ORAL MUCOUS MEMBRANE

Under the guidance of: Dr. M. P. Singh Dr. Rohit Chopra Dr. Preetika Dr. Archana Dr. Archana Submitted by: Aditya Khichy M.D.S. 1st Prof.

The term mucous membrane is used to describe the moist lining of the gastrointestinal tract, nasal passages and other body cavities that communicate with the external environment.
In the oral cavity , this lining is called as ORAL MUCOUS MEMBRANE or ORAL MUCOSA.

TYPES OF ORAL MUCOSA

a) MASTICATORY MUCOSA: It includes gingiva and covering of the hard palate. b) SPECIALISED MUCOSA: It covers the dorsum of the tongue including the taste buds. c) LINING MUCOSA: Lines the remainder of the oral cavity that is lip, cheek, vestibular fornix, alveolar mucosa, floor of the mouth and soft palate.

DEVELOPMENT OF ORAL MUCOSA

After the rupture of buccopharyngeal membrane at about 26th day of gestation, the embryonic stomatodoeum fuses with the foregut to form the primitive oral cavity which is lined by epithelium derived from ectoderm and endoderm.

7 WEEKS

Circumvallate and Foliate papilla followed by Fungiform papilla. The Filiform papilla.

10 WEEKS

13-20 WEEKS -

Keratohyaline granules

FUNCTIONS OF ORAL MUCOSA

1. 2. 3. 4.

PROTECTION SENSATION SECRETION THERMAL REGULATION

TISSUE TURNOVER
25 days - cheek mucosa 41 - 47 days - Gingiva 75 days - skin.

The two main components of oral mucosa are: 1. ORAL EPITHELIUM. 2. LAMINA PROPRIA.

BASEMENT MEMBRANE It is interface between epithelium and connective tissue at light microscopy level. It is a zone of 1-4 m wide and is relatively cell free zone. Ultra structurally, basement membrane is called basal lamina. Basal lamina is made up of clear zone lamina lucida lamina densa

LAMINA PROPRIA
Lamina propria may be defined as connective tissue of variable thickness that supports the epithelium. It is divided into 2 parts: Papillary Reticular Ground substance consists of glycoproteins and proteoglycans . The collagen fibres in the lamina propria are of types i & iii.

SUBMUCOSA

Submucosa consists of connective tissue of varying thickness and density. It attaches the mucous membrane to the underlying structures.

Epithelium of oral mucous membrane is stratified squamous variety, it may be: -- Keratinized or orthokeratinized -- Para keratinized -- Non-Keratinized

DEFINITION OF KERATINIZATION: Acc to Lindhe [4th Ed.], Keratinization is considered as the process of differentiation rather than degeneration. It is a process of protein synthesis which requires energy & is dependent on the functional cells/organelles.

Orthokeratinization The complete keratinization process leads to production of a superficial acellular horny layer with no nuclei in stratum corneum & a well defined stratum granulosum. Parakeratinization The process of keratinization where superficial layer shows keratin formation in the cytoplasm, but stratum corneum retains pyknotic & condensed nuclei & other partially lysed organelles until it desquamates, keratohyline granules are dispersed not giving rise to stratum granulosum.

Non-keratinization Cytokeratins are major component, as in other epithelia but lacks stratum corneum and stratum granulosum. Superficial cells have viable nuclei.

Types of cells Keratinocytes Non keratinocytes KERATINOCYTES These are the principal cell type of the gingival epithelium as well as of other stratified squamous epithelia. The main function of the gingival epithelium (Protection and barrier against the oral environment) is achieved by the proliferation and differentiation of the keratinocytes

Proliferation The proliferation of keratinocytes takes place by mitosis in the basal layer. When the two daughter cells have been formed by cell division an adjacent, "older" basal cells is pushed into the spinous layer and starts as a keratinocyte to traverse the epithelium. As the basal cells migrate through the epithelium, it becomes flattened with its long axis parallel to the epithelial surface.

Differentiation: It involves the process of keratinization which consists of a sequence of biochemical and morphologic events that occur in the cell as it migrates from the basal layer. The main morphological change production of keratohyaline granules and disappearance of the nucleus. K1 keratin is the major component of stratum corneum.

IMPORTANCE OF KERATINIZATION PROCESS Rapid clearance of the surface layer of oral mucosa is probably important in limiting the colonisation & invasion of epithelial surfaces by pathogenic microorganisms including the common oral fungus Candida. The tightly packed Cytokeratins within an insoluble & tough envelope make this layer resistant to mechanical & chemical damage

Keratinized epithelium has four layers:Stratum Basale (basal layer). Stratum Spinosum (prickle layer). Stratum Granulosum (granular layer). Stratum Corneum (keratinized cell layer).

