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1Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc.
Chapter 2
Inflammation and Repair
2Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc.
OutlineOutline InjuryInjury Natural (Innate) Defenses Against InjuryNatural (Innate) Defenses Against Injury InflammationInflammation Regeneration and RepairRegeneration and Repair Injuries to TeethInjuries to Teeth Injuries to Soft TissuesInjuries to Soft Tissues Reactive Connective Tissue HyperplasiaReactive Connective Tissue Hyperplasia Inflammatory Periapical LesionsInflammatory Periapical Lesions
3Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc.
Inflammation and RepairInflammation and Repair (pg. 34)(pg. 34)
The body’s response to injuryThe body’s response to injury InflammationInflammation
• Allows the body to eliminated injurious agents, Allows the body to eliminated injurious agents, contain injuries, and heal defectscontain injuries, and heal defects
4Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc.
InjuryInjury (pg. 34)(pg. 34)
An alteration in the environment that An alteration in the environment that causes tissue damagecauses tissue damage
Examples includeExamples include Physical Physical ChemicalChemical MicroorganismsMicroorganisms Nutritional deficienciesNutritional deficiencies
5Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc.
Natural (Innate) Defenses Natural (Innate) Defenses Against InjuryAgainst Injury
(pg. 34)(pg. 34) Intact skin or mucosa is a physical barrier.Intact skin or mucosa is a physical barrier. Enzymes in saliva have an antibacterial Enzymes in saliva have an antibacterial
activity.activity. Flushing action of tears, saliva, urine, and Flushing action of tears, saliva, urine, and
diarrhea removes foreign substances.diarrhea removes foreign substances.
6Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc.
InflammationInflammation (pgs. 34-44)(pgs. 34-44)
Microscopic Events and Clinical Signs of Microscopic Events and Clinical Signs of InflammationInflammation
White Blood Cells and Their Involvement White Blood Cells and Their Involvement in the Inflammatory Responsein the Inflammatory Response
Biochemical Mediators of InflammationBiochemical Mediators of Inflammation Systemic Manifestations of InflammationSystemic Manifestations of Inflammation Chronic InflammationChronic Inflammation Hyperplasia, Hypertrophy, and AtrophyHyperplasia, Hypertrophy, and Atrophy
7Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc.
Inflammation (cont.)Inflammation (cont.) (pgs. 34-35)(pgs. 34-35)
A nonspecific response to injuryA nonspecific response to injury Occurs in the same manner regardless of the Occurs in the same manner regardless of the
nature of the injurynature of the injury May be local and limited to the area of injury, May be local and limited to the area of injury,
or may be extensive if the injury is extensiveor may be extensive if the injury is extensive May be acute or chronicMay be acute or chronic
8Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc.
Microscopic Events and Clinical Microscopic Events and Clinical Signs of Inflammation (Cont.)Signs of Inflammation (Cont.)
9Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc.
Microscopic Events and Clinical Microscopic Events and Clinical Signs of Inflammation (Cont.)Signs of Inflammation (Cont.)
(pgs. 35-37) (Table 2-1)(pgs. 35-37) (Table 2-1)
Local clinical changes are classic signs of Local clinical changes are classic signs of inflammation.inflammation. Redness, heat, swelling, pain, loss of normal Redness, heat, swelling, pain, loss of normal
tissue functiontissue function Systemic signs may includeSystemic signs may include
Increase in body temperatureIncrease in body temperature Increase in the number of white blood cellsIncrease in the number of white blood cells Enlargement of lymph nodesEnlargement of lymph nodes
10Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc.
Microscopic Events and Clinical Microscopic Events and Clinical Signs of Inflammation (cont.)Signs of Inflammation (cont.)
11Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc.
Microscopic events involve Microscopic events involve microcirculation.microcirculation. Arterioles, capillaries, venules in the area of Arterioles, capillaries, venules in the area of
injuryinjury White blood cellsWhite blood cells Chemical mediatorsChemical mediators
Usually, an exchange of oxygen and Usually, an exchange of oxygen and nutrition is seen in these vessels.nutrition is seen in these vessels. Most of the fluid reenters circulation through Most of the fluid reenters circulation through
venules.venules. Lymphatic system carries away fluid that does Lymphatic system carries away fluid that does
not reenter the blood vessels.not reenter the blood vessels.
Microscopic Events and Clinical Microscopic Events and Clinical Signs of Inflammation (cont.)Signs of Inflammation (cont.)
12Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc.
Sequence of Microscopic EventsSequence of Microscopic Events
(pg. 36)(pg. 36) Injury to tissueInjury to tissue Constriction of microcirculationConstriction of microcirculation Dilation of microcirculationDilation of microcirculation Increase in permeabilityIncrease in permeability Exudate leaves microcirculation.Exudate leaves microcirculation. Increased blood viscosityIncreased blood viscosity Decreased blood flow Decreased blood flow Margination and pavementing of white blood Margination and pavementing of white blood
cells (WBCs)cells (WBCs) WBCs enter tissue.WBCs enter tissue. WBCs ingest foreign material.WBCs ingest foreign material.
13Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc.
Sequence of Microscopic Events Sequence of Microscopic Events (cont.) (cont.)
(pg. 36)(pg. 36) HyperemiaHyperemia
Increased blood flow in capillary beds of injured tissueIncreased blood flow in capillary beds of injured tissue• Will produce redness and heatWill produce redness and heat
ExudateExudate Increased blood plasma and proteins in injured tissueIncreased blood plasma and proteins in injured tissue
• Helps dilute injurious agents, but results in excess fluid in Helps dilute injurious agents, but results in excess fluid in tissues – edematissues – edema
Serous exudateSerous exudate• Mainly plasma fluids and proteins, few WBCsMainly plasma fluids and proteins, few WBCs
Purulent exudate (suppuration)Purulent exudate (suppuration)• Contains plasma fluids and proteins, tissue debris, and Contains plasma fluids and proteins, tissue debris, and
many WBCsmany WBCs
14Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc.
Sequence of Microscopic Events Sequence of Microscopic Events (cont.)(cont.)
(pgs. 36-38)(pgs. 36-38) Swelling develops as exudate escapes into tissue.Swelling develops as exudate escapes into tissue.
May flow out as a thin, clear exudate (serous) or a thick May flow out as a thin, clear exudate (serous) or a thick white-to-yellow pus (purulent)white-to-yellow pus (purulent)
Drainage may occur through a fistula.Drainage may occur through a fistula. Incision and drainage (I & D) may be required.Incision and drainage (I & D) may be required.
A drainage tube may be placed.A drainage tube may be placed. Medication may be administered to treat infection and Medication may be administered to treat infection and
reduce inflammation.reduce inflammation. Pressure from exudate and chemical mediators may cause Pressure from exudate and chemical mediators may cause
pain.pain. Blood viscosity may increase due to loss of plasma fluids.Blood viscosity may increase due to loss of plasma fluids.
MarginationMargination• White blood cells migrate to the periphery of the White blood cells migrate to the periphery of the
vessel.vessel.
15Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc.
Sequence of Microscopic Events Sequence of Microscopic Events (cont.)(cont.)
16Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc.
Sequence of Microscopic Events Sequence of Microscopic Events (cont.)(cont.)
17Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc.
Sequence of Microscopic Events Sequence of Microscopic Events (cont.)(cont.)
(pgs. 37, 39)(pgs. 37, 39) EmigrationEmigration
The process by which WBCs escape from The process by which WBCs escape from blood vessels through gaps in endothelial cellsblood vessels through gaps in endothelial cells
Chemotaxis Chemotaxis Directed movement of WBCs toward the site of Directed movement of WBCs toward the site of
injuryinjury PhagocytosisPhagocytosis
The process by which WBCs ingest and then The process by which WBCs ingest and then digest foreign substances.digest foreign substances.
May include pathogenic organisms and tissue May include pathogenic organisms and tissue debrisdebris
18Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc.
Sequence of Microscopic Events Sequence of Microscopic Events (cont.)(cont.)
19Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc.
(pgs. 37, 39)(pgs. 37, 39) There are six different kinds of WBCs.There are six different kinds of WBCs.
