DHY 221 - Oral Pathology

1Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc.

Chapter 2

Inflammation and Repair


OutlineOutline InjuryInjury Natural (Innate) Defenses Against InjuryNatural (Innate) Defenses Against Injury InflammationInflammation Regeneration and RepairRegeneration and Repair Injuries to TeethInjuries to Teeth Injuries to Soft TissuesInjuries to Soft Tissues Reactive Connective Tissue HyperplasiaReactive Connective Tissue Hyperplasia Inflammatory Periapical LesionsInflammatory Periapical Lesions


Inflammation and RepairInflammation and Repair (pg. 34)(pg. 34)

The body’s response to injuryThe body’s response to injury InflammationInflammation

• Allows the body to eliminated injurious agents, Allows the body to eliminated injurious agents, contain injuries, and heal defectscontain injuries, and heal defects


InjuryInjury (pg. 34)(pg. 34)

An alteration in the environment that An alteration in the environment that causes tissue damagecauses tissue damage

Examples includeExamples include Physical Physical ChemicalChemical MicroorganismsMicroorganisms Nutritional deficienciesNutritional deficiencies


Natural (Innate) Defenses Natural (Innate) Defenses Against InjuryAgainst Injury

(pg. 34)(pg. 34) Intact skin or mucosa is a physical barrier.Intact skin or mucosa is a physical barrier. Enzymes in saliva have an antibacterial Enzymes in saliva have an antibacterial

activity.activity. Flushing action of tears, saliva, urine, and Flushing action of tears, saliva, urine, and

diarrhea removes foreign substances.diarrhea removes foreign substances.


InflammationInflammation (pgs. 34-44)(pgs. 34-44)

Microscopic Events and Clinical Signs of Microscopic Events and Clinical Signs of InflammationInflammation

White Blood Cells and Their Involvement White Blood Cells and Their Involvement in the Inflammatory Responsein the Inflammatory Response

Biochemical Mediators of InflammationBiochemical Mediators of Inflammation Systemic Manifestations of InflammationSystemic Manifestations of Inflammation Chronic InflammationChronic Inflammation Hyperplasia, Hypertrophy, and AtrophyHyperplasia, Hypertrophy, and Atrophy


Inflammation (cont.)Inflammation (cont.) (pgs. 34-35)(pgs. 34-35)

A nonspecific response to injuryA nonspecific response to injury Occurs in the same manner regardless of the Occurs in the same manner regardless of the

nature of the injurynature of the injury May be local and limited to the area of injury, May be local and limited to the area of injury,

or may be extensive if the injury is extensiveor may be extensive if the injury is extensive May be acute or chronicMay be acute or chronic


Microscopic Events and Clinical Microscopic Events and Clinical Signs of Inflammation (Cont.)Signs of Inflammation (Cont.)


Microscopic Events and Clinical Microscopic Events and Clinical Signs of Inflammation (Cont.)Signs of Inflammation (Cont.)

(pgs. 35-37) (Table 2-1)(pgs. 35-37) (Table 2-1)

Local clinical changes are classic signs of Local clinical changes are classic signs of inflammation.inflammation. Redness, heat, swelling, pain, loss of normal Redness, heat, swelling, pain, loss of normal

tissue functiontissue function Systemic signs may includeSystemic signs may include

Increase in body temperatureIncrease in body temperature Increase in the number of white blood cellsIncrease in the number of white blood cells Enlargement of lymph nodesEnlargement of lymph nodes


Microscopic Events and Clinical Microscopic Events and Clinical Signs of Inflammation (cont.)Signs of Inflammation (cont.)


Microscopic events involve Microscopic events involve microcirculation.microcirculation. Arterioles, capillaries, venules in the area of Arterioles, capillaries, venules in the area of

injuryinjury White blood cellsWhite blood cells Chemical mediatorsChemical mediators

Usually, an exchange of oxygen and Usually, an exchange of oxygen and nutrition is seen in these vessels.nutrition is seen in these vessels. Most of the fluid reenters circulation through Most of the fluid reenters circulation through

venules.venules. Lymphatic system carries away fluid that does Lymphatic system carries away fluid that does

not reenter the blood vessels.not reenter the blood vessels.

Microscopic Events and Clinical Microscopic Events and Clinical Signs of Inflammation (cont.)Signs of Inflammation (cont.)


Sequence of Microscopic EventsSequence of Microscopic Events

(pg. 36)(pg. 36) Injury to tissueInjury to tissue Constriction of microcirculationConstriction of microcirculation Dilation of microcirculationDilation of microcirculation Increase in permeabilityIncrease in permeability Exudate leaves microcirculation.Exudate leaves microcirculation. Increased blood viscosityIncreased blood viscosity Decreased blood flow Decreased blood flow Margination and pavementing of white blood Margination and pavementing of white blood

cells (WBCs)cells (WBCs) WBCs enter tissue.WBCs enter tissue. WBCs ingest foreign material.WBCs ingest foreign material.


Sequence of Microscopic Events Sequence of Microscopic Events (cont.) (cont.)

(pg. 36)(pg. 36) HyperemiaHyperemia

Increased blood flow in capillary beds of injured tissueIncreased blood flow in capillary beds of injured tissue• Will produce redness and heatWill produce redness and heat

ExudateExudate Increased blood plasma and proteins in injured tissueIncreased blood plasma and proteins in injured tissue

• Helps dilute injurious agents, but results in excess fluid in Helps dilute injurious agents, but results in excess fluid in tissues – edematissues – edema

Serous exudateSerous exudate• Mainly plasma fluids and proteins, few WBCsMainly plasma fluids and proteins, few WBCs

Purulent exudate (suppuration)Purulent exudate (suppuration)• Contains plasma fluids and proteins, tissue debris, and Contains plasma fluids and proteins, tissue debris, and

many WBCsmany WBCs


Sequence of Microscopic Events Sequence of Microscopic Events (cont.)(cont.)

(pgs. 36-38)(pgs. 36-38) Swelling develops as exudate escapes into tissue.Swelling develops as exudate escapes into tissue.

May flow out as a thin, clear exudate (serous) or a thick May flow out as a thin, clear exudate (serous) or a thick white-to-yellow pus (purulent)white-to-yellow pus (purulent)

Drainage may occur through a fistula.Drainage may occur through a fistula. Incision and drainage (I & D) may be required.Incision and drainage (I & D) may be required.

A drainage tube may be placed.A drainage tube may be placed. Medication may be administered to treat infection and Medication may be administered to treat infection and

reduce inflammation.reduce inflammation. Pressure from exudate and chemical mediators may cause Pressure from exudate and chemical mediators may cause

pain.pain. Blood viscosity may increase due to loss of plasma fluids.Blood viscosity may increase due to loss of plasma fluids.

MarginationMargination• White blood cells migrate to the periphery of the White blood cells migrate to the periphery of the

vessel.vessel.







(pgs. 37, 39)(pgs. 37, 39) EmigrationEmigration

The process by which WBCs escape from The process by which WBCs escape from blood vessels through gaps in endothelial cellsblood vessels through gaps in endothelial cells

Chemotaxis Chemotaxis Directed movement of WBCs toward the site of Directed movement of WBCs toward the site of

injuryinjury PhagocytosisPhagocytosis

The process by which WBCs ingest and then The process by which WBCs ingest and then digest foreign substances.digest foreign substances.

May include pathogenic organisms and tissue May include pathogenic organisms and tissue debrisdebris




(pgs. 37, 39)(pgs. 37, 39) There are six different kinds of WBCs.There are six different kinds of WBCs.

NeutrophilsNeutrophils• First to arrive at the site of injuryFirst to arrive at the site of injury• Primary cell in acute inflammationPrimary cell in acute inflammation

Monocytes (Macrophage)Monocytes (Macrophage)• Second cell in inflammatory responseSecond cell in inflammatory response

Lymphocytes and Plasma CellsLymphocytes and Plasma Cells• Seen in chronic inflammation and the immune responseSeen in chronic inflammation and the immune response

Eosinophils and Mast CellsEosinophils and Mast Cells• Seen in both inflammation and the immune responseSeen in both inflammation and the immune response

White Blood Cells and Their Involvement White Blood Cells and Their Involvement in the Inflammatory Responsein the Inflammatory Response


White Blood Cells and Their Involvement White Blood Cells and Their Involvement in the Inflammatory Response (cont.)in the Inflammatory Response (cont.)

