucopolysaccarides.
 -In skin it is shown to contain Fibronectin, laminin
(glycoproteins), heparin sulfate, proteoglycans, type 4
collagen and some antigens.
 Oral epithelium/ Epidermis
 It is a Stratified Squamous epithelium consisting of cells
tightly attached to each other and arranged in a number
of distinct layers or strata.
 It maintains it’s structural integrity by a process of
continuous cell renewal in which, cells produced by
mitotic division in the deepest layers, migrate to the
surface to replace those that are shed.
 The cells of the epithelium thus can be considered to
consist of two functional populations :

 (1) Progenitor population : Its function is to divide
and provide new cells.


 (2) Maturing population : The cells which continually

undergo a process of maturation to form a protective surface
layer.
 Epithelial Proliferation
 Progenitor cells are situated in basal layer in thin
epithelia (e.g. Floor of mouth) and in lower two or
three cell layer in thick epithelia.

 Dividing cells are present in clusters at the bottom of
epithelial ridges.

 A small population of progenitor cells represent stem
cells. Function of these stem cells is to produce
basal cells and retain proliferative potential of
the tissues.

 Large portion of the progenitor compartment is composed
of amplifying cells. Their function is to increase
the no. of cells available for subsequent maturation.


 Epithelial maturation
 There are two main patterns of maturation :
 (1) Keratinization
 (2)Non-Keratinization


 (1) Keratinization :
 Keratinized epithelium has following layers :
 (a) Stratum basale
 (b) Stratum spinosum
 (c) Stratum Granulosum
 (d) Stratum corneum.
 Layers of oral mucosa
 Stratum basale
 They are present above the basement membrane.
 They have cuboidal or columnar cells.
 Cells of the basal layer shows most mitotic activity.
 This layer is also called Germinative layer.
 They are attached to the basement membrane by hemidesmosomal
junction.

 Stratum Spinosum
 Present just above the basal layer.
 Arranged in several rows.
 Cells are larger elliptical or spherical in shape and are
known as Prickle cell layer.
 Cells are fused together due to the presence of
intercellular bridges or desmosomes.
 In the upper part of this layer, membrane coating granules/
lamellate granules/odland bodies are present.
 These granules are small, membrane bound structures.
 They are 250nm in size.
 They contain glycolipids originating from golgi complex.
Stratum spinosum
 Stratum spinosum  Cells of stratum
spinosum
 Stratum Granulosum
 Present just above the spinous layer.
 Cells are large and flattened containing small granules.
 These granules are Keratohyaline granules and layer is
called granular layer.
 Cells in the superficial part of this layer develop a
noticeable thickening on the inner(intracellular) aspect
of their membrane, that contributes to the considerable
resistance of keratinized layer against chemical solvent.
This thickening is due to protein known as involucrin.
 Membrane coating granules are present and they appear to
fuse with superficial cell membrane to discharge their
content in the intercellular space.
 This discharge is associated with formation of lipid rich
permeability barrier, that limits the movement of aqueous
substance through intercellular spaces.
Stratum granulosum
 Stratum granulosum  Cells
 Stratum Corneum
 Consists of squames or flat cells.
 They do not contain any nuclei.
 They stain bright pink with eosin as they are eosinophilic.
 Pattern of maturation of these cells often is termed as
ORTHOKERATINISATION.
 In Parakeratinised epithelium, surface layer stains for
keratin, but shrunken (pyknotic) nuclei are retained in
many squames/ flat cells.
Ortho


kratin
izd
Strati
fied
Squa
mous
epith
elium

Parak


eratin
ized
epith
elium
of
gingi
va
 As the cells of the granular layer reach the junction with
the keratin layer, sudden changes in appearance occur,
with loss of nuclei, organelles and Keratohyaline
granules.

 Cells get dehydrated and take up hexagonal shape called
Squames.

 Keratinized layer in oral cavity is composed of nearly 20
layers of squames. .

 Incomplete Keratinization / Parakeratinisation : Outer

most squames of keratinized or Parakeratinised layer
do not look like rest of the keratin but show a staining
similar to that of deeper nuclear cells. This is called
Incomplete Keratinization.
 (2) Non - Keratinization :


 Layers of non keratinized epithelium are :



(a) Stratum basale

(b) Stratum intermedium
(c) Stratum superficial / stratum distendum(mechanically
flexible)
 Stratum basale
 This layer is similar to that of keratinized
epithelium.
 Only difference is that the cells of this layer in
non keratinized epithelium are slightly larger
than that of keratinized epithelium.
 Intercellular bridges are less conspicuous.

 Stratum Intermedium
 Glycogen is present
 Rarely keratohyaline granules are also visible at this level,
but they are not associated with tonofilaments.
 Membrane coating granules are present and they appear to be
circular in shape with an amorphous core.
 Granules discharge their content in the intercellular spaces.
But the contents have different lipid composition and do not
form as effective barrier for aqueous substances as
keratinized epithelium.
 FILLAGRIN is absent.
 LORICRIN is present and may contribute to internal thickening of
cell membrane.
 Stratum Superficiale
 Cells appear slightly more flattened than other
layers.
 They contain dispersed tonofilaments and nuclei
and dehydrated cells.
 This surface is flexible and tolerant to
compression and distension.