NeutrophilsNeutrophils• First to arrive at the site of injuryFirst to arrive at the site of injury• Primary cell in acute inflammationPrimary cell in acute inflammation
Monocytes (Macrophage)Monocytes (Macrophage)• Second cell in inflammatory responseSecond cell in inflammatory response
Lymphocytes and Plasma CellsLymphocytes and Plasma Cells• Seen in chronic inflammation and the immune responseSeen in chronic inflammation and the immune response
Eosinophils and Mast CellsEosinophils and Mast Cells• Seen in both inflammation and the immune responseSeen in both inflammation and the immune response
White Blood Cells and Their Involvement White Blood Cells and Their Involvement in the Inflammatory Responsein the Inflammatory Response
20Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc.
White Blood Cells and Their Involvement White Blood Cells and Their Involvement in the Inflammatory Response (cont.)in the Inflammatory Response (cont.)
(pgs. 39-40)(pgs. 39-40) Changes occur in the proportion of WBCs Changes occur in the proportion of WBCs
as the inflammatory response continues.as the inflammatory response continues. The neutrophil is the most common The neutrophil is the most common
inflammatory cell in acute monocyte (in blood) inflammatory cell in acute monocyte (in blood) becomes a macrophage as it enters tissue becomes a macrophage as it enters tissue inflammation.inflammation.
The circulating.The circulating. Neutrophils decrease in number.Neutrophils decrease in number. Macrophages, lymphocytes, and plasma cells Macrophages, lymphocytes, and plasma cells
become predominant with chronic become predominant with chronic inflammation.inflammation.
21Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc.
White Blood Cells and Their Involvement White Blood Cells and Their Involvement in the Inflammatory Response (cont.)in the Inflammatory Response (cont.)
22Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc.
White Blood Cells and Their Involvement White Blood Cells and Their Involvement in the Inflammatory Response (cont.)in the Inflammatory Response (cont.)
23Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc.
Neutrophils (PMNs)Neutrophils (PMNs) (pgs. 39-40)(pgs. 39-40)
60% to 70% of WBC population60% to 70% of WBC population Granular leukocytes along with basophils and Granular leukocytes along with basophils and
eosinophilseosinophils Derived from stem cells in bone marrowDerived from stem cells in bone marrow Contain lysosomal enzymesContain lysosomal enzymes
Function is phagocytosis and then Function is phagocytosis and then enzymatic destruction of foreign enzymatic destruction of foreign substances.substances. Neutrophils then perish.Neutrophils then perish. The enzymes can leak, causing further tissue The enzymes can leak, causing further tissue
damage.damage.
24Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc.
Neutrophils (PMNs) (cont.)Neutrophils (PMNs) (cont.)
25Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc.
MacrophagesMacrophages (pgs. 40-41)(pgs. 40-41)
3% to 8% of WBC population3% to 8% of WBC population Derived from stem cells in bone marrowDerived from stem cells in bone marrow Has a single, round nucleus and a nongranular Has a single, round nucleus and a nongranular
cytoplasmcytoplasm Responds to chemotactic factors, is mobile, Responds to chemotactic factors, is mobile,
can phagocytize – also plays a role in the can phagocytize – also plays a role in the immune systemimmune system
26Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc.
Macrophages (cont.)Macrophages (cont.)
27Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc.
Biochemical Mediators of Biochemical Mediators of InflammationInflammation
(pgs. 40-41)(pgs. 40-41) Cause many of the events in the Cause many of the events in the
inflammatory responseinflammatory response Basic mediators can recruit other mediators Basic mediators can recruit other mediators
and immune mechanisms.and immune mechanisms. May be derived from May be derived from
BloodBlood Endothelial cellsEndothelial cells White blood cells and plateletsWhite blood cells and platelets Pathogenic organisms as they injure the tissuePathogenic organisms as they injure the tissue
28Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc.
Biochemical Mediators of Biochemical Mediators of Inflammation (cont.)Inflammation (cont.)
(pgs. 40-41)(pgs. 40-41) Three interrelated systemsThree interrelated systems
Interaction takes place during activation, Interaction takes place during activation, among their products, and within their various among their products, and within their various actionsactions
Kinin systemKinin system Clotting mechanismClotting mechanism Complement systemComplement system
29Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc.
Kinin SystemKinin System (pg. 40)(pg. 40)
Active in early phases of inflammationActive in early phases of inflammation Activated by substances in plasma and Activated by substances in plasma and
injured tissueinjured tissue Causes increasedCauses increased
Dilation of blood vessels at the site of injuryDilation of blood vessels at the site of injury Permeability of local blood vesselsPermeability of local blood vessels
Induces painInduces pain
30Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc.
Clotting MechanismClotting Mechanism (pg. 41)(pg. 41)
Clots blood and mediates inflammationClots blood and mediates inflammation Some of the clotting mechanisms products that Some of the clotting mechanisms products that
are activated during tissue injury cause local are activated during tissue injury cause local vascular dilation and permeability by activating vascular dilation and permeability by activating kinin.kinin.
31Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc.
Complement SystemComplement System (pg. 41)(pg. 41)
Involves the production of a sequential cascade of plasma Involves the production of a sequential cascade of plasma proteinsproteins They are present in blood in an inactive form.They are present in blood in an inactive form. A trigger (usually an antibody/antigen complex) initiates the A trigger (usually an antibody/antigen complex) initiates the
sequence of steps.sequence of steps. These plasma proteins function in inflammation and immunity.These plasma proteins function in inflammation and immunity.
Some components cause WBCs known as mast cells to Some components cause WBCs known as mast cells to release histamine.release histamine. Histamine causes an increase in vascular permeability and Histamine causes an increase in vascular permeability and
vasodilation.vasodilation. Other components cause cell death, form chemotactic Other components cause cell death, form chemotactic
factors for WBCs, and enhance phagocytosis.factors for WBCs, and enhance phagocytosis.
32Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc.
Other Biochemical Mediators of Other Biochemical Mediators of InflammationInflammation
(pg. 41)(pg. 41) Released by the bodyReleased by the body
ProstaglandinsProstaglandins• Cause increased vascular dilation and permeability, Cause increased vascular dilation and permeability,
tissue pain and redness, and changes in connective tissue pain and redness, and changes in connective tissuetissue
Lysosomal enzymesLysosomal enzymes• Act as chemotactic factorsAct as chemotactic factors• May cause damage to connective tissues and to the May cause damage to connective tissues and to the
clot clot
33Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc.
Other Biochemical Mediators of Other Biochemical Mediators of Inflammation (cont.)Inflammation (cont.)
(pg. 41)(pg. 41) Released by pathogenic microorganismsReleased by pathogenic microorganisms
EndotoxinEndotoxin• Produced by cell walls of gram-negative bacteriaProduced by cell walls of gram-negative bacteria• Serves as chemotactic factor, can activate Serves as chemotactic factor, can activate
complement, function as an antigen, and damage complement, function as an antigen, and damage bone and tissuebone and tissue
Lysosomal enzymesLysosomal enzymes• Have a similar chemical composition and action as Have a similar chemical composition and action as
those released by WBCsthose released by WBCs
34Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc.
Antiinflammatory DrugsAntiinflammatory Drugs (pg. 41)(pg. 41)
Block or suppress the inflammatory Block or suppress the inflammatory responseresponse Prevent or reduce clinical signs of inflammation Prevent or reduce clinical signs of inflammation
and adverse reactions to the injuryand adverse reactions to the injury ExamplesExamples
Nonsteroidal antiinflammatory agentsNonsteroidal antiinflammatory agents• Aspirin, ibuprofen, celecoxibAspirin, ibuprofen, celecoxib
Steroidal antiinflammatory drugSteroidal antiinflammatory drug• PrednisonePrednisone
35Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc.
Systemic Manifestations of Systemic Manifestations of InflammationInflammation
(pgs. 41-42)(pgs. 41-42) May includeMay include
FeverFever LeukocytosisLeukocytosis Elevated C-reactive proteinElevated C-reactive protein LymphadenopathyLymphadenopathy
36Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc.
FeverFever (pg. 42)(pg. 42)
Controlled by the hypothalamusControlled by the hypothalamus Associated with systemic inflammatory Associated with systemic inflammatory
responseresponse PyrogensPyrogens
Fever producing substances produced by Fever producing substances produced by WBCs and pathogensWBCs and pathogens
Pyrogens act on the hypothalamus.Pyrogens act on the hypothalamus. The hypothalamus increases body The hypothalamus increases body
temperature by way of prostaglandins.temperature by way of prostaglandins.
37Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc.
