KMCT DENTAL COLLEGE

Manassery, Mukkam

ORAL MUCOSA
IN HEALTH

Presented By:

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

Definition
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. Oral Cavity Proper (inner)

Boundaries

Superiorly hard & soft palates

Inferiorly floor of mouth and tongue
Posteriorly faucial pillars and tonsils
Anteriorly lips

Functions of Oral Mucosa

1. Protection:
Separates deeper tissues and organs from environment
Protect from mechanical forces and surface abrasions
Adaptations to withstand insults
Barrier to microorganisms and their toxic products
2. Sensation:
Receptors for temperature, touch and pain
Taste buds of tongue
Reflexes are also initiated by receptors
3. Lubrication:
Saliva from salivary glands - maintains moist surface
Sebaceous glands - secrete sebum
4. Thermal Regulation:
Dissipation of body heat in some animals by panting
No such role in humans

Clinical Features
Characteristic features:
Deeper colour
Moist surface
Absence of appendages
Only minor salivary glands, and occasional sebaceous glands (no sweat glands)
Smoother surface, fewer folds/wrinkles
Variable firmness and thickness

Component Tissues and Glands

Two main tissue components:
i. Oral epithelium (stratified squamous epithelium)
ii. Lamina propria (underlying connective tissue layer)
Interface between epithelium and connective tissue is usually irregular. It consist of:
Connective tissue papillae
Epithelial ridges or pegs
At this interface is present the basal lamina, but it is visible only by special staining.
Oral Epithelium
It is composed of stratified squamous epithelium. Cells are tightly attached to each
other and arranged in a number of distinct layers or strata.
Epithelium maintains its structural integrity by a process of continuous renewal. Cells
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.
End phase of this pathway is a unique form of programmed cell death.
Cells consist of two functional populations:
a) Progenitor 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-keratinized stratified squamous epithelium
except gingiva, hard palate and dorsal surface of the tongue
Keratinocytes: They have no nuclei. Cytoplasm is displaced by large numbers of keratin
filaments.
Four layers of cells are present in keratinized epithelium:
1. Stratum Basale
Cuboidal or low columnar cells
Form a single layer resting on the basal lamina
Basal lamina is at the interface of the epithelium and lamina propria
Epithelial cells are in a constant state of renewal
The basal cells show the maximum mitotic activity
2. Stratum Spinosum
Several cells thick
Polyhedral cells with short cytoplasmic processes
Stratum basale and the first layers of stratum spinosum - give rise to new
epithelial cells - stratum germinativum

3. Stratum Granulosum
Cells are flat
Found in layers of three to five cells thick
Prominent in keratinized epithelium (absent in nonkeratinized)
Cells have keratohyaline granules in their cytoplasm - help to form the matrix
of the keratin fibres found in the superficial layer
4. Stratum Corneum
Cells are flat, devoid of nuclei and full of keratin filament surrounded by a
matrix
Cells are continuously being sloughed - replaced by epithelial cells that
migrate from the underlying layers
Parakeratinized Epithelium
Surface cells have dark staining pyknotic nuclei. The cytoplasm contains little if any
keratin filaments.
Nonkeratinized Oral Epithelium
Nonkeratinized epithelial cells in the superficial layers do not have keratin 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
High rate of turnover
Difficult to appreciate on a static diagram or histologic slide
Sulcular epithelium takes 10 days to renew
General oral mucosa takes approximately 12 to 13 days
Nonkeratinocytes
Cells that differ in appearance from other epithelial cells. They have a clear halo around
their nuclei. Such cells have been termed clear cells:
Melanocytes
Langerhan Cells
Merkel Cells
Inflammatory Cells
Melanocytes
Melanocytes
One factor affecting color of the oral mucosa is melanin pigmentation. Melanin is a
pigment produced by specialized cells called melanocytes. Situated in the basal layer of the
oral epithelium, they arise embryologically from the neural crest ectoderm and enter the
epithelium at 11 weeks of gestation. They divide and maintain themselves (selfreproducing). They possess long dendritic (branching) processes that extend between the
keratinocytes. Melanin is synthesized within the melanocytes as small structures called

