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Manassery, Mukkam


Presented By:

Niyas Ummer
1st Year PG Department of Oral Medicine and Radiology

Mucus Membrane: Moist lining of gastrointestinal tract, nasal passages, and other body cavities that communicate with the exterior. This lining of oral cavity is Oral Mucous Membrane or Oral Mucosa.

Parts of Oral Cavity

The oral cavity consists of two parts: i. Vestibule (outer) ii. ral !avity "roper (inner)

Superiorly # hard $ soft palates Inferiorly # floor of mouth and tongue Posteriorly # faucial pillars and tonsils Anteriorly # lips

Functions of Oral Mucosa

%. "rotection: &eparates deeper tissues and organs from environment "rotect from mechanical forces and surface abrasions 'daptations to withstand insults (arrier to microorganisms and their toxic products ). &ensation: *eceptors for temperature, touch and pain Taste buds of tongue *eflexes are also initiated by receptors +. ,ubrication: &aliva from salivary glands - maintains moist surface &ebaceous glands - secrete sebum .. Thermal *egulation: /issipation of body heat in some animals by panting 0o such role in humans

Clinical Features
!haracteristic features: /eeper colour Moist surface 'bsence of appendages nly minor salivary glands, and occasional sebaceous glands (no sweat glands) &moother surface, fewer folds1wrin2les Variable firmness and thic2ness

Component Tissues and Glands

Two main tissue components: i. ral epithelium (stratified s3uamous epithelium) ii. ,amina propria (underlying connective tissue layer) 4nterface between epithelium and connective tissue is usually irregular. 4t consist of: !onnective tissue papillae 5pithelial ridges or pegs 't this interface is present the basal lamina, but it is visible only by special staining. ral 5pithelium 4t is composed of stratified s3uamous epithelium. !ells are tightly attached to each other and arranged in a number of distinct layers or strata. 5pithelium maintains its structural integrity by a process of continuous renewal. !ells are produced by mitotic divisions in the deepest layers mature and undergo terminal differentiation as they migrate passively toward the surface to replace those that are shed. 5nd phase of this pathway is a uni3ue form of programmed cell death. !ells consist of two functional populations: a) "rogenitor population (divide and provide new cells) b) Maturing population (continually differentiate or mature to form a protective surface layer) Keratinized Oral Epithelium Most of the oral mucosal surface is lined by non-2eratini6ed stratified s3uamous epithelium except gingiva, hard palate and dorsal surface of the tongue Keratinocytes: They have no nuclei. !ytoplasm is displaced by large numbers of 2eratin filaments. 7our layers of cells are present in 2eratini6ed epithelium: %. &tratum (asale !uboidal or low columnar cells 7orm a single layer resting on the basal lamina (asal lamina is at the interface of the epithelium and lamina propria 5pithelial cells are in a constant state of renewal The basal cells show the maximum mitotic activity ). &tratum &pinosum &everal cells thic2 "olyhedral cells with short cytoplasmic processes &tratum basale and the first layers of stratum spinosum - give rise to new epithelial cells - stratum germinativum

+. &tratum 8ranulosum !ells are flat 7ound in layers of three to five cells thic2 "rominent in 2eratini6ed epithelium (absent in non2eratini6ed) !ells have 2eratohyaline granules in their cytoplasm - help to form the matrix of the 2eratin fibres found in the superficial layer .. &tratum !orneum !ells are flat, devoid of nuclei and full of 2eratin filament surrounded by a matrix !ells are continuously being sloughed - replaced by epithelial cells that migrate from the underlying layers Para eratinized Epithelium &urface cells have dar2 staining py2notic nuclei. The cytoplasm contains little if any 2eratin filaments. !on eratinized Oral Epithelium 0on2eratini6ed epithelial cells in the superficial layers do not have 2eratin filaments in the cytoplasm. The surface cells also have nuclei. The stratum corneum and stratum granulosum layers are absent. This epithelium is associated with lining of the oral cavity. Turnover of Oral Epithelium 9igh rate of turnover /ifficult to appreciate on a static diagram or histologic slide &ulcular epithelium ta2es %: days to renew 8eneral oral mucosa ta2es approximately %) to %+ days 0on2eratinocytes !ells that differ in appearance from other epithelial cells. They have a clear halo around their nuclei. &uch cells have been termed clear cells" Melanocytes ,angerhan !ells Mer2el !ells 4nflammatory !ells Melanocytes Melanocytes ne factor affecting color of the oral mucosa is melanin pigmentation. Melanin is a pigment produced by speciali6ed cells called melanocytes. &ituated in the basal layer of the oral epithelium, they arise embryologically from the neural crest ectoderm and enter the epithelium at %% wee2s of gestation. They divide and maintain themselves (selfreproducing). They possess long dendritic (branching) processes that extend between the 2eratinocytes. Melanin is synthesi6ed within the melanocytes as small structures called