 Non-Keratinocytes
 Cells that contain clear halo around the nuclei are
caller clear cells .These cells are glycogen
abundant and so they don’t get stained by
Hematoxylin and eosin. Thus resulting in a clear
cytoplasm. They are collectively known as Non
keratinocytes.
 They are :
(a)Melanocytes
(b)Merkel cells
(c)Langerhan’s cells
(d)Inflammatory cells (lymphocytes)
1.Melanocytes :
v Present in basal layers.
v These cells contain dendrites.
v No desmosomes and filaments.
v Premelanosomes and melanosomes are present.
 Functions :
v Synthesizes melanin pigment granules (melanosomes) and
transfer to surrounding keratinocytes. Thus, it causes
endogenous pigmentation of oral mucosa.
 2. Langerhan ’ s cells :
v Present predominantly in suprabasal layer
v Small rod or flask shaped granules called Birbeck granules
present.
v Dendrites present.
v No desmosomes and tonofilaments.


 Functions :
v Antigen trapping and processing.
 3 . Merkel cells :
v Present in basal layer.
v No dendrites present.
v Desmosomes and tonofilaments present.
v Characteristic electron dense vesicles and associated
nerve axon present.


 Function :
v It is a tactile sensory cell.
 4. Lymphocytes ( Inflammatory cell ) :
v Present variably.
v Contains large circular nucleus.
v Cytoplasm is scanty with few organelles.
v No desmosomes and tonofilaments present.
 Function :
v Associated with inflammatory response in oral mucosa.
v
 Ultra structure of Epithelial
cell
 Along with all cell organelles (nuclei, endoplasmic
reticulum, ribosomes, mitochondria, golgi complex) , cells
also contain certain structures :

v Tonofilaments
v Desmosomes
v Hemidesmosomes
v Keratohyalin granules
v Keratin
 Tonofilaments
 They are fibrous proteins and are seen as long filaments.

 Synthesized by ribosomes.

 Diameter is approximately 8nm.

 They belong to a class of intracellular elements called
intermediate filaments.

 They are intimately associated with keratohyalin granules.
 Desmosomes
 Also called macula adherens.

 Circular or oval areas of adjacent cell membranes, adhering
by specialized intracellular thickenings known as
attachment plaques.

 It consists of 2 proteins :- Desmoplakin and Plakoglobin .

 Bundles of tonofilaments get inserted into these attachment
plaques.

 Proteins naming Cadherins (Desmoglein and Desmocollin ),
penetrate the membrane and enter the intercellular region
of desmosome.
 Hemidesmosomes
 Adhesion between epithelium and connective tissue
is provided by hemidesmosomes.

 Hemidesmosomes are present on the basement
membrane of the epithelium.

 Tonofilaments get inserted in hemidesmosomes also.
 Keratins
 Keratins are classified according to their size (i.e.
molecular weight) and charge.

 Different types of keratin are present in different
cells and even in different layers of a single
stratified epithelium.

 When they become aggregated, they form bundles of
filaments called tonofibrils.

 Keratins represent 30 different proteins of differing
molecular weights.

 Those with lowest molecular weight (40 kDa) are found
in glandular and simple epithelia.
 Those with intermediate molecular weight are found
in stratified epithelium.

 Those with highest molecular weight (67 kDa) are
found in keratinized stratified squamous
epithelium.

 All stratified oral epithelium possess keratin 5
and 14.

 All keratinized stratified oral epithelium contain
keratins 1,6,10 and 16.

 All non keratinized epithelium contain keratins 4,
13 and 19.
 Keratohyalin granules
 Keratohyalin granules appear as basophilic granules
under light microscopy and as electron dense
structures in electron microscopy.

 Granules are irregular in shape.

 Their size is 0.5 to 1nm.

 They are synthesized by ribosomes.

 They are associated intimately with Tonofibrils and
are thought to facilitate aggregation and formation
of cross links between the cytokeratin filament of
keratinized layer.

 For this reason, protein making up bulk of these
granules are called FILAGGRIN.


 Sulfur rich component called LORICRIN also occurs.

  Two other type of connections are seen between cells:


v Gap junction or ‘ nexus ’ – Region where membranes of

adjacent cells run closely together, separated by only a
small gap.
 Such junctions may allow electrical or chemical
communication between cells and are sometimes called
‘Communicating Junctions ’.


v Tight Junction –
Ø Also called ‘ Occluding junctions ’.
Ø Here adjacent cell membranes are so tightly joined to each
other, that there is no intercellular space left.
Ø It is very rarely found.