LeukocytosisLeukocytosis (pg. 42)(pg. 42)
A systemic inflammatory response can A systemic inflammatory response can increase the number of WBCs from the increase the number of WBCs from the normal 4000 to 10,000/mm of blood to normal 4000 to 10,000/mm of blood to 10,000 to 30,000/mm.10,000 to 30,000/mm. The primary cell involved is the neutrophil.The primary cell involved is the neutrophil.
The rate of formation is increased and The rate of formation is increased and immature forms are released from bone immature forms are released from bone marrow into the blood.marrow into the blood. The body is attempting to produce more cells The body is attempting to produce more cells
for phagocytosis.for phagocytosis.
38Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc.
Elevated C-Reactive ProteinElevated C-Reactive Protein (pg. 42)(pg. 42)
C-reactive protein is produced in the liver and C-reactive protein is produced in the liver and plays the important role of interacting with the plays the important role of interacting with the complement system.complement system. Elevated levels are present during episodes of acute Elevated levels are present during episodes of acute
inflammation or infection.inflammation or infection. May continue with chronic inflammationMay continue with chronic inflammation
Levels can be used to help assess rheumatoid Levels can be used to help assess rheumatoid arthritis and systemic lupus erythematosus.arthritis and systemic lupus erythematosus. A chronic increased level is associated with an A chronic increased level is associated with an
increased risk for cardiovascular disease.increased risk for cardiovascular disease.
39Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc.
LymphadenopathyLymphadenopathy (pgs. 42-43)(pgs. 42-43)
Enlarged and palpable superficial lymph Enlarged and palpable superficial lymph nodesnodes Follows route of lymphatic drainageFollows route of lymphatic drainage
The enlarged nodes occur due to changes The enlarged nodes occur due to changes in lymphocytes, which are the primary cells in lymphocytes, which are the primary cells of the immune response.of the immune response. HyperplasiaHyperplasia
• An increase in the number of cellsAn increase in the number of cells HypertrophyHypertrophy
• Enlargement of individual cellsEnlargement of individual cells
40Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc.
Lymphadenopathy (cont.)Lymphadenopathy (cont.)
41Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc.
Chronic InflammationChronic Inflammation (pgs. 42-43)(pgs. 42-43)
Due to persistent injuriesDue to persistent injuries Cells involved include macrophages, Cells involved include macrophages,
lymphocytes, and plasma cells as well as lymphocytes, and plasma cells as well as neutrophils and monocytes present in acute neutrophils and monocytes present in acute inflammation.inflammation.
May include proliferation of fibroblasts and May include proliferation of fibroblasts and formation of granulomasformation of granulomas
42Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc.
Chronic Inflammation (cont.)Chronic Inflammation (cont.) (pgs. 42-43)(pgs. 42-43)
GranulomaGranuloma Microscopic groupings of macrophages Microscopic groupings of macrophages
surrounded by lymphocytes and plasma cellssurrounded by lymphocytes and plasma cells Usually contain multinucleated giant cellsUsually contain multinucleated giant cells
• Large macrophages with multiple nucleiLarge macrophages with multiple nuclei Associated with foreign body reactions and Associated with foreign body reactions and
some infections such as tuberculosissome infections such as tuberculosis
43Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc.
Hyperplasia, Hypertrophy, and Hyperplasia, Hypertrophy, and AtrophyAtrophy
(pgs. 43-44)(pgs. 43-44) HyperplasiaHyperplasia
An increase in the number of cells often in response to An increase in the number of cells often in response to chronic irritation or abrasionchronic irritation or abrasion
May return to normal if the insult subsides, or may May return to normal if the insult subsides, or may persist following removal of the irritantpersist following removal of the irritant
HypertrophyHypertrophy An increase in the size of cellsAn increase in the size of cells May be seen in cardiac muscle as a response to May be seen in cardiac muscle as a response to
hypertensionhypertension AtrophyAtrophy
A decrease in size or function of a cell, tissue, organ, or A decrease in size or function of a cell, tissue, organ, or entire bodyentire body
44Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc.
Hyperplasia, Hypertrophy, and Hyperplasia, Hypertrophy, and Atrophy (cont.)Atrophy (cont.)
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Regeneration and RepairRegeneration and Repair (pgs. 44-46)(pgs. 44-46)
Microscopic Events That Occur During Microscopic Events That Occur During RepairRepair
Types of RepairTypes of Repair Bone Tissue RepairBone Tissue Repair
46Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc.
(pg. 44)(pg. 44) RegenerationRegeneration
If the inflamed area returns to normal structure If the inflamed area returns to normal structure and functionand function
RepairRepair Occurs when the damage is too great for the Occurs when the damage is too great for the
tissue to return to normaltissue to return to normal Functioning cells and tissue often are replaced Functioning cells and tissue often are replaced
with nonfunctioning scar tissue. with nonfunctioning scar tissue.
Regeneration and Repair (cont.)Regeneration and Repair (cont.)
47Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc.
Microscopic Events That Occur Microscopic Events That Occur During RepairDuring Repair
(pgs. 44-45)(pgs. 44-45) Takes about 2 weeksTakes about 2 weeks
Occurs almost simultaneously in both Occurs almost simultaneously in both epithelium and connective tissueepithelium and connective tissue
48Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc.
Microscopic Events That Occur Microscopic Events That Occur During Repair (cont.)During Repair (cont.)
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Day of InjuryDay of Injury (pg. 45)(pg. 45)
Blood flows into injured tissue to produce a Blood flows into injured tissue to produce a clot.clot. The clot contains fibrin, clumped red blood The clot contains fibrin, clumped red blood
cells (RBCs), and platelets.cells (RBCs), and platelets.
50Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc.
One Day After InjuryOne Day After Injury (pg. 45)(pg. 45)
Neutrophils migrate from the Neutrophils migrate from the microcirculation into injured tissue in an microcirculation into injured tissue in an acute inflammatory response.acute inflammatory response. They phagocytize foreign material and necrotic They phagocytize foreign material and necrotic
tissue.tissue.
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Two Days After InjuryTwo Days After Injury (pg. 45)(pg. 45)
Monocytes migrate from microcirculation and become macrophages Monocytes migrate from microcirculation and become macrophages in tissue.in tissue. They also phagocytize.They also phagocytize.
Fibroblasts increase in number and produce new collagen fibers.Fibroblasts increase in number and produce new collagen fibers. Granulation tissue is formed in the connective tissue portion of Granulation tissue is formed in the connective tissue portion of
injury.injury.• This growth may be excessive.This growth may be excessive.
New surface epithelium is formed in the epithelial tissue portion of New surface epithelium is formed in the epithelial tissue portion of injury.injury.• They use the fibrin meshwork to migrate.They use the fibrin meshwork to migrate.• This meshwork also protects newly formed tissue from This meshwork also protects newly formed tissue from
additional injury.additional injury. Lymphocytes and plasma cells migrate to the area as chronic Lymphocytes and plasma cells migrate to the area as chronic
inflammation and the immune response begins.inflammation and the immune response begins.
52Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc.
Seven Days After InjurySeven Days After Injury (pg. 45)(pg. 45)
Fibrin is digested by tissue enzymes.Fibrin is digested by tissue enzymes. It sloughs off and the initial repair is complete.It sloughs off and the initial repair is complete.
The new tissue is relatively red.The new tissue is relatively red. New epithelium is thin.New epithelium is thin. New connective tissue is highly vascularized.New connective tissue is highly vascularized.
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Two Weeks After InjuryTwo Weeks After Injury (pg. 45)(pg. 45)
Initial granulation tissue and its fibers are Initial granulation tissue and its fibers are remodeled.remodeled.
The new tissue is scar tissue.The new tissue is scar tissue. It is whiter and paler due to increased collagen It is whiter and paler due to increased collagen
and decreased vascularity.and decreased vascularity.
54Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc.
Types of RepairTypes of Repair (pgs. 45-46)(pgs. 45-46)
Healing by primary intentionHealing by primary intention Healing of an injury where there is little loss of Healing of an injury where there is little loss of
tissuetissue The margins are close together and very little The margins are close together and very little
granulation tissue forms.granulation tissue forms. Healing by secondary intentionHealing by secondary intention
The edges of the injury cannot be joined during The edges of the injury cannot be joined during healing.healing.
A large clot forms, resulting in increased A large clot forms, resulting in increased granulation tissue.granulation tissue.
May result in excess scar tissue – a keloidMay result in excess scar tissue – a keloid
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Types of Repair (cont.)Types of Repair (cont.)
