 Classification

 Physical injuries
- Bone
- Soft tissues
 Radiation induced injuries
 Chemical injuries
 Physical injuries

 Chemical injuries
 Injuries of teeth

 Injuries of bone

 Injuries of soft tissue

 Non – allergic reaction to Drugs and chemicals –

locally

 Non – allergic reaction to Drugs and chemicals –

Systemically
 Bruxism

 Fracture of teeth

 Tooth ankylosis
It is the habitual grinding of the teeth either
during sleep or as an unconscious habit during
waking hours

Etiology
Local factors

Systemic

Psychologic

Occupational
Local factors- Mild occlusal disturbance, tension, transition from
primary to Permanent

Systemic- GIT disturbance, Sub clinical nutritional deficiency, Allergy or

endocrine disturbance, Hereditary

Psychologic- Emotional tension, Person suffers – fear , rejection,

Nervous tension

Occupational- Watch makers, Tobacco chewers , Objects – tooth picks

and pencils
 Typical grinding and clenching – sleeping

 Grinding and grating noise

 Effect on dentition, periodontium, masticatory muscles,

TMJ, head pain and psychological and behavioral

effect.
 Severe attrition of teeth
 Occlusal wear and inter proximal wear
 Both the surface – actual facets
 Periodontal loss – loosening or drifting of teeth
 Gingival recession with alveolar bone loss
 Hypertrophy of the masticatory muscles

 Facial pain and headache

 Underlying cause

 Removable splints

 Guide the movement so that periodontal damage is

minimal
 Common injury – sudden severe trauma

 Fall , blow, automobile accident

 Large restoration - thin walls or unsupported cusps

ELLIS CLASSIFICATION
Class 1 – simple fracture of the crown involving little or no dentin

Class 2 – extensive fracture of the crown, involving considerable dentin

but not pulp

Class 3 – extensive fracture of the crown, involving considerable dentin

and exposing pulp

Class 4 – non-vital tooth with or without loss of crown structure

Class 5 – teeth lost as a result of trauma

Class 6 – fracture of root with or without loss of crown structure

Class 7 – displacement of a tooth, without fracture of crown or root

Class 8 – fracture of the crown en mass

Class 9 – traumatic injuries to deciduous teeth
 Any age – children
 Dental pulp is pierced by fractured crown or root
Bacteria

Tubules

Infected pulp
Pulpitis
 Root fracture- uncommon in younger age group

 Roots are not completely formed

 Healing - in the union of the two fragments by calcified

tissue

 The clot between the root fragments is organized & this

CT is subsequently the site of new cementum and bone

formation.
Tubular dentin

osteoid formation

Not repaired
completely
 It occurs when the connective tissue of PDL is lost
allowing cementum or dentin to come in direct contact
with the alveolar bone, leading to fusion of these two
calcified structures.

 Ankylosis – when the normal physiological resorption

of roots is interrupted (deciduous teeth)

 Cause- acute or chronic trauma to the teeth.

 In deciduous teeth- submerged teeth

 On percurssion – dull, muffled sound rather than

normal sharp sound.

 R/G- loss of thin radiolucent line(PDL), with mild

sclerosis of the bone and apparently blending of the
bone with the root.
 Reveals area of root resorption, which is replaced by
calcified material (bone or cememtum) – continuous
with the alveolar bone.

 PDL- completely obliterated in the area of ankylosis.

 Traumatic bone cyst

 Surgical ciliated cyst of maxilla

 Effect of orthodontic movement

 It is a pseudo cyst which occurs in mandible
Demographics :
• Age: young inviduals
• Sex: Equal
• Site :Mandible
 Pathogenesis :
Trauma to bone