melanosomes. It is transferred into the cytoplasm of adjacent keratinocytes by the dendritic

processes of melanocytes. Groups of melanosomes are called melanin granules.
Lightly and darkly pigmented individuals have the same number of melanocytes in
any given region. Color differences result from:
Relative activity of the melanocytes in producing melanin
Rate at which melanosomes are broken down in the keratinocytes
Melanophages are macrophages that have taken 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. Source is bone
marrow. They appear in the epithelium at the same time as, or just 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.
Immunologic function - recognizing and processing antigenic material and presenting it to T
lymphocytes. They are characterized ultrastructurally by a small rod- or flask-shaped
granule, sometimes called the Birbeck granule.

Merkel Cells
They are situated in the basal layer of epithelium. They are not dendritic and does
possess keratin tonofilaments and occasional desmosomes. They arise from the
differentiation of an epidermal progenitor during embryonic development.
Merkel cells are sensory and respond to touch. Characteristic feature is presence of
small membrane-bound vesicles in the cytoplasm, situated adjacent to a nerve fiber
associated with the cell. Granules liberate a transmitter substance across the synapse-like
junction between the Merkel cell and the nerve fiber, which triggers an impulse.
Inflammatory Cells
Clinically normal areas of mucosa show a number of inflammatory cells in the
nucleated cell layers. Cells are transient and do not reproduce themselves.
Cells seen:
Lymphocytes (frequently)
Polymorphonuclear leukocytes
Mast cells
Lymphocytes often are associated with Langerhans cells, which are able to activate T
lymphocytes

Keratinocytes produce cytokines that modulate function of Langerhans cells. Langerhans

cells produce cytokines (interleukin-1) which activate T lymphocytes and aid in responding
to antigenic challenge. Interleukin-1 also increases activity of melanocytes, which affects
pigmentation. Cytokines can also influence the activity of fibroblasts.

Junction of Epithelium and Lamina Propria

It is the region where connective tissue of the lamina propria meets the overlying
oral epithelium. It shows an undulating interface at which papillae of the connective tissue
interdigitate with epithelial ridges.
Significance:
1. Larger surface area of the interface for better attachment
2. Enable forces applied at the surface to be dispersed over a greater area of
connective tissue
3. Metabolic exchange between the epithelium and connective tissue (epithelium has
no blood vessels)
4. Masticatory mucosa - greatest number of papillae per unit area
5. Lining mucosa - papillae are fewer and shorter

Basal Lamina
It cannot be visualized directly by light microscopy using conventional stains. In
histologic sections of oral mucosa stained by the periodic acidSchiff reaction, it appears as
a bright, structureless band at the interface between the epithelium and subjacent
connective tissue.
Basal lamina runs parallel to the basal cell membrane of the epithelial cells.
At the ultrastructural level, it consists of three zones:
Lamina Lucida - slightly thinner than the lamina densa appears as clear zone
Lamina Densa - homogeneous, finely fibrillar planar assembly of extracellular matrix
molecules
Lamina Fibroreticularis
Anchoring fibrils:
They are made up of collagen type VII. They insert into the lamina densa, and form a
flexible attachment between the basal lamina and subjacent connective tissue.
Cells of Lamina Propria
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. Low rate of proliferation is
seen.
During wound healing, fibroblasts divide in the adjacent uninjured tissues and their
numbers increase. They can become contractile and actin content increases. This results in
wound contraction. In certain disease states, they may be activated and secrete more
ground substance.
Macrophages
Round, 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. Cytoplasm contains lysosomes.
Functions:
i. Phagocytosis - Ingest damaged tissue or foreign material and initiate breakdown
ii. Antigen presenting - Processing of ingested material and increasing its antigenicity
before presenting to cells of the lymphoid series
iii. Repair - Stimulation of fibroblast proliferation

Two special types of macrophages can be identified specifically:

