Chapter 2

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Chapter 2Inflammation and epair

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OutlineOutline

In!uryIn!ury"atural #Innate$ %efenses &'ainst In!ury"atural #Innate$ %efenses &'ainst In!ury

InflammationInflammatione'eneration and epair e'eneration and epair In!uries to (eethIn!uries to (eethIn!uries to Soft (issuesIn!uries to Soft (issues

eactive Connective (issue )yperplasiaeactive Connective (issue )yperplasiaInflammatory *eriapical +esionsInflammatory *eriapical +esions

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Inflammation and epair Inflammation and epair

#p'. -$#p'. -$ (he body s response to in!ury(he body s response to in!ury

InflammationInflammation/ &llo s the body to eliminated in!urious a'ents, &llo s the body to eliminated in!urious a'ents,

contain in!uries, and heal defectscontain in!uries, and heal defects

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In!uryIn!ury

#p'. -$#p'. -$ &n alteration in the environment that &n alteration in the environment that

causes tissue dama'ecauses tissue dama'e E amples includeE amples include

*hysical*hysicalChemicalChemical

icroor'anismsicroor'anisms

"utritional deficiencies"utritional deficiencies

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"atural #Innate$ %efenses"atural #Innate$ %efenses &'ainst In!ury &'ainst In!ury

#p'. -$#p'. -$ Intact s4in or mucosa is a physical barrier.Intact s4in or mucosa is a physical barrier. En5ymes in saliva have an antibacterialEn5ymes in saliva have an antibacterial

activity.activity. 6lushin' action of tears, saliva, urine, and6lushin' action of tears, saliva, urine, and

diarrhea removes forei'n substances.diarrhea removes forei'n substances.

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InflammationInflammation

#p's. -8--$#p's. -8--$ icroscopic Events and Clinical Si'ns oficroscopic Events and Clinical Si'ns of

InflammationInflammation hite :lood Cells and (heir Involvementhite :lood Cells and (heir Involvement

in the Inflammatory esponsein the Inflammatory esponse :iochemical ediators of Inflammation:iochemical ediators of Inflammation Systemic anifestations of InflammationSystemic anifestations of Inflammation Chronic InflammationChronic Inflammation )yperplasia, )ypertrophy, and &trophy)yperplasia, )ypertrophy, and &trophy

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Inflammation #cont.$Inflammation #cont.$

#p's. -8 3$#p's. -8 3$ & nonspecific response to in!ury & nonspecific response to in!ury

<ccurs in the same manner re'ardless of the<ccurs in the same manner re'ardless of the

nature of the in!urynature of the in!uryay be local and limited to the area of in!ury, oray be local and limited to the area of in!ury, ormay be e tensive if the in!ury is e tensivemay be e tensive if the in!ury is e tensive

ay be acute or chronicay be acute or chronic

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icroscopic Events and Clinicalicroscopic Events and ClinicalSi'ns of Inflammation #Cont.$Si'ns of Inflammation #Cont.$

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icroscopic Events and Clinicalicroscopic Events and ClinicalSi'ns of Inflammation #Cont.$Si'ns of Inflammation #Cont.$

#p's. 38 ;$ #(able 281$#p's. 38 ;$ #(able 281$

+ocal clinical chan'es are classic si'ns of+ocal clinical chan'es are classic si'ns ofinflammation.inflammation.

edness, heat, s ellin', pain, loss of normaledness, heat, s ellin', pain, loss of normaltissue functiontissue function

Systemic si'ns may includeSystemic si'ns may includeIncrease in body temperatureIncrease in body temperatureIncrease in the number of hite blood cellsIncrease in the number of hite blood cellsEnlar'ement of lymph nodesEnlar'ement of lymph nodes

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icroscopic Events and Clinicalicroscopic Events and ClinicalSi'ns of Inflammation #cont.$Si'ns of Inflammation #cont.$

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icroscopic events involveicroscopic events involvemicrocirculation.microcirculation.

&rterioles, capillaries, venules in the area of &rterioles, capillaries, venules in the area of

in!uryin!uryhite blood cellshite blood cellsChemical mediatorsChemical mediators

>sually, an e chan'e of o y'en and>sually, an e chan'e of o y'en and

nutrition is seen in these vessels.nutrition is seen in these vessels.ost of the fluid reenters circulation throu'host of the fluid reenters circulation throu'hvenules.venules.+ymphatic system carries a ay fluid that does+ymphatic system carries a ay fluid that doesnot reenter the blood vessels.not reenter the blood vessels.

icroscopic Events and Clinicalicroscopic Events and ClinicalSi'ns of Inflammation #cont.$Si'ns of Inflammation #cont.$

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Se?uence of icroscopic EventsSe?uence of icroscopic Events

#p'. 7$#p'. 7$In!ury to tissueIn!ury to tissueConstriction of microcirculationConstriction of microcirculation

%ilation of microcirculation%ilation of microcirculationIncrease in permeabilityIncrease in permeabilityE udate leaves microcirculation.E udate leaves microcirculation.Increased blood viscosityIncreased blood viscosity%ecreased blood flo%ecreased blood flo

ar'ination and pavementin' of hite bloodar'ination and pavementin' of hite bloodcells # :Cs$cells # :Cs$

:Cs enter tissue.:Cs enter tissue.:Cs in'est forei'n material.:Cs in'est forei'n material.

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Se?uence of icroscopic EventsSe?uence of icroscopic Events#cont.$#cont.$

#p'. 7$#p'. 7$ )yperemia)yperemia

Increased blood flo in capillary beds of in!ured tissueIncreased blood flo in capillary beds of in!ured tissue/ ill produce redness and heatill produce redness and heat

E udateE udateIncreased blood plasma and proteins in in!ured tissueIncreased blood plasma and proteins in in!ured tissue

/ )elps dilute in!urious a'ents, but results in e cess fluid in)elps dilute in!urious a'ents, but results in e cess fluid intissues @ edematissues @ edema

Serous e udateSerous e udate/ ainly plasma fluids and proteins, fe :Csainly plasma fluids and proteins, fe :Cs

*urulent e udate #suppuration$*urulent e udate #suppuration$/ Contains plasma fluids and proteins, tissue debris, andContains plasma fluids and proteins, tissue debris, and

many :Csmany :Cs

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#p's. 78 =$#p's. 78 =$ S ellin' develops as e udate escapes into tissue.S ellin' develops as e udate escapes into tissue.

ay flo out as a thin, clear e udate #serous$ or a thic4ay flo out as a thin, clear e udate #serous$ or a thic4hite8to8yello pus #purulent$hite8to8yello pus #purulent$

%raina'e may occur throu'h a fistula.%raina'e may occur throu'h a fistula. Incision and draina'e #I A %$ may be re?uired.Incision and draina'e #I A %$ may be re?uired. & draina'e tube may be placed. & draina'e tube may be placed.

edication may be administered to treat infection andedication may be administered to treat infection andreduce inflammation.reduce inflammation.

*ressure from e udate and chemical mediators may cause*ressure from e udate and chemical mediators may causepain.pain.

:lood viscosity may increase due to loss of plasma fluids.:lood viscosity may increase due to loss of plasma fluids.ar'inationar'ination/ hite blood cells mi'rate to the periphery of thehite blood cells mi'rate to the periphery of the

vessel.vessel.

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#p's. ;, 9$#p's. ;, 9$ Emi'rationEmi'ration

(he process by hich :Cs escape from(he process by hich :Cs escape from

blood vessels throu'h 'aps in endothelial cellsblood vessels throu'h 'aps in endothelial cells Chemota isChemota is%irected movement of :Cs to ard the site of%irected movement of :Cs to ard the site ofin!uryin!ury

*ha'ocytosis*ha'ocytosis(he process by hich :Cs in'est and then(he process by hich :Cs in'est and thendi'est forei'n substances.di'est forei'n substances.

ay include patho'enic or'anisms and tissueay include patho'enic or'anisms and tissuedebrisdebris

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#p's. ;, 9$#p's. ;, 9$ (here are si different 4inds of :Cs.(here are si different 4inds of :Cs.

"eutrophils"eutrophils/ 6irst to arrive at the site of in!ury6irst to arrive at the site of in!ury

/ *rimary cell in acute inflammation*rimary cell in acute inflammationonocytes # acropha'e$onocytes # acropha'e$/ Second cell in inflammatory responseSecond cell in inflammatory response

+ymphocytes and *lasma Cells+ymphocytes and *lasma Cells/ Seen in chronic inflammation and the immune responseSeen in chronic inflammation and the immune response

Eosinophils and ast CellsEosinophils and ast Cells/ Seen in both inflammation and the immune responseSeen in both inflammation and the immune response

hite :lood Cells and (heir Involvementhite :lood Cells and (heir Involvementin the Inflammatory esponsein the Inflammatory esponse

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hite :lood Cells and (heir Involvementhite :lood Cells and (heir Involvementin the Inflammatory esponse #cont.$in the Inflammatory esponse #cont.$

#p's. 98-0$#p's. 98-0$ Chan'es occur in the proportion of :CsChan'es occur in the proportion of :Cs

as the inflammatory response continues.as the inflammatory response continues.