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Healing by Tertiary IntentionHealing by Tertiary Intention (pg. 46)(pg. 46)
Delaying surgical tissue repair until Delaying surgical tissue repair until infection is resolvedinfection is resolved An injured area may become infected – An injured area may become infected –
especially with puncture wounds.especially with puncture wounds. In some situations, an infected injury is left In some situations, an infected injury is left
open until infection is controlled.open until infection is controlled.
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Factors That Impair HealingFactors That Impair Healing (pg. 46)(pg. 46)
Local factors that impair healingLocal factors that impair healing Bacterial infectionBacterial infection Tissue destruction and necrosisTissue destruction and necrosis HematomaHematoma Excessive movement of injured tissueExcessive movement of injured tissue Poor blood supplyPoor blood supply
Systemic factorsSystemic factors MalnutritionMalnutrition ImmunosuppressionImmunosuppression Genetic connective tissue disordersGenetic connective tissue disorders Metabolic disordersMetabolic disorders
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Bone Tissue RepairBone Tissue Repair (pg. 46)(pg. 46)
Osteoblasts create new bone tissue.Osteoblasts create new bone tissue. May be delayed byMay be delayed by
• Increased movement of boneIncreased movement of bone• EdemaEdema• Infection in the tissueInfection in the tissue• Excessive or inadequate movement of bone tissueExcessive or inadequate movement of bone tissue
59Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc.
Injuries to TeethInjuries to Teeth AttritionAttrition AbrasionAbrasion AbfractionAbfraction ErosionErosion Methamphetamine abuseMethamphetamine abuse
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AttritionAttrition (pgs. 47-48)(pgs. 47-48)
Tooth-to-tooth wearTooth-to-tooth wear May be observed both in May be observed both in
primary and permanent primary and permanent dentitiondentition
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BruxismBruxism (pgs. 47-48)(pgs. 47-48)
Grinding and clenching teeth for nonfunctional Grinding and clenching teeth for nonfunctional purposespurposes
Signs and symptoms includeSigns and symptoms include Wear facets, abnormal rate of attrition, hypertrophy of Wear facets, abnormal rate of attrition, hypertrophy of
masticatory muscles, increased muscle tone, muscle masticatory muscles, increased muscle tone, muscle tenderness, muscle fatigue, cheek biting, pain in the TM joint tenderness, muscle fatigue, cheek biting, pain in the TM joint area, tooth mobility, and pulpal sensitivity to coldarea, tooth mobility, and pulpal sensitivity to cold
May be due to local factors such as occlusal May be due to local factors such as occlusal interferences in combination with stress and tensioninterferences in combination with stress and tension Management includes fabrication of an acrylic splint and Management includes fabrication of an acrylic splint and
elimination of occlusal interferences through occlusal elimination of occlusal interferences through occlusal adjustments.adjustments.
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Bruxism (cont.)Bruxism (cont.)
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AbrasionAbrasion (pg. 48)(pg. 48)
Wearing away of tooth structure from a Wearing away of tooth structure from a repetitive mechanical habitrepetitive mechanical habit Most frequently seen as a notching on root Most frequently seen as a notching on root
surfaces with gingival recessionsurfaces with gingival recession May occur from back-and-forth toothbrushing May occur from back-and-forth toothbrushing
techniquetechnique May be seen in patients who are May be seen in patients who are
seamstresses, musicians, or pipe smokersseamstresses, musicians, or pipe smokers
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Abrasion (cont.)Abrasion (cont.)
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AbfractionAbfraction (pg. 48)(pg. 48)
Typically appears as wedge-shaped Typically appears as wedge-shaped lesions at the cervical areas of teethlesions at the cervical areas of teeth May be related to fatigue, flexure, fracture, and May be related to fatigue, flexure, fracture, and
deformation of tooth structuredeformation of tooth structure May occur in combination with abrasionMay occur in combination with abrasion
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ErosionErosion (pgs. 48-49)(pgs. 48-49)
Loss of tooth structure Loss of tooth structure due to chemicalsdue to chemicals Tooth structure may be lost Tooth structure may be lost
around a restoration, around a restoration, making the restoration making the restoration stand out.stand out.
Occlusal surfaces may be Occlusal surfaces may be cupped out.cupped out.
May be on facial surfaces May be on facial surfaces from food and lingual from food and lingual surfaces from vomiting due surfaces from vomiting due to bulimiato bulimia
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BulimiaBulimia (pg. 49)(pg. 49)
Self-induced purging (vomiting) Self-induced purging (vomiting) after eatingafter eating The bulimic maintains normal body The bulimic maintains normal body
weight.weight. May see electrolyte imbalance May see electrolyte imbalance
and/or malnutritionand/or malnutrition Management may include Management may include
fluoride rinse and toothpaste.fluoride rinse and toothpaste. Rinsing with water after purgingRinsing with water after purging
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Methamphetamine AbuseMethamphetamine Abuse (pgs. 49-50)(pgs. 49-50)
Rapid destruction of Rapid destruction of teeth teeth Due to acid content of Due to acid content of
methamphetamine, methamphetamine, decreased salivary flow, decreased salivary flow, craving for high sugar craving for high sugar beverages with lack of beverages with lack of oral hygieneoral hygiene
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Injuries to Oral Soft TissuesInjuries to Oral Soft Tissues Aspirin BurnAspirin Burn Phenol BurnsPhenol Burns Electric BurnsElectric Burns Other BurnsOther Burns Lesions Lesions
Associated with Associated with Cocaine UseCocaine Use
Lesions from Lesions from Self-Induced Self-Induced InjuriesInjuries
HematomaHematoma
Traumatic Ulcer Frictional Keratosis Linea Alba Nicotinic Stomatitis Tobacco Pouch
Keratosis Traumatic Neuroma Amalgam Tattoo
Melanosis Solar Cheilitis Mucocele Necrotizing
Sialometaplasia Sialolith Acute and
Chronic Sialadenitis
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Aspirin BurnAspirin Burn (pgs. 49-50)(pgs. 49-50)
Topical application is a Topical application is a common misuse of this common misuse of this product.product. The tissue becomes The tissue becomes
necrotic and white.necrotic and white. The surface may slough off The surface may slough off
leaving a painful ulcer.leaving a painful ulcer. The ulcer usually heals in 7 The ulcer usually heals in 7
to 21 days. to 21 days.
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Phenol BurnPhenol Burn (pgs. 50-51)(pgs. 50-51)
Used in dentistry as a cavity sterilizing Used in dentistry as a cavity sterilizing agent and a cauterizing agentagent and a cauterizing agent Will cause whitening and sloughing of the area Will cause whitening and sloughing of the area
as a result of tissue destructionas a result of tissue destruction
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Electric BurnElectric Burn (pg. 50)(pg. 50)
May be seen in infants or young children May be seen in infants or young children who have chewed an electrical cordwho have chewed an electrical cord May be quite extensive, damaging oral tissue May be quite extensive, damaging oral tissue
and even tooth budsand even tooth buds May cause constriction of the commissureMay cause constriction of the commissure
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Other BurnsOther Burns (pgs. 50-51)(pgs. 50-51)
Hot food burnsHot food burns From soup or cheese on pizzaFrom soup or cheese on pizza
Products containing hydrogen peroxide or Products containing hydrogen peroxide or eugenoleugenol
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Lesions Associated with Cocaine Lesions Associated with Cocaine UseUse
(pgs. 50-51) (Fig. 2-28C)(pgs. 50-51) (Fig. 2-28C) Lesions located at the midline of the hard palate may Lesions located at the midline of the hard palate may
vary from ulcers to keratotic lesions to exophytic vary from ulcers to keratotic lesions to exophytic reactive lesions as a result of smoking crack cocaine.reactive lesions as a result of smoking crack cocaine.
Necrotic ulcers of the tongue and epiglottis have been Necrotic ulcers of the tongue and epiglottis have been reported as a result of free-basing cocaine.reported as a result of free-basing cocaine.
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Lesions from Self-Induced InjuriesLesions from Self-Induced Injuries
(pgs. 51, 53-54)(pgs. 51, 53-54) A factitious injuryA factitious injury
Due to a habit such as chronic lip, cheek or Due to a habit such as chronic lip, cheek or tongue biting, or trauma to the teeth from a tongue biting, or trauma to the teeth from a fingernailfingernail
Lesions may range from ulceration to epithelial Lesions may range from ulceration to epithelial hyperplasia and hyperkeratosis.hyperplasia and hyperkeratosis.