Melanophage - in pigmented oral mucosa, cell has ingested melanin granules
extruded from melanocytes
Siderophage - contains hemosiderin derived from extravasated red blood cells due
to mechanical injury
Mast Cells
Large spherical or elliptical mononuclear cell. Nucleus is small relative to cell size.
Large 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
Lymphocyte and plasma cell are present in small numbers scattered throughout the lamina
propria. Following an injury, they are found in significant numbers, and release cytokines,
which influences the behavior of the overlying epithelium.
Type of inflammatory cell depends on the nature and duration of injury:
Acute conditions - polymorphonuclear leukocytes
Chronic conditions - lymphocytes, plasma cells, monocytes, and macrophages

Fibres and Ground Substance

Intercellular matrix consists of two major types of fibers:
Collagen
Elastin
These fibres together with fibronectin are embedded in a ground substance.
Collagen
Collagen in the lamina propria is primarily type I and type III. Types IV and VII
occurring as part of the basal lamina. Type V may be present in inflamed tissue.
Elastic Fibers
When 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. Unlike collagen fibers, elastic fibers
branch, anastomose, and run singly rather than in bundles.
Ground Substance
It appears amorphous by light and electron microscopy. It consists of heterogeneous
molecular complexes permeated by tissue fluid. Chemically, they are subdivided into two:
1. Proteoglycans - polypeptide core to which glycosaminoglycans (consisting of hexose
and hexuronic acid residues) are attached
E.g. hyaluronan, heparan sulfate, versican, decorin, biglycan, and syndecan
2. Glycoproteins - polypeptide chain to which only a few simple hexoses are attached

Blood Supply
Rich blood supply is present. Arteries run parallel to the surface in the submucosa or
deep part of the reticular layer, and anastomose with adjacent vessels in the reticular layer
to form a, extensive capillary network in the papillary layer. From this network, capillary
loops pass into the connective tissue papillae and lie close to the basal layer. In cheek,
arterioles are tortuous with extensive branching. There is more profuse capillary loops than
in skin.
Blood flow:
Gingiva > Other oral mucosae > Skin
It lacks arteriovenous shunts. Due to rich anastomoses of arterioles and capillaries, it
has the ability to heal more rapidly after injury.
Nerve Supply
Oral mucosa is innervated densely. Nerves monitor all substances entering.
They also initiate and maintain voluntary and reflexive activities (involved in mastication,
salivation, swallowing, gagging, and speaking).
Efferent autonomic supply affects blood vessels and minor salivary glands. Nerves
arise mainly from second and third divisions of the trigeminal nerve, facial (VII),

glossopharyngeal (IX), and vagus (X) nerves. Sensory nerves lose their myelin sheaths to
form a network in the reticular layer of the lamina propria which terminates in a
subepithelial plexus.

Classification of Oral Mucosa

Oral mucus membrane can be classified into:
Masticatory
Lining
Specialized
Masticatory Mucosa
It covers areas exposed to compressive and shear forces and to abrasion during the
mastication of food. It is found in hard palate and gingiva.
Histology:

Epithelium is moderately thick and frequently orthokeratinized. Surfaces are

inextensible and withstand abrasion.
Junction 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.
Thick lamina propria has dense network of large, closely packed bundles of collagen
fibers, which follow a direct course between anchoring points. The tissue has little
slack 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. When it is directly attached to the periosteum of underlying
bone, it is known as mucoperiosteum. Indirectly it may be attached by a fibrous submucosa.
In lateral regions of palate, fibrous submucosa is interspersed with areas of fat and
glandular tissue, which cushion the mucosa against mechanical loads and protect the
underlying nerves and blood vessels.

Lining Mucosa
It covers the underside of the tongue, inside of the lips, cheeks, floor of the mouth,
and alveolar processes as far as the gingiva. The mucosa is subject to movement. These
regions, together with the soft palate, are classified as lining mucosa.
Histology:

Epithelium has larger thickness and is nonkeratinized. Surface is thus flexible and
able to withstand stretching.

Interface with connective tissue is smooth. Slender connective tissue papillae may be
present
Lamina propria: Thicker with fewer collagen fibers, which follow a more irregular
course between anchoring points. Elastic fibers control the extensibility of the
mucosa.