Intramedullary haemorrhage

Failure of organization of blood clot

Liquefaction of the clot

Traumatic cyst
 Radiographic features :
 Refers to a lesions characterized by the accumulation of
mucin, completely encased by epithelium.
 ETIOLOGY – trauma or after surgery (Caldwell-
Luc surgery)
 Clinically- spherical in shape & degree of symptoms
depends on the location & extent of expansion,
destruction.
 Histologically- lined by pseudostratified, ciliated
columnar epithelium or squamous or metaplastic
squamous epithelium.
 Traumatic ulcer ( Decubitus ulcer )
 Sore spots
 Denture sore mouth
 Inflammatory ( fibrous ) hyperplasia
 Palatal papillomatosis
 Factitial injuries
 Mainly caused by trauma
 Biting the mucosa , denture irritation, tooth brush
injuries
 Iatrogenic injury – “ cotton role injury”
 Site – Lateral border of the tongue, buccal mucosa, lip
 Occasionally – palate.
 Tongue ulcers – neoplasm ulcer - biopsy
 Accidentally self – induced injuries ( habit)
 Lip biting- Morsicatio labiorum, Factitious cheilitis.
 Cheek biting - Morsicatio buccarum
 Tongue – Morsicatio linguarum.
 Patients with Gilles de la Tourette syndrome- prone
to spontaneous erratic behavior & incoherent facial
expressions, verbalization. Part of this syndrome is
the tendency for self-mutilation, which is often
directed to oral mucosa.
 Buccal lesion- located bilaterally in the mid portion of the
anterior buccal mucosa along the occlusal plane.
 Lesion-thickened, shredded white areas, with irregular ragged
surface.
 Sometimes- areas of erythema, erosion.
 Persistent scaling & flaking of the vermilion border of lips due
to chronic injury such as lip biting.
 Fingernail injury- seen in gingiva. Presents as vertical clefts
produced by forcing the free gingival margins apically. Often
results in root exposure, chronic non-healing ulcer.
 Cause - Denture irritation

Clinical features,

 Develop within day or two

 Number – one or more

 Over extension of the flanges

 Sequestration of spicule of bone under the denture

 Small irregular shaped, painful ulcer.

 Ulcer covered by delicate gray necrotic membrane.

 Loss of continuity of the surface epithelium
 Fibrous exudate covering the exposed CT
 Infiltration of polymorphonuclear leukocytes ,
macrophages
 Lymphocytes and plasma cells
 Capillary dilatation and proliferation
 Correct the underlying the cause

 Relief the flanges

 Removal of a tiny sequestrum

 Also known as denture stomatitis, erythematous
candidiasis/chronic atrophic candidiasis.
 Uncommon condition manifesting as areas of erythema
confined to denture bearing areas of maxillary
removable denture.
 Due to infection with “Candida albicans”
 The important aspect of colonization by candidal
organism is the attachment of the yeast to the denture,
which is enhanced by mucus & serum & decreased by
the presence of salivary pellicle.
 Extremely red , swollen , smooth or granular and
painful.
 Multiple pinpoint foci of hyperemia
 Severe burning sensation
 Redness of the mucosa – contact with the denture

 Treatment – Anti fungal therapy

 Chronically ill fitting denture
 Hyperplasia of the mucosa along with the denture border
 Location – gingiva , buccal mucosa , angle of the mouth
 Leaf like denture fibroma- less common variant of fibrous
hyperplasia. Present beneath maxillary denture, as a
flattened pink mass closely attached to the palate by a
narrow stalk. The edge of the lesion is serrated as a leaf.
 Result – denture injury
 Elongated rolls of tissue – mucolabial or muco buccal
fold area
 Proliferation of tissue – slow
 Resorption of the alveolar ridge
 Ulceration in the base of the fold
 Palpation - firm
 Excessive bulk of fibrous connective tissue covered by
surface epithelium.
 Hyper ortho or para keratosis
 CT – coarse bundles of collagen fibers with few
fibroblasts.
 Base of the fissure - ulceration
 Fibrous
proliferation

Hyperplastic
Epithelium
 Surface epithelium of inflammatory fibrous
hyperplasia is “ Mucopolysaccharide keratin
dystrophy” – plasma pooling
 Homogenous , eosinophilic pools material in the
superficial spinous layer of epithelium, where it
appears to have replaced individual cells.
 Significance – not known

 Treatment - surgical excised

 Unusual condition
 Involving the mucosa of the palate
 Etiology – unknown
- Ill fitting denture
- Frictional irritation
- Poor state of oral hygiene
 Edentulous patient

 Numerous closely arranged , red , edentulous papillary

projections involving palate

 Lesion – alveolar mucosa , mandibular alveolar mucosa

 Individual papilla – 1-2 mm

 Tissue exhibits – inflammation and ulceration

 Numerous small vertical projection composed of

parakeratotic or ortho keratotic surface epithelium with

central core of connective tissue.

 Pseudo epitheliomatous hyperplasia in varying degree.

Thin and slender
Retepegs

Hyperplastic
epithelium
 Discontinuing the use of ill fitting denture
 Construction of new denture
 Syn- traumatic ulcerative granuloma with stromal
eosinophilia (TUGSE), eosinophilic granuloma of
tongue, traumatic granuloma.

 It is a histologically unique type of chronic ulceration

of the oral mucosa characterized by a deep
pseudoinvasive inflammatory reaction.
 Unknown but a traumatic background has been
suggested.

 Trauma – due to malposed teeth, partial denture or

commonly by an erupting teeth during nursing which
results in sublingual ulcerations in infants.

