PHYSICAL & CHEMICAL INJURIES OF ORAL CAVITY

PREPARED BY : RAJNISH SINGH & RAKHEE SAWHNEY

PHYSICAL INJURIES OF ORAL CAVITY

(A) PHYSICAL INJURIES OF TEETH
1.BRUXISM
(i) (ii) Also known as NIGHT-GRINDING or BRUXOMANIA Habitual grinding or clenching of the teeth either during sleep or as an unconscious habit during walking hours Incidence - 5% & 20% ETIOLOGY Local factors Malocclusion Systemic factors - Nutritional deficiency - GIT disturbances - Endocrinal disturbances - Allergy - Hereditary Psychological factors - Anxiety - Stress - Emotional Tension - Fear - Rage - Rejection

(iii)

(iv) Occupations - Athletes - Watch Makers - Other persons associated with precise work - Voluntary Bruxism seen in persons having habit of chew gum, tobacco, toothpicks, pencils etc

(a) (a) (b) (c) (d) (e)

CLINICAL FEATURES History of clenching during sleep or walking hours is given by patient The symptomatic effects of this habit have been reviewed by GLAROS & RAO, who divide them into 6 major categories: Effects on the dentition - severe attrition at occlusal & proximal surfaces - loosening & drifting of teeth Effects on the periodontium- gingival recession Effects on the masticatory muscles - fatigue of muscles Effects on TMJ Head pain Psychological & behavioral effects TREATMENT Removable splint should be worn at night Correction of underlying causes should be done

2. FRACTURES OF TEETH
CAUSES Traumatic episodes It occurs frequently after endodontic treatment due to brittle nature of non vital tooth CLINICAL FEATURES Mostly seen in children & maxillary teeth are affected mostly Class-1 - Simple fracture of the crown, involving little or no dentin Class-2 - Extensive fracture of the crown, involving considerable dentin but not the dental pulp Class-3 - Extensive fracture of the crown, involving considerable dentin & exposing the dental pulp Class-4 - The traumatized tooth becomes non vital, with or without loss of crown structure Class-5 - Teeth lost as a result of trauma Class-6 - Fracture of the root, with or without loss of crown structure

Class-7 - Displacement of a tooth, without fracture of crown or root

Class-8 - Fracture of the crown en masse & its replacement Class-9 - Traumatic injuries to deciduous teeth

TOOTH FRACTURE

HISTOLOGICAL FEATURES Histological features during healing are similar to that of bony fractures Clot is organized with deposit of cementum & bone, later restoration & remodeling at ends of fragments occurs TREATMENT If enamel is fractured - Restoration of missing tooth structure is done If dentin is involved - Placement of sedative base (zinc oxide eugenol) is done at fractured dentin & tooth is restored If pulp is involved - Pulp capping - Pulpotomy (coronal pulp removal) - Pulpectomy

3. INJURIES TO THE SUPPORTING STRUCTURES OF THE TOOTH

CONCUSSION - produce by injury which is not strong enough to cause serious, visible damage to the tooth & the periodontal structures Characteristic feature- increased sensitivity of tooth to percussion Treatment - selective grinding of tooth to eliminate occlusal forces

SUBLUXATION - abnormal loosening of tooth without displacement due to sudden trauma - Tooth is mobile on palpation & sensitive to percussion & occlusal forces - tooth becomes nonvital due to severance of apical blood supply AVULSION - dislocation of the tooth from its socket due to traumatic injury - partial or total - Partial includes-intrusion, extrusion or facial, lingual or palatal or lateral displacement - mainly accompanied by fracture of alveolar bone

4. TOOTH ANKYLOSIS
Fusion of tooth with bone Occur mainly after any traumatic episode (occlusal trauma) or periapiucal inflammatory processes or after RCT
CLINICAL FEATURES

Tooth shows lack of mobility There may be evidence of pulpal ds. Percussion over tooth gives characteristic solid sound Deciduous tooth if affected becomes submerged b/c of eruption of adjacent permanent teeth & growth of dental arch

1
RADIOGRAPHIC FEATURES Blending of bone with tooth root is in radiograph HISTOLOGICAL FEATURES Area of root resorption is found, which have been repaired by bony tissues or cementum TREATMENT AND PROGNOSIS There is no treatment for ankylosis Good prognosis Unless removed for some other reason, should serve well indefinitely

(B) PHYSICAL INJURIES OF BONE

1. FRACTURES OF JAW
Commonly due to automobile, industrial & sports accidents & fight Easily occur in bones which are already weakened by developmental & systemic disorders May be - Simple - bone is broken completely - overlying structure are intact & not exposed to exterior

-Greenstick - common in children - characterized by break of bone in on side & bend on the other side - Compound - external wound in associated with the break - e.g road traffic accidents - comminuted - bone is crushed - may or may not be exposed to exterior a) Mandible is more prone for fractures FRACTURES OF MAXILLA - More serious - In Road traffic accidents, blow, fall & industrial accidents - Extent of fracture is determined by - Direction , force & location *CLASSIFICATION 1. Le Fort-I / Horizontal Fracture / Floating Fracture - separation of body of maxilla from base of skull below the level of zygomatic process 2. Le Fort-II / Pyramidal Fracture - vertical fractures through the facial aspects of maxilla & extend upward to nasal & ethmoid bones & usually extend from maxillary sinus