Mucosa can be stretched to a certain extent before these fibers become taut and limit
further distention. As the mucosa becomes slack during masticatory movements, the elastic
fibers retract the mucosa toward the muscle and prevent it from bulging between the teeth
and being bitten.
Alveolar mucosa and mucosa covering the floor of the mouth are attached loosely to
the underlying structures by a thick submucosa. Mucosa of the underside of the tongue is
bound firmly to underlying muscle. Soft palate is flexible but not highly mobile; mucosa is
separated from the loose and highly glandular submucosa by a layer of elastic fibers.

Specialized Mucosa
It includes the mucosa of the dorsal surface of the tongue. Functionally, it is a
masticatory mucosa, but also a highly extensible lining. It has different types of lingual
papillae. Some possess a mechanical function, whereas others bear taste buds (sensory
function).
Tongue mucosa is composed of two parts, divided by sulcus terminalis:
i. Anterior two thirds (body) - derived from the first pharyngeal arch
ii. Posterior third (base) - derived from the third pharyngeal arch
Extensive nodules of lymphoid tissue in the base of tongue are known as lingual tonsils.
a) Fungiform Papillae
Anterior portion of the tongue and tip
Fungiform = fungus-like
Single fungiform papillae scattered between the numerous filiform papillae
Smooth, round structures that appear red because of
Highly vascular connective tissue core
Thin, nonkeratinized covering epithelium
Taste buds - present in the epithelium on the superior surface
b) Filiform Papillae
Cover entire anterior part of the tongue
Cone-shaped structures, each with a core of connective tissue covered by a thick
keratinized epithelium
Form a tough, abrasive surface
Compressing and breaking food
when the tongue is apposed
to the hard palate

 Tongue is highly extensible because of nonkeratinized, flexible epithelium

between the filiform papillae
Buildup of keratin results in elongation of the filiform papillae in some patients
The dorsum of the tongue then has a hairy appearance called hairy tongue
c) Foliate Papillae
Leaf-like pink papillae
Lateral margins of the posterior part of the tongue
Few taste buds are present in the epithelium of the lateral walls of the ridges
Consist of parallel ridges that alternate with deep grooves in the mucosa
d) Circumvallate Papillae
Adjacent and anterior to the sulcus terminalis
Circumvallate = walled
8 to 12 papillae
Large structures each surrounded by a deep, circular groove into which open the
ducts of minor salivary glands (the glands of Ebner)
Connective tissue core covered on the superior surface by a keratinized
epithelium
Epithelium covering the lateral walls is nonkeratinized - contains taste buds

Taste Buds
They are specialized receptors which occur only in the oral cavity and pharynx. They
are found in the fungiform, foliate, and circumvallate papillae of the tongue.
Histology:
Barrel-shaped structure composed of 30 to 80 spindle-shaped cells
Separated from underlying connective tissue by the basal lamina
Apical ends terminate just below the epithelial surface in a taste pit
Communicates with the surface via taste pore
Cells:
They are of 3 types - light (type I), dark (type II), and intermediate (type III)
Type I - most common
Type II - morphologically similar, contain numerous vesicles, adjacent to the
intraepithelial nerves
They are replaced continually. Their existence depends on presence of a functional
gustatory nerve. Initial events stimulating sensation of taste involve amorphous material
within the taste pits. The microvilli of constituent cells project into these pits.
Generation of taste stimuli:
1. Adsorption of molecules onto membrane receptors on the surface
2. Activation of signaling cascade mediated by membrane-associated proteins such as
transducin and gustducin