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Lesions from Self-Induced Injuries Lesions from Self-Induced Injuries (cont.)(cont.)
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HematomaHematoma ((pgs. 51-52)pgs. 51-52)
A bruise inside the A bruise inside the mouthmouth Blood in an Blood in an
extravascular spaceextravascular space• Appears as a red to Appears as a red to
purple to bluish-gray purple to bluish-gray massmass
Most frequently seen Most frequently seen on labial or buccal on labial or buccal mucosamucosa
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Traumatic UlcerTraumatic Ulcer (pgs. 51-53)(pgs. 51-53)
May be due to such events as biting the cheek, May be due to such events as biting the cheek, lip, or tongue, irritation from a complete or partial lip, or tongue, irritation from a complete or partial denture, mucosal injury from sharp edges of food, denture, mucosal injury from sharp edges of food, or removal of a dry cotton roll after a dental or removal of a dry cotton roll after a dental procedure (some patients are sensitive to the procedure (some patients are sensitive to the starch in a cotton roll)starch in a cotton roll) Persistent trauma may cause a hard (indurated), raised Persistent trauma may cause a hard (indurated), raised
traumatic granuloma.traumatic granuloma. TreatmentTreatment
Usually heals within 7 to 14 days unless the trauma Usually heals within 7 to 14 days unless the trauma persistspersists
May require a biopsyMay require a biopsy
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Traumatic Ulcer (cont.)Traumatic Ulcer (cont.)
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Frictional KeratosisFrictional Keratosis (pgs. 52, 54)(pgs. 52, 54)
Due to chronic rubbing or friction against an oral Due to chronic rubbing or friction against an oral mucosal surfacemucosal surface
A form of hyperkeratosisA form of hyperkeratosis Resembles a callus on skinResembles a callus on skin
Results in a opaque white appearanceResults in a opaque white appearance TreatmentTreatment
Identify the traumatic cause of the lesion whether it be an Identify the traumatic cause of the lesion whether it be an opposing third molar, chronic cheek or tongue chewing, opposing third molar, chronic cheek or tongue chewing, or some other entity.or some other entity.
Eliminate the cause.Eliminate the cause. Must be differentiated from idiopathic leukoplakia Must be differentiated from idiopathic leukoplakia
because leukoplakia may be premalignantbecause leukoplakia may be premalignant
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Frictional Keratosis (cont.)Frictional Keratosis (cont.)
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Linea AlbaLinea Alba (pgs. 52, 54)(pgs. 52, 54)
A white, raised line most commonly on the buccal A white, raised line most commonly on the buccal mucosa at the occlusal planemucosa at the occlusal plane May be the result of a teeth clenching habitMay be the result of a teeth clenching habit Sometimes the pattern of the teeth can be seen in the Sometimes the pattern of the teeth can be seen in the
lesion.lesion. Due to epithelial hyperplasia and hyperkeratosisDue to epithelial hyperplasia and hyperkeratosis
TreatmentTreatment NoneNone
May be used to evaluate severity of bruxing May be used to evaluate severity of bruxing and/or tongue thrusting habitand/or tongue thrusting habit
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Linea Alba (cont.)Linea Alba (cont.)
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Nicotinic StomatitisNicotinic Stomatitis (pgs. 52, 55)(pgs. 52, 55)
A benign lesion typically associated with A benign lesion typically associated with pipe and/or cigar smoking; may also occur pipe and/or cigar smoking; may also occur with cigarette smokingwith cigarette smoking Presence indicates increased risk for Presence indicates increased risk for
development of malignancy.development of malignancy. Initially, erythema is seen, but over time Initially, erythema is seen, but over time
keratinization takes place, resulting in keratinization takes place, resulting in increased opacity.increased opacity.• Raised red areas may be seen at the openings of Raised red areas may be seen at the openings of
ducts of minor salivary glands on the palatal surface.ducts of minor salivary glands on the palatal surface. This is due to obstruction by keratin at the mucosal This is due to obstruction by keratin at the mucosal
openings of the ducts. openings of the ducts.
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Nicotinic Stomatitis (cont.)Nicotinic Stomatitis (cont.)
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Tobacco Pouch KeratosisTobacco Pouch Keratosis (pgs. 52, 55)(pgs. 52, 55)
A white lesion located where chewing tobacco is A white lesion located where chewing tobacco is placed, most often in the mucobuccal foldplaced, most often in the mucobuccal fold Early lesions may have a granular or wrinkled Early lesions may have a granular or wrinkled
appearance.appearance. Long standing lesions may be more opaquely white and Long standing lesions may be more opaquely white and
have a corrugated surface.have a corrugated surface. TreatmentTreatment
May require biopsyMay require biopsy• Long-term exposure to chewing tobacco has been Long-term exposure to chewing tobacco has been
associated with increased risk of squamous cell carcinoma.associated with increased risk of squamous cell carcinoma.
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Tobacco Pouch Keratosis (cont.)Tobacco Pouch Keratosis (cont.)
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Traumatic NeuromaTraumatic Neuroma (pg. 53)(pg. 53)
A lesion caused by injury to a peripheral nerveA lesion caused by injury to a peripheral nerve When the nerve sheath of Schwann is disrupted, When the nerve sheath of Schwann is disrupted,
occasionally the proximal end of damaged nerve occasionally the proximal end of damaged nerve proliferates into a mass of nerve and Schwann cells proliferates into a mass of nerve and Schwann cells mixed with dense fibrous scar tissue.mixed with dense fibrous scar tissue.
Painful, ranging from pain on palpation to severe, Painful, ranging from pain on palpation to severe, intractable painintractable pain
DiagnosisDiagnosis Biopsy and microscopic examinationBiopsy and microscopic examination
TreatmentTreatment Surgical excisionSurgical excision
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Amalgam TattooAmalgam Tattoo (pgs. 53, 55)(pgs. 53, 55)
A flat, bluish-gray lesion of oral mucosa due to the A flat, bluish-gray lesion of oral mucosa due to the introduction of amalgam into tissueintroduction of amalgam into tissue May occur during placement or removal of an amalgam May occur during placement or removal of an amalgam
restoration or during an extractionrestoration or during an extraction May be seen in any location in the oral cavity, most May be seen in any location in the oral cavity, most
commonly on gingiva or alveolar ridgecommonly on gingiva or alveolar ridge Amalgam particles may be seen on radiograph, aiding in Amalgam particles may be seen on radiograph, aiding in
diagnosis.diagnosis. DiagnosisDiagnosis
Patient history and radiographs may help.Patient history and radiographs may help. Must be differentiated from malignant melanomaMust be differentiated from malignant melanoma
TreatmentTreatment None providing melanoma has been ruled outNone providing melanoma has been ruled out
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Amalgam Tattoo (cont.)Amalgam Tattoo (cont.)
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MelanosisMelanosis (pgs. 54-55) (pgs. 54-55) (see also pgs. 9, 24 and Figs. 1-18, 1-51)(see also pgs. 9, 24 and Figs. 1-18, 1-51)
Normal physiologic pigmentation of oral Normal physiologic pigmentation of oral mucosamucosa May be geneticMay be genetic May occur as a result of inflammation due to May occur as a result of inflammation due to
retained hemosiderin (a blood pigment) retained hemosiderin (a blood pigment) retained in tissueretained in tissue
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Melanosis (cont.)Melanosis (cont.)
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Melanosis (cont.)Melanosis (cont.) Oral Melanotic MaculeOral Melanotic Macule
A flat, well-circumscribed lesion of unknown A flat, well-circumscribed lesion of unknown causecause• Less than 1 cm in diameterLess than 1 cm in diameter
Smoker’s MelanosisSmoker’s Melanosis Melanin pigmentation associated with smokingMelanin pigmentation associated with smoking
• More common in women than in menMore common in women than in men Most common in anterior labial gingivaMost common in anterior labial gingiva
Melanosis may also be associated with Melanosis may also be associated with genetic, bone, and systemic diseasesgenetic, bone, and systemic diseases..
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Solar Cheilitis (Actinic Cheilitis)Solar Cheilitis (Actinic Cheilitis) (pg. 56)(pg. 56)
A degeneration of the tissue of the lips due to exposure to the sunA degeneration of the tissue of the lips due to exposure to the sun Occurs particularly in fair-skinned individualsOccurs particularly in fair-skinned individuals
The lower lip is usually more involved than the upper lip.The lower lip is usually more involved than the upper lip. The epithelium is thinner than normal; the vermilion appears The epithelium is thinner than normal; the vermilion appears
pale pink and mottled.pale pink and mottled. The interface between lips and skin is indistinct.The interface between lips and skin is indistinct.