(he neutrophil is the most common(he neutrophil is the most commoninflammatory cell in acute monocyte #in blood$inflammatory cell in acute monocyte #in blood$becomes a macropha'e as it enters tissuebecomes a macropha'e as it enters tissueinflammation.inflammation.(he circulatin'.(he circulatin'."eutrophils decrease in number."eutrophils decrease in number.

acropha'es, lymphocytes, and plasma cellsacropha'es, lymphocytes, and plasma cellsbecome predominant ith chronicbecome predominant ith chronicinflammation.inflammation.

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"eutrophils #* "s$"eutrophils #* "s$

#p's. 98-0$#p's. 98-0$ 70B to ;0B of :C population70B to ;0B of :C population

ranular leu4ocytes alon' ith basophils andranular leu4ocytes alon' ith basophils andeosinophilseosinophils%erived from stem cells in bone marro%erived from stem cells in bone marroContain lysosomal en5ymesContain lysosomal en5ymes

6unction is pha'ocytosis and then6unction is pha'ocytosis and thenen5ymatic destruction of forei'nen5ymatic destruction of forei'nsubstances.substances.

"eutrophils then perish."eutrophils then perish.(he en5ymes can lea4, causin' further tissue(he en5ymes can lea4, causin' further tissuedama'e.dama'e.

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"eutrophils #* "s$ #cont.$"eutrophils #* "s$ #cont.$

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acropha'esacropha'es

#p's. -08-1$#p's. -08-1$ B to =B of :C populationB to =B of :C population

%erived from stem cells in bone marro%erived from stem cells in bone marro

)as a sin'le, round nucleus and a non'ranular)as a sin'le, round nucleus and a non'ranularcytoplasmcytoplasm

esponds to chemotactic factors, is mobile,esponds to chemotactic factors, is mobile,can pha'ocyti5e @ also plays a role in thecan pha'ocyti5e @ also plays a role in theimmune systemimmune system

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acropha'es #cont.$acropha'es #cont.$

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:iochemical ediators of:iochemical ediators ofInflammationInflammation

#p's. -08-1$#p's. -08-1$ Cause many of the events in theCause many of the events in the

inflammatory responseinflammatory response

:asic mediators can recruit other mediators:asic mediators can recruit other mediatorsand immune mechanisms.and immune mechanisms. ay be derived fromay be derived from

:lood:loodEndothelial cellsEndothelial cells

hite blood cells and plateletshite blood cells and platelets*atho'enic or'anisms as they in!ure the tissue*atho'enic or'anisms as they in!ure the tissue

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:iochemical ediators of:iochemical ediators ofInflammation #cont.$Inflammation #cont.$

#p's. -08-1$#p's. -08-1$ (hree interrelated systems(hree interrelated systems

Interaction ta4es place durin' activation,Interaction ta4es place durin' activation,

amon' their products, and ithin their variousamon' their products, and ithin their variousactionsactions

Dinin systemDinin system Clottin' mechanismClottin' mechanism

Complement systemComplement system

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Dinin SystemDinin System

#p'. -0$#p'. -0$ &ctive in early phases of inflammation &ctive in early phases of inflammation &ctivated by substances in plasma and &ctivated by substances in plasma and

in!ured tissuein!ured tissue Causes increasedCauses increased%ilation of blood vessels at the site of in!ury%ilation of blood vessels at the site of in!ury*ermeability of local blood vessels*ermeability of local blood vessels

Induces painInduces pain

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Clottin' echanismClottin' echanism

#p'. -1$#p'. -1$ Clots blood and mediates inflammationClots blood and mediates inflammation

Some of the clottin' mechanisms products thatSome of the clottin' mechanisms products that

are activated durin' tissue in!ury cause localare activated durin' tissue in!ury cause localvascular dilation and permeability by activatin'vascular dilation and permeability by activatin'4inin.4inin.

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Complement SystemComplement System#p'. -1$#p'. -1$

Involves the production of a se?uential cascade of plasmaInvolves the production of a se?uential cascade of plasmaproteinsproteins

(hey are present in blood in an inactive form.(hey are present in blood in an inactive form. & tri''er #usually an antibody anti'en comple $ initiates the & tri''er #usually an antibody anti'en comple $ initiates these?uence of steps.se?uence of steps.(hese plasma proteins function in inflammation and immunity.(hese plasma proteins function in inflammation and immunity.

Some components cause :Cs 4no n as mast cells toSome components cause :Cs 4no n as mast cells torelease histamine.release histamine.

)istamine causes an increase in vascular permeability and)istamine causes an increase in vascular permeability and

vasodilation.vasodilation. <ther components cause cell death, form chemotactic<ther components cause cell death, form chemotacticfactors for :Cs, and enhance pha'ocytosis.factors for :Cs, and enhance pha'ocytosis.

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<ther :iochemical ediators of<ther :iochemical ediators ofInflammationInflammation

#p'. -1$#p'. -1$ eleased by the bodyeleased by the body

*rosta'landins*rosta'landins/ Cause increased vascular dilation and permeability,Cause increased vascular dilation and permeability,

tissue pain and redness, and chan'es in connectivetissue pain and redness, and chan'es in connectivetissuetissue

+ysosomal en5ymes+ysosomal en5ymes/ &ct as chemotactic factors &ct as chemotactic factors/ ay cause dama'e to connective tissues and to theay cause dama'e to connective tissues and to the

clotclot

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<ther :iochemical ediators of<ther :iochemical ediators ofInflammation #cont.$Inflammation #cont.$

#p'. -1$#p'. -1$ eleased by patho'enic microor'anismseleased by patho'enic microor'anisms

Endoto inEndoto in/ *roduced by cell alls of 'ram8ne'ative bacteria*roduced by cell alls of 'ram8ne'ative bacteria/ Serves as chemotactic factor, can activateServes as chemotactic factor, can activate

complement, function as an anti'en, and dama'ecomplement, function as an anti'en, and dama'ebone and tissuebone and tissue

+ysosomal en5ymes+ysosomal en5ymes/ )ave a similar chemical composition and action as)ave a similar chemical composition and action as

those released by :Csthose released by :Cs

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&ntiinflammatory %ru's &ntiinflammatory %ru's

#p'. -1$#p'. -1$ :loc4 or suppress the inflammatory:loc4 or suppress the inflammatory

responseresponse

*revent or reduce clinical si'ns of inflammation*revent or reduce clinical si'ns of inflammationand adverse reactions to the in!uryand adverse reactions to the in!ury E amplesE amples

"onsteroidal antiinflammatory a'ents"onsteroidal antiinflammatory a'ents/ &spirin, ibuprofen, celeco ib &spirin, ibuprofen, celeco ib

Steroidal antiinflammatory dru'Steroidal antiinflammatory dru'/ *rednisone*rednisone

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Systemic anifestations ofSystemic anifestations ofInflammationInflammation

#p's. -18-2$#p's. -18-2$ ay includeay include

6ever 6ever +eu4ocytosis+eu4ocytosisElevated C8reactive proteinElevated C8reactive protein+ymphadenopathy+ymphadenopathy

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6ever 6ever

#p'. -2$#p'. -2$ Controlled by the hypothalamusControlled by the hypothalamus

&ssociated ith systemic inflammatory &ssociated ith systemic inflammatoryresponseresponse

*yro'ens*yro'ens6ever producin' substances produced by6ever producin' substances produced by

:Cs and patho'ens:Cs and patho'ens*yro'ens act on the hypothalamus.*yro'ens act on the hypothalamus.

(he hypothalamus increases body(he hypothalamus increases bodytemperature by ay of prosta'landins.temperature by ay of prosta'landins.

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+eu4ocytosis+eu4ocytosis

#p'. -2$#p'. -2$ & systemic inflammatory response can & systemic inflammatory response can

increase the number of :Cs from theincrease the number of :Cs from the

normal -000 to 10,000 mm of blood tonormal -000 to 10,000 mm of blood to10,000 to 0,000 mm.10,000 to 0,000 mm.(he primary cell involved is the neutrophil.(he primary cell involved is the neutrophil.

(he rate of formation is increased and(he rate of formation is increased and

immature forms are released from boneimmature forms are released from bonemarro into the blood.marro into the blood.

(he body is attemptin' to produce more cells(he body is attemptin' to produce more cellsfor pha'ocytosis.for pha'ocytosis.

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+ymphadenopathy+ymphadenopathy

#p's. -28- $#p's. -28- $ Enlar'ed and palpable superficial lymphEnlar'ed and palpable superficial lymph

nodesnodes

6ollo s route of lymphatic draina'e6ollo s route of lymphatic draina'e (he enlar'ed nodes occur due to chan'es(he enlar'ed nodes occur due to chan'esin lymphocytes, hich are the primary cellsin lymphocytes, hich are the primary cellsof the immune response.of the immune response.