(pgs. 39-40)(pgs. 39-40) Changes occur in the proportion of WBCs Changes occur in the proportion of WBCs

as the inflammatory response continues.as the inflammatory response continues. The neutrophil is the most common The neutrophil is the most common

inflammatory cell in acute monocyte (in blood) inflammatory cell in acute monocyte (in blood) becomes a macrophage as it enters tissue becomes a macrophage as it enters tissue inflammation.inflammation.

The circulating.The circulating. Neutrophils decrease in number.Neutrophils decrease in number. Macrophages, lymphocytes, and plasma cells Macrophages, lymphocytes, and plasma cells

become predominant with chronic become predominant with chronic inflammation.inflammation.






Neutrophils (PMNs)Neutrophils (PMNs) (pgs. 39-40)(pgs. 39-40)

60% to 70% of WBC population60% to 70% of WBC population Granular leukocytes along with basophils and Granular leukocytes along with basophils and

eosinophilseosinophils Derived from stem cells in bone marrowDerived from stem cells in bone marrow Contain lysosomal enzymesContain lysosomal enzymes

Function is phagocytosis and then Function is phagocytosis and then enzymatic destruction of foreign enzymatic destruction of foreign substances.substances. Neutrophils then perish.Neutrophils then perish. The enzymes can leak, causing further tissue The enzymes can leak, causing further tissue

damage.damage.


Neutrophils (PMNs) (cont.)Neutrophils (PMNs) (cont.)


MacrophagesMacrophages (pgs. 40-41)(pgs. 40-41)

3% to 8% of WBC population3% to 8% of WBC population Derived from stem cells in bone marrowDerived from stem cells in bone marrow Has a single, round nucleus and a nongranular Has a single, round nucleus and a nongranular

cytoplasmcytoplasm Responds to chemotactic factors, is mobile, Responds to chemotactic factors, is mobile,

can phagocytize – also plays a role in the can phagocytize – also plays a role in the immune systemimmune system


Macrophages (cont.)Macrophages (cont.)


Biochemical Mediators of Biochemical Mediators of InflammationInflammation

(pgs. 40-41)(pgs. 40-41) Cause many of the events in the Cause many of the events in the

inflammatory responseinflammatory response Basic mediators can recruit other mediators Basic mediators can recruit other mediators

and immune mechanisms.and immune mechanisms. May be derived from May be derived from

BloodBlood Endothelial cellsEndothelial cells White blood cells and plateletsWhite blood cells and platelets Pathogenic organisms as they injure the tissuePathogenic organisms as they injure the tissue


Biochemical Mediators of Biochemical Mediators of Inflammation (cont.)Inflammation (cont.)

(pgs. 40-41)(pgs. 40-41) Three interrelated systemsThree interrelated systems

Interaction takes place during activation, Interaction takes place during activation, among their products, and within their various among their products, and within their various actionsactions

Kinin systemKinin system Clotting mechanismClotting mechanism Complement systemComplement system


Kinin SystemKinin System (pg. 40)(pg. 40)

Active in early phases of inflammationActive in early phases of inflammation Activated by substances in plasma and Activated by substances in plasma and

injured tissueinjured tissue Causes increasedCauses increased

Dilation of blood vessels at the site of injuryDilation of blood vessels at the site of injury Permeability of local blood vesselsPermeability of local blood vessels

Induces painInduces pain


Clotting MechanismClotting Mechanism (pg. 41)(pg. 41)

Clots blood and mediates inflammationClots blood and mediates inflammation Some of the clotting mechanisms products that Some of the clotting mechanisms products that

are activated during tissue injury cause local are activated during tissue injury cause local vascular dilation and permeability by activating vascular dilation and permeability by activating kinin.kinin.


Complement SystemComplement System (pg. 41)(pg. 41)

Involves the production of a sequential cascade of plasma Involves the production of a sequential cascade of plasma proteinsproteins They are present in blood in an inactive form.They are present in blood in an inactive form. A trigger (usually an antibody/antigen complex) initiates the A trigger (usually an antibody/antigen complex) initiates the

sequence of steps.sequence of steps. These plasma proteins function in inflammation and immunity.These plasma proteins function in inflammation and immunity.

Some components cause WBCs known as mast cells to Some components cause WBCs known as mast cells to release histamine.release histamine. Histamine causes an increase in vascular permeability and Histamine causes an increase in vascular permeability and

vasodilation.vasodilation. Other components cause cell death, form chemotactic Other components cause cell death, form chemotactic

factors for WBCs, and enhance phagocytosis.factors for WBCs, and enhance phagocytosis.


Other Biochemical Mediators of Other Biochemical Mediators of InflammationInflammation

(pg. 41)(pg. 41) Released by the bodyReleased by the body

ProstaglandinsProstaglandins• Cause increased vascular dilation and permeability, Cause increased vascular dilation and permeability,

tissue pain and redness, and changes in connective tissue pain and redness, and changes in connective tissuetissue

Lysosomal enzymesLysosomal enzymes• Act as chemotactic factorsAct as chemotactic factors• May cause damage to connective tissues and to the May cause damage to connective tissues and to the

clot clot


Other Biochemical Mediators of Other Biochemical Mediators of Inflammation (cont.)Inflammation (cont.)

(pg. 41)(pg. 41) Released by pathogenic microorganismsReleased by pathogenic microorganisms

EndotoxinEndotoxin• Produced by cell walls of gram-negative bacteriaProduced by cell walls of gram-negative bacteria• Serves as chemotactic factor, can activate Serves as chemotactic factor, can activate

complement, function as an antigen, and damage complement, function as an antigen, and damage bone and tissuebone and tissue

Lysosomal enzymesLysosomal enzymes• Have a similar chemical composition and action as Have a similar chemical composition and action as

those released by WBCsthose released by WBCs


Antiinflammatory DrugsAntiinflammatory Drugs (pg. 41)(pg. 41)

Block or suppress the inflammatory Block or suppress the inflammatory responseresponse Prevent or reduce clinical signs of inflammation Prevent or reduce clinical signs of inflammation

and adverse reactions to the injuryand adverse reactions to the injury ExamplesExamples

Nonsteroidal antiinflammatory agentsNonsteroidal antiinflammatory agents• Aspirin, ibuprofen, celecoxibAspirin, ibuprofen, celecoxib

Steroidal antiinflammatory drugSteroidal antiinflammatory drug• PrednisonePrednisone


Systemic Manifestations of Systemic Manifestations of InflammationInflammation

(pgs. 41-42)(pgs. 41-42) May includeMay include

FeverFever LeukocytosisLeukocytosis Elevated C-reactive proteinElevated C-reactive protein LymphadenopathyLymphadenopathy


FeverFever (pg. 42)(pg. 42)

Controlled by the hypothalamusControlled by the hypothalamus Associated with systemic inflammatory Associated with systemic inflammatory

responseresponse PyrogensPyrogens

Fever producing substances produced by Fever producing substances produced by WBCs and pathogensWBCs and pathogens

Pyrogens act on the hypothalamus.Pyrogens act on the hypothalamus. The hypothalamus increases body The hypothalamus increases body

temperature by way of prostaglandins.temperature by way of prostaglandins.


LeukocytosisLeukocytosis (pg. 42)(pg. 42)

A systemic inflammatory response can A systemic inflammatory response can increase the number of WBCs from the increase the number of WBCs from the normal 4000 to 10,000/mm of blood to normal 4000 to 10,000/mm of blood to 10,000 to 30,000/mm.10,000 to 30,000/mm. The primary cell involved is the neutrophil.The primary cell involved is the neutrophil.

The rate of formation is increased and The rate of formation is increased and immature forms are released from bone immature forms are released from bone marrow into the blood.marrow into the blood. The body is attempting to produce more cells The body is attempting to produce more cells

for phagocytosis.for phagocytosis.