Stratum Basale

Basal layer is made up of cells that synthesize DNA and undergo mitosis thus provide new cells. Ultra structurally, basal lamina is found to consist of a complex of fibrils & ground substance. Two zones seen are: 1) Lamina lucida which is 20-40nm thick, lying immediately beneath the epithelium. Laminin & Type IV collagen promote epithelial cell growth & guide epithelial cell movement through chemotaxis. Lamina densa which is thicker, 20-120nm thick, lying deep to Lamina lucida.

Stratum Spinosum
Irregularly polyhedral and large than basal cells that are joined by intracellular bridges. Intercellular bridges are dermatomes and tonofibrils. Tonofibrils are bundles of tonofilaments. The intracellular spaces in keratinized epithelium are larger. Thus desmosomes are more prominent and these cells are given prickly appearance.

These cells are more active in protein synthesis. Upper part of stratum spinosum consists of Odland bodies / keratinosomes which are modified lysosomes. They contain large amount of acid phosphatase, an enzyme involved in the destruction of organelle membrane which occurs suddenly between stratum granulosum & stratum corneum & during the intercellular cementation of the cornified cells.

Stratum Granulosum
Cells of this layer are larger than spinous layer. This is named because of keratohyline granules. Nuclei show signs of degeneration and pyknosis. These cells are larger and flatter but most significantly now contain large number of small granules called keratohyaline granules. which contain precursor to filaggrin.

Stratum Corneum
The surface layer is composed of flat squamous cells & assume the form of hexagonal disks termed squames that are eosinophillic & do not contain any nuclei. Nuclei, ribosomes, mitochondria and all other organelles disappear. Ultrastructrucally, the cells of cornified layer are composed of densely packed filaments developed from tonofilaments and coated by basic protein of keratohyline granules filagrin.

Non Keratinizing epithelium has 3 layers:-- Stratum basal -- Stratum intermedium -- Stratum Superficial The basal layer & the prickle layer are similar to that of the keratinized epithelium. But cells of the nonkeratinizing epithelium are slightly larger & intercellular bridges or prickles are less conspicuous. For this reason, term prickle cell is avoided for non-keratinized epithelium. The intercellular space is not obvious or distended & hence the cells do not have prickly appearance. Morphologically, they are not spinous & bio chemically they do not keratinize.

Stratum intermedium: - Cells of intermedium are larger than stratum spinosum. Intra cellular space is not obvious or distented and hence cells do not have prickly appearance. In parakeratinized the cells retain pyknotic and condensed nuclei and other partially lysed cell organelles until they desquamate. They contain no filaggrin.

NON KERATINOCYTES
Melanocytes: - These are located in basal or spinous layer of gingival epithelium. These cells synthesize melanin in premalanosomes. Phagocytosed by melanophages. Langerhans cells: - These are found in oral epithelium of normal gingiva and in smaller amounts in sulcular epithelium. Absent in junctional epithelium of normal gingiva. These are dendritic cells located among the keratinocytes at all suprabasal levels

Merkel cells: They are identified as tactile receptors. These are located in basal layers of epithelium and epidermis. These are connected by desmosomes and have nerve endings.

FIBERS AND GROUND SUBSTANCE

Collagen Collagen type i forms the bulk of lamina propria and provides tensile strength to the gingival tissue. Type iv collagen branches between the collagen type I and is continuous with fibres of basement membrane and blood Bessel walls.

Elastic Fibers Elastic fibers consist of two protein components that are distinctly different in amino acid composition and morphology. The principal protein of the mature fiber is elastin, which is responsible for the elastic properties of the fiber. The second component is a glycoprotein with microfibrillar morphology

The different types of cells present in connective tissue are: i) FIBROBLASTS ii) MAST CELLS iii) MACROPHAGES

FIBROBLASTS
Predominant cells of the connective tissue. 65% of the total cell population.

Synthesis of different collagen and other fibers as well as the glycoproteins and proteoglycans of the ground substance.
Play an active role in the resorption & remodeling of the collagenous framework.

MAST CELLS

Large spherical cells. Are generally located perivascularly. They produce histamine, which mediates the early stages of inflammation. They also produce heparin, which may modulate the rate of bone resorption.

MACROPHAGES

Their role is defensive.

The macrophages are mononuclear cells that are derived from circulating monocytes.

TYPES OF ORAL MUCOSA

(i)

MASTICATORY MUCOSA: The epithelium of masticatory mucosa is moderately thick and frequently is orthokeratinized, although normally parakeratinized areas of the gingiva and occasionally of the palate do occur.