)yperplasia)yperplasia/ &n increase in the number of cells &n increase in the number of cells)ypertrophy)ypertrophy

/ Enlar'ement of individual cellsEnlar'ement of individual cells

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+ymphadenopathy #cont.$+ymphadenopathy #cont.$

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Chronic InflammationChronic Inflammation

#p's. -28- $#p's. -28- $ %ue to persistent in!uries%ue to persistent in!uries

Cells involved include macropha'es,Cells involved include macropha'es,lymphocytes, and plasma cells as ell aslymphocytes, and plasma cells as ell asneutrophils and monocytes present in acuteneutrophils and monocytes present in acuteinflammation.inflammation.

ay include proliferation of fibroblasts anday include proliferation of fibroblasts andformation of 'ranulomasformation of 'ranulomas

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Chronic Inflammation #cont.$Chronic Inflammation #cont.$

#p's. -28- $#p's. -28- $ ranulomaranuloma

icroscopic 'roupin's of macropha'esicroscopic 'roupin's of macropha'essurrounded by lymphocytes and plasma cellssurrounded by lymphocytes and plasma cells>sually contain multinucleated 'iant cells>sually contain multinucleated 'iant cells

/ +ar'e macropha'es ith multiple nuclei+ar'e macropha'es ith multiple nuclei &ssociated ith forei'n body reactions and &ssociated ith forei'n body reactions andsome infections such as tuberculosissome infections such as tuberculosis

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)yperplasia, )ypertrophy, and)yperplasia, )ypertrophy, and &trophy &trophy

#p's. - 8--$#p's. - 8--$ )yperplasia)yperplasia

&n increase in the number of cells often in response to &n increase in the number of cells often in response tochronic irritation or abrasionchronic irritation or abrasion

ay return to normal if the insult subsides, or mayay return to normal if the insult subsides, or maypersist follo in' removal of the irritantpersist follo in' removal of the irritant )ypertrophy)ypertrophy

&n increase in the si5e of cells &n increase in the si5e of cellsay be seen in cardiac muscle as a response toay be seen in cardiac muscle as a response to

hypertensionhypertension &trophy &trophy & decrease in si5e or function of a cell, tissue, or'an, or & decrease in si5e or function of a cell, tissue, or'an, orentire bodyentire body

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)yperplasia, )ypertrophy, and)yperplasia, )ypertrophy, and &trophy #cont.$ &trophy #cont.$

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e'eneration and epair e'eneration and epair

#p's. --8-7$#p's. --8-7$ icroscopic Events (hat <ccur %urin'icroscopic Events (hat <ccur %urin'

epair epair

(ypes of epair (ypes of epair :one (issue epair :one (issue epair

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#p'. --$#p'. --$ e'eneratione'eneration

If the inflamed area returns to normal structureIf the inflamed area returns to normal structureand functionand function

epair epair <ccurs hen the dama'e is too 'reat for the<ccurs hen the dama'e is too 'reat for thetissue to return to normaltissue to return to normal6unctionin' cells and tissue often are replaced6unctionin' cells and tissue often are replaced

ith nonfunctionin' scar tissue.ith nonfunctionin' scar tissue.

e'eneration and epair #cont.$e'eneration and epair #cont.$

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icroscopic Events (hat <ccuricroscopic Events (hat <ccur%urin' epair %urin' epair

#p's. --8-3$#p's. --8-3$ (a4es about 2 ee4s(a4es about 2 ee4s

<ccurs almost simultaneously in both<ccurs almost simultaneously in bothepithelium and connective tissueepithelium and connective tissue

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icroscopic Events (hat <ccuricroscopic Events (hat <ccur%urin' epair #cont.$%urin' epair #cont.$

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%ay of In!ury%ay of In!ury

#p'. -3$#p'. -3$ :lood flo s into in!ured tissue to produce a:lood flo s into in!ured tissue to produce a

clot.clot.

(he clot contains fibrin, clumped red blood(he clot contains fibrin, clumped red bloodcells # :Cs$, and platelets.cells # :Cs$, and platelets.

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<ne %ay &fter In!ury<ne %ay &fter In!ury

#p'. -3$#p'. -3$ "eutrophils mi'rate from the"eutrophils mi'rate from the

microcirculation into in!ured tissue in anmicrocirculation into in!ured tissue in an

acute inflammatory response.acute inflammatory response.(hey pha'ocyti5e forei'n material and necrotic(hey pha'ocyti5e forei'n material and necrotictissue.tissue.

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( o %ays &fter In!ury( o %ays &fter In!ury

#p'. -3$#p'. -3$ onocytes mi'rate from microcirculation and become macropha'esonocytes mi'rate from microcirculation and become macropha'es

in tissue.in tissue.(hey also pha'ocyti5e.(hey also pha'ocyti5e.

6ibroblasts increase in number and produce ne colla'en fibers.6ibroblasts increase in number and produce ne colla'en fibers.ranulation tissue is formed in the connective tissue portion ofranulation tissue is formed in the connective tissue portion of

in!ury.in!ury./ (his 'ro th may be e cessive.(his 'ro th may be e cessive.

"e surface epithelium is formed in the epithelial tissue portion"e surface epithelium is formed in the epithelial tissue portionof in!ury.of in!ury.

/ (hey use the fibrin mesh or4 to mi'rate.(hey use the fibrin mesh or4 to mi'rate./ (his mesh or4 also protects ne ly formed tissue from(his mesh or4 also protects ne ly formed tissue fromadditional in!ury.additional in!ury.

+ymphocytes and plasma cells mi'rate to the area as chronic+ymphocytes and plasma cells mi'rate to the area as chronicinflammation and the immune response be'ins.inflammation and the immune response be'ins.

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Seven %ays &fter In!urySeven %ays &fter In!ury

#p'. -3$#p'. -3$ 6ibrin is di'ested by tissue en5ymes.6ibrin is di'ested by tissue en5ymes.

It slou'hs off and the initial repair is complete.It slou'hs off and the initial repair is complete.

(he ne tissue is relatively red.(he ne tissue is relatively red."e epithelium is thin."e epithelium is thin."e connective tissue is hi'hly vasculari5ed."e connective tissue is hi'hly vasculari5ed.

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( o ee4s &fter In!ury( o ee4s &fter In!ury

#p'. -3$#p'. -3$ Initial 'ranulation tissue and its fibers areInitial 'ranulation tissue and its fibers are

remodeled.remodeled.

(he ne tissue is scar tissue.(he ne tissue is scar tissue.It is hiter and paler due to increased colla'enIt is hiter and paler due to increased colla'enand decreased vascularity.and decreased vascularity.

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(ypes of epair (ypes of epair

#p's. -38-7$#p's. -38-7$ )ealin' by primary intention)ealin' by primary intention

)ealin' of an in!ury here there is little loss of)ealin' of an in!ury here there is little loss oftissuetissue(he mar'ins are close to'ether and very little(he mar'ins are close to'ether and very little'ranulation tissue forms.'ranulation tissue forms.

)ealin' by secondary intention)ealin' by secondary intention(he ed'es of the in!ury cannot be !oined durin'(he ed'es of the in!ury cannot be !oined durin'healin'.healin'.

& lar'e clot forms, resultin' in increased & lar'e clot forms, resultin' in increased'ranulation tissue.'ranulation tissue.

ay result in e cess scar tissue @ a 4eloiday result in e cess scar tissue @ a 4eloid

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(ypes of epair #cont.$(ypes of epair #cont.$

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)ealin' by (ertiary Intention)ealin' by (ertiary Intention

#p'. -7$#p'. -7$ %elayin' sur'ical tissue repair until%elayin' sur'ical tissue repair until

infection is resolvedinfection is resolved

&n in!ured area may become infected @ &n in!ured area may become infected @especially ith puncture ounds.especially ith puncture ounds.In some situations, an infected in!ury is leftIn some situations, an infected in!ury is leftopen until infection is controlled.open until infection is controlled.

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6actors (hat Impair )ealin'6actors (hat Impair )ealin'

#p'. -7$#p'. -7$ +ocal factors that impair healin'+ocal factors that impair healin'

:acterial infection:acterial infection(issue destruction and necrosis(issue destruction and necrosis)ematoma)ematomaE cessive movement of in!ured tissueE cessive movement of in!ured tissue*oor blood supply*oor blood supply

Systemic factorsSystemic factorsalnutritionalnutrition

ImmunosuppressionImmunosuppressionenetic connective tissue disordersenetic connective tissue disordersetabolic disordersetabolic disorders

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:one (issue epair :one (issue epair

#p'. -7$#p'. -7$ <steoblasts create ne bone tissue.<steoblasts create ne bone tissue.

ay be delayed byay be delayed by/ Increased movement of boneIncreased movement of bone

/ EdemaEdema/ Infection in the tissueInfection in the tissue/ E cessive or inade?uate movement of bone tissueE cessive or inade?uate movement of bone tissue

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In!uries to (eethIn!uries to (eeth &ttrition &ttrition &brasion &brasion &bfraction &bfraction

ErosionErosion ethamphetamine abuseethamphetamine abuse

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&ttrition &ttrition

#p's. -;8-=$#p's. -;8-=$ (ooth8to8tooth ear (ooth8to8tooth ear

ay be observed both inay be observed both inprimary and permanentprimary and permanentdentitiondentition

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:ru ism:ru ism

#p's. -;8-=$#p's. -;8-=$ rindin' and clenchin' teeth for nonfunctionalrindin' and clenchin' teeth for nonfunctional

purposespurposes Si'ns and symptoms includeSi'ns and symptoms include

ear facets, abnormal rate of attrition, hypertrophy ofear facets, abnormal rate of attrition, hypertrophy ofmasticatory muscles, increased muscle tone, musclemasticatory muscles, increased muscle tone, muscletenderness, muscle fati'ue, chee4 bitin', pain in the ( !ointtenderness, muscle fati'ue, chee4 bitin', pain in the ( !ointarea, tooth mobility, and pulpal sensitivity to coldarea, tooth mobility, and pulpal sensitivity to cold

ay be due to local factors such as occlusalay be due to local factors such as occlusal

interferences in combination ith stress and tensioninterferences in combination ith stress and tensionana'ement includes fabrication of an acrylic splint andana'ement includes fabrication of an acrylic splint and

elimination of occlusal interferences throu'h occlusalelimination of occlusal interferences throu'h occlusalad!ustments.ad!ustments.