Elevated C-Reactive ProteinElevated C-Reactive Protein (pg. 42)(pg. 42)

C-reactive protein is produced in the liver and C-reactive protein is produced in the liver and plays the important role of interacting with the plays the important role of interacting with the complement system.complement system. Elevated levels are present during episodes of acute Elevated levels are present during episodes of acute

inflammation or infection.inflammation or infection. May continue with chronic inflammationMay continue with chronic inflammation

Levels can be used to help assess rheumatoid Levels can be used to help assess rheumatoid arthritis and systemic lupus erythematosus.arthritis and systemic lupus erythematosus. A chronic increased level is associated with an A chronic increased level is associated with an

increased risk for cardiovascular disease.increased risk for cardiovascular disease.


LymphadenopathyLymphadenopathy (pgs. 42-43)(pgs. 42-43)

Enlarged and palpable superficial lymph Enlarged and palpable superficial lymph nodesnodes Follows route of lymphatic drainageFollows route of lymphatic drainage

The enlarged nodes occur due to changes The enlarged nodes occur due to changes in lymphocytes, which are the primary cells in lymphocytes, which are the primary cells of the immune response.of the immune response. HyperplasiaHyperplasia

• An increase in the number of cellsAn increase in the number of cells HypertrophyHypertrophy

• Enlargement of individual cellsEnlargement of individual cells


Lymphadenopathy (cont.)Lymphadenopathy (cont.)


Chronic InflammationChronic Inflammation (pgs. 42-43)(pgs. 42-43)

Due to persistent injuriesDue to persistent injuries Cells involved include macrophages, Cells involved include macrophages,

lymphocytes, and plasma cells as well as lymphocytes, and plasma cells as well as neutrophils and monocytes present in acute neutrophils and monocytes present in acute inflammation.inflammation.

May include proliferation of fibroblasts and May include proliferation of fibroblasts and formation of granulomasformation of granulomas


Chronic Inflammation (cont.)Chronic Inflammation (cont.) (pgs. 42-43)(pgs. 42-43)

GranulomaGranuloma Microscopic groupings of macrophages Microscopic groupings of macrophages

surrounded by lymphocytes and plasma cellssurrounded by lymphocytes and plasma cells Usually contain multinucleated giant cellsUsually contain multinucleated giant cells

• Large macrophages with multiple nucleiLarge macrophages with multiple nuclei Associated with foreign body reactions and Associated with foreign body reactions and

some infections such as tuberculosissome infections such as tuberculosis


Hyperplasia, Hypertrophy, and Hyperplasia, Hypertrophy, and AtrophyAtrophy

(pgs. 43-44)(pgs. 43-44) HyperplasiaHyperplasia

An increase in the number of cells often in response to An increase in the number of cells often in response to chronic irritation or abrasionchronic irritation or abrasion

May return to normal if the insult subsides, or may May return to normal if the insult subsides, or may persist following removal of the irritantpersist following removal of the irritant

HypertrophyHypertrophy An increase in the size of cellsAn increase in the size of cells May be seen in cardiac muscle as a response to May be seen in cardiac muscle as a response to

hypertensionhypertension AtrophyAtrophy

A decrease in size or function of a cell, tissue, organ, or A decrease in size or function of a cell, tissue, organ, or entire bodyentire body


Hyperplasia, Hypertrophy, and Hyperplasia, Hypertrophy, and Atrophy (cont.)Atrophy (cont.)


Regeneration and RepairRegeneration and Repair (pgs. 44-46)(pgs. 44-46)

Microscopic Events That Occur During Microscopic Events That Occur During RepairRepair

Types of RepairTypes of Repair Bone Tissue RepairBone Tissue Repair


(pg. 44)(pg. 44) RegenerationRegeneration

If the inflamed area returns to normal structure If the inflamed area returns to normal structure and functionand function

RepairRepair Occurs when the damage is too great for the Occurs when the damage is too great for the

tissue to return to normaltissue to return to normal Functioning cells and tissue often are replaced Functioning cells and tissue often are replaced

with nonfunctioning scar tissue. with nonfunctioning scar tissue.

Regeneration and Repair (cont.)Regeneration and Repair (cont.)


Microscopic Events That Occur Microscopic Events That Occur During RepairDuring Repair

(pgs. 44-45)(pgs. 44-45) Takes about 2 weeksTakes about 2 weeks

Occurs almost simultaneously in both Occurs almost simultaneously in both epithelium and connective tissueepithelium and connective tissue


Microscopic Events That Occur Microscopic Events That Occur During Repair (cont.)During Repair (cont.)


Day of InjuryDay of Injury (pg. 45)(pg. 45)

Blood flows into injured tissue to produce a Blood flows into injured tissue to produce a clot.clot. The clot contains fibrin, clumped red blood The clot contains fibrin, clumped red blood

cells (RBCs), and platelets.cells (RBCs), and platelets.


One Day After InjuryOne Day After Injury (pg. 45)(pg. 45)

Neutrophils migrate from the Neutrophils migrate from the microcirculation into injured tissue in an microcirculation into injured tissue in an acute inflammatory response.acute inflammatory response. They phagocytize foreign material and necrotic They phagocytize foreign material and necrotic

tissue.tissue.


Two Days After InjuryTwo Days After Injury (pg. 45)(pg. 45)

Monocytes migrate from microcirculation and become macrophages Monocytes migrate from microcirculation and become macrophages in tissue.in tissue. They also phagocytize.They also phagocytize.

Fibroblasts increase in number and produce new collagen fibers.Fibroblasts increase in number and produce new collagen fibers. Granulation tissue is formed in the connective tissue portion of Granulation tissue is formed in the connective tissue portion of

injury.injury.• This growth may be excessive.This growth may be excessive.

New surface epithelium is formed in the epithelial tissue portion of New surface epithelium is formed in the epithelial tissue portion of injury.injury.• They use the fibrin meshwork to migrate.They use the fibrin meshwork to migrate.• This meshwork also protects newly formed tissue from This meshwork also protects newly formed tissue from

additional injury.additional injury. Lymphocytes and plasma cells migrate to the area as chronic Lymphocytes and plasma cells migrate to the area as chronic

inflammation and the immune response begins.inflammation and the immune response begins.


Seven Days After InjurySeven Days After Injury (pg. 45)(pg. 45)

Fibrin is digested by tissue enzymes.Fibrin is digested by tissue enzymes. It sloughs off and the initial repair is complete.It sloughs off and the initial repair is complete.

The new tissue is relatively red.The new tissue is relatively red. New epithelium is thin.New epithelium is thin. New connective tissue is highly vascularized.New connective tissue is highly vascularized.


Two Weeks After InjuryTwo Weeks After Injury (pg. 45)(pg. 45)

Initial granulation tissue and its fibers are Initial granulation tissue and its fibers are remodeled.remodeled.

The new tissue is scar tissue.The new tissue is scar tissue. It is whiter and paler due to increased collagen It is whiter and paler due to increased collagen

and decreased vascularity.and decreased vascularity.


Types of RepairTypes of Repair (pgs. 45-46)(pgs. 45-46)

Healing by primary intentionHealing by primary intention Healing of an injury where there is little loss of Healing of an injury where there is little loss of

tissuetissue The margins are close together and very little The margins are close together and very little

granulation tissue forms.granulation tissue forms. Healing by secondary intentionHealing by secondary intention

The edges of the injury cannot be joined during The edges of the injury cannot be joined during healing.healing.

A large clot forms, resulting in increased A large clot forms, resulting in increased granulation tissue.granulation tissue.

May result in excess scar tissue – a keloidMay result in excess scar tissue – a keloid


Types of Repair (cont.)Types of Repair (cont.)


Healing by Tertiary IntentionHealing by Tertiary Intention (pg. 46)(pg. 46)

Delaying surgical tissue repair until Delaying surgical tissue repair until infection is resolvedinfection is resolved An injured area may become infected – An injured area may become infected –

especially with puncture wounds.especially with puncture wounds. In some situations, an infected injury is left In some situations, an infected injury is left

open until infection is controlled.open until infection is controlled.