melanosomes. 4t is transferred into the cytoplasm of ad;acent 2eratinocytes by the dendritic processes of melanocytes. 8roups of melanosomes are called melanin granules. ,ightly and dar2ly pigmented individuals have the same number of melanocytes in any given region. !olor differences result from: *elative activity of the melanocytes in producing melanin *ate at which melanosomes are bro2en down in the 2eratinocytes Melanophages are macrophages that have ta2en up melanosomes produced by melanocytes in the epithelium. Melanin pigmentation seen most commonly clinically gingiva, buccal mucosa, hard palate, and tongue. Langerhan Cells They are dendritic cells seen above the basal layers of epithelium. &ource is bone marrow. They appear in the epithelium at the same time as, or ;ust before, the melanocytes. They are capable of limited division within the epithelium. They move in and out of the epithelium and can migrate from epithelium to regional lymph nodes. 4mmunologic function - recogni6ing and processing antigenic material and presenting it to T lymphocytes. They are characteri6ed ultrastructurally by a small rod- or flas2-shaped granule, sometimes called the #irbec granule.

Merkel Cells They are situated in the basal layer of epithelium. They are not dendritic and does possess 2eratin tonofilaments and occasional desmosomes. They arise from the differentiation of an epidermal progenitor during embryonic development. Mer2el cells are sensory and respond to touch. !haracteristic feature is presence of small membrane-bound vesicles in the cytoplasm, situated ad;acent to a nerve fiber associated with the cell. 8ranules liberate a transmitter substance across the synapse-li2e ;unction between the Mer2el cell and the nerve fiber, which triggers an impulse. Inflammatory Cells !linically normal areas of mucosa show a number of inflammatory cells in the nucleated cell layers. !ells are transient and do not reproduce themselves. !ells seen: ,ymphocytes (fre3uently) "olymorphonuclear leu2ocytes Mast cells ,ymphocytes often are associated with ,angerhans cells, which are able to activate T lymphocytes

<eratinocytes produce cyto2ines that modulate function of ,angerhans cells. ,angerhans cells produce cyto2ines (interleu2in-%) which activate T lymphocytes and aid in responding to antigenic challenge. 4nterleu2in-% also increases activity of melanocytes, which affects pigmentation. !yto2ines can also influence the activity of fibroblasts.

=unction of 5pithelium and ,amina "ropria 4t is the region where connective tissue of the lamina propria meets the overlying oral epithelium. 4t shows an undulating interface at which papillae of the connective tissue interdigitate with epithelial ridges. Significance" %. ,arger surface area of the interface for better attachment ). 5nable forces applied at the surface to be dispersed over a greater area of connective tissue +. Metabolic exchange between the epithelium and connective tissue (epithelium has no blood vessels) .. Masticatory mucosa - greatest number of papillae per unit area >. ,ining mucosa - papillae are fewer and shorter

(asal ,amina 4t cannot be visuali6ed directly by light microscopy using conventional stains. 4n histologic sections of oral mucosa stained by the periodic acid#&chiff reaction, it appears as a bright, structureless band at the interface bet$een the epithelium and sub%acent connective tissue. (asal lamina runs parallel to the basal cell membrane of the epithelial cells. 't the ultrastructural level, it consists of three 6ones: amina ucida - slightly thinner than the lamina densa # appears as clear 6one amina Densa - homogeneous, finely fibrillar planar assembly of extracellular matrix molecules amina Fi!roreticularis Anchoring fibrils" They are made up of collagen type V44. They insert into the lamina densa, and form a flexible attachment between the basal lamina and sub;acent connective tissue. !ells of ,amina "ropria The lamina propria contains several different cells: fibroblasts, macrophages, mast cells, and inflammatory cells.

