INTRODUCTION TO ORAL AND DENTAL DISEASES

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INTRODUCTION TO ORAL AND DENTAL DISEASES

• DR.Rami ALJUAIDI

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ORAL MUCOSA

• The oral mucoua is the mucous membrane that
  covers
• all oral structures except the clinical crowns of
  the teeth.
• It is composed of two layers (1) the stratified
  squamous
• epithelium and (2) supporting connective tissue,
  called
• the lamina propria. The epithelium may be
  keratinized,
• parakeratinized, or nonkeratinized depending
• upon its location.

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• The lamina propria varies in thickness The oral
  mucosa may be divided into three major
• functional types (1) masticatory mucosa, (2)
  lining or
• reflective mucosa, and (3) specialized mucosa.

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• The masticatory mucosa is composed of the free
  and attached gingiva and the mucosa
• of the hard palate. The epithelium of these
  tissues
• is keratinized, and the lamina propria is a
  dense, thick,
• firm connective tissue containing collagenous
  fibers.
• The dense lamina propria of
• the attached gingiva is connected to the cementum
• and the periosteum of the bony alveolar process

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• The lining or reflective mucosa covers the inside
  of the
• lips, cheek, vestibule, lateral surfaces of the
  alveolar
• process (except the mucosa of the hard palate),
  floor of
• the mouth, soft palate, and inferior surface of
  the
• tongue. Lining mucosa is a thin, movable tissue
  with a
• relatively thick, nonkeratinized epithelium and a
  thin
• lamina propria. The submucosa is composed mostly
  of
• thin, loose connective tissue with muscle and
  collagenous
• and elastic fibers, with different areas varying
• from one another in their structure. The junction
  of lining
• mucosa with masticatory mucosa is the
  mucogingival
• junction, located at the apical border of the
  attached gingiva
• facially and lingually in the mandibular arch and
• facially in the maxillary arch .
• .

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• the specialized mucosa covers the dorsum of the
  tongue and the taste buds. The epithelium is
  nonkeratinized
• except for the covering of the dermal filiform
• papillae

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• 
  The bar in the image
  
  shows you the thickness
  
  of the stratified squamous
  
  epithelium. The layers
  
  underneath it are
  
  composed mainly
  
  of connective tissue and muscle
  
  .

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•   The cells of the outermost layers of the
  stratified squamous epithelium are not all
  squamous (flat). some of the cells seem to be
  separating from the surface of the tissue. This
  is called sloughing and is a normal process in
  epithelial tissues that form coverings and
  linings, especially the stratified tissues.

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• Keratine covers the dry areas of the skin whilest
  the moist areas of the skin are not keratinized

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• The epidermis is the outermost layer of the
  skin,1 composed of terminally differentiated
  stratified squamous epithelium,2 acting as the
  body's major barrier against an inhospitable
  environment.3 It is the thinnest on the eyelids
  at .05 mm and the thickest on the palms and soles
  at 1.5 mm

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• Cellular components
• The epidermis is avascular, nourished by
  diffusion from the dermis, and composed of
  four types of cells,i.e keratinocytes,
  melanocytes, Langerhans cells, and the Merkel
  cells.1 Keratinocytes are the major
  constituent, constituting 95 of the
  epidermis.2 . The melanocyte produces pigment
  (melanin), the Langerhans' cell is the frontline
  defense of the immune system in the skin, and the
  Merkel's cell's function is not clearly known.

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• Layers
• The epidermis is composed of 4-5 layers depending
  on the region of skin being considered. Those
  layers in descending order are the stratum
  corneum, stratum lucidum, stratum granulosum,
  stratum spinosum, and stratum basale.3 The term
  Malpighian layer refers to both the basal and
  spinosum layers

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• Cellular kinetics
• The stratified squamous epithelium is maintained
  by cell division within the basal layer.
  Differentiating cells slowly displace outwards
  through the stratum spinosum to the stratum
  corneum, where anucleate corneal cells are
  continually shed from the surface (desquamation).
  In normal skin the rate of production equals the
  rate of loss,2 taking about two weeks for a
  cell to migrate from the basal cell layer to the
  top of the granular cell layer, and an additional
  two weeks to cross the stratum corneum

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• keratinisation - organic process by which keratin
  is deposited in cells

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parakeratosis

• the persistence of nuclei in the stratum corneum
  keratin layer of stratified squamous epithelium.

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Precancerous Lesions

• What is a precancerous lesion?A precancerous
  lesion is a change in some areas of your skin
  that carries the risk of turning into skin
  cancer. It is a preliminary stage of cancer.
  These precancerous lesions can have several
  causes UV radiation, genetics, exposure to such
  cancer-causing substances (carcinogens) as
  arsenic, tar or x-ray radiation.
• Because precancerous lesions can turn into skin
  cancer and since skin cancer can possibly lead to
  death it is very important to catch skin cancer
  at an early stage. If you discover any suspicious
  lesion take it seriously and seek the advice of a
  dermatologist.