Factors That Impair HealingFactors That Impair Healing (pg. 46)(pg. 46)

Local factors that impair healingLocal factors that impair healing Bacterial infectionBacterial infection Tissue destruction and necrosisTissue destruction and necrosis HematomaHematoma Excessive movement of injured tissueExcessive movement of injured tissue Poor blood supplyPoor blood supply

Systemic factorsSystemic factors MalnutritionMalnutrition ImmunosuppressionImmunosuppression Genetic connective tissue disordersGenetic connective tissue disorders Metabolic disordersMetabolic disorders


Bone Tissue RepairBone Tissue Repair (pg. 46)(pg. 46)

Osteoblasts create new bone tissue.Osteoblasts create new bone tissue. May be delayed byMay be delayed by

• Increased movement of boneIncreased movement of bone• EdemaEdema• Infection in the tissueInfection in the tissue• Excessive or inadequate movement of bone tissueExcessive or inadequate movement of bone tissue


Injuries to TeethInjuries to Teeth AttritionAttrition AbrasionAbrasion AbfractionAbfraction ErosionErosion Methamphetamine abuseMethamphetamine abuse


AttritionAttrition (pgs. 47-48)(pgs. 47-48)

Tooth-to-tooth wearTooth-to-tooth wear May be observed both in May be observed both in

primary and permanent primary and permanent dentitiondentition


BruxismBruxism (pgs. 47-48)(pgs. 47-48)

Grinding and clenching teeth for nonfunctional Grinding and clenching teeth for nonfunctional purposespurposes

Signs and symptoms includeSigns and symptoms include Wear facets, abnormal rate of attrition, hypertrophy of Wear facets, abnormal rate of attrition, hypertrophy of

masticatory muscles, increased muscle tone, muscle masticatory muscles, increased muscle tone, muscle tenderness, muscle fatigue, cheek biting, pain in the TM joint tenderness, muscle fatigue, cheek biting, pain in the TM joint area, tooth mobility, and pulpal sensitivity to coldarea, tooth mobility, and pulpal sensitivity to cold

May be due to local factors such as occlusal May be due to local factors such as occlusal interferences in combination with stress and tensioninterferences in combination with stress and tension Management includes fabrication of an acrylic splint and Management includes fabrication of an acrylic splint and

elimination of occlusal interferences through occlusal elimination of occlusal interferences through occlusal adjustments.adjustments.


Bruxism (cont.)Bruxism (cont.)


AbrasionAbrasion (pg. 48)(pg. 48)

Wearing away of tooth structure from a Wearing away of tooth structure from a repetitive mechanical habitrepetitive mechanical habit Most frequently seen as a notching on root Most frequently seen as a notching on root

surfaces with gingival recessionsurfaces with gingival recession May occur from back-and-forth toothbrushing May occur from back-and-forth toothbrushing

techniquetechnique May be seen in patients who are May be seen in patients who are

seamstresses, musicians, or pipe smokersseamstresses, musicians, or pipe smokers


Abrasion (cont.)Abrasion (cont.)


AbfractionAbfraction (pg. 48)(pg. 48)

Typically appears as wedge-shaped Typically appears as wedge-shaped lesions at the cervical areas of teethlesions at the cervical areas of teeth May be related to fatigue, flexure, fracture, and May be related to fatigue, flexure, fracture, and

deformation of tooth structuredeformation of tooth structure May occur in combination with abrasionMay occur in combination with abrasion


ErosionErosion (pgs. 48-49)(pgs. 48-49)

Loss of tooth structure Loss of tooth structure due to chemicalsdue to chemicals Tooth structure may be lost Tooth structure may be lost

around a restoration, around a restoration, making the restoration making the restoration stand out.stand out.

Occlusal surfaces may be Occlusal surfaces may be cupped out.cupped out.

May be on facial surfaces May be on facial surfaces from food and lingual from food and lingual surfaces from vomiting due surfaces from vomiting due to bulimiato bulimia


BulimiaBulimia (pg. 49)(pg. 49)

Self-induced purging (vomiting) Self-induced purging (vomiting) after eatingafter eating The bulimic maintains normal body The bulimic maintains normal body

weight.weight. May see electrolyte imbalance May see electrolyte imbalance

and/or malnutritionand/or malnutrition Management may include Management may include

fluoride rinse and toothpaste.fluoride rinse and toothpaste. Rinsing with water after purgingRinsing with water after purging


Methamphetamine AbuseMethamphetamine Abuse (pgs. 49-50)(pgs. 49-50)

Rapid destruction of Rapid destruction of teeth teeth Due to acid content of Due to acid content of

methamphetamine, methamphetamine, decreased salivary flow, decreased salivary flow, craving for high sugar craving for high sugar beverages with lack of beverages with lack of oral hygieneoral hygiene


Injuries to Oral Soft TissuesInjuries to Oral Soft Tissues Aspirin BurnAspirin Burn Phenol BurnsPhenol Burns Electric BurnsElectric Burns Other BurnsOther Burns Lesions Lesions

Associated with Associated with Cocaine UseCocaine Use

Lesions from Lesions from Self-Induced Self-Induced InjuriesInjuries

HematomaHematoma

Traumatic Ulcer Frictional Keratosis Linea Alba Nicotinic Stomatitis Tobacco Pouch

Keratosis Traumatic Neuroma Amalgam Tattoo

Melanosis Solar Cheilitis Mucocele Necrotizing

Sialometaplasia Sialolith Acute and

Chronic Sialadenitis


Aspirin BurnAspirin Burn (pgs. 49-50)(pgs. 49-50)

Topical application is a Topical application is a common misuse of this common misuse of this product.product. The tissue becomes The tissue becomes

necrotic and white.necrotic and white. The surface may slough off The surface may slough off

leaving a painful ulcer.leaving a painful ulcer. The ulcer usually heals in 7 The ulcer usually heals in 7

to 21 days. to 21 days.


Phenol BurnPhenol Burn (pgs. 50-51)(pgs. 50-51)

Used in dentistry as a cavity sterilizing Used in dentistry as a cavity sterilizing agent and a cauterizing agentagent and a cauterizing agent Will cause whitening and sloughing of the area Will cause whitening and sloughing of the area

as a result of tissue destructionas a result of tissue destruction


Electric BurnElectric Burn (pg. 50)(pg. 50)

May be seen in infants or young children May be seen in infants or young children who have chewed an electrical cordwho have chewed an electrical cord May be quite extensive, damaging oral tissue May be quite extensive, damaging oral tissue

and even tooth budsand even tooth buds May cause constriction of the commissureMay cause constriction of the commissure


Other BurnsOther Burns (pgs. 50-51)(pgs. 50-51)

Hot food burnsHot food burns From soup or cheese on pizzaFrom soup or cheese on pizza

Products containing hydrogen peroxide or Products containing hydrogen peroxide or eugenoleugenol


Lesions Associated with Cocaine Lesions Associated with Cocaine UseUse

(pgs. 50-51) (Fig. 2-28C)(pgs. 50-51) (Fig. 2-28C) Lesions located at the midline of the hard palate may Lesions located at the midline of the hard palate may

vary from ulcers to keratotic lesions to exophytic vary from ulcers to keratotic lesions to exophytic reactive lesions as a result of smoking crack cocaine.reactive lesions as a result of smoking crack cocaine.

Necrotic ulcers of the tongue and epiglottis have been Necrotic ulcers of the tongue and epiglottis have been reported as a result of free-basing cocaine.reported as a result of free-basing cocaine.


Lesions from Self-Induced InjuriesLesions from Self-Induced Injuries

(pgs. 51, 53-54)(pgs. 51, 53-54) A factitious injuryA factitious injury

Due to a habit such as chronic lip, cheek or Due to a habit such as chronic lip, cheek or tongue biting, or trauma to the teeth from a tongue biting, or trauma to the teeth from a fingernailfingernail

Lesions may range from ulceration to epithelial Lesions may range from ulceration to epithelial hyperplasia and hyperkeratosis.hyperplasia and hyperkeratosis.


Lesions from Self-Induced Injuries Lesions from Self-Induced Injuries (cont.)(cont.)