 Lamina Propria
 Connective tissue supporting the oral epithelium is termed
as Lamina propria.
 It is divided into 2 layers :
v Superficial papillary layer (associated with epithelial
ridges) : Here, collagen fibers are thin and loosely
arranged.
v Deeper reticular layer (lies between papillary layer
and underlying structures) : This layer has collagen
fibers arranged in thick bundles that tend to lie
parallel to the surface plane.



 Lamina propria consists of cells, blood vessels, neural
elements and fibers embedded .
Cells of Connective tissue :

1 . FIBROBLASTS -
v They are stellate or elongated cells with abundant
 endoplasmic reticulum.
v They secrete fibers and ground substance.
v They are disturbed throughout the lamina propria.
v
v
v
2. HISTIOCYTES –
v Spindle or stellate shaped cells.
v They contain dark staining nuclei.
v Contain abundant Lysosomal vesicles.
v They are precursors of functional macrophages.
v They are present throughout the lamina propria.

3. MACROPHAGES –
v They are round with pale staining nucleus.
v Contain lysosomes and phagocytic vesicles.
v Helps in phagocytosis.
v Present in areas of chronic inflammation.


4. MAST CELLS –
v They are round cells with basophilic granules.
v They stain metachromatically.
v Secretes inflammatory mediators.
v Present throughout the lamina propria.

 5. PMN CELLS –
v They are round with lobed nucleus.
v Helps in phagocytosis.
v Present in areas of acute inflammation.


6. LYMPHOCYTES –
v They are round with dark staining nucleus and scanty cytoplasm.
v They help in humoral and cell mediated immunity.
v Found in areas of chronic inflammation.



 7. PLASMA CELL –
v They have cart wheel pattern with basophilic nucleus.
v They contain abundant rough endoplasmic reticulum.
v Helps in synthesis of immunoglobulins.
v Seen in areas of chronic inflammation.


8. ENDOTHELIAL CELLS – Present in lining of the blood

 Vessel.

 Submucosa
 High concentration of blood vessels and nerves are present.

 It is a site of the minor salivary glands.

 In the intestine the submucosa is called the muscularis mucosae

 There is no such thing in oral mucosa.

 In cheeks, lips and part of the hard palate – submucosa layer is made
of loose areolar or adipose tissue

 In regions such as gingiva and part of the hard palate, the
submucosais not present and the oral mucosa attaches directly to
the periosteum of underlying bone. This is called
 Arterial blood supply of oral
mucosa
 Hard palate -
Ø Major palatine artery.
Ø Nasopalatine artery.
Ø Sphenopalatine artery.

 Soft palate :
Ø Minor palatine artery
Ø
 Floor of mouth :
Ø Sublingual artery
Ø Branch of lingual artery


 Tongue :
Ø Deep lingual artery .
Ø Dorsal lingual artery.

 Nerve supply of oral mucosa
 Hard palate:
Ø Greater palatine
Ø Lesser palatine
Ø Sphenopalatine branches of maxillary nerve.


 Soft palate :
Ø Lesser palatine branch of maxillary nerve
Ø Nerve of pterygoid canal
Ø
 Tongue :
Ø Lingual branch of mandibular nerve
Ø Glossopharyngeal nerve.
Ø
 Tongue
 Mucosa of dorsal surface of the tongue, although covered by what is
functionally a masticatory mucosa, has different types of lingual
papillae.

 Some of these papillae possess mechanical functions, whereas some
bare taste buds, therefore having sensory function.

 Following papillae's are present on the tongue :


v Fungiform papillae
v Filiform papillae
v Foliate papillae
v Circumvallate papillae
 Fungiform papillae :
v Present on the anterior portion of the tongue along with
Filiform papillae.
v
v Single Fungiform papillae is surrounded by numerous
filiform papillaes at the tip of the tongue.
v
v They are smooth and round structures.
v
v They appear red, because of their highly vascular connective
tissue core.
v
v Present on the superior surface.
v
FUNGIFORM PAPILLAE

A : Fungiform papilla
B : Filiform papillae

D : Heavy Keratinization
 Filiform papillae :
v Cover entire anterior part
v
v Consist of cone shaped structures, each covered by a thick
keratinized epithelium.
v
v Together form a tough, abrasive surface that is involved in
compressing and breaking the food.
v
v Dorsal mucosa functions as masticatory mucosa.
v

 Tiny

Proje
ction
s

Histo


logic
Filif al
appe
orm aranc
e
Papi
llae
 Foliate papillae :
v leaf like.
v
v Sometimes present on lateral margins of posterior part of
tongue.
v
v Pink papillae with 4 to 11 parallel ridges with deep grooves
in mucosa.
v
v Few taste buds are present in the epithelium of lateral walls
of ridges.
v
v Seen in mammals, not in human beings.
 Histo


logic
al
appe
aranc
e

Elev


ation
Foli s :-
foliat
ate e
papill
Papi ae

llae
 Circumvallate papillae :
v Present adjacent and anterior to the sulcus terminalis.
v
v They are 8 to 12 in number.
v
v Large structures, each surrounded by a deep, circular groove
into which ducts of minor salivary glands (glands of von
ebner)open.
v
v Superiorly, connective tissue core of these papillae is
covered with keratinized epithelium, whereas on lateral
walls, it is covered with non keratinized epithelium.
v
v Taste buds are present on the lateral walls.
CIRCUMVALLATE PAPILLAE
 Taste Buds
 It is composed of two types of cells, neuroepithelial and
supporting (sustentacular) cells.