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Oral and MaxillofacialPathology

• . GENERAL
• Oral mucosa has the same susceptibility to
  pathological change as does other covering
  tissue. Common abnormalities of the skin and the
  gastrointestinal tract may evidence themselves on
  oral mucosa. Local, focal oral mucosal lesions,
  generalized mucosal involvement, or intraoral
  lesions associated with a systemic problem may be
  caused by bacterial, fungal, or viral organisms.
  Benign or malignant lesions must always be
  considered when examining a patient's mouth.

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• Elementary lesions of the oral mucosa
• Diseases that manifest themselves on the oral
  mucosa generally produce tissue morphological
  alterations as clinical signs that are so
  characteristic, that they have been classified as
  primitive elementary lesions. Many of these
  lesions do not retain their original appearance
  due to causes such as traumatism, mastication,
  maceration, movement of the tissues, and time
  itself the lesions thus derived from these
  primitive or primary ones are known as secondary
  lesions. This labelling is important in terms of
  order of appearance but not clinical importance,
  since in many cases these lesions are as useful
  as the primary ones to help establish a
  diagnosis.The primitive lesions that occur most
  frequently, both on skin and mucosa are spots,
  papules, nodules, vesicles, blisters, pustules,
  keratosis, warts, tubercules, hives and
  tumors.The most common secondary lesions of the
  oral cavity are erosions, fissueas or cracks,
  ulcers, ulcerations, scabs, scars y
  desquamations."Elementary lesions are like the
  letters of the alphabet. Without a knowledge of
  them you cannot learn the language of
  stomatology". David Grinspan    

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• VESICLE
• A vesicle is a circumscribed, superficial
  elevation on the skin or mucous membrane
  containing fluid (serum, plasma, or blood). If
  the vesicle opens, it becomes an ulcer (an
  inflammatory loesin

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• ULCER (Figure 1- 7)
• An ulcer is an open sore of a superficial nature
  extending below the covering epithelial surface.
  The base of an ulcer is composed of granulation
  tissue resulting from initial healing. A
  secondary infection may develop in an ulcer,
  resulting in delay of the healing and repair
  process. A common cause of oral ulceration is
  trauma, which might even be a result of
  toothbrush injury. Irritation from a rough or
  broken tooth surface can also result in
  ulceration. Some ulcers start with vesicle
  formation. This painful ulceration on the lateral
  border of the tongue represents a nonspecific
  response to tissue injury. The cause of an ulcer
  must be determined and appropriate treatment
  initiated. Normal healing will often result
  without use of medication

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• Spots
• A spot is just a change of coloration of the oral
  mucosa, which is not elevated. They occur very
  frequently. They are primarily constituted by
  variations of hematologic or melanocitic
  pigments, but also by the organisms own pigments
  or external ones. Structural changes of the soft
  tissues also produce changes in coloration.

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• White spots due to
• Lichen Leukoplakia 
•   on the oral mucosa

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• Brown spots due to
• Pigmentation in AIDS
• Racial pigmentation
• Fixed pigmented erythema

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• Red spots due to
• PúrpuraFlat hemangioma on skin and oral mucosa

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• Spots due to foreign pigments
• Due to ballpoint pen

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• Vesicles, bullae (blisters) and pustules
• Vesicles, bullae and pustules are superficial
  lesions with a liquid content. The two first
  ones can only secondarily become pustulent by
  overlaying infections. The pustule initially
  contains pus and is very rare in th oral mucosa.
  These lesions are rarely found intact when
  occuring inside the mouth, since masticatory
  trauma ruptures them rather easily.Vesicles are
  primarily formed by spongiosis of an eczema or by
  a ballooning and reticular degeneration during
  viral infections.The mechanism by which a
  blister is formed is fundamental to confirm the
  diagnosis of the underlying disease. Blisters may
  be intraepithelial, by acantholysis of the spiny
  cells, as occurs in the different types of
  pemphigus, or subepidermal separating the
  connective tissue from the epithelium as occurs
  in the pemphigoidal lesions Duhrings disease,
  erythema multiforme, and bullous pemphigoid.

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• Vesicles due to
• Labial herpes
• Coalescence of vesicles during labial herpes
• Herpes zoster

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• Vesiculopustular lesions due to
• Varicella

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• Bullae (blisters) due to
• Pemphigus on skin
• Pemphigus blistered roof
• Pemphigus on the gingiva

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• Pustules due to
• Impétigo

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• Pigmented oral lesions Most red oral lesions are
  inflammatory in nature, but some are potentially
  malignant, especially erythroplasia.