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:ru ism #cont.$:ru ism #cont.$

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&brasion &brasion

#p'. -=$#p'. -=$ earin' a ay of tooth structure from aearin' a ay of tooth structure from a

repetitive mechanical habitrepetitive mechanical habitost fre?uently seen as a notchin' on rootost fre?uently seen as a notchin' on root

surfaces ith 'in'ival recessionsurfaces ith 'in'ival recessionay occur from bac48and8forth toothbrushin'ay occur from bac48and8forth toothbrushin'

techni?uetechni?ueay be seen in patients ho areay be seen in patients ho are

seamstresses, musicians, or pipe smo4ersseamstresses, musicians, or pipe smo4ers

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&brasion #cont.$ &brasion #cont.$

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&bfraction &bfraction

#p'. -=$#p'. -=$ (ypically appears as ed'e8shaped(ypically appears as ed'e8shaped

lesions at the cervical areas of teethlesions at the cervical areas of teethay be related to fati'ue, fle ure, fracture, anday be related to fati'ue, fle ure, fracture, and

deformation of tooth structuredeformation of tooth structureay occur in combination ith abrasionay occur in combination ith abrasion

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ErosionErosion

#p's. -=8-9$#p's. -=8-9$ +oss of tooth structure+oss of tooth structure

due to chemicalsdue to chemicals(ooth structure may be lost(ooth structure may be lost

around a restoration,around a restoration,ma4in' the restorationma4in' the restorationstand out.stand out.<cclusal surfaces may be<cclusal surfaces may becupped out.cupped out.

ay be on facial surfacesay be on facial surfacesfrom food and lin'ualfrom food and lin'ualsurfaces from vomitin' duesurfaces from vomitin' dueto bulimiato bulimia

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:ulimia:ulimia

#p'. -9$#p'. -9$ Self8induced pur'in' #vomitin'$Self8induced pur'in' #vomitin'$

after eatin'after eatin'(he bulimic maintains normal body(he bulimic maintains normal body

ei'ht.ei'ht.ay see electrolyte imbalanceay see electrolyte imbalanceand or malnutritionand or malnutrition

ana'ement may includeana'ement may includefluoride rinse and toothpaste.fluoride rinse and toothpaste.

insin' ith ater after pur'in'insin' ith ater after pur'in'

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ethamphetamine &buseethamphetamine &buse

#p's. -9830$#p's. -9830$ apid destruction ofapid destruction of

teethteeth%ue to acid content of%ue to acid content ofmethamphetamine,methamphetamine,decreased salivary flo ,decreased salivary flo ,cravin' for hi'h su'arcravin' for hi'h su'arbevera'es ith lac4 ofbevera'es ith lac4 oforal hy'ieneoral hy'iene

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In!uries to <ral Soft (issuesIn!uries to <ral Soft (issues &spirin :urn &spirin :urn *henol :urns*henol :urns Electric :urnsElectric :urns <ther :urns<ther :urns +esions+esions

&ssociated ith &ssociated ithCocaine >seCocaine >se

+esions from+esions fromSelf8InducedSelf8InducedIn!uriesIn!uries

)ematoma)ematoma

(raumatic >lcer 6rictional Deratosis +inea &lba "icotinic Stomatitis (obacco *ouch

Deratosis (raumatic "euroma &mal'am (attoo

elanosis Solar Cheilitis ucocele "ecroti5in'

Sialometaplasia Sialolith &cute and

ChronicSialadenitis

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;0Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc.

&spirin :urn &spirin :urn

#p's. -9830$#p's. -9830$ (opical application is a(opical application is a

common misuse of thiscommon misuse of this

product.product.(he tissue becomes(he tissue becomesnecrotic and hite.necrotic and hite.(he surface may slou'h off(he surface may slou'h offleavin' a painful ulcer.leavin' a painful ulcer.(he ulcer usually heals in ;(he ulcer usually heals in ;to 21 days.to 21 days.

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*henol :urn*henol :urn

#p's. 30831$#p's. 30831$ >sed in dentistry as a cavity sterili5in'>sed in dentistry as a cavity sterili5in'

a'ent and a cauteri5in' a'enta'ent and a cauteri5in' a'entill cause hitenin' and slou'hin' of the areaill cause hitenin' and slou'hin' of the area

as a result of tissue destructionas a result of tissue destruction

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Electric :urnElectric :urn

#p'. 30$#p'. 30$ ay be seen in infants or youn' childrenay be seen in infants or youn' children

ho have che ed an electrical cordho have che ed an electrical corday be ?uite e tensive, dama'in' oral tissueay be ?uite e tensive, dama'in' oral tissue

and even tooth budsand even tooth budsay cause constriction of the commissureay cause constriction of the commissure

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<ther :urns<ther :urns

#p's. 30831$#p's. 30831$ )ot food burns)ot food burns

6rom soup or cheese on pi55a6rom soup or cheese on pi55a *roducts containin' hydro'en pero ide or*roducts containin' hydro'en pero ide or

eu'enoleu'enol

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

+esions &ssociated ith Cocaine+esions &ssociated ith Cocaine>se>se

#p's. 30831$ #6i'. 282=C$#p's. 30831$ #6i'. 282=C$ +esions located at the midline of the hard palate may+esions located at the midline of the hard palate may

vary from ulcers to 4eratotic lesions to e ophyticvary from ulcers to 4eratotic lesions to e ophyticreactive lesions as a result of smo4in' crac4 cocaine.reactive lesions as a result of smo4in' crac4 cocaine.

"ecrotic ulcers of the ton'ue and epi'lottis have been"ecrotic ulcers of the ton'ue and epi'lottis have beenreported as a result of free8basin' cocaine.reported as a result of free8basin' cocaine.

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+esions from Self8Induced In!uries+esions from Self8Induced In!uries

#p's. 31, 3 83-$#p's. 31, 3 83-$ & factitious in!ury & factitious in!ury

%ue to a habit such as chronic lip, chee4 or%ue to a habit such as chronic lip, chee4 orton'ue bitin', or trauma to the teeth from aton'ue bitin', or trauma to the teeth from afin'ernailfin'ernail+esions may ran'e from ulceration to epithelial+esions may ran'e from ulceration to epithelialhyperplasia and hyper4eratosis.hyperplasia and hyper4eratosis.

f lf d d

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+esions from Self8Induced In!uries+esions from Self8Induced In!uries#cont.$#cont.$

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

)ematoma)ematoma

##p's. 31832$p's. 31832$ & bruise inside the & bruise inside the

mouthmouth

:lood in an:lood in ane travascular spacee travascular space/ &ppears as a red to &ppears as a red to

purple to bluish8'raypurple to bluish8'raymassmass

ost fre?uently seenost fre?uently seenon labial or buccalon labial or buccalmucosamucosa

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

(raumatic >lcer (raumatic >lcer

#p's. 3183 $#p's. 3183 $ ay be due to such events as bitin' the chee4,ay be due to such events as bitin' the chee4,

lip, or ton'ue, irritation from a complete or partiallip, or ton'ue, irritation from a complete or partialdenture, mucosal in!ury from sharp ed'es of food,denture, mucosal in!ury from sharp ed'es of food,

or removal of a dry cotton roll after a dentalor removal of a dry cotton roll after a dentalprocedure #some patients are sensitive to theprocedure #some patients are sensitive to thestarch in a cotton roll$starch in a cotton roll$

*ersistent trauma may cause a hard #indurated$, raised*ersistent trauma may cause a hard #indurated$, raisedtraumatic 'ranuloma.traumatic 'ranuloma.

(reatment(reatment>sually heals ithin ; to 1- days unless the trauma>sually heals ithin ; to 1- days unless the traumapersistspersists

ay re?uire a biopsyay re?uire a biopsy

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(raumatic >lcer #cont.$(raumatic >lcer #cont.$

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=0Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc.