HematomaHematoma ((pgs. 51-52)pgs. 51-52)

A bruise inside the A bruise inside the mouthmouth Blood in an Blood in an

extravascular spaceextravascular space• Appears as a red to Appears as a red to

purple to bluish-gray purple to bluish-gray massmass

Most frequently seen Most frequently seen on labial or buccal on labial or buccal mucosamucosa


Traumatic UlcerTraumatic Ulcer (pgs. 51-53)(pgs. 51-53)

May be due to such events as biting the cheek, May be due to such events as biting the cheek, lip, or tongue, irritation from a complete or partial lip, or tongue, irritation from a complete or partial denture, mucosal injury from sharp edges of food, denture, mucosal injury from sharp edges of food, or removal of a dry cotton roll after a dental or removal of a dry cotton roll after a dental procedure (some patients are sensitive to the procedure (some patients are sensitive to the starch in a cotton roll)starch in a cotton roll) Persistent trauma may cause a hard (indurated), raised Persistent trauma may cause a hard (indurated), raised

traumatic granuloma.traumatic granuloma. TreatmentTreatment

Usually heals within 7 to 14 days unless the trauma Usually heals within 7 to 14 days unless the trauma persistspersists

May require a biopsyMay require a biopsy


Traumatic Ulcer (cont.)Traumatic Ulcer (cont.)


Frictional KeratosisFrictional Keratosis (pgs. 52, 54)(pgs. 52, 54)

Due to chronic rubbing or friction against an oral Due to chronic rubbing or friction against an oral mucosal surfacemucosal surface

A form of hyperkeratosisA form of hyperkeratosis Resembles a callus on skinResembles a callus on skin

Results in a opaque white appearanceResults in a opaque white appearance TreatmentTreatment

Identify the traumatic cause of the lesion whether it be an Identify the traumatic cause of the lesion whether it be an opposing third molar, chronic cheek or tongue chewing, opposing third molar, chronic cheek or tongue chewing, or some other entity.or some other entity.

Eliminate the cause.Eliminate the cause. Must be differentiated from idiopathic leukoplakia Must be differentiated from idiopathic leukoplakia

because leukoplakia may be premalignantbecause leukoplakia may be premalignant


Frictional Keratosis (cont.)Frictional Keratosis (cont.)


Linea AlbaLinea Alba (pgs. 52, 54)(pgs. 52, 54)

A white, raised line most commonly on the buccal A white, raised line most commonly on the buccal mucosa at the occlusal planemucosa at the occlusal plane May be the result of a teeth clenching habitMay be the result of a teeth clenching habit Sometimes the pattern of the teeth can be seen in the Sometimes the pattern of the teeth can be seen in the

lesion.lesion. Due to epithelial hyperplasia and hyperkeratosisDue to epithelial hyperplasia and hyperkeratosis

TreatmentTreatment NoneNone

May be used to evaluate severity of bruxing May be used to evaluate severity of bruxing and/or tongue thrusting habitand/or tongue thrusting habit


Linea Alba (cont.)Linea Alba (cont.)


Nicotinic StomatitisNicotinic Stomatitis (pgs. 52, 55)(pgs. 52, 55)

A benign lesion typically associated with A benign lesion typically associated with pipe and/or cigar smoking; may also occur pipe and/or cigar smoking; may also occur with cigarette smokingwith cigarette smoking Presence indicates increased risk for Presence indicates increased risk for

development of malignancy.development of malignancy. Initially, erythema is seen, but over time Initially, erythema is seen, but over time

keratinization takes place, resulting in keratinization takes place, resulting in increased opacity.increased opacity.• Raised red areas may be seen at the openings of Raised red areas may be seen at the openings of

ducts of minor salivary glands on the palatal surface.ducts of minor salivary glands on the palatal surface. This is due to obstruction by keratin at the mucosal This is due to obstruction by keratin at the mucosal

openings of the ducts. openings of the ducts.


Nicotinic Stomatitis (cont.)Nicotinic Stomatitis (cont.)


Tobacco Pouch KeratosisTobacco Pouch Keratosis (pgs. 52, 55)(pgs. 52, 55)

A white lesion located where chewing tobacco is A white lesion located where chewing tobacco is placed, most often in the mucobuccal foldplaced, most often in the mucobuccal fold Early lesions may have a granular or wrinkled Early lesions may have a granular or wrinkled

appearance.appearance. Long standing lesions may be more opaquely white and Long standing lesions may be more opaquely white and

have a corrugated surface.have a corrugated surface. TreatmentTreatment

May require biopsyMay require biopsy• Long-term exposure to chewing tobacco has been Long-term exposure to chewing tobacco has been

associated with increased risk of squamous cell carcinoma.associated with increased risk of squamous cell carcinoma.


Tobacco Pouch Keratosis (cont.)Tobacco Pouch Keratosis (cont.)


Traumatic NeuromaTraumatic Neuroma (pg. 53)(pg. 53)

A lesion caused by injury to a peripheral nerveA lesion caused by injury to a peripheral nerve When the nerve sheath of Schwann is disrupted, When the nerve sheath of Schwann is disrupted,

occasionally the proximal end of damaged nerve occasionally the proximal end of damaged nerve proliferates into a mass of nerve and Schwann cells proliferates into a mass of nerve and Schwann cells mixed with dense fibrous scar tissue.mixed with dense fibrous scar tissue.

Painful, ranging from pain on palpation to severe, Painful, ranging from pain on palpation to severe, intractable painintractable pain

DiagnosisDiagnosis Biopsy and microscopic examinationBiopsy and microscopic examination

TreatmentTreatment Surgical excisionSurgical excision


Amalgam TattooAmalgam Tattoo (pgs. 53, 55)(pgs. 53, 55)

A flat, bluish-gray lesion of oral mucosa due to the A flat, bluish-gray lesion of oral mucosa due to the introduction of amalgam into tissueintroduction of amalgam into tissue May occur during placement or removal of an amalgam May occur during placement or removal of an amalgam

restoration or during an extractionrestoration or during an extraction May be seen in any location in the oral cavity, most May be seen in any location in the oral cavity, most

commonly on gingiva or alveolar ridgecommonly on gingiva or alveolar ridge Amalgam particles may be seen on radiograph, aiding in Amalgam particles may be seen on radiograph, aiding in

diagnosis.diagnosis. DiagnosisDiagnosis

Patient history and radiographs may help.Patient history and radiographs may help. Must be differentiated from malignant melanomaMust be differentiated from malignant melanoma

TreatmentTreatment None providing melanoma has been ruled outNone providing melanoma has been ruled out


Amalgam Tattoo (cont.)Amalgam Tattoo (cont.)


MelanosisMelanosis (pgs. 54-55) (pgs. 54-55) (see also pgs. 9, 24 and Figs. 1-18, 1-51)(see also pgs. 9, 24 and Figs. 1-18, 1-51)

Normal physiologic pigmentation of oral Normal physiologic pigmentation of oral mucosamucosa May be geneticMay be genetic May occur as a result of inflammation due to May occur as a result of inflammation due to

retained hemosiderin (a blood pigment) retained hemosiderin (a blood pigment) retained in tissueretained in tissue


Melanosis (cont.)Melanosis (cont.)


Melanosis (cont.)Melanosis (cont.) Oral Melanotic MaculeOral Melanotic Macule

A flat, well-circumscribed lesion of unknown A flat, well-circumscribed lesion of unknown causecause• Less than 1 cm in diameterLess than 1 cm in diameter

Smoker’s MelanosisSmoker’s Melanosis Melanin pigmentation associated with smokingMelanin pigmentation associated with smoking

• More common in women than in menMore common in women than in men Most common in anterior labial gingivaMost common in anterior labial gingiva

Melanosis may also be associated with Melanosis may also be associated with genetic, bone, and systemic diseasesgenetic, bone, and systemic diseases..


Solar Cheilitis (Actinic Cheilitis)Solar Cheilitis (Actinic Cheilitis) (pg. 56)(pg. 56)

A degeneration of the tissue of the lips due to exposure to the sunA degeneration of the tissue of the lips due to exposure to the sun Occurs particularly in fair-skinned individualsOccurs particularly in fair-skinned individuals

The lower lip is usually more involved than the upper lip.The lower lip is usually more involved than the upper lip. The epithelium is thinner than normal; the vermilion appears The epithelium is thinner than normal; the vermilion appears

pale pink and mottled.pale pink and mottled. The interface between lips and skin is indistinct.The interface between lips and skin is indistinct.

TreatmentTreatment No specific treatmentNo specific treatment Biopsy may be indicated for persistent scaling or ulceration.Biopsy may be indicated for persistent scaling or ulceration.