TreatmentTreatment No specific treatmentNo specific treatment Biopsy may be indicated for persistent scaling or ulceration.Biopsy may be indicated for persistent scaling or ulceration.
• A relationship is found between these epithelial and A relationship is found between these epithelial and connective tissue changes and the development of basal connective tissue changes and the development of basal cell carcinoma of the skin or squamous cell carcinoma of cell carcinoma of the skin or squamous cell carcinoma of the lips and skin.the lips and skin.
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Solar Cheilitis (Actinic Cheilitis) Solar Cheilitis (Actinic Cheilitis) (cont.)(cont.)
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MucoceleMucocele (pgs. 56-57)(pgs. 56-57)
A lesion that forms when a minor salivary gland duct is damagedA lesion that forms when a minor salivary gland duct is damaged Not a true cystNot a true cyst
• The mucous salivary gland secretion is walled off by granulation The mucous salivary gland secretion is walled off by granulation tissue to form a cystlike structure lined by compressed granulation tissue to form a cystlike structure lined by compressed granulation tissue.tissue.
Most commonly found in the lower lipMost commonly found in the lower lip It may increase or decrease in size over time.It may increase or decrease in size over time. May appear bluish if near the surfaceMay appear bluish if near the surface
TreatmentTreatment If persistent, they are surgically removed.If persistent, they are surgically removed.
May observe a mucus cyst or mucus retention cystMay observe a mucus cyst or mucus retention cyst Usually in people over age 50Usually in people over age 50 Treated by removal of affected salivary glandsTreated by removal of affected salivary glands
These lesions must be differentiated from mucoepidermoid These lesions must be differentiated from mucoepidermoid carcinoma.carcinoma.
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Mucocele (cont.)Mucocele (cont.)
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RanulaRanula (pg. 56) (pg. 56)
A unilateral mucocele-like lesion that forms A unilateral mucocele-like lesion that forms on the floor of the mouthon the floor of the mouth Associated with the ducts of submandibular Associated with the ducts of submandibular
and sublingual glandsand sublingual glands
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Necrotizing SialometaplasiaNecrotizing Sialometaplasia (pgs. 57-58)(pgs. 57-58)
A benign condition of salivary glands A benign condition of salivary glands Moderately painful swelling and ulcerationModerately painful swelling and ulceration Thought to result from blockage of the blood Thought to result from blockage of the blood
supply to the affected areasupply to the affected area• Necrosis of the salivary glands is seen histologically.Necrosis of the salivary glands is seen histologically.• Salivary gland epithelium is replaced by squamous Salivary gland epithelium is replaced by squamous
epithelium (metaplasia).epithelium (metaplasia). The ulcer usually heals by secondary intention.The ulcer usually heals by secondary intention.
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Necrotizing Sialometaplasia (cont.)Necrotizing Sialometaplasia (cont.)
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SialolithSialolith (pgs. 57-59)(pgs. 57-59)
A salivary gland stoneA salivary gland stone May be found in both minor and major salivary May be found in both minor and major salivary
glandsglands Formed by precipitation of calcium salts around Formed by precipitation of calcium salts around
a central corea central core May often be seen on radiographMay often be seen on radiograph
TreatmentTreatment Sometimes the calcification can be “milked” Sometimes the calcification can be “milked”
from the duct.from the duct. It may require surgical removal, this may It may require surgical removal, this may
damage the duct.damage the duct.
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Sialolith (cont.)Sialolith (cont.)
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Acute and Chronic SialadenitisAcute and Chronic Sialadenitis (pg. 58)(pg. 58)
Painful swelling of the involved salivary Painful swelling of the involved salivary gland due to obstruction of the salivary gland due to obstruction of the salivary gland ductgland duct May occur as result of infectionMay occur as result of infection
DiagnosisDiagnosis May involve injection of a radiopaque dye into May involve injection of a radiopaque dye into
the gland followed by a radiograph the gland followed by a radiograph (sialography)(sialography)
TreatmentTreatment May require antibioticsMay require antibiotics
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Reactive Connective Tissue Reactive Connective Tissue HyperplasiaHyperplasia
(pgs. 58-63)(pgs. 58-63) Pyogenic GranulomaPyogenic Granuloma Giant Cell GranulomaGiant Cell Granuloma Irritation FibromaIrritation Fibroma Denture-Induced Fibrous HyperplasiaDenture-Induced Fibrous Hyperplasia Papillary Hyperplasia of the PalatePapillary Hyperplasia of the Palate Gingival EnlargementGingival Enlargement Chronic Hyperplastic PulpitisChronic Hyperplastic Pulpitis
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Reactive Connective Tissue Reactive Connective Tissue Hyperplasia (cont.)Hyperplasia (cont.)
(pg. 58)(pg. 58) Proliferating, exuberant granulation tissue Proliferating, exuberant granulation tissue
and dense fibrous connective tissue and dense fibrous connective tissue resulting from overzealous repairresulting from overzealous repair May be a response to a single event or chronic May be a response to a single event or chronic
low-grade injurylow-grade injury
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Pyogenic GranulomaPyogenic Granuloma (pgs. 58-59)(pgs. 58-59)
A proliferation of connective tissue A proliferation of connective tissue containing numerous blood vessels and containing numerous blood vessels and inflammatory cells occurring as a response inflammatory cells occurring as a response to injuryto injury The name is a misnomer; the lesion is neither The name is a misnomer; the lesion is neither
pyogenic (pus forming) nor a true granuloma.pyogenic (pus forming) nor a true granuloma.
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Pyogenic Granuloma (cont.)Pyogenic Granuloma (cont.)
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Pyogenic Granuloma (cont.)Pyogenic Granuloma (cont.) The lesion is usually ulcerated, soft to palpation, The lesion is usually ulcerated, soft to palpation,
and bleeds easily.and bleeds easily. It is deep red to purple.It is deep red to purple. Generally elevated, may be sessile or pedunculatedGenerally elevated, may be sessile or pedunculated Most commonly observed on the gingiva, it may be seen Most commonly observed on the gingiva, it may be seen
on other intraoral areason other intraoral areas May vary in size from a few millimeters to several May vary in size from a few millimeters to several
centimeterscentimeters Usually develop rapidly and then remain staticUsually develop rapidly and then remain static Most common in teenagers and young adults, but may Most common in teenagers and young adults, but may
occur at any ageoccur at any age If seen in a pregnant female, it is called a pregnancy If seen in a pregnant female, it is called a pregnancy
tumor.tumor. TreatmentTreatment
Surgically excised if it does not regress spontaneouslySurgically excised if it does not regress spontaneously
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Pregnancy TumorPregnancy Tumor
(pg. 58)(pg. 58) A pyogenic granuloma seen in a pregnant A pyogenic granuloma seen in a pregnant
womanwoman The lesions are identical to those seen in men The lesions are identical to those seen in men
and nonpregnant women.and nonpregnant women. May be caused by hormonal changes and May be caused by hormonal changes and
increased response to plaqueincreased response to plaque They often regress after delivery.They often regress after delivery.
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Pregnancy Tumor (cont.)Pregnancy Tumor (cont.)
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Peripheral Giant Cell GranulomaPeripheral Giant Cell Granuloma
(pgs. 58, 60)(pgs. 58, 60) A lesion that contains many A lesion that contains many
multinucleated giant cells, well-multinucleated giant cells, well-vascularized connective tissue, RBCs, vascularized connective tissue, RBCs, and chronic inflammatory cellsand chronic inflammatory cells Occurs only in the jawsOccurs only in the jaws Seems to originate from periodontal Seems to originate from periodontal
ligament or periosteum in response to ligament or periosteum in response to injuryinjury
Peripheral Peripheral Lesions occurring outside of boneLesions occurring outside of bone
CentralCentral Lesions within bone of the mandible or Lesions within bone of the mandible or
maxillamaxilla
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Peripheral Giant Cell Granuloma Peripheral Giant Cell Granuloma (cont.)(cont.)