6rictional Deratosis6rictional Deratosis

#p's. 32, 3-$#p's. 32, 3-$ %ue to chronic rubbin' or friction a'ainst an oral%ue to chronic rubbin' or friction a'ainst an oral

mucosal surfacemucosal surface & form of hyper4eratosis & form of hyper4eratosis

esembles a callus on s4inesembles a callus on s4in esults in a opa?ue hite appearanceesults in a opa?ue hite appearance (reatment(reatment

Identify the traumatic cause of the lesion hether it be anIdentify the traumatic cause of the lesion hether it be anopposin' third molar, chronic chee4 or ton'ue che in', oropposin' third molar, chronic chee4 or ton'ue che in', or

some other entity.some other entity.Eliminate the cause.Eliminate the cause. ust be differentiated from idiopathic leu4opla4iaust be differentiated from idiopathic leu4opla4ia

because leu4opla4ia may be premali'nantbecause leu4opla4ia may be premali'nant

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6rictional Deratosis #cont.$6rictional Deratosis #cont.$

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+inea &lba+inea &lba

#p's. 32, 3-$#p's. 32, 3-$ & hite, raised line most commonly on the buccal & hite, raised line most commonly on the buccal

mucosa at the occlusal planemucosa at the occlusal planeay be the result of a teeth clenchin' habitay be the result of a teeth clenchin' habit

Sometimes the pattern of the teeth can be seen in theSometimes the pattern of the teeth can be seen in thelesion.lesion.%ue to epithelial hyperplasia and hyper4eratosis%ue to epithelial hyperplasia and hyper4eratosis

(reatment(reatment"one"one

ay be used to evaluate severity of bru in'ay be used to evaluate severity of bru in'and or ton'ue thrustin' habitand or ton'ue thrustin' habit

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

+inea &lba #cont.$+inea &lba #cont.$

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

"icotinic Stomatitis"icotinic Stomatitis

#p's. 32, 33$#p's. 32, 33$ & beni'n lesion typically associated ith & beni'n lesion typically associated ith

pipe and or ci'ar smo4in'F may also occurpipe and or ci'ar smo4in'F may also occurith ci'arette smo4in'ith ci'arette smo4in'

*resence indicates increased ris4 for*resence indicates increased ris4 fordevelopment of mali'nancy.development of mali'nancy.Initially, erythema is seen, but over timeInitially, erythema is seen, but over time4eratini5ation ta4es place, resultin' in4eratini5ation ta4es place, resultin' inincreased opacity.increased opacity.

/ aised red areas may be seen at the openin's ofaised red areas may be seen at the openin's ofducts of minor salivary 'lands on the palatal surface.ducts of minor salivary 'lands on the palatal surface.

(his is due to obstruction by 4eratin at the mucosal(his is due to obstruction by 4eratin at the mucosalopenin's of the ducts.openin's of the ducts.

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"icotinic Stomatitis #cont.$"icotinic Stomatitis #cont.$

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(obacco *ouch Deratosis(obacco *ouch Deratosis

#p's. 32, 33$#p's. 32, 33$ & hite lesion located here che in' tobacco is & hite lesion located here che in' tobacco is

placed, most often in the mucobuccal foldplaced, most often in the mucobuccal foldEarly lesions may have a 'ranular or rin4ledEarly lesions may have a 'ranular or rin4led

appearance.appearance.+on' standin' lesions may be more opa?uely hite and+on' standin' lesions may be more opa?uely hite andhave a corru'ated surface.have a corru'ated surface.

(reatment(reatmentay re?uire biopsyay re?uire biopsy/ +on'8term e posure to che in' tobacco has been+on'8term e posure to che in' tobacco has been

associated ith increased ris4 of s?uamous cell carcinoma.associated ith increased ris4 of s?uamous cell carcinoma.

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

(obacco *ouch Deratosis #cont.$(obacco *ouch Deratosis #cont.$

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

(raumatic "euroma(raumatic "euroma

#p'. 3 $#p'. 3 $ & lesion caused by in!ury to a peripheral nerve & lesion caused by in!ury to a peripheral nerve

hen the nerve sheath of Sch ann is disrupted,hen the nerve sheath of Sch ann is disrupted,occasionally the pro imal end of dama'ed nerveoccasionally the pro imal end of dama'ed nerveproliferates into a mass of nerve and Sch ann cellsproliferates into a mass of nerve and Sch ann cellsmi ed ith dense fibrous scar tissue.mi ed ith dense fibrous scar tissue.*ainful, ran'in' from pain on palpation to severe,*ainful, ran'in' from pain on palpation to severe,intractable painintractable pain

%ia'nosis%ia'nosis:iopsy and microscopic e amination:iopsy and microscopic e amination

(reatment(reatmentSur'ical e cisionSur'ical e cision

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&mal'am (attoo &mal'am (attoo

#p's. 3 , 33$#p's. 3 , 33$ & flat, bluish8'ray lesion of oral mucosa due to the & flat, bluish8'ray lesion of oral mucosa due to the

introduction of amal'am into tissueintroduction of amal'am into tissueay occur durin' placement or removal of an amal'amay occur durin' placement or removal of an amal'am

restoration or durin' an e tractionrestoration or durin' an e traction

ay be seen in any location in the oral cavity, mostay be seen in any location in the oral cavity, mostcommonly on 'in'iva or alveolar rid'ecommonly on 'in'iva or alveolar rid'e

&mal'am particles may be seen on radio'raph, aidin' in &mal'am particles may be seen on radio'raph, aidin' india'nosis.dia'nosis.

%ia'nosis%ia'nosis*atient history and radio'raphs may help.*atient history and radio'raphs may help.

ust be differentiated from mali'nant melanomaust be differentiated from mali'nant melanoma (reatment(reatment

"one providin' melanoma has been ruled out"one providin' melanoma has been ruled out

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&mal'am (attoo #cont.$ &mal'am (attoo #cont.$

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elanosiselanosis

#p's. 3-833$#p's. 3-833$#see also p's. 9, 2- and 6i's. 181=, 1831$#see also p's. 9, 2- and 6i's. 181=, 1831$

"ormal physiolo'ic pi'mentation of oral"ormal physiolo'ic pi'mentation of oralmucosamucosa

ay be 'eneticay be 'eneticay occur as a result of inflammation due toay occur as a result of inflammation due to

retained hemosiderin #a blood pi'ment$retained hemosiderin #a blood pi'ment$retained in tissueretained in tissue

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elanosis #cont.$elanosis #cont.$

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elanosis #cont.$elanosis #cont.$ <ral elanotic acule<ral elanotic acule

& flat, ell8circumscribed lesion of un4no n & flat, ell8circumscribed lesion of un4no ncausecause

/ +ess than 1 cm in diameter +ess than 1 cm in diameter Smo4er s elanosisSmo4er s elanosis

elanin pi'mentation associated ith smo4in'elanin pi'mentation associated ith smo4in'/ ore common in omen than in menore common in omen than in menost common in anterior labial 'in'ivaost common in anterior labial 'in'iva

elanosis may also be associated ithelanosis may also be associated ith'enetic, bone, and systemic diseases'enetic, bone, and systemic diseases ..

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Solar Cheilitis #&ctinic Cheilitis$Solar Cheilitis #&ctinic Cheilitis$

#p'. 37$#p'. 37$ & de'eneration of the tissue of the lips due to e posure to the sun & de'eneration of the tissue of the lips due to e posure to the sun

<ccurs particularly in fair8s4inned individuals<ccurs particularly in fair8s4inned individuals (he lo er lip is usually more involved than the upper lip.(he lo er lip is usually more involved than the upper lip.

(he epithelium is thinner than normalF the vermilion appears(he epithelium is thinner than normalF the vermilion appears

pale pin4 and mottled.pale pin4 and mottled.(he interface bet een lips and s4in is indistinct.(he interface bet een lips and s4in is indistinct.

(reatment(reatment"o specific treatment"o specific treatment:iopsy may be indicated for persistent scalin' or ulceration.:iopsy may be indicated for persistent scalin' or ulceration.

/ & relationship is found bet een these epithelial and & relationship is found bet een these epithelial andconnective tissue chan'es and the development of basalconnective tissue chan'es and the development of basalcell carcinoma of the s4in or s?uamous cell carcinoma ofcell carcinoma of the s4in or s?uamous cell carcinoma ofthe lips and s4in.the lips and s4in.

Solar Cheilitis #&ctinic Cheilitis$Solar Cheilitis #&ctinic Cheilitis$

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Solar Cheilitis #&ctinic Cheilitis$Solar Cheilitis #&ctinic Cheilitis$#cont.$#cont.$

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ucoceleucocele

#p's. 3783;$#p's. 3783;$ & lesion that forms hen a minor salivary 'land duct is dama'ed & lesion that forms hen a minor salivary 'land duct is dama'ed

"ot a true cyst"ot a true cyst/ (he mucous salivary 'land secretion is alled off by 'ranulation(he mucous salivary 'land secretion is alled off by 'ranulation

tissue to form a cystli4e structure lined by compressed 'ranulationtissue to form a cystli4e structure lined by compressed 'ranulation

tissue.tissue.

ost commonly found in the lo er lipost commonly found in the lo er lipIt may increase or decrease in si5e over time.It may increase or decrease in si5e over time.

ay appear bluish if near the surfaceay appear bluish if near the surface (reatment(reatment

If persistent, they are sur'ically removed.If persistent, they are sur'ically removed. ay observe a mucus cyst or mucus retention cystay observe a mucus cyst or mucus retention cyst

>sually in people over a'e 30>sually in people over a'e 30(reated by removal of affected salivary 'lands(reated by removal of affected salivary 'lands

(hese lesions must be differentiated from mucoepidermoid(hese lesions must be differentiated from mucoepidermoidcarcinoma.carcinoma.