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Causes of red lesions

• Widespread redness Localised red
  patches    Candidiasis  
   Candidiasis   
• Iron deficiency   Erythroplasia   
• Avitaminosis B   Purpura   
• Irradiation mucositis   Telangiectases  
•  Lichen planus   Angiomas   
• Mucosal atrophy   Kaposi's sarcoma   
• Polycythaemia   Burns  
• Lichen planus 
•  Lupus
  erythematosus  
• 
  Avitaminosis

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• Erythroplasia (erythroplakia) Erythroplasia is a
  rare, isolated, red, velvety lesion that affects
  patients mainly in their 60s and 70s. It usually
  involves the floor of the mouth, the ventrum of
  the tongue, or the soft palate. This is one of
  the most important oral lesions because 75-90 of
  lesions prove to be carcinoma or carcinoma in
  situ or are severely dysplastic. The incidence of
  malignant change is 17 times higher in
  erythroplasia than in leucoplakia. Erythroplasia
  should be excised and sent for histological
  examination
• Erythroplasia is an isolated red lesion that
  typically occurs in elderly peopleIt is usually
  dysplastic or malignant and is bestremoved

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Erythematous candidiasis

• Erythematous candidiasis may complicate
  treatment with corticosteroids or antimicrobials
  and cause widespread erythema and soreness of the
  oral mucosa, sometimes with thrush. It may also
  occasionally be seen in HIV infection,
  xerostomia, diabetes, and in people who smoke.
• Red persistent lesions are especially noticeable
  on the palate and tongue. Median rhomboid
  glossitis (central papillary atrophy) is a red
  depapillated rhomboidal area in the centre of the
  tongue dorsum, now believed to be associated with
  candidiasis. Biopsy may show pseudoepitheliomatous
  hyperplasia, but the condition is not
  potentially malignant.
• ManagementErythematous candidiasis may respond to
  stopping smoking and antifungal agents (usually
  fluconazole).

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• Denture induced stomatitis (denture sore mouth)
  This is a common form of mild chronic
  erythematous candidiasis, usually seen after
  middle age as erythema limited to the area
  beneath an upper denture. The fitting surface of
  the denture is infested mainly with Candida
  albicans. Despite its name, this condition is
  rarely sore, though angular stomatitis may be
  associated. Patients are usually otherwise
  healthy.

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• Factors that predispose to denture induced
  stomatitis include wearing dentures (especially
  through the night), poor oral and denture
  hygiene, xerostomia, and carbohydrate-rich diets.
  It is not caused by allergy to the denture
  material.
• Management includes
• Denture stomatitis occurs mainly when Candida
  proliferate beneath and infest the dentureIt may
  be asymptomatic but may be associated with
  angular stomatitisDenture wearing should be
  minimised and the infection eradicated

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• Eradicating infection by soaking dentures
  overnight in chlorhexidine or 1 (v/v)
  hypochlorite solution then using miconazole
  denture lacquer. Metal dentures should not be
  soaked in hypochlorite as they may discolour
• Using miconazole gel (5 ml), nystatin pastilles
  (100 000 units), or amphotericin lozenges (10 mg)
  in the mouth four times daily for up to one month
  
• Using systemic fluconazole 50 mg daily for
  resistant cases
• Adjustment of the dentures.
• Other red lesions Petechiae are usually caused
  by trauma or suction but may also be seen in
  thrombocytopenia, amyloidosis, localised oral
  purpura, or scurvy. Telangiectasia may be a
  feature of hereditary haemorrhagic telangiectasia
  or systemic sclerosis.

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Non keratotic white lesions

• Habitual cheek biting
• Burns
• Uremic stomatitis
• Radiation mucositis
• Koplik.s spots

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Cheek Chewing

• White lesions of the oral tissues may result from
  chronic irritation
• due to repeated sucking, nibbling, or chewing.
• These insults result in the traumatized area
  becoming thickened,
• scarred, and paler than the surrounding tissues.
  Cheek
• chewing is most commonly seen in people who are
  under
• stress or in psychological situations in which
  cheek and lip
• biting become habitual.Most patients with this
  condition are
• somewhat aware of their habit but do not
  associate it with
• their lesions.