• A relationship is found between these epithelial and A relationship is found between these epithelial and connective tissue changes and the development of basal connective tissue changes and the development of basal cell carcinoma of the skin or squamous cell carcinoma of cell carcinoma of the skin or squamous cell carcinoma of the lips and skin.the lips and skin.


Solar Cheilitis (Actinic Cheilitis) Solar Cheilitis (Actinic Cheilitis) (cont.)(cont.)


MucoceleMucocele (pgs. 56-57)(pgs. 56-57)

A lesion that forms when a minor salivary gland duct is damagedA lesion that forms when a minor salivary gland duct is damaged Not a true cystNot a true cyst

• The mucous salivary gland secretion is walled off by granulation The mucous salivary gland secretion is walled off by granulation tissue to form a cystlike structure lined by compressed granulation tissue to form a cystlike structure lined by compressed granulation tissue.tissue.

Most commonly found in the lower lipMost commonly found in the lower lip It may increase or decrease in size over time.It may increase or decrease in size over time. May appear bluish if near the surfaceMay appear bluish if near the surface

TreatmentTreatment If persistent, they are surgically removed.If persistent, they are surgically removed.

May observe a mucus cyst or mucus retention cystMay observe a mucus cyst or mucus retention cyst Usually in people over age 50Usually in people over age 50 Treated by removal of affected salivary glandsTreated by removal of affected salivary glands

These lesions must be differentiated from mucoepidermoid These lesions must be differentiated from mucoepidermoid carcinoma.carcinoma.


Mucocele (cont.)Mucocele (cont.)


RanulaRanula (pg. 56) (pg. 56)

A unilateral mucocele-like lesion that forms A unilateral mucocele-like lesion that forms on the floor of the mouthon the floor of the mouth Associated with the ducts of submandibular Associated with the ducts of submandibular

and sublingual glandsand sublingual glands


Necrotizing SialometaplasiaNecrotizing Sialometaplasia (pgs. 57-58)(pgs. 57-58)

A benign condition of salivary glands A benign condition of salivary glands Moderately painful swelling and ulcerationModerately painful swelling and ulceration Thought to result from blockage of the blood Thought to result from blockage of the blood

supply to the affected areasupply to the affected area• Necrosis of the salivary glands is seen histologically.Necrosis of the salivary glands is seen histologically.• Salivary gland epithelium is replaced by squamous Salivary gland epithelium is replaced by squamous

epithelium (metaplasia).epithelium (metaplasia). The ulcer usually heals by secondary intention.The ulcer usually heals by secondary intention.


Necrotizing Sialometaplasia (cont.)Necrotizing Sialometaplasia (cont.)


SialolithSialolith (pgs. 57-59)(pgs. 57-59)

A salivary gland stoneA salivary gland stone May be found in both minor and major salivary May be found in both minor and major salivary

glandsglands Formed by precipitation of calcium salts around Formed by precipitation of calcium salts around

a central corea central core May often be seen on radiographMay often be seen on radiograph

TreatmentTreatment Sometimes the calcification can be “milked” Sometimes the calcification can be “milked”

from the duct.from the duct. It may require surgical removal, this may It may require surgical removal, this may

damage the duct.damage the duct.


Sialolith (cont.)Sialolith (cont.)


Acute and Chronic SialadenitisAcute and Chronic Sialadenitis (pg. 58)(pg. 58)

Painful swelling of the involved salivary Painful swelling of the involved salivary gland due to obstruction of the salivary gland due to obstruction of the salivary gland ductgland duct May occur as result of infectionMay occur as result of infection

DiagnosisDiagnosis May involve injection of a radiopaque dye into May involve injection of a radiopaque dye into

the gland followed by a radiograph the gland followed by a radiograph (sialography)(sialography)

TreatmentTreatment May require antibioticsMay require antibiotics


Reactive Connective Tissue Reactive Connective Tissue HyperplasiaHyperplasia

(pgs. 58-63)(pgs. 58-63) Pyogenic GranulomaPyogenic Granuloma Giant Cell GranulomaGiant Cell Granuloma Irritation FibromaIrritation Fibroma Denture-Induced Fibrous HyperplasiaDenture-Induced Fibrous Hyperplasia Papillary Hyperplasia of the PalatePapillary Hyperplasia of the Palate Gingival EnlargementGingival Enlargement Chronic Hyperplastic PulpitisChronic Hyperplastic Pulpitis


Reactive Connective Tissue Reactive Connective Tissue Hyperplasia (cont.)Hyperplasia (cont.)

(pg. 58)(pg. 58) Proliferating, exuberant granulation tissue Proliferating, exuberant granulation tissue

and dense fibrous connective tissue and dense fibrous connective tissue resulting from overzealous repairresulting from overzealous repair May be a response to a single event or chronic May be a response to a single event or chronic

low-grade injurylow-grade injury


Pyogenic GranulomaPyogenic Granuloma (pgs. 58-59)(pgs. 58-59)

A proliferation of connective tissue A proliferation of connective tissue containing numerous blood vessels and containing numerous blood vessels and inflammatory cells occurring as a response inflammatory cells occurring as a response to injuryto injury The name is a misnomer; the lesion is neither The name is a misnomer; the lesion is neither

pyogenic (pus forming) nor a true granuloma.pyogenic (pus forming) nor a true granuloma.


Pyogenic Granuloma (cont.)Pyogenic Granuloma (cont.)


Pyogenic Granuloma (cont.)Pyogenic Granuloma (cont.) The lesion is usually ulcerated, soft to palpation, The lesion is usually ulcerated, soft to palpation,

and bleeds easily.and bleeds easily. It is deep red to purple.It is deep red to purple. Generally elevated, may be sessile or pedunculatedGenerally elevated, may be sessile or pedunculated Most commonly observed on the gingiva, it may be seen Most commonly observed on the gingiva, it may be seen

on other intraoral areason other intraoral areas May vary in size from a few millimeters to several May vary in size from a few millimeters to several

centimeterscentimeters Usually develop rapidly and then remain staticUsually develop rapidly and then remain static Most common in teenagers and young adults, but may Most common in teenagers and young adults, but may

occur at any ageoccur at any age If seen in a pregnant female, it is called a pregnancy If seen in a pregnant female, it is called a pregnancy

tumor.tumor. TreatmentTreatment

Surgically excised if it does not regress spontaneouslySurgically excised if it does not regress spontaneously


Pregnancy TumorPregnancy Tumor

(pg. 58)(pg. 58) A pyogenic granuloma seen in a pregnant A pyogenic granuloma seen in a pregnant

womanwoman The lesions are identical to those seen in men The lesions are identical to those seen in men

and nonpregnant women.and nonpregnant women. May be caused by hormonal changes and May be caused by hormonal changes and

increased response to plaqueincreased response to plaque They often regress after delivery.They often regress after delivery.


Pregnancy Tumor (cont.)Pregnancy Tumor (cont.)


Peripheral Giant Cell GranulomaPeripheral Giant Cell Granuloma

(pgs. 58, 60)(pgs. 58, 60) A lesion that contains many A lesion that contains many

multinucleated giant cells, well-multinucleated giant cells, well-vascularized connective tissue, RBCs, vascularized connective tissue, RBCs, and chronic inflammatory cellsand chronic inflammatory cells Occurs only in the jawsOccurs only in the jaws Seems to originate from periodontal Seems to originate from periodontal

ligament or periosteum in response to ligament or periosteum in response to injuryinjury

Peripheral Peripheral Lesions occurring outside of boneLesions occurring outside of bone

CentralCentral Lesions within bone of the mandible or Lesions within bone of the mandible or

maxillamaxilla


Peripheral Giant Cell Granuloma Peripheral Giant Cell Granuloma (cont.)(cont.)