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ucocele #cont.$ucocele #cont.$

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anulaanula

#p'. 37$#p'. 37$ & unilateral mucocele8li4e lesion that forms & unilateral mucocele8li4e lesion that forms

on the floor of the mouthon the floor of the mouth &ssociated ith the ducts of submandibular &ssociated ith the ducts of submandibularand sublin'ual 'landsand sublin'ual 'lands

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"ecroti5in' Sialometaplasia"ecroti5in' Sialometaplasia

#p's. 3;83=$#p's. 3;83=$ & beni'n condition of salivary 'lands & beni'n condition of salivary 'lands

oderately painful s ellin' and ulcerationoderately painful s ellin' and ulceration(hou'ht to result from bloc4a'e of the blood(hou'ht to result from bloc4a'e of the bloodsupply to the affected areasupply to the affected area

/ "ecrosis of the salivary 'lands is seen histolo'ically."ecrosis of the salivary 'lands is seen histolo'ically./ Salivary 'land epithelium is replaced by s?uamousSalivary 'land epithelium is replaced by s?uamous

epithelium #metaplasia$.epithelium #metaplasia$.(he ulcer usually heals by secondary intention.(he ulcer usually heals by secondary intention.

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"ecroti5in' Sialometaplasia #cont.$"ecroti5in' Sialometaplasia #cont.$

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SialolithSialolith

#p's. 3;839$#p's. 3;839$ & salivary 'land stone & salivary 'land stone

ay be found in both minor and ma!or salivaryay be found in both minor and ma!or salivary'lands'lands6ormed by precipitation of calcium salts6ormed by precipitation of calcium saltsaround a central corearound a central core

ay often be seen on radio'raphay often be seen on radio'raph (reatment(reatment

Sometimes the calcification can be Gmil4edHSometimes the calcification can be Gmil4edHfrom the duct.from the duct.It may re?uire sur'ical removal, this mayIt may re?uire sur'ical removal, this maydama'e the duct.dama'e the duct.

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Sialolith #cont.$Sialolith #cont.$

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&cute and Chronic Sialadenitis &cute and Chronic Sialadenitis

#p'. 3=$#p'. 3=$ *ainful s ellin' of the involved salivary*ainful s ellin' of the involved salivary

'land due to obstruction of the salivary'land due to obstruction of the salivary'land duct'land duct

ay occur as result of infectionay occur as result of infection %ia'nosis%ia'nosis

ay involve in!ection of a radiopa?ue dye intoay involve in!ection of a radiopa?ue dye intothe 'land follo ed by a radio'raphthe 'land follo ed by a radio'raph#sialo'raphy$#sialo'raphy$

(reatment(reatmentay re?uire antibioticsay re?uire antibiotics

eactive Connective (issueeactive Connective (issue

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eactive Connective (issueeactive Connective (issue)yperplasia)yperplasia

#p's. 3=87 $#p's. 3=87 $ *yo'enic ranuloma*yo'enic ranuloma iant Cell ranulomaiant Cell ranuloma Irritation 6ibromaIrritation 6ibroma %enture8Induced 6ibrous )yperplasia%enture8Induced 6ibrous )yperplasia *apillary )yperplasia of the *alate*apillary )yperplasia of the *alate in'ival Enlar'ementin'ival Enlar'ement

Chronic )yperplastic *ulpitisChronic )yperplastic *ulpitis

eactive Connective (issueeactive Connective (issue

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eactive Connective (issueeactive Connective (issue)yperplasia #cont.$)yperplasia #cont.$

#p'. 3=$#p'. 3=$ *roliferatin', e uberant 'ranulation tissue*roliferatin', e uberant 'ranulation tissue

and dense fibrous connective tissueand dense fibrous connective tissueresultin' from over5ealous repair resultin' from over5ealous repair

ay be a response to a sin'le event or chronicay be a response to a sin'le event or chroniclo 8'rade in!urylo 8'rade in!ury

l

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*yo'enic ranuloma*yo'enic ranuloma

#p's. 3=839$#p's. 3=839$ & proliferation of connective tissue & proliferation of connective tissue

containin' numerous blood vessels andcontainin' numerous blood vessels andinflammatory cells occurrin' as a responseinflammatory cells occurrin' as a responseto in!uryto in!ury

(he name is a misnomerF the lesion is neither(he name is a misnomerF the lesion is neitherpyo'enic #pus formin'$ nor a true 'ranuloma.pyo'enic #pus formin'$ nor a true 'ranuloma.

$l $

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*yo'enic ranuloma #cont.$*yo'enic ranuloma #cont.$

$* ' i l # $

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*yo'enic ranuloma #cont.$*yo'enic ranuloma #cont.$ (he lesion is usually ulcerated, soft to palpation,(he 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.

enerally elevated, may be sessile or pedunculatedenerally elevated, may be sessile or pedunculatedost commonly observed on the 'in'iva, it may be seenost commonly observed on the 'in'iva, it may be seen

on other intraoral areason other intraoral areasay vary in si5e from a fe millimeters to severalay vary in si5e from a fe millimeters to severalcentimeterscentimeters>sually develop rapidly and then remain static>sually develop rapidly and then remain static

ost common in teena'ers and youn' adults, but mayost common in teena'ers and youn' adults, but mayoccur at any a'eoccur at any a'eIf seen in a pre'nant female, it is called a pre'nancyIf seen in a pre'nant female, it is called a pre'nancytumor.tumor.

(reatment(reatmentSur'ically e cised if it does not re'ress spontaneouslySur'ically e cised if it does not re'ress spontaneously

* ' (* ' (

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*re'nancy (umor *re'nancy (umor

#p'. 3=$#p'. 3=$ & pyo'enic 'ranuloma seen in a pre'nant & pyo'enic 'ranuloma seen in a pre'nant

omanoman(he lesions are identical to those seen in men(he lesions are identical to those seen in menand nonpre'nant omen.and nonpre'nant omen.

ay be caused by hormonal chan'es anday be caused by hormonal chan'es andincreased response to pla?ueincreased response to pla?ue(hey often re'ress after delivery.(hey often re'ress after delivery.

* ' ( # t $* ' ( # t $

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*re'nancy (umor #cont.$*re'nancy (umor #cont.$

* i h l i C ll l* i h l i C ll l

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*eripheral iant Cell ranuloma*eripheral iant Cell ranuloma

#p's. 3=, 70$#p's. 3=, 70$ & lesion that contains many & lesion that contains many

multinucleated 'iant cells, ell8multinucleated 'iant cells, ell8vasculari5ed connective tissue, :Cs,vasculari5ed connective tissue, :Cs,

and chronic inflammatory cellsand chronic inflammatory cells<ccurs only in the !a s<ccurs only in the !a sSeems to ori'inate from periodontalSeems to ori'inate from periodontalli'ament or periosteum in response toli'ament or periosteum in response toin!uryin!ury

*eripheral*eripheral+esions occurrin' outside of bone+esions occurrin' outside of bone

CentralCentral+esions ithin bone of the mandible or+esions ithin bone of the mandible orma illama illa

*eripheral iant Cell ranuloma*eripheral iant Cell ranuloma

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e p e a a t Ce a u o ap#cont.$#cont.$

<ccurs on 'in'iva or alveolar process,<ccurs on 'in'iva or alveolar process,usually anterior to the molarsusually anterior to the molars

ary in si5e from 0.3 to 1.3 cmary in si5e from 0.3 to 1.3 cm>sually dar4 red from vasculari5ation>sually dar4 red from vasculari5ation

ost fre?uent in people from -0 to 70 years ofost fre?uent in people from -0 to 70 years ofa'ea'e

ore common in omen than in menore common in omen than in men (reatment(reatment

Sur'ical e cisionSur'ical e cision

C l i C ll lC t l i t C ll l

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Central iant Cell ranulomaCentral iant Cell ranuloma

#p's. 3=$#p's. 3=$ <ccurs ithin the bone of the ma illa or mandible<ccurs ithin the bone of the ma illa or mandible

ost fre?uent in children and youn' adultsost fre?uent in children and youn' adults/ ore common in females than in malesore common in females than in males

*ain is not a common feature.*ain is not a common feature.