Occurs on gingiva or alveolar process, Occurs on gingiva or alveolar process, usually anterior to the molarsusually anterior to the molars Vary in size from 0.5 to 1.5 cmVary in size from 0.5 to 1.5 cm Usually dark red from vascularizationUsually dark red from vascularization Most frequent in people from 40 to 60 years of Most frequent in people from 40 to 60 years of
age age More common in women than in menMore common in women than in men
TreatmentTreatment Surgical excisionSurgical excision
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Central Giant Cell GranulomaCentral Giant Cell Granuloma (pgs. 58)(pgs. 58)
Occurs within the bone of the maxilla or mandibleOccurs within the bone of the maxilla or mandible Most frequent in children and young adultsMost frequent in children and young adults
• More common in females than in malesMore common in females than in males Pain is not a common feature.Pain is not a common feature. Usually discovered on routine radiographsUsually discovered on routine radiographs
• RadiolucentRadiolucent• Borders may be sclerotic or ill-defined.Borders may be sclerotic or ill-defined.• Lesion may be unilocular or multilocular.Lesion may be unilocular or multilocular.• May cause divergence of roots of adjacent teethMay cause divergence of roots of adjacent teeth
Treatment Treatment Surgical removalSurgical removal May recurMay recur
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Irritation FibromaIrritation Fibroma (pgs. 60-61)(pgs. 60-61)
The most common mass on the The most common mass on the gingivagingiva A broad-based, persistent A broad-based, persistent
exophytic lesion composed of exophytic lesion composed of dense, scarlike connective tissue dense, scarlike connective tissue with few blood vesselswith few blood vessels• The result of trauma such as cheek The result of trauma such as cheek
chewing or cheek bitingchewing or cheek biting Usually a small lesion, less than 1 Usually a small lesion, less than 1
cm in diametercm in diameter• Most often occurs on buccal mucosaMost often occurs on buccal mucosa
May occur on tongue, lips, and palateMay occur on tongue, lips, and palate
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Irritation Fibroma (cont.)Irritation Fibroma (cont.) Usually lighter than surrounding mucosaUsually lighter than surrounding mucosa
• The surface is covered by stratified squamous The surface is covered by stratified squamous epithelium.epithelium.
May be opaque if thick or ulcerated due to local May be opaque if thick or ulcerated due to local secondary traumasecondary trauma
TreatmentTreatment Surgically removedSurgically removed Must be differentiated from many soft tissue Must be differentiated from many soft tissue
tumorstumors
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Denture-Induced Fibrous Hyperplasia (Epulis Denture-Induced Fibrous Hyperplasia (Epulis fissuratum) (Inflammatory hyperplasia)fissuratum) (Inflammatory hyperplasia)
(pgs. 60-61)(pgs. 60-61) Observed in the vestibule as elongated Observed in the vestibule as elongated
folds of tissue into which of an ill-fitting folds of tissue into which of an ill-fitting denture fitsdenture fits Composed of dense, fibrous connective tissue Composed of dense, fibrous connective tissue
with a surface of stratified squamous with a surface of stratified squamous epitheliumepithelium
The surface may be ulcerated.The surface may be ulcerated. TreatmentTreatment
Surgical removal of excess tissue and Surgical removal of excess tissue and construction of a new dentureconstruction of a new denture
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Denture-Induced Fibrous Hyperplasia (Epulis Denture-Induced Fibrous Hyperplasia (Epulis fissuratum) (Inflammatory hyperplasia) (cont.)fissuratum) (Inflammatory hyperplasia) (cont.)
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Papillary Hyperplasia of the Palate Papillary Hyperplasia of the Palate (Palatal papillomatosis)(Palatal papillomatosis)
(pgs. 60-62)(pgs. 60-62) Almost always associated with a removable full or Almost always associated with a removable full or
partial denture or orthodontic appliance that is partial denture or orthodontic appliance that is worn continuouslyworn continuously The palatal vault is covered by multiple papillary The palatal vault is covered by multiple papillary
projections.projections.• Each projection consists of fibrous connective tissue, Each projection consists of fibrous connective tissue,
usually chronically inflamed and surfaced by stratified usually chronically inflamed and surfaced by stratified squamous epithelium.squamous epithelium.
The cause is unknown.The cause is unknown. TreatmentTreatment
Surgical removal of the projections prior to construction Surgical removal of the projections prior to construction of a new dentureof a new denture
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Papillary Hyperplasia of the Palate Papillary Hyperplasia of the Palate (Palatal papillomatosis) (cont.)(Palatal papillomatosis) (cont.)
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Gingival EnlargementGingival Enlargement (pgs. 61-62)(pgs. 61-62)
An increase in the bulk of free and An increase in the bulk of free and attached gingiva, especially the interdental attached gingiva, especially the interdental papillaepapillae Gingival margins are rounded.Gingival margins are rounded. Color may vary from normal pink to pale or Color may vary from normal pink to pale or
erythematous depending upon the degree of erythematous depending upon the degree of inflammation and vascularity.inflammation and vascularity.
May be generalized or localizedMay be generalized or localized
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Gingival Enlargement (cont.)Gingival Enlargement (cont.)
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Gingival Enlargement (cont.)Gingival Enlargement (cont.) May vary from focal enlargement of interdental papillae May vary from focal enlargement of interdental papillae
to severe generalized gingival enlargement that may to severe generalized gingival enlargement that may cover the crowns of teethcover the crowns of teeth
Usually an unusual tissue response to chronic Usually an unusual tissue response to chronic inflammation associated with local irritants such inflammation associated with local irritants such as plaque or calculusas plaque or calculus
May be from an increased response to local May be from an increased response to local tissue factors due to tissue factors due to Hormonal changes during pregnancy or pubertyHormonal changes during pregnancy or puberty Certain drugs such as phenytoin, calcium channel Certain drugs such as phenytoin, calcium channel
blockers, and cyclosporineblockers, and cyclosporine May be hereditaryMay be hereditary
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Gingival Enlargement (cont.)Gingival Enlargement (cont.) TreatmentTreatment
GingivoplastyGingivoplasty• Reshaping the gingivaReshaping the gingiva
GingivectomyGingivectomy• Removing gingival tissueRemoving gingival tissue
Tissue may need to undergo a biopsy to Tissue may need to undergo a biopsy to rule out gingival enlargement seen in rule out gingival enlargement seen in individuals with leukemia.individuals with leukemia.
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Chronic Hyperplastic PulpitisChronic Hyperplastic Pulpitis (Pulp polyp) (Pulp polyp)
(pg. 62)(pg. 62) An excessive proliferation of chronically An excessive proliferation of chronically
inflamed dental pulp tissueinflamed dental pulp tissue In children and young adults, it occurs in teeth In children and young adults, it occurs in teeth
with large, open carious lesions often in with large, open carious lesions often in primary and permanent molars.primary and permanent molars.
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Chronic Hyperplastic PulpitisChronic Hyperplastic Pulpitis (Pulp polyp) (cont.) (Pulp polyp) (cont.)
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Chronic Hyperplastic PulpitisChronic Hyperplastic Pulpitis A red or pink nodule that fills the entire A red or pink nodule that fills the entire
cavity of the tooth, with tissue protruding cavity of the tooth, with tissue protruding from the pulp chamberfrom the pulp chamber Usually asymptomaticUsually asymptomatic May be related to the large root opening and May be related to the large root opening and
blood supply of the involved toothblood supply of the involved tooth Primarily granulation tissue surfaced by a Primarily granulation tissue surfaced by a
stratified squamous epitheliumstratified squamous epithelium TreatmentTreatment
Extraction or endodontic treatment of the Extraction or endodontic treatment of the involved toothinvolved tooth
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Inflammatory Periapical LesionsInflammatory Periapical Lesions
Periapical AbscessPeriapical Abscess Dental or Periapical GranulomaDental or Periapical Granuloma Radicular Cyst (Periapical Cyst)Radicular Cyst (Periapical Cyst) Resorption of TeethResorption of Teeth Focal Sclerosing OsteomyelitisFocal Sclerosing Osteomyelitis Alveolar Osteitis (“Dry Socket”)Alveolar Osteitis (“Dry Socket”)
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Inflammatory Periapical Lesions Inflammatory Periapical Lesions (cont.) (cont.)
(pg. 63)(pg. 63) Caries or trauma may result inCaries or trauma may result in
InflammationInflammation InfectionInfection Chronic hyperplastic pulpitisChronic hyperplastic pulpitis Necrosis of the pulpNecrosis of the pulp
The inflammatory process begins in pulp The inflammatory process begins in pulp and then extends to the periapical area.and then extends to the periapical area. Accessory canals may lead to areas of Accessory canals may lead to areas of
inflammation on the lateral portion of the root.inflammation on the lateral portion of the root.