 The neuroepithelial cells communicate with the free surface of the
mucosa by the taste canal.

- Microvilli ("taste hairs") project from the ends of the neuroepithelial
cells into the taste canal.
-
- The neuroepithelial cells are usually located centrally in the
structure, surrounded by their supporting or sustentacular cells.

 A :-


Taste
buds

B :-


Micro
Tast villi
(tast
e e
hairs)
bud
s
 Papillae are mainly concerned with different taste sensations :

v Vallate papillae : Bitter
v Fungiform papillae : Sweet and salty
v Foliate papillae : Sour
 Junctions in oral mucosa
A. Mucocutaneous junction :
v Junction between skin and mucosa.
v At this junction, few sebaceous glands are present.
v Epithelium is keratinized but thin.
v Red in color (vermilion zone) due to close proximity with blood.
v No salivary gland are there in the vermilion zone and only few sebaceous
glands are present, so it tends to dry out and cracked in winters.
B. Mucogingival junction :
C.
v Junction between gingiva and alveolar mucosa.
v
v Histologically, a change occurs in this junction, not only in type of
epithelium but also in composition of the lamina propria.
v
v Stippling is seen, and reflects the attachment of the collagen fibers.
C. Dentogingival Junction :
D.
v Region where oral mucosa meets the surface of the tooth is called
dentogingival junction.
 Junctional Epithelium
 The junctional epithelium is that epithelium which lies
at, the base of the gingival sulcus. It attaches to
the surface of the tooth with hemidesmosomes.

 It is 1mm in width.

 Cells in the junctional epithelium tend to have
 wide intercellular spaces, to allow the transmission
of
 W.B.C’s from blood vessels to bottom of the
 gingival sulcus, to help prevent the disease.

 Its irregular in texture.
 Gingiva
 Tissue which covers the alveolus and encircles the neck of teeth is
called gingiva.

 Functions :
v Surrounds and supports the teeth.
v Prevents invasion of bacteria to periodontal ligament.
v
 Parts of Gingiva :
v Free gingiva (Marginal or unattached)
v Attached gingiva
v Interdental papilla
 Free gingiva :

v Knife edge part of gingiva.
v
v In normal healthy individual, width is about 1mm.
v
v Causes food lodgment, when knife edge is thickened.
v
 Attached gingiva :

v Part which is firmly bound to periosteum is called attached gingiva.
v
v Superiorly, it is bound to free gingival groove and inferiorly extends
up to mucogingival line.
v
v It is firm and reselient.
v It’s width is maximum in maxillary incisor region :- 3.5 to 4.5 mm
v
v It’s width is minimum in mandibular 1st premolar region :- 1.8mm
v
v Increase in width of attached gingiva is due to supra eruption of a
tooth with increased cementum deposition.
v
v Any decrease in width is pathological.
v
 Interdental Papillae :

v Part which extends between two teeth up to the contact point is
called interdental papillae.
v
v It has a ‘facial side’ and a ‘lingual side’ .
v
v It’s margins are concave.
v
v Due to inflammation, interdental papillae looses it’s concavity.
v
 COL :
v Connecting facial and lingual side of the interdental papilla (on
proximal side) is an epithelial structure called COL.
v
v It’s concave shape means, gingiva is healthy.
v
v It becomes dome shaped, in gingival recession and inflammation.
v
v It is covered by non keratinized stratified squamous mucosa.
  Fibers in gingiva :


v Dentogingival fibers : Run from cementum to

 gingiva.
v
v Circular fibers : Hugs around the tooth.
v
v Alveologingival group of fibers : Run from alveolar crest into
lamina propria of free and attached gingiva.
v
v Dentoperiosteal group : Run from cementum to periosteum of
alveolar crest.
 Functions :
v Braces marginal gingiva firmly against the tooth.
v
v Withstand forces of mastication.
v
v Unites attached gingiva with cementum to augment, action of
junctional epithelium.
 Age changes in oral mucosa
 Oral mucosa of an elderly patient has a smoother and dryer surface
than younger patient, due to dry therapy or any systemic
diseases.

 Epithelium appears thinner histologically.

 Flattening of epithelial ridges.

 Reduction in no. of filiform papillae.

 Glossy and smooth appearance.

 Langerhan’s cells become fewer with age, leading to decrease in cell
mediated immunity.


 Nodular varicose veins on the under surface of the tongue(caviar
tongue).

 Decrease in cellularity occurs in lamina propria with increase in
collagen.

 Sebaceous (Fordyce’s spots) glands of lips and cheeks increase with
age.