>sually discovered on routine radio'raphs>sually discovered on routine radio'raphs/ adiolucentadiolucent/ :orders may be sclerotic or ill8defined.:orders may be sclerotic or ill8defined./ +esion may be unilocular or multilocular.+esion may be unilocular or multilocular./ ay cause diver'ence of roots of ad!acent teethay cause diver'ence of roots of ad!acent teeth

(reatment(reatmentSur'ical removalSur'ical removalay recur ay recur

I i i 6ibI it ti 6ib

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Irritation 6ibromaIrritation 6ibroma

#p's. 70871$#p's. 70871$ (he most common mass on the(he most common mass on the

'in'iva'in'iva & broad8based, persistent & broad8based, persistent

e ophytic lesion composed ofe ophytic lesion composed ofdense, scarli4e connective tissuedense, scarli4e connective tissueith fe blood vesselsith fe blood vessels/ (he result of trauma such as chee4(he result of trauma such as chee4

che in' or chee4 bitin'che in' or chee4 bitin'

>sually a small lesion, less than 1>sually a small lesion, less than 1cm in diameter cm in diameter / ost often occurs on buccal mucosaost often occurs on buccal mucosa

ay occur on ton'ue, lips, and palateay occur on ton'ue, lips, and palate

I i i 6ib # $I it ti 6ib # t $

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Irritation 6ibroma #cont.$Irritation 6ibroma #cont.$

>sually li'hter than surroundin' mucosa>sually li'hter than surroundin' mucosa/ (he surface is covered by stratified s?uamous(he surface is covered by stratified s?uamous

epithelium.epithelium.ay be opa?ue if thic4 or ulcerated due to localay be opa?ue if thic4 or ulcerated due to local

secondary traumasecondary trauma

(reatment(reatmentSur'ically removedSur'ically removed

ust be differentiated from many soft tissueust be differentiated from many soft tissuetumorstumors

%enture8Induced 6ibrous )yperplasia%enture8Induced 6ibrous )yperplasia#E li fi t $ #I fl t#E li fi t $ #I fl t

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#Epulis fissuratum$ #Inflammatory#Epulis fissuratum$ #Inflammatoryhyperplasia$hyperplasia$

#p's. 70871$#p's. 70871$ <bserved in the vestibule as elon'ated<bserved in the vestibule as elon'ated

folds of tissue into hich of an ill8fittin'folds of tissue into hich of an ill8fittin'denture fitsdenture fits

Composed of dense, fibrous connective tissueComposed of dense, fibrous connective tissueith a surface of stratified s?uamousith a surface of stratified s?uamous

epitheliumepithelium(he surface may be ulcerated.(he surface may be ulcerated.

(reatment(reatmentSur'ical removal of e cess tissue andSur'ical removal of e cess tissue andconstruction of a ne dentureconstruction of a ne denture

%enture8Induced 6ibrous )yperplasia #Epulis%enture8Induced 6ibrous )yperplasia #Epulis

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)yp p p)yp p pfissuratum$ #Inflammatory hyperplasia$ #cont.$fissuratum$ #Inflammatory hyperplasia$ #cont.$

*apillary )yperplasia of the *alate*apillary )yperplasia of the *alate

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p y )yp pp y )yp p#*alatal papillomatosis$#*alatal papillomatosis$

#p's. 70872$#p's. 70872$ &lmost al ays associated ith a removable full or &lmost al ays associated ith a removable full or

partial denture or orthodontic appliance that ispartial denture or orthodontic appliance that isorn continuouslyorn continuously

(he palatal vault is covered by multiple papillary(he palatal vault is covered by multiple papillarypro!ections.pro!ections.

/ Each pro!ection consists of fibrous connective tissue,Each pro!ection consists of fibrous connective tissue,usually chronically inflamed and surfaced by stratifiedusually chronically inflamed and surfaced by stratifieds?uamous epithelium.s?uamous epithelium.

(he cause is un4no n.(he cause is un4no n. (reatment(reatment

Sur'ical removal of the pro!ections prior to constructionSur'ical removal of the pro!ections prior to constructionof a ne dentureof a ne denture

*apillary )yperplasia of the *alate*apillary )yperplasia of the *alate

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p y )yp pp y )yp p#*alatal papillomatosis$ #cont.$#*alatal papillomatosis$ #cont.$

i 'i l E l ' tin'ival Enlar'ement

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in'ival Enlar'ementin'ival Enlar'ement

#p's. 71872$#p's. 71872$ &n increase in the bul4 of free and &n increase in the bul4 of free and

attached 'in'iva, especially the interdentalattached 'in'iva, especially the interdentalpapillaepapillae

in'ival mar'ins are rounded.in'ival mar'ins are rounded.Color may vary from normal pin4 to pale orColor may vary from normal pin4 to pale orerythematous dependin' upon the de'ree oferythematous dependin' upon the de'ree ofinflammation and vascularity.inflammation and vascularity.

ay be 'enerali5ed or locali5eday be 'enerali5ed or locali5ed

in'i al Enlar'ement #cont $in'ival Enlar'ement #cont $

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in'ival Enlar'ement #cont.$in ival Enlar ement #cont.$

in'ival Enlar'ement #cont $in'ival Enlar'ement #cont $

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in'ival Enlar'ement #cont.$in ival Enlar ement #cont.$

ay vary from focal enlar'ement of interdental papillaeay vary from focal enlar'ement of interdental papillaeto severe 'enerali5ed 'in'ival enlar'ement that mayto severe 'enerali5ed 'in'ival enlar'ement that maycover the cro ns of teethcover the cro ns of teeth

>sually an unusual tissue response to chronic>sually an unusual tissue response to chronicinflammation associated ith local irritants suchinflammation associated ith local irritants suchas pla?ue or calculusas pla?ue or calculus

ay be from an increased response to localay be from an increased response to localtissue factors due totissue factors due to

)ormonal chan'es durin' pre'nancy or puberty)ormonal chan'es durin' pre'nancy or puberty

Certain dru's such as phenytoin, calcium channelCertain dru's such as phenytoin, calcium channelbloc4ers, and cyclosporinebloc4ers, and cyclosporine ay be hereditaryay be hereditary

in'ival Enlar'ement #cont $in'ival Enlar'ement #cont $

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in'ival Enlar'ement #cont.$in ival Enlar ement #cont.$ (reatment(reatment

in'ivoplastyin'ivoplasty/ eshapin' the 'in'ivaeshapin' the 'in'ivain'ivectomyin'ivectomy

/ emovin' 'in'ival tissueemovin' 'in'ival tissue (issue may need to under'o a biopsy to(issue may need to under'o a biopsy torule out 'in'ival enlar'ement seen inrule out 'in'ival enlar'ement seen inindividuals ith leu4emia.individuals ith leu4emia.


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#*ulp polyp$#*ulp polyp$#p'. 72$#p'. 72$

&n e cessive proliferation of chronically &n e cessive proliferation of chronicallyinflamed dental pulp tissueinflamed dental pulp tissue

In children and youn' adults, it occurs in teethIn children and youn' adults, it occurs in teethith lar'e, open carious lesions often inith lar'e, open carious lesions often in

primary and permanent molars.primary and permanent molars.


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#*ulp polyp$ #cont.$#*ulp polyp$ #cont.$


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& red or pin4 nodule that fills the entire & red or pin4 nodule that fills the entirecavity of the tooth, ith tissue protrudin'cavity of the tooth, ith tissue protrudin'from the pulp chamber from the pulp chamber

>sually asymptomatic>sually asymptomaticay be related to the lar'e root openin' anday be related to the lar'e root openin' and

blood supply of the involved toothblood supply of the involved tooth*rimarily 'ranulation tissue surfaced by a*rimarily 'ranulation tissue surfaced by astratified s?uamous epitheliumstratified s?uamous epithelium

(reatment(reatmentE traction or endodontic treatment of theE traction or endodontic treatment of theinvolved toothinvolved tooth

Inflammatory *eriapical +esionsInflammatory *eriapical +esions

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Inflammatory *eriapical +esionsInflammatory eriapical +esions

*eriapical &bscess*eriapical &bscess %ental or *eriapical ranuloma%ental or *eriapical ranuloma adicular Cyst #*eriapical Cyst$adicular Cyst #*eriapical Cyst$ esorption of (eethesorption of (eeth 6ocal Sclerosin' <steomyelitis6ocal Sclerosin' <steomyelitis &lveolar <steitis #G%ry Soc4etH$ &lveolar <steitis #G%ry Soc4etH$

Inflammatory *eriapical +esionsInflammatory *eriapical +esions

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#cont.$#cont.$#p'. 7 $#p'. 7 $

Caries or trauma may result inCaries or trauma may result inInflammationInflammationInfectionInfection

Chronic hyperplastic pulpitisChronic hyperplastic pulpitis"ecrosis of the pulp"ecrosis of the pulp

(he inflammatory process be'ins in pulp(he inflammatory process be'ins in pulpand then e tends to the periapical area.and then e tends to the periapical area.

&ccessory canals may lead to areas of &ccessory canals may lead to areas ofinflammation on the lateral portion of the root.inflammation on the lateral portion of the root.

*eriapical &bscess*eriapical &bscess

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*eriapical &bscesseriapical &bscess

#p's. =, 7 $#p's. =, 7 $ *urulent e udate surrounded by*urulent e udate surrounded by

connective tissue containin' neutrophilsconnective tissue containin' neutrophilsand lymphocytesand lymphocytes

Inflammation produces severe pain.Inflammation produces severe pain. ay develop directly from inflammation inay develop directly from inflammation in

the pulpthe pulpore commonly develops in an area ofore commonly develops in an area of

previously e istin' chronic inflammationpreviously e istin' chronic inflammation

*eriapical &bscess #cont $*eriapical &bscess #cont $

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1 0Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc.