Occurs on gingiva or alveolar process, Occurs on gingiva or alveolar process, usually anterior to the molarsusually anterior to the molars Vary in size from 0.5 to 1.5 cmVary in size from 0.5 to 1.5 cm Usually dark red from vascularizationUsually dark red from vascularization Most frequent in people from 40 to 60 years of Most frequent in people from 40 to 60 years of

age age More common in women than in menMore common in women than in men

TreatmentTreatment Surgical excisionSurgical excision


Central Giant Cell GranulomaCentral Giant Cell Granuloma (pgs. 58)(pgs. 58)

Occurs within the bone of the maxilla or mandibleOccurs within the bone of the maxilla or mandible Most frequent in children and young adultsMost frequent in children and young adults

• More common in females than in malesMore common in females than in males Pain is not a common feature.Pain is not a common feature. Usually discovered on routine radiographsUsually discovered on routine radiographs

• RadiolucentRadiolucent• Borders may be sclerotic or ill-defined.Borders may be sclerotic or ill-defined.• Lesion may be unilocular or multilocular.Lesion may be unilocular or multilocular.• May cause divergence of roots of adjacent teethMay cause divergence of roots of adjacent teeth

Treatment Treatment Surgical removalSurgical removal May recurMay recur


Irritation FibromaIrritation Fibroma (pgs. 60-61)(pgs. 60-61)

The most common mass on the The most common mass on the gingivagingiva A broad-based, persistent A broad-based, persistent

exophytic lesion composed of exophytic lesion composed of dense, scarlike connective tissue dense, scarlike connective tissue with few blood vesselswith few blood vessels• The result of trauma such as cheek The result of trauma such as cheek

chewing or cheek bitingchewing or cheek biting Usually a small lesion, less than 1 Usually a small lesion, less than 1

cm in diametercm in diameter• Most often occurs on buccal mucosaMost often occurs on buccal mucosa

May occur on tongue, lips, and palateMay occur on tongue, lips, and palate


Irritation Fibroma (cont.)Irritation Fibroma (cont.) Usually lighter than surrounding mucosaUsually lighter than surrounding mucosa

• The surface is covered by stratified squamous The surface is covered by stratified squamous epithelium.epithelium.

May be opaque if thick or ulcerated due to local May be opaque if thick or ulcerated due to local secondary traumasecondary trauma

TreatmentTreatment Surgically removedSurgically removed Must be differentiated from many soft tissue Must be differentiated from many soft tissue

tumorstumors


Denture-Induced Fibrous Hyperplasia (Epulis Denture-Induced Fibrous Hyperplasia (Epulis fissuratum) (Inflammatory hyperplasia)fissuratum) (Inflammatory hyperplasia)

(pgs. 60-61)(pgs. 60-61) Observed in the vestibule as elongated Observed in the vestibule as elongated

folds of tissue into which of an ill-fitting folds of tissue into which of an ill-fitting denture fitsdenture fits Composed of dense, fibrous connective tissue Composed of dense, fibrous connective tissue

with a surface of stratified squamous with a surface of stratified squamous epitheliumepithelium

The surface may be ulcerated.The surface may be ulcerated. TreatmentTreatment

Surgical removal of excess tissue and Surgical removal of excess tissue and construction of a new dentureconstruction of a new denture


Denture-Induced Fibrous Hyperplasia (Epulis Denture-Induced Fibrous Hyperplasia (Epulis fissuratum) (Inflammatory hyperplasia) (cont.)fissuratum) (Inflammatory hyperplasia) (cont.)


Papillary Hyperplasia of the Palate Papillary Hyperplasia of the Palate (Palatal papillomatosis)(Palatal papillomatosis)

(pgs. 60-62)(pgs. 60-62) Almost always associated with a removable full or Almost always associated with a removable full or

partial denture or orthodontic appliance that is partial denture or orthodontic appliance that is worn continuouslyworn continuously The palatal vault is covered by multiple papillary The palatal vault is covered by multiple papillary

projections.projections.• Each projection consists of fibrous connective tissue, Each projection consists of fibrous connective tissue,

usually chronically inflamed and surfaced by stratified usually chronically inflamed and surfaced by stratified squamous epithelium.squamous epithelium.

The cause is unknown.The cause is unknown. TreatmentTreatment

Surgical removal of the projections prior to construction Surgical removal of the projections prior to construction of a new dentureof a new denture


Papillary Hyperplasia of the Palate Papillary Hyperplasia of the Palate (Palatal papillomatosis) (cont.)(Palatal papillomatosis) (cont.)


Gingival EnlargementGingival Enlargement (pgs. 61-62)(pgs. 61-62)

An increase in the bulk of free and An increase in the bulk of free and attached gingiva, especially the interdental attached gingiva, especially the interdental papillaepapillae Gingival margins are rounded.Gingival margins are rounded. Color may vary from normal pink to pale or Color may vary from normal pink to pale or

erythematous depending upon the degree of erythematous depending upon the degree of inflammation and vascularity.inflammation and vascularity.

May be generalized or localizedMay be generalized or localized


Gingival Enlargement (cont.)Gingival Enlargement (cont.)


Gingival Enlargement (cont.)Gingival Enlargement (cont.) May vary from focal enlargement of interdental papillae May vary from focal enlargement of interdental papillae

to severe generalized gingival enlargement that may to severe generalized gingival enlargement that may cover the crowns of teethcover the crowns of teeth

Usually an unusual tissue response to chronic Usually an unusual tissue response to chronic inflammation associated with local irritants such inflammation associated with local irritants such as plaque or calculusas plaque or calculus

May be from an increased response to local May be from an increased response to local tissue factors due to tissue factors due to Hormonal changes during pregnancy or pubertyHormonal changes during pregnancy or puberty Certain drugs such as phenytoin, calcium channel Certain drugs such as phenytoin, calcium channel

blockers, and cyclosporineblockers, and cyclosporine May be hereditaryMay be hereditary


Gingival Enlargement (cont.)Gingival Enlargement (cont.) TreatmentTreatment

GingivoplastyGingivoplasty• Reshaping the gingivaReshaping the gingiva

GingivectomyGingivectomy• Removing gingival tissueRemoving gingival tissue

Tissue may need to undergo a biopsy to Tissue may need to undergo a biopsy to rule out gingival enlargement seen in rule out gingival enlargement seen in individuals with leukemia.individuals with leukemia.


Chronic Hyperplastic PulpitisChronic Hyperplastic Pulpitis (Pulp polyp) (Pulp polyp)

(pg. 62)(pg. 62) An excessive proliferation of chronically An excessive proliferation of chronically

inflamed dental pulp tissueinflamed dental pulp tissue In children and young adults, it occurs in teeth In children and young adults, it occurs in teeth

with large, open carious lesions often in with large, open carious lesions often in primary and permanent molars.primary and permanent molars.


Chronic Hyperplastic PulpitisChronic Hyperplastic Pulpitis (Pulp polyp) (cont.) (Pulp polyp) (cont.)


Chronic Hyperplastic PulpitisChronic Hyperplastic Pulpitis A red or pink nodule that fills the entire A red or pink nodule that fills the entire

cavity of the tooth, with tissue protruding cavity of the tooth, with tissue protruding from the pulp chamberfrom the pulp chamber Usually asymptomaticUsually asymptomatic May be related to the large root opening and May be related to the large root opening and

blood supply of the involved toothblood supply of the involved tooth Primarily granulation tissue surfaced by a Primarily granulation tissue surfaced by a

stratified squamous epitheliumstratified squamous epithelium TreatmentTreatment

Extraction or endodontic treatment of the Extraction or endodontic treatment of the involved toothinvolved tooth


Inflammatory Periapical LesionsInflammatory Periapical Lesions

Periapical AbscessPeriapical Abscess Dental or Periapical GranulomaDental or Periapical Granuloma Radicular Cyst (Periapical Cyst)Radicular Cyst (Periapical Cyst) Resorption of TeethResorption of Teeth Focal Sclerosing OsteomyelitisFocal Sclerosing Osteomyelitis Alveolar Osteitis (“Dry Socket”)Alveolar Osteitis (“Dry Socket”)


Inflammatory Periapical Lesions Inflammatory Periapical Lesions (cont.) (cont.)

(pg. 63)(pg. 63) Caries or trauma may result inCaries or trauma may result in

InflammationInflammation InfectionInfection Chronic hyperplastic pulpitisChronic hyperplastic pulpitis Necrosis of the pulpNecrosis of the pulp

The inflammatory process begins in pulp The inflammatory process begins in pulp and then extends to the periapical area.and then extends to the periapical area. Accessory canals may lead to areas of Accessory canals may lead to areas of

inflammation on the lateral portion of the root.inflammation on the lateral portion of the root.