 Elderly post menopausal women, have symptoms such as dryness of
mouth, burning sensations and abnormal taste.
Clinical Considerations
 Classification of oral
lesions
 Mucosal lesions :
:
v Leukoedema
v Oral leukoplakia
v Proliferative verrucous leukoplakia
v Epithelial dysplasia
v Oral hairy leukoplakia
v Oral lichen planus
v Candidiasis


 Oral ulcerative lesions :

§ Acute :
v Traumatic
v Bacterial
v Troponemal

v Viral
v Fungal
v Drug reactions
v Erythema Multiforme
v Lupus Erythematosus
v Reiter’s syndrome
v
v
 Chronic :
v Vesiculobullous lesions
v Malignant diseases
 Recurrent :

v Recurrent Apthous stomatitis :
 - Major Apthous ulcers
 - Minor Apthous ulcers


v Herpetiform ulcers
v Bechet’s syndrome


 Acute ulcerative :
v Acute necrotizing ulcerative gingivostomatitis (ANUG)
v Streptococcal gingivostomatitis
v Oral Tuberculosis
v Gonococcal stomatitis
 Syphilis :

 - Congenital syphilis
 - Primary syphilis
 - Secondary syphilis
 - Tertiary syphilis
 Fungal :
v Oral Candidiasis
v Histoplasmosis


 Viral :
v Herpes simplex
v Recurrent Herpes simplex
v Herpes labialis
 v Varicella zoster
v Coxsackie


 Discoid Lupus Erythematosus


 Reiter’s syndrome
 Bechet’s syndrome

 Drug Reactions : Barbiturates, Salicylates, Phenolphthalein,
Quinine, digitalis, Grisefulvin, Dilantin

  Chronic ulcerative :
v Pemphigus vulgaris
v Mucous membrane (cicatricial) pemphigoid
v Traumatic Granuloma


 Hyperpigmentation of oral mucosa :

v Exogenous :
qForeign material – Amalgam tattoos, , carbon, seeds,
leaves of various plants, tobacco
qPharmacologic agents: Minocycline, AZT, anti-
malarials, amiodarone, OCP, doxorubicin
qHeavy metal exposure: bismuth, mercury, silver, lead,
tin, copper
 v Endogenous :
q Systemic : Addison’s disease, Peutz-Jeghers syndrome,
hemochromatosis
q Neoplasms: nevi, oral and labial melanotic macules,
melanoma
q Reactive process: post-inflammatory hyperpigmentation
q
v Others : - Acute Tonsilitis
 - Carcinoma of Tongue
 - Angular Chelitis
 - Torus Palatinus
 - Torus Mandibularis
 - Cold Sores
- Oro Pharynx Necrosis


- Salivary gland stone
 - Oral Fibroma
 - Lingual Cavernous Hemangioma
 - Lingual Hemangioma
 - Mass on base of Tongue
 - Sialocele
 - Oro Maxillary Fistula
 - Lichenoid reaction
v Pigmentation :
 Melanoplakia


v White sponge nevus


  Keratotic lesions :
 - Hyperplastic
 - Atrophic


 Dyskeratotic lesions – eg. Dyskeratotic leukoplakia



Malignant tumors :

 - Oral Squamous cell carcinoma
 - Adenocarcinoma
 Dermatological lesions :
- Stevens-Johnsons syndrome


 - Lichen Planus

 - Discoid Lupus Erythematosus


Developmental disturbances
of Oral mucosa:
 Fordyce’s disease (Fordyce’s
granules)
 It is a developmental anomaly characterized by heterotrophic
collections of sebaceous glands at various sites in oral cavity.
 Clinical features :
v Small yellow spots.

v They form large plaques.

v Found frequently in a bilateral symmetrical pattern on the mucosa of

cheeks, opposite molars and also on the inner surface of lips.

v
FOR
DYC
E’S
GRA
NUL Yellow small macular or papular structures on buccal mucosa. They are usually


symptomless.
ES
v Occasionally they are found on tongue, gingiva, frenum and palate.

v Besides oral cavity, they are also found in esophagus, female

genitalia, palms and soles, parotid gland, larynx and orbit.


 Histological features :
v Heterotrophic collections of sebaceous glands are common in skin,
but not associated with hair follicles.
v Glands are usually superficial and may consist of only a few or
many lobules, grouping around one or more ducts opening on the
surface of mucosa.
v Ducts may show keratin plugging.
HIST
OLO
GIC
AL
IMA Lobules of Sebaceous glands emptying into ductal structures that communicate


with the surface of the mucosa.

GE
HIST
OLO
GIC
AL
IMA Excessive accumulation of larger lobules of Sebaceous glands that often produce


a noticeable mucosa swelling.