*eriapical &bscess #cont.$eriapical &bscess #cont.$

*eriapical &bscess #cont $*eriapical &bscess #cont $

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eriapical &bscess #cont.$eriapical &bscess #cont.$

(he pus may cause a fistula to form.(he pus may cause a fistula to form.(he tooth may be e truded.(he tooth may be e truded.

If the acute abscess forms directly fromIf the acute abscess forms directly frompulpal inflammationpulpal inflammation

(here may be no radio'raphic chan'es e cept(here may be no radio'raphic chan'es e ceptfor a sli'ht thic4enin' of the apical periodontalfor a sli'ht thic4enin' of the apical periodontalli'ament space.li'ament space.

If the abscess forms in a pree istin' areaIf the abscess forms in a pree istin' areaof periapical chronic inflammationof periapical chronic inflammation

& distinct radio'raphic lucency may be seen at & distinct radio'raphic lucency may be seen atthe ape .the ape .

*eriapical &bscess*eriapical &bscess

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eriapical &bscesseriapical &bscess

(reatment(reatmentay re?uire incision and draina'e of theay re?uire incision and draina'e of the

abscessabscessEndodontics or e tractionEndodontics or e traction

%ental or *eriapical ranuloma%ental or *eriapical ranuloma

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%ental or eriapical ranuloma%ental or eriapical ranuloma

#p's. 7 87-$#p's. 7 87-$ & locali5ed mass of chronically inflamed & locali5ed mass of chronically inflamed

'ranula that forms at the openin' of the'ranula that forms at the openin' of thepulp canal, 'enerally at the ape of apulp canal, 'enerally at the ape of anonvital tooth rootnonvital tooth root

ranulation tissue ith lymphocytes, plasmaranulation tissue ith lymphocytes, plasmacells and macropha'es @ neutrophils may becells and macropha'es @ neutrophils may bepresentpresent

>sually asymptomatic>sually asymptomaticay be sensitive to pressure or percussionay be sensitive to pressure or percussion


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

#cont.$#cont.$


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#cont.$#cont.$ (he tooth may be sli'htly e truded from(he tooth may be sli'htly e truded from

the soc4et.the soc4et. adio'raphicadio'raphic

ay vary from sli'ht thic4enin' of theay vary from sli'ht thic4enin' of theperiodontal li'ament space to a diffuseperiodontal li'ament space to a diffuseradiolucency, to a distinct, ell8circumscribedradiolucency, to a distinct, ell8circumscribedradiolucency surroundin' the root aperadiolucency surroundin' the root ape

(reatment(reatmentEndodontia or e tractionEndodontia or e traction

adicular Cyst #*eriapical Cyst$adicular Cyst #*eriapical Cyst$

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adicular Cyst # eriapical Cyst$adicular Cyst # eriapical Cyst$

#p's. 7-873$#p's. 7-873$ & true epithelium8lined cyst & true epithelium8lined cyst

&ssociated ith the root of a nonvital tooth &ssociated ith the root of a nonvital tooth (he most commonly occurrin' cyst in the(he most commonly occurrin' cyst in the

oral re'ionoral re'ion & result of proliferation of the rests of alasse5 & result of proliferation of the rests of alasse5>sually asymptomatic and discovered on>sually asymptomatic and discovered onradio'raphradio'raph

adicular Cyst #*eriapical Cyst$adicular Cyst #*eriapical Cyst$$

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

#cont.$#cont.$

adicular Cystadicular Cyst

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

adicular Cystadicular Cyst

adio'raphicadio'raphic(he appearance is the same as for a periapical(he appearance is the same as for a periapical'ranuloma.'ranuloma.

(reatment(reatmentEndodontia, apicoectomy, or e traction andEndodontia, apicoectomy, or e traction andcuretta'e of periapical tissuecuretta'e of periapical tissue

esorption of (eethesorption of (eeth

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esorption of (eethesorption of (eeth

#p's. 73877$#p's. 73877$ ay occur hen inflammation is presentay occur hen inflammation is present

<ccurs in deciduous teeth durin' e foliation<ccurs in deciduous teeth durin' e foliation Can occur ith e cessive occlusal orCan occur ith e cessive occlusal or

orthodontic forces or ith beni'n ororthodontic forces or ith beni'n ormali'nant tumorsmali'nant tumors

apid orthodontic movement in an adult mayapid orthodontic movement in an adult maycause e ternal root resorptioncause e ternal root resorption

& reimplanted tooth ill resorb. & reimplanted tooth ill resorb. ay be classified as e ternal or internalay be classified as e ternal or internal

E ternal oot esorptionE ternal oot esorption

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1-0Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc.

E ternal oot esorptionE ternal oot esorption

#p'. 73$#p'. 73$ Initially appears as a sli'htInitially appears as a sli'ht

ra''edness or bluntin' of thera''edness or bluntin' of theroot aperoot ape

"ot reversible"ot reversible*ro'ression can be avoided if*ro'ression can be avoided ifthe cause is identified andthe cause is identified andremovedremoved

Impacted teeth may resorb.Impacted teeth may resorb.

Internal (ooth or oot esorptionInternal (ooth or oot esorption

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Internal (ooth or oot esorptionte a (oot o oot eso pt o

#p'. 73$#p'. 73$ Idiopathic, thou'ht to be associated ith anIdiopathic, thou'ht to be associated ith an

inflammatory response in the pulpinflammatory response in the pulpIf seen ithin the cro n, the tooth ill appear pin4 dueIf seen ithin the cro n, the tooth ill appear pin4 dueto inflamed vascular connective tissue G*in4 tooth ofto inflamed vascular connective tissue G*in4 tooth of

ummery.Hummery.HIf seen ithin the root, it ill be seenIf seen ithin the root, it ill be seen radio'raphically.radio'raphically.

(reatment(reatmentIf the root is not perforated, calcium hydro ide is placedIf the root is not perforated, calcium hydro ide is placedand endodontics performed in an attempt to save theand endodontics performed in an attempt to save thetooth.tooth.If the tooth is perforated, it must be removed.If the tooth is perforated, it must be removed.

6ocal Sclerosin' <steomyelitis6ocal Sclerosin' <steomyelitisd $#C d i ' i i $

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#Condensin' <steitis$#Condensin' <steitis$#p's. 73877$#p's. 73877$

& chan'e in the bone & chan'e in the bonenear the apices of teethnear the apices of teeth

(hou'ht to be a reaction to(hou'ht to be a reaction to

lo 8'rade infectionlo 8'rade infection enerally asymptomaticFenerally asymptomaticF

if painful, may beif painful, may beassociated ith pulpalassociated ith pulpalinflammatory diseaseinflammatory disease

6ocal Sclerosin' <steomyelitis6ocal Sclerosin' <steomyelitis

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6ocal Sclerosin steomyelitis6ocal Sclerosin steomyelitis

adio'raphicadio'raphic &ppears as a radiopa?ue area, most commonly &ppears as a radiopa?ue area, most commonlyassociated ith the mandibular first molar associated ith the mandibular first molar :orders may be diffuse or ell8defined:orders may be diffuse or ell8defined

(reatment(reatment>sually not necessary>sually not necessary:iopsy may be re?uired to rule out other:iopsy may be re?uired to rule out otherradiopa?ue lesions such as osteoma, compleradiopa?ue lesions such as osteoma, comple

odontoma, or ossifyin' fibroma.odontoma, or ossifyin' fibroma.

&lveolar <steitis #G%ry Soc4etH$ &lveolar <steitis #G%ry Soc4etH$

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

y $y $

#p'. 77$#p'. 77$ & postoperative complication follo in' tooth & postoperative complication follo in' tooth

removal.removal.ost often in the area of the mandibular third molar ost often in the area of the mandibular third molar

(he blood clot is lost before healin' can ta4e(he blood clot is lost before healin' can ta4eplace, leavin' ra , e posed nerve endin's.place, leavin' ra , e posed nerve endin's.

(he patient may complain of pain, bad odor, and bad(he patient may complain of pain, bad odor, and badtaste.taste.

(reatment(reatment

%aily application of %ry Soc4et *aste containin'%aily application of %ry Soc4et *aste containin'eucalyptol until symptoms are relievedeucalyptol until symptoms are relieved

%iscussion Juestions%iscussion Juestions

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%iscussion Juestions

hat cells appear first durin' an inflammatoryhat cells appear first durin' an inflammatoryresponseKresponseK

hat is the difference bet een healin' by primary,hat is the difference bet een healin' by primary,secondary, and tertiary intentionKsecondary, and tertiary intentionK

hat is the difference bet een re'eneration and repairKhat is the difference bet een re'eneration and repairK

hat is the difference bet een attrition, abrasion, andhat is the difference bet een attrition, abrasion, anderosionKerosionKhat in!uries to oral soft tissues may be observed ithinhat in!uries to oral soft tissues may be observed ithin

the oral cavityKthe oral cavityKhat is the definition of reactive tissue hyperplasia andhat is the definition of reactive tissue hyperplasia and

hat forms may be observed ithin the oral cavityKhat forms may be observed ithin the oral cavityKhat inflammatory periapical lesions may be observedhat inflammatory periapical lesions may be observedithin the oral cavityKithin the oral cavityK

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Chapter 2

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