3. Change in membrane polarization

4. Release of transmitter substances
5. Stimulate unmyelinated afferent fibers of the glossopharyngeal nerve (IX)

Junctions in Oral Mucosa

Within the oral mucosa are three junctions that merit further discussion:
mucocutaneous (between the skin 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 Junction
The skin is continuous with the oral mucosa at the lips. It is a transitional region
where appendages are absent except for a few sebaceous glands (situated mainly at the
angles of the mouth).
Epithelium is keratinized 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 zone from the hair-bearing skin of the lip is called the vermilion
border.
In young people this border is demarcated sharply, but as a person is exposed to ultraviolet
radiation, the border becomes diffuse and poorly defined. Because the vermilion zone lacks
salivary glands and contains only a few sebaceous glands, it tends to dry out, often
becoming cracked and sore in cold weather.
Between the vermilion zone and the thicker, nonkeratinized labial mucosa is an
intermediate zone covered by parakeratinized oral epithelium. In infants, this region is
thickened and appears more opalescent, which represents an adaptation to suckling called
the suckling pad.
Mucogingival Junction
Although masticatory mucosa meets lining mucosa at several sites, none is more
abrupt than the junction between attached gingiva and alveolar mucosa. This junction is
identified clinically by a slight indentation called the mucogingival groove and by the change
from the bright pink of the alveolar mucosa to the paler pink of the gingiva. Histologically, a
change occurs at this junction, not only in the type of epithelium but also in the composition
of the lamina propria.
The epithelium of the attached gingiva is keratinized or parakeratinized, 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 junction, where the alveolar
mucosa has a thicker, nonkeratinized epithelium overlying a loose lamina propria with
numerous elastic fibers extending into the thick submucosa. These elastic fibers return the
alveolar mucosa to its original position after distention by the labial muscles during
mastication and speech.
Coronal to the mucogingival junction 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
unlike the mucogingival junction, no significant change in the structure of the mucosa
occurs at the free gingival groove.

Development of Oral Mucosa

At 26 days of gestation, there is rupture of the buccopharyngeal membrane and

fusion of the embryonic stomatodeum with the foregut. This forms the primitive oral
cavity. Epithelium covering structures that develop in the branchial arches (tongue,
epiglottis, pharynx) is derived from endoderm, while epithelium covering the palate,
cheeks, and gingivae are ectodermal in origin.
At 5 to 6 weeks of gestation, a single layer of lining cells forms two cell layers.
At 8 weeks of gestation, there is thickening of the vestibular dental lamina complex
By 10 to 14 weeks, cellular degeneration occurs at central region of this thickening.
This causes separation of the cells covering the cheek area and the alveolar mucosa,
which forms the oral vestibule.
By 8 to 11 weeks, the palatal shelves elevate and closure occurs.
By 7 weeks, the lingual epithelium shows specialization. The circumvallate and
foliate papillae first appear, followed by the fungiform papillae. The taste buds soon
develop.
By 10 weeks, the filiform papillae become apparent.
By 10 to 12 weeks, the future lining and masticatory mucosa show stratification of
epithelium.
Between 13 and 20 weeks, all the oral epithelia thicken and there is appearance of
sparse keratohyalin granules. During this period, melanocytes and Langerhans cells
appear in the epithelium. Surface layers of the epithelium show parakeratosis.
Orthokeratinization does not occur until after teeth erupt.
Initially, ectomesenchyme consists of widely spaced stellate cells in an amorphous
matrix
By 6 to 8 weeks, extracellular reticular fibers accumulate
Between 8 and 12 weeks, capillary buds and collagen fibers can be detected. As
collagen fibers increase in number, they are arranged in the form of bundles.
Between 17 and 20 weeks, the elastic fibers become prominent in the connective
tissue of lining mucosa.

Age Changes

Smoother and dryer surface - atrophic or friable

Epithelium appears thinner
Flattening of epithelial ridges - smoothing of the epithelium-connective tissue
interface
Dorsum of the tongue - reduction in the number of filiform papillae - smooth or
glossy appearance
Reduced number of filiform papillae - make fungiform papillae more prominent erroneously considered a disease
Decreased rates of metabolic activity
Langerhans cells become fewer - decline in cell-mediated immunity
Vascular changes may be prominent, with the development of varicosities
Nodular varicose veins on the undersurface of the tongue (sometimes called caviar
tongue)
Lamina propria - a decreased cellularity occurs and increased amount of collagen,
which becomes more highly cross-linked
Sebaceous glands (Fordyces spots) of the lips and cheeks also increase
Minor salivary glands - atrophy with fibrous replacement
Elderly patients, particularly postmenopausal women, may have symptoms such as
dryness of the mouth, burning sensations, and abnormal taste

References
1. Tencates Oral Histology 8th Edition
2. Orbans Oral Histology & Emrbyology 13th Edition
3. Grays Anatomy for Students 2nd Edition