Fibroblasts They are the principal cells responsible for the elaboration and turnover of fiber and ground substance, and maintains connective tissue integrity. ,ow rate of proliferation is seen. /uring wound healing, fibroblasts divide in the ad;acent unin;ured tissues and their numbers increase. They can become contractile and actin content increases. This results in wound contraction. 4n certain disease states, they may be activated and secrete more ground substance. Macrophages *ound, stellate or sometimes fusiform cells which are difficult to distinguish from fibroblasts unless they hav phagocyted extracellular debris. They have smaller and denser nuclei, with less rough endoplasmic reticulum. !ytoplasm contains lysosomes. 7unctions: i. Pha"ocytosis - 4ngest damaged tissue or foreign material and initiate brea2down ii. #nti"en presentin" - "rocessing of ingested material and increasing its antigenicity before presenting to cells of the lymphoid series iii. $epair - &timulation of fibroblast proliferation

Two special types of macrophages can be identified specifically: Melanopha"e - in pigmented oral mucosa, cell has ingested melanin granules extruded from melanocytes %ideropha"e - contains hemosiderin derived from extravasated red blood cells due to mechanical in;ury Mast Cells ,arge spherical or elliptical mononuclear cell. 0ucleus is small relative to cell si6e. ,arge number of intensely staining granules that occupy its cytoplasm, which contain histamine and heparin. They play an important role in maintaining normal tissue stability and vascular homeostasis. Inflammatory Cells ,ymphocyte and plasma cell are present in small numbers scattered throughout the lamina propria. 7ollowing an in;ury, they are found in significant numbers, and release cyto2ines, which influences the behavior of the overlying epithelium. Type of inflammatory cell depends on the nature and duration of in;ury: #cute conditions - polymorphonuclear leu2ocytes Chronic conditions - lymphocytes, plasma cells, monocytes, and macrophages

7ibres and 8round &ubstance 4ntercellular matrix consists of two ma;or types of fibers: !ollagen 5lastin These fibres together with fibronectin are embedded in a ground substance. !ollagen !ollagen in the lamina propria is primarily type 4 and type 444. Types 4V and V44 occurring as part of the basal lamina. Type V may be present in inflamed tissue. 5lastic 7ibers ?hen stained using specific methods, some elastic fibers can be seen in most regions of the oral mucosa, but they are more abundant in the flexible lining mucosa, where they function to restore tissue form after stretching. @nli2e collagen fibers, elastic fibers branch, anastomose, and run singly rather than in bundles. 8round &ubstance 4t appears amorphous by light and electron microscopy. 4t consists of heterogeneous molecular complexes permeated by tissue fluid. !hemically, they are subdivided into two: %. Proteo"lycans - polypeptide core to which glycosaminoglycans (consisting of hexose and hexuronic acid residues) are attached 5.g. hyaluronan, heparan sulfate, versican, decorin, biglycan, and syndecan ). Glycoproteins - polypeptide chain to which only a few simple hexoses are attached