Areas of division of masticatory mucosa: 1) Hard palate 2) Incisive papilla 3) Palatine rugae 4) Gingiva

1)

HARD PALATE

Fig showing surface view of hard and soft palate The Mucous membrane of the hard palate is tightly fixed to the underlying periosteum and therefore immovable.

Various zones in hard palate can be classified as

1. Gingival region, adjacent to the teeth 2. Palatine raphe, also known as the median area, extending from the incisive or palatine papilla posteriorly 3. Anterolateral area or fatty zone between the raphe and gingiva 4. Posterolateral area or glandular zone between the raphe and gingiva

2) INCISIVE PAPILLA

The oral incisive (palatine) papilla is formed of dense connective tissue.

It contains the oral parts of the vestigial nasopalatine ducts.

3) PALATINE RUGAE (transverse palatine ridges)

The palatine rugae, irregular and often asymmetric in humans, are ridges of mucous membrane extending laterally from the incisive papilla and the anterior part of the raphe. Epithelial pearls - In the midline, especially in the region of the incisive papilla, epithelial pearls may be found in the lamina propria. They are remnants of the epithelium formed in the line of fusion between the palatine processes.

4) GINGIVA The gingiva is the part of the oral mucosa that covers the alveolar processes of the jaws and surrounds the necks of the teeth. The gingiva is divided anatomically into marginal, attached, and interdental areas. Marginal Gingiva The marginal, or unattached, gingiva is the terminal edge or border of the gingiva surrounding the teeth in collar like fashion

Fig showing anatomical landmarks of gingiva

Gingival Sulcus The gingival sulcus is the shallow crevice or space around the tooth bounded by the surface of the tooth on one side and the epithelium lining the free margin of the gingiva on the other. The probing depth of a clinically normal gingival sulcus in humans is 2 to 3 mm.

Attached Gingiva The attached gingiva is continuous with the marginal gingiva. It is firm, resilient, and tightly bound to the underlying periosteum of alveolar bone. It is generally greatest in the incisor region (3.5 to 4.5 mm in the maxilla and 3.3 to 3.9 mm in the mandible) and less in the posterior segments, with the least width in the first premolar area (1.9 mm in the maxilla and 1.8 mm in the mandible).

Interdental Gingiva
The interdental gingiva occupies the gingival embrasure, which is the interproximal space beneath the area of tooth contact. The interdental gingiva can be pyramidal or have a "col" shape.

Gingival Fibers They consist of type I collagen. The gingival fibers have the following functions: 1. To brace the marginal gingiva firmly against the tooth 2. To provide the rigidity necessary to withstand the forces of mastication without being deflected away from the tooth surface 3. To unite the free marginal gingiva with the cementum of the root and the adjacent attached gingiva

Collagen fibres course in various directions, and though they are intimately blended, they are classified into following groups: 1) CIRCULAR FIBERS (CF) maintain the contour and position of free gingiva holding it against the tooth 2) DENTOGINGIVAL FIBERS (DGF) 3) ALVEOLOGINGIVAL FIBERS attach gingiva to alveolar bone. 4) PERIOSTEO-GINGIVAL FIBRES These fibres attach gingiva to alveolar bone. 5) TRANSSEPTAL FIBERS. (TF) They protect interproximal bone and maintain tooth to tooth contact.

Fig showing gingival collagen fibre group in horizontal section 6) TRANSGINGIVAL FIBERS This fiber group maintains the alignment of teeth in the arch.

7) INTERPAPILLARY FIBRES provide support to gingival papilla. 8) INTERCIRCULAR FIBRES 9) INTERGINGIVAL FIBERS They provide support and contour to attached gingiva.

Structural Characteristics of the Different Areas of Gingival Epithelium

ORAL OR OUTER EPITHELIUM. The oral or outer epithelium covers the crest and outer surface of the marginal gingiva and the surface of the attached gingiva. It is keratinized or parakeratinized or presents various combinations of these conditions. SULCULAR EPITHELIUM. The sulcular epithelium lines the gingival sulcus. It is a thin, nonkeratinized stratified squamous epithelium without rete pegs and extends from the coronal limit of the junctional epithelium to the crest of the gingival margin.

The sulcular epithelium has the potential to keratinize if (1) It is reflected and exposed to the oral cavity (2) The bacterial flora of the sulcus is totally eliminated.

JUNCTIONAL EPITHELIUM. The junctional epithelium consists of a collar like band of stratified squamous nonkeratinizing epithelium. It is three to four layers thick in early life, but the number of layers increases with age to 10 or even 20 layers. The length of the junctional epithelium ranges from 0.25 to 1.35 mm.