 This characteristic ulcerations of infancy are referred to

as Riga-Fede disease
 Age – all age group
 Sex- male
 Site- anteroventral dorsal surface of the tongue. Other
sites- gingiva, palate, mucobuccal fold.
 Duration- weeks- 8 months
 Erythematous area surrounding a central removable
yellow fibropurulent membrane.
 Rolled borders and proliferation of the underlying
granulation tissue can lead to a raised lesion resembling
pyogenic granuloma
 Riga-Fede disease- appears between one week to one
year of life.

 Site- anteroventral surface of the tongue, caused by the

contact with the mandibular incisors. It can also occur
on the anterodorsal surface of the tongue
 Deeper extension of inflammatory infiltrate, presence
of sheets of lymphocytes & histiocytes along with
eosinophils.
 Hyperplasia of the vascular connective tissue leading to
elevation of the surface.
 Ulceration induced by the trauma- ingress micro-
organisms, toxins & foreign bodies into the connective
tissue
 Treatment – removal of the cause.
 Radiation – two different forms of energy

1. Derived from electromagnetic radiation

2. Derived from particle radiation

 Spectrum of varying wavelength ranging from long

electrical and radio waves

 Infra red , Visible light , UV light , Gamma rays

 Artificial radioactive material .
Ex- Cyclotron and Betatron

 Most of the radiation – Alpha and Beta

 Alpha particles – little ability to penetrate the tissue

with short distance

 Beta particles (-Ve charged ), rapid motion– greater

penetration
 Exact which radiation – unknown
Factors
 Toxic effect of protein break down products
 Inactivation of enzyme system
 Coagulation of protoplasmin colloids
 Denaturation of Nucleoproteins
 Common treatment – neoplasm – X radiation
 Radiation effect depending up on –
 1. Source of radiation
 2. Total number of radiation administered
 3. Period of time
 4. Type of filtration used
 5.Total area of tissue irradiated
 Skin

 Oral mucosa

 Salivary gland

 Teeth

 Bone
 Heavy therapeutic doses of X radiation
 Erythema – earliest visible reaction
 Erythema fades quickly – reappear with in 2 – 4 weeks
 Secondary erythema – fades slowly , pigmented a light
tan shade
 Secondary erythema – edema with desquamation of
epithelial cells – denudation of the surface
 Re epitheliazation occur – 10 – 14 days
 Alterations of the sebaceous glands – decreases
secretion with dryness of the skin
 Hair follicle - sensitive
 Vascular damage - thickening of the intima ,
thrombosis
 Veins and arteries shows subintimal fibrosis with
thickening of the wall at the expense of the lumen
 Endophlebitis and Phlebosclerosis --evident
 Dose and duration of therapy
 Erythema – hyperemic and edematous mucositis
If treatment continued ,
 Mucosa become denuded , ulcerated and covered with
a fibrinous exudate – great discomfort
Large , irregular area of epithelial ulceration
 Lidocaine mouth rinses before meal times

 Pain and dysphasia could not controlled with Lidocaine

and analgesics

 Lose of their sense of taste – damage the microvilli and

outer surface of the taste cells

 Usually transitory – 60 – 120 days

 Epithelium –
necrotic

Homogenization
of the collagen
 Xerostomia
 Alteration of salivary gland - diminution or complete
loss of secretion - Week or two after radiation
 Decreases the number of secretion of the granules
 Congestion , edema and inflammatory cell infiltration –
interstitial CT
 No remarkable changes in Ducts of salivary glands

 Acute post irradiation sialadenitis is the elevation of

serum and urinary amylase

 Loss of secretion – permanent sequela of the radiation

 Erupted teeth are often affects
 Peculiar destruction of tooth substance , resembling
dental caries – Radiation caries
 Begins at cervical area of the teeth
 Demineralization will be more– sweeps across the
tooth
 Teeth – brittle and pieces of enamel may fracture
 Primary cause – alterations of saliva ( directly or
indirectly)
 Saliva become thicker and more tenacious after
irradiation
 Xerostomia – collection of debris on the teeth surface-
caries
 Xerostomia – decreases in the total daily out put of
caries protective salivary electrolytes and Immuno
proteins
 Depending up on the age of the patient – at the time

of irradiation

 There may be complete cessation of odontogenesis

resulting in anodontia in the involved area or simply

stunting of the teeth

 Resistant to X- ray radiation

 Osteoblasts are sensitive

 Normal balance between forming and resorption of

bone will altered

• Damage of the vascular bed with subsequent

disturbance of the typical inflammatory response

• Radiation delay the wound healing

• Healing response will be poor and slow

It is radiation induced pathologic process characterized
by a chronic and painful infection and necrosis
accompanied by late sequestration and sometimes
permanent deformity

ETIOLOGY
 Radiation
 Trauma
 infection
Radiation causes proliferation of the
intima of the blood vessels (endarteritis
obliterans) leading to thrombosis of the
end arteries.