Periapical AbscessPeriapical Abscess (pgs. 38, 63)(pgs. 38, 63)

Purulent exudate surrounded by Purulent exudate surrounded by connective tissue containing neutrophils connective tissue containing neutrophils and lymphocytesand lymphocytes Inflammation produces severe pain.Inflammation produces severe pain.

May develop directly from inflammation in May develop directly from inflammation in the pulpthe pulp More commonly develops in an area of More commonly develops in an area of

previously existing chronic inflammationpreviously existing chronic inflammation


Periapical Abscess (cont.)Periapical Abscess (cont.)


Periapical Abscess (cont.)Periapical Abscess (cont.) The pus may cause a fistula to form.The pus may cause a fistula to form.

The tooth may be extruded.The tooth may be extruded. If the acute abscess forms directly from If the acute abscess forms directly from

pulpal inflammationpulpal inflammation There may be no radiographic changes except There may be no radiographic changes except

for a slight thickening of the apical periodontal for a slight thickening of the apical periodontal ligament space.ligament space.

If the abscess forms in a preexisting area If the abscess forms in a preexisting area of periapical chronic inflammation of periapical chronic inflammation A distinct radiographic lucency may be seen at A distinct radiographic lucency may be seen at

the apex.the apex.


Periapical AbscessPeriapical Abscess TreatmentTreatment

May require incision and drainage of the May require incision and drainage of the abscessabscess

Endodontics or extractionEndodontics or extraction


Dental or Periapical GranulomaDental or Periapical Granuloma (pgs. 63-64)(pgs. 63-64)

A localized mass of chronically inflamed A localized mass of chronically inflamed granula that forms at the opening of the granula that forms at the opening of the pulp canal, generally at the apex of a pulp canal, generally at the apex of a nonvital tooth rootnonvital tooth root Granulation tissue with lymphocytes, plasma Granulation tissue with lymphocytes, plasma

cells and macrophages – neutrophils may be cells and macrophages – neutrophils may be presentpresent

Usually asymptomaticUsually asymptomatic May be sensitive to pressure or percussionMay be sensitive to pressure or percussion


Dental or Periapical Granuloma Dental or Periapical Granuloma (cont.)(cont.)


Dental or Periapical Granuloma Dental or Periapical Granuloma (cont.)(cont.)

The tooth may be slightly extruded from The tooth may be slightly extruded from the socket.the socket.

RadiographicRadiographic May vary from slight thickening of the May vary from slight thickening of the

periodontal ligament space to a diffuse periodontal ligament space to a diffuse radiolucency, to a distinct, well-circumscribed radiolucency, to a distinct, well-circumscribed radiolucency surrounding the root apexradiolucency surrounding the root apex

TreatmentTreatment Endodontia or extractionEndodontia or extraction


Radicular Cyst (Periapical Cyst)Radicular Cyst (Periapical Cyst)

(pgs. 64-65)(pgs. 64-65) A true epithelium-lined cystA true epithelium-lined cyst

Associated with the root of a nonvital toothAssociated with the root of a nonvital tooth The most commonly occurring cyst in the The most commonly occurring cyst in the

oral regionoral region A result of proliferation of the rests of MalassezA result of proliferation of the rests of Malassez Usually asymptomatic and discovered on Usually asymptomatic and discovered on

radiographradiograph


Radicular Cyst (Periapical Cyst) Radicular Cyst (Periapical Cyst) (cont.)(cont.)


Radicular CystRadicular Cyst RadiographicRadiographic

The appearance is the same as for a periapical The appearance is the same as for a periapical granuloma.granuloma.

TreatmentTreatment Endodontia, apicoectomy, or extraction and Endodontia, apicoectomy, or extraction and

curettage of periapical tissuecurettage of periapical tissue


Resorption of TeethResorption of Teeth (pgs. 65-66)(pgs. 65-66)

May occur when inflammation is presentMay occur when inflammation is present Occurs in deciduous teeth during exfoliationOccurs in deciduous teeth during exfoliation

Can occur with excessive occlusal or Can occur with excessive occlusal or orthodontic forces or with benign or orthodontic forces or with benign or malignant tumorsmalignant tumors Rapid orthodontic movement in an adult may Rapid orthodontic movement in an adult may

cause external root resorptioncause external root resorption A reimplanted tooth will resorb.A reimplanted tooth will resorb. May be classified as external or internalMay be classified as external or internal


External Root ResorptionExternal Root Resorption (pg. 65)(pg. 65)

Initially appears as a slight Initially appears as a slight raggedness or blunting of the raggedness or blunting of the root apexroot apex Not reversibleNot reversible Progression can be avoided if Progression can be avoided if

the cause is identified and the cause is identified and removedremoved

Impacted teeth may resorb.Impacted teeth may resorb.


Internal Tooth or Root ResorptionInternal Tooth or Root Resorption

(pg. 65) (pg. 65) Idiopathic, thought to be associated with an Idiopathic, thought to be associated with an

inflammatory response in the pulpinflammatory response in the pulp If seen within the crown, the tooth will appear pink due If seen within the crown, the tooth will appear pink due

to inflamed vascular connective tissue “Pink tooth of to inflamed vascular connective tissue “Pink tooth of Mummery.”Mummery.”

If seen within the root, it will be seenIf seen within the root, it will be seen radiographically. radiographically. TreatmentTreatment

If the root is not perforated, calcium hydroxide is placed If the root is not perforated, calcium hydroxide is placed and endodontics performed in an attempt to save the and endodontics performed in an attempt to save the tooth.tooth.

If the tooth is perforated, it must be removed. If the tooth is perforated, it must be removed.


Focal Sclerosing Osteomyelitis Focal Sclerosing Osteomyelitis (Condensing Osteitis)(Condensing Osteitis)

(pgs. 65-66)(pgs. 65-66) A change in the bone A change in the bone

near the apices of teethnear the apices of teeth Thought to be a reaction to Thought to be a reaction to

low-grade infectionlow-grade infection Generally asymptomatic; Generally asymptomatic;

if painful, may be if painful, may be associated with pulpal associated with pulpal inflammatory diseaseinflammatory disease


Focal Sclerosing OsteomyelitisFocal Sclerosing Osteomyelitis RadiographicRadiographic

Appears as a radiopaque area, most Appears as a radiopaque area, most commonly associated with the mandibular first commonly associated with the mandibular first molarmolar

Borders may be diffuse or well-definedBorders may be diffuse or well-defined TreatmentTreatment

Usually not necessaryUsually not necessary Biopsy may be required to rule out other Biopsy may be required to rule out other

radiopaque lesions such as osteoma, complex radiopaque lesions such as osteoma, complex odontoma, or ossifying fibroma.odontoma, or ossifying fibroma.


Alveolar Osteitis (“Dry Socket”)Alveolar Osteitis (“Dry Socket”)

(pg. 66)(pg. 66) A postoperative complication following tooth A postoperative complication following tooth

removal.removal. Most often in the area of the mandibular third molarMost often in the area of the mandibular third molar

The blood clot is lost before healing can take The blood clot is lost before healing can take place, leaving raw, exposed nerve endings.place, leaving raw, exposed nerve endings. The patient may complain of pain, bad odor, and bad The patient may complain of pain, bad odor, and bad

taste.taste. TreatmentTreatment

Daily application of Dry Socket Paste containing Daily application of Dry Socket Paste containing eucalyptol until symptoms are relievedeucalyptol until symptoms are relieved


Discussion Questions Discussion Questions What cells appear first during an inflammatory What cells appear first during an inflammatory

response?response? What is the difference between healing by primary, What is the difference between healing by primary,

secondary, and tertiary intention?secondary, and tertiary intention? What is the difference between regeneration and repair?What is the difference between regeneration and repair? What is the difference between attrition, abrasion, and What is the difference between attrition, abrasion, and

erosion?erosion? What injuries to oral soft tissues may be observed within What injuries to oral soft tissues may be observed within

the oral cavity?the oral cavity? What is the definition of reactive tissue hyperplasia and What is the definition of reactive tissue hyperplasia and

what forms may be observed within the oral cavity?what forms may be observed within the oral cavity? What inflammatory periapical lesions may be observed What inflammatory periapical lesions may be observed

within the oral cavity?within the oral cavity?

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DHY 221 - Oral Pathology