Dentogingival junction The region where the oral mucosa meets the surface of the tooth is a unique junction of considerable importance because it represents a potential weakness in the otherwise continuous epithelial lining of the oral cavity.

Shift of dentogingival junction

The position of the gingiva on the surface of the tooth changes with time. When the tip of the enamel first emerges through the mucous membrane of the oral cavity, the epithelium covers almost the entire enamel.

Fig showing different stages of tooth eruption.

Epithelial attachment.

The ultrastructural attachment of the ameloblasts (primary attachment epithelium) to the tooth was first shown by Stren and confirmed by Listarten and Schroeder, among others, to be basal lamina to which hemidesmosomes are attached. This mode of attachment is referred to as the epithelial attachment.

Migration of attachment epithelium

The lamina propria below the junctional epithelium is the deep connective tissue of the periodontal ligament, (unlike other lamina propria) which keeps the epithelial cells of the junctional epithelium immature so that it can develop hemidesomsomes and attach to the tooth. They then migrate over it, with their attachment being maintained by the hemidesmosomes.

NONKERATINIZED AREAS
(ii) LINING MUCOSA Lining mucosa is found on the lip, cheek, vestibular fornix, and alveolar mucosa. All the zones of the lining mucosa are characterized by a relatively thick nonkeratinized epithelium and a thin lamina propria

a) Vestibular fornix and alveolar mucosa The mucosa of the lips and cheeks reflects from the vestibular fornix to the alveolar mucosa covering the bone. The medial and lateral labial frenula are folds of the mucous membrane containing loose connective tissue. No muscle fibers are found in these folds.

b) Inferior surface of tongue and floor of oral cavity The mucous membrane on the floor of the oral cavity is thin and loosely attached to the underlying structures to allow for the free mobility of the tongue. The epithelium is nonkeratinized

c) Soft palate The mucous membrane on the oral surface of the soft palate is highly vascularized and reddish in color. The papillae of the connective tissue are few and short. The stratified squamous epithelium is nonkeratinized.

(iii) SPECIALIZED MUCOSA a) Dorsal lingual mucosa The superior surface of the tongue is rough and irregular. A V-shaped line divides it into an anterior part, or body, and a posterior part, or base.

b) Taste buds Taste buds are small ovoid or battleshaped intraepithelial organs. They extend from the basal lamina to the surface of the epithelium. A rich plexus of nerves is found below the taste buds. Some fibers enter the epithelium and end in contact with the sensory cells of the taste bud.

The classic view maintains that the primary taste sensations, that is, sweet, salty, bitter, and sour, are perceived in different regions of the tongue and palate 1) Sweet at the tip, 2) Salty at the lateral border of the tongue, 3) Bitter and sour on the palate and also in the posterior part of the tongue and bitter in the middle 4) Sour in the lateral areas of the tongue.

NERVE SUPPLY

The efferent supply is autonomic, supplies the blood vessels and minor salivary glands, and also may modulate the activity of some sensory receptors. The nerves arise mainly from the second and third divisions of the trigeminal nerve; but afferent fibers of the facial (VII), glossopharyngeal (IX), and vagus (X) nerves also are involved. The sensory nerves lose their myelin sheaths and form a network in the reticular layer of the lamina propria that terminates in a subepithelial plexus.

Within the lamina propria, organized nerve endings usually are found in the papillary region. They consist of groups of coiled fibers surrounded by a connective tissue capsule. These specialized endings have been grouped according to their morphology as Meissners or Ruffinis corpuscles, Krauses bulbs, and the mucocutaneous end organs.

BLOOD SUPPLY OF ORAL MUCOSA: Major blood supply is from external carotid artery. Maxillary artery directly supplies the cheek, hard palate and upper and lower gingiva. Facial artery gives to lips and soft palate. Lingual artery supplies the tongue, floor of the mouth and lower gingiva.

AGE CHANGES IN ORAL MUCOSA With age the oral mucosa becomes smooth and dry. These are due to epithelium becoming thin mainly due to the reduction in the thickness of epithelial ridges and decrease in the salivary secretion. The filiform papilla becomes reduced and the tongue appears smooth owing to the reduction in the thickness of the epithelium. Nutritional deficiencies may also be a contributing factor for this change. Varicose veins on the as lingual varices. Ectopic sebaceous glands (Fordyce's Spots) are seen commonly in the elderly.

CONCLUSION

Complete understanding of normal oral mucosa is must for a dentist as oral mucosal diseases are very common in oral cavity. Proper understanding of oral mucosa will help us to appreciate its diagnostic value and to also at times use it as an efficient means of systemic drug delivery.

THANKS