This results in non-vital bone. The altered

bone becomes hypoxic, hypovascular &
hypocellular.

Osteoradionecrosis – non-healing, dead bone.

This devitalized bone may undergo
sequestration, there is no clear demarcation
between vital & non-vital bone.
 Irradiation of an area of previous surgery before proper
healing take place
 Irradiation lesion in close proximity of bone
 High dose of irradiation with or without proper
fractionation
 Combination of external radiation and intra oral
implants
 Poor oral hygiene
 Surgery in the irradiation area
 Indiscriminate use of prosthetic appliances following
radiation therapy
 Failure to prevent trauma to irradiated bony area
 Presence of numerous physical & nutritional problems
prior to therapy.
 Mandible is more frequently affected than maxilla
 Infection entry to the bone – traumatic injury ,
extraction and pulp infection
 Necrosis of bone , periosteum and overlying mucosa
 Sequestration occurs - months and several years
 Pain , cortical perforation, fistula formation, surface
ulceration, pathologic fracture.
 Destruction of osteocytes and absence of osteoblasts
 Lack of new bone or osteoid formation
 Regional blood vessels wall – thickened by fibrous
tissue.
 Loose CT – replaces the bone marrow is infiltrate by
lymphocytes and plasma cells
 Devitalized bone undergo sequestrum
 No clear line demarcation between vital and non vital
bone
Fistula formation
 Non – allergic reaction to drugs and chemicals - locally

 Non – allergic reaction to drugs and chemicals -

Systemically
 Aspirin ( Acetyl salicylic acid )
 Sodium perborate
 Phenol
 Silver nitrate
 Trichloroacetic acid
 Volatile oils
 Miscellaneous- Strong acids , alkali , germicidal
 Local obtundant – relief of tooth ache

 Harmful to the oral mucosa – locally

 Local use is to place the tablets against the offending

tooth

 Location – cheek and lip

 Surface become blanched or whitened in appearance

 Separation and sloughing of the epithelium and

frequently bleeding

 Healing usually takes a week or more

 Arsenic
 Bismuth
 Dilantinsodium
 Lead
 Acrodynia ( Pink diseases )
 Silver
 Tetracycline
 Cancer chemotherapeutic agents
 Anticonvulsant drugs – epileptic seizures

 Side effect – fibrous hyperplasia of the gingiva

 Dilantin – stimulates of fibroblastic proliferation

 Increases the collagen synthesis

 Gingival hyperplasia – two weeks – few months
 Painless increases in the size of gingiva
 Enlargement of one or two interdental papillae
 Surface – cauliflower , warty or pebbled surface
 Enlargement and become lobulated

 Clefts remains b/w each enlarged gingiva

 Palpation – dense , resilient and insensitive

 Stratified squamous surface epithelium
 Thin keratinized layer
 Rete pegs are extremely long and thin – “ Test tube
pegs”
 Bulk of the tissue – bundles of collagen fibers
interspersed with fibroblasts and fibrocytes
 Vascularity is not a prominent features

 If chronic inflammation – super imposed on this

hyperplasia

 Plasma cells and leukocytes will be found

 Treatment – Surgical excision

 Occupational hazard today

 Exposure – acute or chronic nature

 Inhalation of lead vapor or dust

 Infants – chewing of wood painted with lead contain

paints
 Intoxication – GIT disturbance

 Nausea , vomiting , constipation

 Peripheral neuritis – wrist drop or foot drop

 Encephalitis , Hypochromic anemia

 Skeletal changes – growing bone in children

 “ lead lines “ occur on soft
tissue
 Gray or bluish black line of
sulfide pigmentation – Gingiva-
halo saturninus or Burtonian’s
line
 Ulcerative stomatitis
 Excessive salivation and
metallic taste
 Swelling of the salivary gland
 Uncommon diseases
 Hg poising
 Cutaneous manifestation
 Sources – teething power , ammoniated Hg ointment,
calomel lotion or Bichloride of Hg disinfectant
 Young infants – before the age of two
yrs
 Skin – hand , feet , nose , ears and
cheeks
 Red or pink in colour appears - Raw
beef
 Cold , clammy feeling
 Effected skin – peels frequently
 Maculopapular rash which are
purities
 Extreme irritability
 Photophobia with lacrimation
 Muscle weakness
 Tachycardia
 Hypertension
 Stomatitis
 Profuse salivation – dribbling
 Gingiva – extremely sensitive or painful
 Ulceration – gingiva
 Bruxism
 Loosening and premature shedding of teeth

Treatment – discontinuance of possible exposure to Hg