Blood %upply *ich blood supply is present. 'rteries run parallel to the surface in the submucosa or deep part of the reticular layer, and anastomose with ad;acent vessels in the reticular layer to form a, extensive capillary networ2 in the papillary layer. 7rom this networ2, capillary loops pass into the connective tissue papillae and lie close to the basal layer. 4n chee2, arterioles are tortuous with extensive branching. There is more profuse capillary loops than in s2in. (lood flow: 8ingiva A ther oral mucosae A &2in 4t lac2s arteriovenous shunts. /ue to rich anastomoses of arterioles and capillaries, it has the ability to heal more rapidly after in;ury. &erve %upply ral mucosa is innervated densely. 0erves monitor all substances entering. They also initiate and maintain voluntary and reflexive activities (involved in mastication, salivation, swallowing, gagging, and spea2ing). 5fferent autonomic supply affects blood vessels and minor salivary glands. 0erves arise mainly from second and third divisions of the trigeminal nerve, facial (V44),

glossopharyngeal (4B), and vagus (B) nerves. &ensory nerves lose their myelin sheaths to form a net$or in the reticular layer of the lamina propria which terminates in a subepithelial ple&us.

Classification of Oral Mucosa

ral mucus membrane can be classified into: Masticatory ,ining &peciali6ed Masticatory Mucosa 4t covers areas exposed to compressive and shear forces and to a!rasion durin" the mastication of food. 4t is found in hard palate and gingiva. 9istology: Epithelium is moderately thic2 and fre3uently ortho2eratini6ed. &urfaces are inextensible and withstand abrasion. 'unction between epithelium and underlying lamina propria is convoluted with numerous elongated papillae. This provides good mechanical attachment and prevent the epithelium from being stripped off under shear force. Thic2 lamina propria has dense networ2 of large, closely pac2ed bundles of collagen fibers, which follow a direct course between anchoring points. The tissue has little slac2 and does not yield on impact, hence resist heavy loading. Masticatory mucosa covers immobile structures and is bound firmly to them by attachment of lamina propria. ?hen it is directly attached to the periosteum of underlying bone, it is 2nown as mucoperiosteum. 4ndirectly it may be attached by a fibrous submucosa. 4n lateral regions of palate, fibrous submucosa is interspersed $ith areas of fat and glandular tissue, which cushion the mucosa against mechanical loads and protect the underlying nerves and blood vessels.

,ining Mucosa 4t covers the underside of the tongue, inside of the lips, chee2s, floor of the mouth, and alveolar processes as far as the gingiva. The mucosa is sub;ect to movement. These regions, together with the soft palate, are classified as lining mucosa. 9istology: 5pithelium has larger thic2ness and is non2eratini6ed. &urface is thus flexible and able to withstand stretching.

4nterface with connective tissue is smooth. &lender connective tissue papillae may be present ,amina propria: Thic2er with fewer collagen fibers, which follow a more irregular course between anchoring points. 5lastic fibers control the extensibility of the mucosa. Mucosa can be stretched to a certain extent before these fibers become taut and limit further distention. 's the mucosa becomes slac2 during masticatory movements, the elastic fibers retract the mucosa toward the muscle and prevent it from bulging between the teeth and being bitten. 'lveolar mucosa and mucosa covering the floor of the mouth are attached loosely to the underlying structures by a thic2 submucosa. Mucosa of the underside of the tongue is !ound firmly to underlying muscle. &oft palate is fle(i!le !ut not hi"hly mo!ile) mucosa is separated from the loose and highly glandular submucosa by a layer of elastic fibers.

&peciali6ed Mucosa 4t includes the mucosa of the dorsal surface of the tongue. 7unctionally, it is a masticatory mucosa, but also a highly extensible lining. 4t has different types of lin"ual papillae* &ome possess a mechanical function, whereas others bear taste buds (sensory function). Tongue mucosa is composed of two parts, divided by sulcus terminalis: i. #nterior t+o thirds ,!ody- - derived from the first pharyngeal arch ii. Posterior third ,!ase- - derived from the third pharyngeal arch 5xtensive nodules of lymphoid tissue in the base of tongue are 2nown as lingual tonsils. a) 7ungiform "apillae #nterior portion of the ton"ue and tip 'ungiform C fungus-li2e &ingle fungiform papillae scattered between the numerous filiform papillae %mooth. round structures that appear red because of 9ighly vascular connective tissue core Thin, non2eratini6ed covering epithelium Taste !uds / present in the epithelium on the superior surface b) 7iliform "apillae !over entire anterior part of the tongue Cone/shaped structures, each with a core of connective tissue covered by a thic2 2eratini6ed epithelium 7orm a tou"h. a!rasive surface !ompressing and brea2ing food when the tongue is apposed to the hard palate