GE
 Focal Epithelial Hyperplasia
(Heck’s disease)
 Clinical features :

v Primarily occurs in children.

v It is HPV induced epithelial proliferation and is known to be

produced by subtypes of HPV, i.e. HPV -13 and possibly HPV –

32.
HEC
K’S
DISE Multiple Sessile and papillary lesions of the anterior gingiva and labial mucosa of


an adult.
ASE
v No gender predilection.
v Site – Labial, buccal, lingual mucosa. Some gingival and tonsillar
lesions have also been reported.
v Fissured appearance of entire mucosal area, due to clustering of the
hyper plastic lesions.
v Lesion is papillary in nature.

 Histological appearance :

 Focal acanthosis of oral epithelium.

 Mucosa is 8-10 times thicker than normal.

 Lesional rete ridges are at same depths as normal rete ridges.

 Ridges are widened and club shaped.

 Mitotic figures (mitosoid cell) seen.

 Sessile in nature.
HIST
OLO
GIC
AL
IMA Spinous layer epithelial cells with unusual arrangement of the nuclear material


resembling abnormal mitotic figures (mitosoid cells).

GE
 Lacks central keratin filled core of keratoacanthoma.

 Lacks sub epithelial foamy or granular histocytes like cells required

for diagnosis of Verruciform Xanthoma.


 Leukoedema
v Common oral mucosa condition of unknown cause.

v More common in blacks than in whites.



 Clinical Features :

v Diffuse, grayish- white, milky, opalescent appearance of mucosa.

v Wrinkles present on the surface of mucosa.

v Lesion does not rub off.

 v Occurs bilaterally but adjacent mucosa can also be involved.

v Occurs mainly on buccal mucosa and extends up to labial mucosa.

Sometimes it can also involve floor of the mouth.


  Histological appearance :

v Increase in thickness of the epithelium.

v Intracellular edema of the spinous layer is seen.

v Pyknotic nuclei present in large vacuolated cells.

v Epithelial surface is frequently parakeratinized

v Rete ridges are broad and elongated.


HIST
OLO
GIC
AL
IMA
GE
Developmental disturbances
of Gingiva :
 Fibromatosis gingivae :
 Also called Elephantiasis gingivae, hereditary gingival fibromatosis,
congenital microgingivae.
 It is a diffused fibrous overgrowth of gingival tissues.
 It is considered Hereditary, being transferred from dominant
autosomal gene.
 Clinical features :
v
v It is a dense, diffuse, smooth or nodular overgrowth of gingival
tissues usually appearing at the time of eruption of permanent
incisors.
 Histological appearance :

v Epithelium thickened.

v Elongated Rete pegs.

v Coarse bundle of collagen fibers with few fibroblasts and blood

vessels.
 Retrocuspid Papilla
v Small, 2-4 mm slightly elevated nodule on the lingual mucosa of

mandibular cuspids.

v Soft, well circumscribed, sessile, mucosal nodule, bilateral but can

also be unilateral.

v Prominent in children.
CLIN
ICAL
IMA A reddish, slightly-raised sessile small nodule behind or lingual to the lower


cuspid tooth.
GE
 Histological appearance :

v Appears as an elevated mucosal tag often showing mild

hyperkeratosis or hyperparakeratosis.

v Surfaced of orthokeratinized or parakeratinized squamous

epithelium.

v Can be with or without acanthosis.

v Underlying connective tissue is highly vascularised.

v Large stellate fibroblasts.

v Occasional epithelial rests.


Developmental disturbances
of Tongue :
 Aglossia and Microglossia
syndrome
v Very rare.

v Associated with malformations in extremities, mainly hands and

feet, cleft palate.

v Actually, Aglossia syndrome is a microglossia with extreme

glossoptosis (Rudimentary or small tongue).

 Mandible does not grow in the anterior direction due to lack of
muscular stimulus.

 It’s etiology is unknown, but some say it’s some sort of fetal cell
traumatism in first few weeks of gestation.
CLIN
ICAL
IMA Congenital short lingual frenum of the tongue with microglossia


GE
 Macroglossia
v Also called as tongue hypertrophy, prolapsus of tongue, enlarged

tongue, pseudomacroglossia.

v It means large tongue.

v May occur due to some congenital syndromes. E.g. Down’s

syndrome and Beckwith- wiedmann syndrome.

MAC
ROG
LOS
SIA
 Ankyloglossia or Tongue tie
v Occurs when inferior frenum attaches to the bottom of the tongue

and resists it’s free movement.

v Tongue tie may contribute to dental problems as well, causing

persistent gap between mandibular incisors

v There is difficulty in speech and feeding.

v Frenulectomy is recommended.
ANKYLOGLOSSIA IMAGES
 Cleft tongue
v A complete cleft or bifid tongue is a rare condition.

v Occurs due to lack of merging of lateral lingual swellings.

v A partial cleft tongue is more common and is actually a deep groove

in the midline of dorsal surface.

v It occurs due to incomplete merging and faliure of groove

obliteration by underlying mesenchymal proliferation.

v It is a feature of oral- facial- digital syndrome.