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• The white lesions of cheek chewing may sometimes
• be confused with other dermatologic disorders
  involving
• the oral mucosa, which can lead to misdiagnosis.
• Prevalence rates ranging from 0.12 to 0.5 have
  been reported

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TYPICAL FEATURES

• The lesions are most frequently found bilaterally
  on the posterior
• buccal mucosa along the plane of occlusion. They
  may
• be seen in combination with traumatic lesions on
  the lips or
• tongue. Patients often complain of roughness or
  small tags of
• tissue that they actually tear free from the
  surface. This produces
• a distinctive clinical presentation
• The lesions are poorly outlined whitish patches
  that may be
• intermixed with areas of erythema or ulceration.
  The occurrence
• is twice as prevalent in females and three times
  more
• common after the age of 35 years.
• The histopathologic picture is distinctive and
  includes
• hyperparakeratosis and acanthosis. The keratin
  surface is usually
• shaggy and ragged with numerous projections of
  keratin
• that demonstrate adherent bacterial colonies.When
  the lesion
• is seen on the lateral tongue, the clinical and
  histomorphologic
• features mimic those of oral hairy leukoplakia.

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• TREATMENT AND PROGNOSIS
• Since the lesions result from an unconscious
  and/or nervous
• habit, no treatment is indicated. However, for
  those desiring
• treatment and unable to stop the chewing habit, a
  plastic
• occlusal night guard may be fabricated. Isolated
  tongue
• involvement requires further investigation to
  rule out oral
• hairy leukoplakia especially when appropriate
  risk factors for
• infection with human immunodeficiency virus (HIV)
  are present.
• Differential diagnosis also includes chemical
  burns,
• and candidiasis.

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Morsicatio buccarum represented by a frayed
macerated irregular leukoplakic area in the cheek.
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burns

• Chemical Injuries of the Oral Mucosa
• Transient nonkeratotic white lesions of the oral
  mucosa are
• often a result of chemical injuries caused by a
  variety of agents
• that are caustic when retained in the mouth for
  long periods
• of time, such as aspirin, silver nitrate,
  formocresol, sodium
• hypochlorite, paraformaldehyde, dental cavity
  varnishes, acidetching
• materials, and hydrogen peroxide. The white
• lesions are attributable to the formation of a
  superficial
• pseudomembrane composed of a necrotic surface
  tissue and
• an inflammatory exudate.

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burns
Aspirin burn, creating a pseudomembranous
necrotic white area.
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Diffuse slough of marginal gingivae due to misuse
of commercial mouthwash
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TYPICAL FEATURES

• The lesions are usually located on the mucobuccal
  fold area
• and gingiva. The injured area is irregular in
  shape, white, covered
• with a pseudomembrane, and very painful. The area
  of
• involvement may be extensive.When contact with
  the tissue is
• brief, a superficial white and wrinkled
  appearance without
• resultant necrosis is usually seen. Long-term
  contact (usually
• with aspirin, sodium hypochlorite, phenol,
  paraformaldehyde,
• etc) can cause severer damage and sloughing of
  the necrotic
• mucosa. The unattached nonkeratinized tissue is
  more commonly
• affected than the attached mucosa.

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TREATMENT AND PROGNOSIS

• The best treatment of chemical burns of the oral
  cavity is prevention.
• Children especially should be supervised while
  taking
• aspirin tablets, to prevent prolonged retention
  of the agent in
• the oral cavity. The proper use of a rubber dam
  during
• endodontic procedures reduces the risk of
  iatrogenic chemical
• burns. Most superficial burns heal within 1 or 2
  weeks. A
• protective emollient agent such as a film of
  methyl cellulose
• may provide relief. However, deep-tissue burns
  and necrosis
• may require careful débridement of the surface,
  followed by
• antibiotic coverage. In case of ingestion of
  caustic chemicals or
• accidental exposure to severely corrosive agents,
  extensive scarring
• that may require surgery and/or prosthetic
  rehabilitation
• may occur

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Uremic stomatitis

• It is a rarely reported oral mucosal disorder
  possibly associated with longstanding uremia Four
  of 300 patients with uremia were observed to have
  probable uremic stomatitis, The clinical features
  of uremic stomatitis are poorly defined and are
  rarely detailed in relevant textbooks

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Radiation mucositis

• Oral tissue damage and mucositis pain can be a
  significant problem for patients undergoing
  cancer therapy. The frequency and severity of
  these problems can vary significantly with the
  type of therapy and from patient to patient.
  While oral complications primarily are associated
  with discomfort and interference with oral
  function, in patients who are also
  immunocompromised or debilitated, these
  complications can become life threatening

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Koplik's spots

• and when found in(mucosa are found on the,
  combination with rash, cough, are diagnostic for
  measles.1
• They are small, irregular red spots, each with a
  minute bluish white speck in the center, seen on
  the lingual and buccal mucosa (the inside ofthe
  cheek and tongue) and are pathognomonicof early
  stages of measles.
• They often appear a few days before the rash
  arrives and can be a useful sign to look for
  children known to be exposed to the in measles
  virus.

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