Tongue is highly extensible # because of non2eratini6ed, flexible epithelium between the filiform papillae (uildup of 2eratin results in elongation of the filiform papillae in some patients The dorsum of the tongue then has a hairy appearance called hairy tongue c) 7oliate "apillae ,eaf-li2e pin2 papillae ,ateral margins of the posterior part of the ton"ue 7ew taste buds are present in the epithelium of the lateral walls of the ridges !onsist of parallel ridges that alternate with deep grooves in the mucosa d) !ircumvallate "apillae 'd;acent and anterior to the sulcus terminalis (ircumvallate C walled 0 to 12 papillae ,arge structures each surrounded !y a deep. circular "roove into which open the ducts of minor salivary glands (the glands of 5bner) !onnective tissue core covered on the superior surface by a 2eratini6ed epithelium 5pithelium coverin" the lateral +alls is non3eratini4ed - contains taste buds

Taste Buds They are speciali6ed receptors which occur only in the oral cavity and pharynx. They are found in the fungiform, foliate, and circumvallate papillae of the tongue. 9istology: (arrel-shaped structure composed of +: to D: spindle-shaped cells &eparated from underlying connective tissue by the basal lamina 'pical ends terminate ;ust below the epithelial surface in a taste pit !ommunicates with the surface via taste pore !ells: They are of + types - light (type 4), dar2 (type 44), and intermediate (type 444) Type 4 - most common Type 44 - morphologically similar, contain numerous vesicles, ad;acent to the intraepithelial nerves They are replaced continually. Their existence depends on presence of a functional gustatory nerve. 4nitial events stimulating sensation of taste involve amorphous material within the taste pits. The microvilli of constituent cells pro;ect into these pits. 8eneration of taste stimuli: %. #dsorption of molecules onto membrane receptors on the surface ). #ctivation of si"nalin" cascade mediated by membrane-associated proteins such as transducin and gustducin

+. !hange in mem!rane polari4ation .. $elease of transmitter substances >. %timulate unmyelinated afferent fi!ers of the glossopharyngeal nerve (4B)

'unctions in Oral Mucosa

?ithin the oral mucosa are three ;unctions that merit further discussion: mucocutaneous (between the s2in and mucosa), mucogingival (between the gingiva and alveolar mucosa) dentogingival (interface between the gingiva and the tooth) The latter is of considerable anatomic and clinical importance because it represents the first line of defense in periodontal diseases. Mucocutaneous =unction The s2in is continuous with the oral mucosa at the lips. 4t is a transitional region where appendages are absent except for a few sebaceous glands (situated mainly at the angles of the mouth). 5pithelium is 2eratini6ed but thin, with long connective tissue papillae containing capillary loops. This arrangement brings the blood close to the surface and accounts for the strong red coloration in this region, called the red (or vermilion) zone of the lip. The line separating the vermilion 6one from the hair-bearing s2in of the lip is called the vermilion border. 4n young people this border is demarcated sharply, but as a person is exposed to ultraviolet radiation, the border becomes diffuse and poorly defined. (ecause the vermilion 6one lac2s salivary glands and contains only a few sebaceous glands, it tends to dry out, often becoming crac2ed and sore in cold weather. (etween the vermilion 6one and the thic2er, non2eratini6ed labial mucosa is an intermediate 6one covered by para2eratini6ed oral epithelium. 4n infants, this region is thic2ened and appears more opalescent, which represents an adaptation to suc2ling called the suc ling pad. Mucogingival =unction 'lthough masticatory mucosa meets lining mucosa at several sites, none is more abrupt than the ;unction between attached gingiva and alveolar mucosa. This ;unction is identified clinically by a slight indentation called the mucogingival groove and by the change from the bright pin2 of the alveolar mucosa to the paler pin2 of the gingiva. 9istologically, a change occurs at this ;unction, not only in the type of epithelium but also in the composition of the lamina propria. The epithelium of the attached gingiva is 2eratini6ed or para2eratini6ed, and the lamina propria contains numerous coarse collagen bundles attaching the tissue to