 Scrotal tongue/ fissured
tongue, lingua plicata
v Grooves that vary in depth are present along the dorsal and lateral

aspects of tongue.

v A polygenic mode of inheritance is suspected.

v Seen in Melkersson – Rosenthal syndrome, Down’s syndrome,

Geographic tongue (Benign migratory glossitis)

Clinical images
 Histological appearance :

v Increase in the thickness of the lamina propria.

v Loss of filiform papillae of surface mucosa.

v Hyperplasia of rete pegs.

v Mixed inflammatory infiltrate in lamina propria.

 Median Rhomboid Glossitis
v Post dorsal point of fusion is occasionally defective, leaving a

rhomboid shape, smooth and erythematous mucosa.

v Lack of papillae/ taste buds.

v Occurs in candidiasis and also

 known as ‘Chronic Atrophic

 Candidiasis’.
 Clinical features :

v Kissing lesion : Infected cases may also demonstrate a midline soft

palate erythema in the area of routine contact with the underlying

tongue involvement. This is commonly called kissing lesion.

v
v
 Histological appearance :

v Smooth or nodular surface covered by atrophic stratified squamous

epithelium.

v Dilated capillaries.

v Fungiform and filiform papillae not seen.

v Chronic inflammatory cell infiltrate may be seen.

v Extreme elongation of rete processes

v Dyskeratosis.
Histological images
 Benign migratory glossitis
(Geographic tongue)
v Psoriasiform mucositis of the dorsum of tongue.

v It’s dominant characteristic is constantly changing pattern of

serpiginous white lines surrounding areas of smooth,

depapillated mucosa.
Clinical images
 Histological appearance :

v Thickened keratin layer with neutorphils.

v Inflammatory cells often produce small micro abscesses, called

Monroe's abscesses in keratin and spinous layer.

v Rete ridges are thin and elongated.

v Chronic inflammatory cells seen in variable numbers within stroma.

HIST
OLO
GIC
AL
IMA Hyperkeratotic epithelium


GE
  Hairy
Also known astongue
Lingua nigra, lingua villosa, lingua villosa nigra,

black hairy tongue.

v It is a condition of defective desquamation of filiform papillae.

v It may appear brown, white, green, pink.


Clinical images
v Etiology :-

Ø Hypertrophy of filiform papillae on dorsal surface of the

tongue.

Ø Occurs due to poor oral hygiene.

Ø Tobacco use.

Ø Coffee and tea drinking.

 Histological appearance :

v Elongated filiform papillae.

v Mild hyperkeratosis.

v Occasional inflammatory cells.

 Lingual varices (lingual/
sublingual varicosities)
v Varix is a dilated, tortuous vein.

v Appear as red or purple shot like clusters of vessels on ventral

surface and lateral borders of tongue as well as in floor of mouth.

v Also occur in upper and lower lip, buccal mucosa, buccal

commissure.
Clinical images
 Lingual thyroid nodule
v It is an anamolous condition in which follicles of thyroid tissue are
found in the substance of the tongue.

CLIN
ICAL
IMA
GE
 Histological appearance :
v Nodules exhibit colloid degeneration or goiter.


HIST
OLO
GIC
AL
IMA Lingual thyroid nodule


GE 
Developmental disturbances
of oral lymphoid tissue
 Reactive lymphoid aggregate
(Reactive lymphoid

hyperplasia)
v Lingual tonsil, located on the posterior portion of the tongue frequently
becomes inflamed and enlarged.
v It is bilateral .
v Also is called ‘foliate papillitis’ due to foliate papillaes present in this area.
v They are firm, nodular, sub mucosal mass.
v They are tender.
CLIN
ICAL
IMA Reddish smooth-surfaced papules of the posterior lateral border of the


tongue in the foliate papilla area.

GE
HIST
OLO
GIC
AL
IMA Superficial and deep perivascular and periadnexal lymphoid infiltrate.


GE
v Lymphoid hamartoma
 Also called angiofollicular lymph node hyperplasia, angiomatous

lymphoid, castleman tumor, follicular reticuloma giant benign

lymphoma, hamartoma of lymphatics, giant lymph node

hyperplasia)

v Castleman’s disease is a rare disorder characterized by noncancerous

benign growth that may develop in the lymph node tissue

throughout the body.

v Most often, occurring in chest, stomach and neck.

v Abnormal enlargement of lymph nodes occur.


 3 types of Castleman's disease :

a) Hyaline vascular type (90%) : These are non cancerous

overgrowths.

b) Plasma cell type : Associated with fever, weight loss, skin rash,

early destruction of R.B.C.

c) Multicentric / Generalized Castleman’s disease :

v Abnormal large liver and spleen (hepatospleenomegaly).

 v Exact cause of castleman’s disease is not known.

v Some researches say it’s because of increase in production of

interleukin- 6 (IL-6)

v Interleukin – 6 is a substitute produced by structures within lymph

nodes.