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Periapical AbscessPeriapical Abscess (pgs. 38, 63)(pgs. 38, 63)
Purulent exudate surrounded by Purulent exudate surrounded by connective tissue containing neutrophils connective tissue containing neutrophils and lymphocytesand lymphocytes Inflammation produces severe pain.Inflammation produces severe pain.
May develop directly from inflammation in May develop directly from inflammation in the pulpthe pulp More commonly develops in an area of More commonly develops in an area of
previously existing chronic inflammationpreviously existing chronic inflammation
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Periapical Abscess (cont.)Periapical Abscess (cont.)
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Periapical Abscess (cont.)Periapical Abscess (cont.) The pus may cause a fistula to form.The pus may cause a fistula to form.
The tooth may be extruded.The tooth may be extruded. If the acute abscess forms directly from If the acute abscess forms directly from
pulpal inflammationpulpal inflammation There may be no radiographic changes except There may be no radiographic changes except
for a slight thickening of the apical periodontal for a slight thickening of the apical periodontal ligament space.ligament space.
If the abscess forms in a preexisting area If the abscess forms in a preexisting area of periapical chronic inflammation of periapical chronic inflammation A distinct radiographic lucency may be seen at A distinct radiographic lucency may be seen at
the apex.the apex.
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Periapical AbscessPeriapical Abscess TreatmentTreatment
May require incision and drainage of the May require incision and drainage of the abscessabscess
Endodontics or extractionEndodontics or extraction
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Dental or Periapical GranulomaDental or Periapical Granuloma (pgs. 63-64)(pgs. 63-64)
A localized mass of chronically inflamed A localized mass of chronically inflamed granula that forms at the opening of the granula that forms at the opening of the pulp canal, generally at the apex of a pulp canal, generally at the apex of a nonvital tooth rootnonvital tooth root Granulation tissue with lymphocytes, plasma Granulation tissue with lymphocytes, plasma
cells and macrophages – neutrophils may be cells and macrophages – neutrophils may be presentpresent
Usually asymptomaticUsually asymptomatic May be sensitive to pressure or percussionMay be sensitive to pressure or percussion
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Dental or Periapical Granuloma Dental or Periapical Granuloma (cont.)(cont.)
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Dental or Periapical Granuloma Dental or Periapical Granuloma (cont.)(cont.)
The tooth may be slightly extruded from The tooth may be slightly extruded from the socket.the socket.
RadiographicRadiographic May vary from slight thickening of the May vary from slight thickening of the
periodontal ligament space to a diffuse periodontal ligament space to a diffuse radiolucency, to a distinct, well-circumscribed radiolucency, to a distinct, well-circumscribed radiolucency surrounding the root apexradiolucency surrounding the root apex
TreatmentTreatment Endodontia or extractionEndodontia or extraction
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Radicular Cyst (Periapical Cyst)Radicular Cyst (Periapical Cyst)
(pgs. 64-65)(pgs. 64-65) A true epithelium-lined cystA true epithelium-lined cyst
Associated with the root of a nonvital toothAssociated with the root of a nonvital tooth The most commonly occurring cyst in the The most commonly occurring cyst in the
oral regionoral region A result of proliferation of the rests of MalassezA result of proliferation of the rests of Malassez Usually asymptomatic and discovered on Usually asymptomatic and discovered on
radiographradiograph
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Radicular Cyst (Periapical Cyst) Radicular Cyst (Periapical Cyst) (cont.)(cont.)
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Radicular CystRadicular Cyst RadiographicRadiographic
The appearance is the same as for a periapical The appearance is the same as for a periapical granuloma.granuloma.
TreatmentTreatment Endodontia, apicoectomy, or extraction and Endodontia, apicoectomy, or extraction and
curettage of periapical tissuecurettage of periapical tissue
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Resorption of TeethResorption of Teeth (pgs. 65-66)(pgs. 65-66)
May occur when inflammation is presentMay occur when inflammation is present Occurs in deciduous teeth during exfoliationOccurs in deciduous teeth during exfoliation
Can occur with excessive occlusal or Can occur with excessive occlusal or orthodontic forces or with benign or orthodontic forces or with benign or malignant tumorsmalignant tumors Rapid orthodontic movement in an adult may Rapid orthodontic movement in an adult may
cause external root resorptioncause external root resorption A reimplanted tooth will resorb.A reimplanted tooth will resorb. May be classified as external or internalMay be classified as external or internal
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External Root ResorptionExternal Root Resorption (pg. 65)(pg. 65)
Initially appears as a slight Initially appears as a slight raggedness or blunting of the raggedness or blunting of the root apexroot apex Not reversibleNot reversible Progression can be avoided if Progression can be avoided if
the cause is identified and the cause is identified and removedremoved
Impacted teeth may resorb.Impacted teeth may resorb.
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Internal Tooth or Root ResorptionInternal Tooth or Root Resorption
(pg. 65) (pg. 65) Idiopathic, thought to be associated with an Idiopathic, thought to be associated with an
inflammatory response in the pulpinflammatory response in the pulp If seen within the crown, the tooth will appear pink due If seen within the crown, the tooth will appear pink due
to inflamed vascular connective tissue “Pink tooth of to inflamed vascular connective tissue “Pink tooth of Mummery.”Mummery.”
If seen within the root, it will be seenIf seen within the root, it will be seen radiographically. radiographically. TreatmentTreatment
If the root is not perforated, calcium hydroxide is placed If the root is not perforated, calcium hydroxide is placed and endodontics performed in an attempt to save the and endodontics performed in an attempt to save the tooth.tooth.
If the tooth is perforated, it must be removed. If the tooth is perforated, it must be removed.
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Focal Sclerosing Osteomyelitis Focal Sclerosing Osteomyelitis (Condensing Osteitis)(Condensing Osteitis)
(pgs. 65-66)(pgs. 65-66) A change in the bone A change in the bone
near the apices of teethnear the apices of teeth Thought to be a reaction to Thought to be a reaction to
low-grade infectionlow-grade infection Generally asymptomatic; Generally asymptomatic;
if painful, may be if painful, may be associated with pulpal associated with pulpal inflammatory diseaseinflammatory disease
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Focal Sclerosing OsteomyelitisFocal Sclerosing Osteomyelitis RadiographicRadiographic
Appears as a radiopaque area, most Appears as a radiopaque area, most commonly associated with the mandibular first commonly associated with the mandibular first molarmolar
Borders may be diffuse or well-definedBorders may be diffuse or well-defined TreatmentTreatment
Usually not necessaryUsually not necessary Biopsy may be required to rule out other Biopsy may be required to rule out other
radiopaque lesions such as osteoma, complex radiopaque lesions such as osteoma, complex odontoma, or ossifying fibroma.odontoma, or ossifying fibroma.
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Alveolar Osteitis (“Dry Socket”)Alveolar Osteitis (“Dry Socket”)
(pg. 66)(pg. 66) A postoperative complication following tooth A postoperative complication following tooth
removal.removal. Most often in the area of the mandibular third molarMost often in the area of the mandibular third molar
The blood clot is lost before healing can take The blood clot is lost before healing can take place, leaving raw, exposed nerve endings.place, leaving raw, exposed nerve endings. The patient may complain of pain, bad odor, and bad The patient may complain of pain, bad odor, and bad
taste.taste. TreatmentTreatment
Daily application of Dry Socket Paste containing Daily application of Dry Socket Paste containing eucalyptol until symptoms are relievedeucalyptol until symptoms are relieved
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Discussion Questions Discussion Questions What cells appear first during an inflammatory What cells appear first during an inflammatory
response?response? What is the difference between healing by primary, What is the difference between healing by primary,
secondary, and tertiary intention?secondary, and tertiary intention? What is the difference between regeneration and repair?What is the difference between regeneration and repair? What is the difference between attrition, abrasion, and What is the difference between attrition, abrasion, and
erosion?erosion? What injuries to oral soft tissues may be observed within What injuries to oral soft tissues may be observed within
the oral cavity?the oral cavity? What is the definition of reactive tissue hyperplasia and What is the definition of reactive tissue hyperplasia and
what forms may be observed within the oral cavity?what forms may be observed within the oral cavity? What inflammatory periapical lesions may be observed What inflammatory periapical lesions may be observed
within the oral cavity?within the oral cavity?