3. Le Fort III / Transverse Fracture - high level fracture that extends across the orbits through the base of the nose & ethmoid region to the zygomatic arch - bony orbit is fractured & the lateral rim is separated at the zygomaticofrontal suture - zygomatic arch is fractured Common Features - Displacement, anterior open bite, swollen face, reddish eye due to subcojuntival hemorrhage & nasal hemorrhage - If skull is involved - unconsciousness, cerebrospinal fluid rhinorrhea b) FRACTURES OF MANDIBLE - mostly involve angle of mandible followed by condyle, molar region,mental region & symphosis - displacement of mandible depends on direction of the line of fracture, muscle pull & direction of force Clinical Features of mandibular fracture Pain during movement Occlusal derangement Abnormal mobility Gingival lacerations Crepitus on movement Trismus Loss of sensation of involved side Ecchymosis

Treatment Immobilization of fractured bone Complications Nonunion Malunion Fibrous union

2. TRAUMATIC CYST (SOLITARY CONE CYST, HEMORRHAGIC CYST, EXTRAVASATION CYST, UNICAMERAL BONE CYST, SIMPLE BONE CYST, IDIOPATHIC BONE CAVITY)
Is a pseudo cyst (lack epithelial lining) & an uncommon lesion comprises about 1% of all jaw cyst Occur in other bones of skeleton as well ETIOLOGY

unknown THE TRAUMA HEMORRHAGE THEORY in widely accepted theory

Trauma heals by organization of clot eventual formation of connective tissue & new bone Acc. to the theory, clot breaks down & leaves empty cavity within the bone - steady expansion of lesion occurs secondary to altered or obstructed lymphatic or venous drainage - this expansion tends to cease when the cyst-like lesion reaches the cortical layer of bone - expansion of involved bone is not a common finding in this TIME LAG B/W INJURY & DISCOVERY OF THE LESION - 1 MONTH to 20 YEARS CLINICAL FEATURES Occurs most frequently in young persons Maxilla mainly develops it Swelling or rarely pain HISTOLOGICAL FEATURES Thin connective tissue membrane lining the cavity There may be presence of few RBCs, blood pigments or giant cells adhering to the bone surface TREATMENT & PROGNOSIS 6 to 8 months for filling of space after surgery In large spaces, bony chips are used

TRAUMATIC CYST

3. FOCAL OSTEOPOROTIC BONE-MARROW DEFECT OF THE JAW

Defect of bone closely associated with chronic anemia Jaw marrow starts haemopoiesis in response of anemia leading to this defect CLINICAL FEATURES Asymptomatic condition Females are more affected (75%) Mandible is affected more than maxilla (85%) RADIOGRAPHIC FEATURES Poorly defined radiolucency that is found at molar area, a few mm to cm or more Poorly defined periphery HISTOLOGICAL FEATURES Normal red marrow, fatty marrow or both Trabeculae of bone present in sections are long, thin, irregular & devoid of osteoblastic layer Megakaryocytes & small lymphoid aggregates may present TREATMENT No treatment is necessary

FOCAL OSTEOPOROTIC BONE MARROW DEFECT OF JAW

4. SURGICAL CILIATED CYST OF MAXILLA ( SINUS MUCOCELE )

Sometimes epithelial cells get implanted in maxillary sinus during surgical access maxillary sinus When these cells proliferate they form a cyst there CLINICAL FEATURES Middle aged or older patients are mostly affected Nonspecific, poorly localized pain, tenderness or discomfort in the maxilla Extraoral or intraoral swelling 10-20 years after surgery of maxilla or maxillary sinus when mucocele is infected, the lesion is called MUCOPYOCELE Common in Japan RADIOLOGICAL FEATURES Well defined radiolucency close to maxillary sinus is seen This radiolucency is anatomically separated from sinus A filling defect of cyst can be seen after injecting radiopaque material in sinus HISTOLOGICAL FEATURES Cyst lining is formed by pseudostratified ciliated columnar ep. Squamous metaplasia may be found if infection or inflammation is present Cyst wall is composed of fibrous connective tissue with or without inflammatory cell infiltration

SURGICAL CILIATED CYST OF MAXILLA

TREATMENT Enucleation of cyst. It doesnt tend to reoccur

(C) PHYSICAL INJURIES TO SOFT TISSUES

1. LINEA ALBA
White line seen on the buccal mucosa extending from the commissures posteriorly at the level of occlusal plane Caused by physical irritation & pressure exerted by the posterior teeth Usually bilateral More pronounced in persons having clenching habit or bruxism Histologically - Hyperkeratosis & intracellular edema of epithelium is seen

2. TOOTHBRUSH TRAUMA
Occurs to gingiva & produced by toothbrush Appears as white, reddish or ulcerative lesions or linear superficial erosions, involving marginal or attached gingiva of maxillary canine & premolar region HISTOLOGICAL FEATURE Focal ulceration with formation of granulation tissue with diffuse chronic inflammatory cell infiltration Epithelium shows hyperkeratosis & acanthosis adjacent to the ulcers