 Angiolymphoid hyperplasia
with eosinophilia
v Also called Epitheloid hemangioma, histocytoid hemangioma,

pseudopyogenic granuloma, papular angioplasia, inflammatory

angiomatous nodules.

v Uncommon disorder.

v Present with isolated or grouped plaques or nodules in skin of head

and neck.

v Lesion is benign.
v
v A distinct entity, ALHE is marked by proliferation of blood vessels

with distinctive large endothelial cells.

 Histological appearance :

v Papules around ear may suggest ALHE enlarged endothelial cells

with uniform ovoid nuclei and intracytoplasmic vacuoles.

HIST
OLO
GIC
AL
IMA Benign cutaneous vascular tumor largely composed of epithelioid vascular cells


with focal glomeruloid features.

GE
 Lymphoepithelial cyst
v Develops within a benign lymphoid aggregate or accessory tonsil of

the oral or pharyngeal mucosa.

v Surface of such aggregates may be indented with tonsillar crypts.

v The crypts may become obstructed by keratin or other debris.

v Certain cases develop complete disunion of the crypt epithelium

from the surface epithelium.

HIST
OLO
GIC
AL
IMA 
GE Yellow lymphoepithelial cyst on the margin of the tongue

 Histological appearance :

v Lined by atrophic and often degenerated stratified squamous

epithelium.

v Lack rete processes.

v Minimal granular cell layer.

v Rarely, mucus filled goblet cells may be seen within superficial

layers of the epithelium.

v Orthokeratin seen sloughing from the epithelial surface into the

cystic lumen.

HIST
OLO
GIC
AL
IMA Often lined by squamous epithelium


GE
HIST
OLO
GIC
AL
IMA Lined by non-neoplastic glandular epithelium


GE
ORA
L
LEU
KOP
LAKI
A
ORA
L
VER
RUC
OUS
LEU
KOP
LAKI
A
EPIT
HELI
AL
DYS
PLA Nodular leukoplakia showing severe epithelial dysplasia


SIA
ORA
L
HAIR
Y
LEU
KOP
LAKI Leathery white callus on the side of the tongue


A
ORA
L
HAIR
Y
LEU
KOP
LAKI It is considered pathognomonic for aids. When a clinician encounters a patient


with hairy leukoplakia, he assumes he is dealing with a person with HIV virus and
A recommends that the patient have serological test for HIV
ORA
L
LICH
EN
PLA
NUS
CAN
DIDI
ASIS
ORA
L
ULC
ERA
TIVE
LESI
ON
Acute Necrotizing Ulcerative
Gingvostomatitis
ORA
L
TUB
ERC
ULO
SIS
SYP
HILI
S
HIST
OPL
ASM
OSIS
HER
PES
LABI
ALIS
COX
SAC
KIE
VIR
US
INFE
CTIO
N
DIS
COI
D
LUP
US
ERY
THE
MAT
OSU (A.) Extraoral photograph of patient with discoid lupus erythematosus. Note the


butterfly shaped rash on the malar area. (B) Intraoral photograph of the same patient
S showing erosive lesions surrounded by radiating white striae on the left buccal mucosa.

REIT
ER’S
SYN
DRO Tongue lesion


ME
BEC
HET’
S
SYN
DRO
ME
PEM
PHG
US
VUL
GAR
IS
MUC
OUS
MEM
BRA
NE
PEM
PHIG
OID
REC
URR
ENT
APT
HOU
S
STO
MATI
TIS
Acute tonsllitis
TOR
US
PAL
ATIN
US
TOR
US
MAN
DIB
ULA
RIS
ANG
ULA
R
CHE
LITIS
COL
D
SOR
ES
STE
VEN
S-
JOH
NSO
N
SYN
DRO Also called erythema multiforme


ME
ORA
L
PHA
RYN
X
NEC
ROS
IS
Salivary gland stone
ORA
L
FIBR
OMA
LING
UAL
CAVE
RNO
US
HEM
ANGI
OMA
MAS
S AT
BAS
E OF
THE
TON
GUE
SIAL
OCE
LE
ORA
L
MAX
ILLA
RY
FIST
ULA
 References :
 Tencate’s textbook of dental histology; 7th edition.
 Orban’s textbook of oral histology; 11th edition.
 Oral anatomy, histology& embryology ; berkovitz ; 3rd
edition.
 Textbook of periodontology; Carranza ; 10th edition
 Oral and Maxillofacial Pathology; Neville; 2nd edition.
 Shafer’s Textbook of Oral Pathology; 6th edition.
 Contemporary Oral and Maxillofacial Pathology ; 2nd
edition.
 Handbook Of Oral Disease, diagnosis and management ;
Crispian scully ; 1st edition.
 Francis.V.Howell. Oral mucous membrane lesions.
California Medicine 1964 ; 100(3); 186-91.
 Francis B. Quinn ,Matthew W. Ryan. Ulcerative Lesions Of
The Oral Cavity. UTMB Grand rounds 2002 ;1-11

 Brad W. Neville, Terry A. Day. Oral Cancer and
Precancerous Lesions. CA Cancer J Clin 2002;52:195-215