periosteum. The stippling seen clinically at the surface of healthy attached gingiva probably reflects the presence of this collagen attachment, the surface of the free gingiva being smooth. The structure of mucosa changes at the mucogingival ;unction, where the alveolar mucosa has a thic2er, non2eratini6ed epithelium overlying a loose lamina propria with numerous elastic fibers extending into the thic2 submucosa. These elastic fibers return the alveolar mucosa to its original position after distention by the labial muscles during mastication and speech. !oronal to the mucogingival ;unction is another clinically visible depression in the gingiva, the free gingival groove, the level of which corresponds approximately to that of the bottom of the gingival sulcus. This demarcates the free and attached gingivae, although unli2e the mucogingival ;unction, no significant change in the structure of the mucosa occurs at the free gingival groove.

Development of Oral Mucosa

#t 25 days of "estation, there is rupture of the buccopharyngeal membrane and fusion of the embryonic stomatodeum with the foregut. This forms the primitive oral cavity. 5pithelium covering structures that develop in the branchial arches (tongue, epiglottis, pharynx) is derived from endoderm, while epithelium covering the palate, chee2s, and gingivae are ectodermal in origin. #t 6 to 5 +ee3s of "estation, a single layer of lining cells forms two cell layers. #t 0 +ee3s of "estation, there is thic2ening of the vestibular dental lamina complex By 17 to 18 +ee3s. cellular degeneration occurs at central region of this thic2ening. This causes separation of the cells covering the chee2 area and the alveolar mucosa, which forms the oral vestibule. By 0 to 11 +ee3s, the palatal shelves elevate and closure occurs. By 9 wee2s, the lingual epithelium shows speciali6ation. The circumvallate and foliate papillae first appear, followed by the fungiform papillae. The taste buds soon develop. By 17 wee2s, the filiform papillae become apparent. By 17 to 12 +ee3s, the future lining and masticatory mucosa show stratification of epithelium. Bet+een 1: and 27 +ee3s, all the oral epithelia thic2en and there is appearance of sparse 2eratohyalin granules. /uring this period, melanocytes and ,angerhans cells appear in the epithelium. &urface layers of the epithelium show para2eratosis. rtho2eratini6ation does not occur until after teeth erupt. ;nitially, ectomesenchyme consists of widely spaced stellate cells in an amorphous matrix By 5 to 0 +ee3s, extracellular reticular fibers accumulate Bet+een 0 and 12 +ee3s, capillary buds and collagen fibers can be detected. 's collagen fibers increase in number, they are arranged in the form of bundles. Bet+een 19 and 27 wee2s, the elastic fibers become prominent in the connective tissue of lining mucosa.

#"e Chan"es
&moother and dryer surface - atrophic or friable 5pithelium appears thinner 7lattening of epithelial ridges - smoothing of the epithelium-connective tissue interface /orsum of the tongue - reduction in the number of filiform papillae - smooth or glossy appearance *educed number of filiform papillae - ma2e fungiform papillae more prominent erroneously considered a disease /ecreased rates of metabolic activity ,angerhans cells become fewer - decline in cell-mediated immunity Vascular changes may be prominent, with the development of varicosities 0odular varicose veins on the undersurface of the tongue (sometimes called caviar tongue) ,amina propria - a decreased cellularity occurs and increased amount of collagen, which becomes more highly cross-lin2ed &ebaceous glands (7ordyceEs spots) of the lips and chee2s also increase Minor salivary glands - atrophy with fibrous replacement 5lderly patients, particularly postmenopausal women, may have symptoms such as dryness of the mouth, burning sensations, and abnormal taste

%. TencateEs ral 9istology # )th Edition ). rbanEs ral 9istology $ 5mrbyology # *+th Edition +. 8rayEs 'natomy for &tudents , -nd Edition