LINEA ALBA

TREATMENT Symptomatic treatment Teaching proper brushing technique

3. TRAUMATIC ULCERS ( DECUBITUS ULCERS)

Ulcers of mucous membrane formed due to traumatic injury MOST COMMON SITES ARE : Lateral borders of tongue At occlusal level of teeth in buccal mucosa Lips TRAUMA MAY BE DUE TO: Sharp teeth Cheek or lip biting TREATMENT No treatment is required as these ulcers heal within 7 to 10 days Symptomatic relief can be provided by lignocaine or any other topical anesthetic gel

TRAUMATIC ULCER

4. FACTITIAL OR SELF-INDUCED INJURIES

MAY INCLUDE: Lip biting (morsicatio labiorum) Cheek biting (morsicatio buccarum) May be habitual, accidental or psychological LIP & CHEEK BITING Holding, biting & tearing of epithelium of lip, buccal mucosa, or tongue, chewing of cheek or stripping of epithelium using fingers & creating negative pressure by sucking the lips & cheeks Gingiva may also be involved CLINICAL FEATURES Usually bilateral along the occlusal line & vestibular surface of lips Mucosa appears white & shredded with areas of redness Ulceration is common More prominent in females HISTOLOGICAL FEATURES Extensive areas of hyperkeratosis with keratin projections Chronic inflammatory cell infiltration seen in areas of ulceration

TREATMENT Counseling & psychotherapy are treatment of choice An acrylic shield will help to prevent the access of teeth to lips & cheeks

5. DENTURE INJURIES
Caused by denture wearing CAN APPEAR AS: a) Traumatic ulcer (Sore spots) b) Generalized inflammation (Denture sore mouth, Denture stomatitis) c) Inflammatory (fibrous) hyperplasia (Denture injury tumor, epulis fissuratum, redundant tissue) d) Inflammatory papillary hyperplasia (Palatal papillomatosis) e) Denture base intolerance or Allergy a) TRAUMATIC ULCER (SORE SPOTS) Caused due to: - either sharp spicules of bone or high spot on inner aspect of denture - over extended flanges may also cause sore spots at vestibular area CLINICAL FEATURES - Ulcers are small, painful & irregular - covered by grey necroting membrane

SORE MOUTH

TREATMENT - Correction of underlying cause - relief of the flange - removal of high spots

b) GENERALIZED INFLAMMATION (DENTURE SORE MOUTH, DENTURE STOMATITIS) - Characterized by burning erythematous granular mucosa, restricted to area beneath the denture CAUSES - Candida albicans - Saliva retention in glands TREATMENT - Not successful - denture surface is covered with topical nystatin coating - For oral condition nystatin tablets(500,000 IU) should de dissolved in mouth* TDS* 14 days

C) INFLAMMATORY (FIBROUS) HYPERPLASIA (DENTURE INJURY TUMOR, EPULIS FISSURATUM, REDUNDANT TISSUE) One of the most common tissue rxn to a chronically ill-fitting denture Occur on buccal mucosa gingiva & angle of mouth

FIBROUS HYPERPLASIA

CLINICAL FEATURES - mucolabial or mucobucal folds may develop excessive enlarged folds of tissues HISTOLOGICAL FEATURES -excessive fibrous connective tissues - hyperkeratosis is present - pseudoepitheliomatous hyperplasia is often found - connective tissue is composed of coarse bundles of collagen fibres with new fibroblasts or blood vessels TREATMENT - Surgical excision of excessive tissues - New denture should be made

d) INFLAMMATORY PAPILLARY HYPERPLASIA (PALATAL PAPILLOMATOSIS) It is the condition in palatal mucosa associated with many erythematous & oedamatous papillary projections. It is predominantly see in edentulous patients CAUSES - Ill fitting dentures

PALATAL PAPILLOMATOSIS

HISTOLOGICAL FEATURES - papillary projections of keratinized stratified squamous epithelium with vascular connective tissue present TREATMENT - construction of new denture

E) DENTURE BASE INTOLERANCE / ALLERGY Allergy may be due to denture base material as in cobalt chromium alloy, it may be due to nickel or in vulcanite dentures, it may be due to sulphur CLINICAL FEATURES - generalized inflammation of area in contact with denture TREATMENT - First determine the cause of allergy then reconstruct the denture with minimal or no use of that material

6. MUCOUS RETENTION PHENOMENON (MUCOCELE, MUCOUS RETENTION CYST)

It is the most common type of salivary & soft tissue cyst It is either due to retention of mucous or extravasation of mucous into surrounding tissues

ETIOLOGY Obstruction (such as salivary calculi) in duct of salivary gland Trauma due to cheek biting or lip biting Scar after trauma may also cause retention of mucous in gland CLINICAL FEATURES Occur most frequently on the lower lip May also occur on the palate, cheek, tongue(involving glands of Blandin-Nuhn) & floor of mouth Superficial lesion appears as a raised, circumscribed vesicle, several millimeters to a centimeter or more in diameter with bluish, translucent cast Deeper lesion appears as swelling with normal color PATHOGENESIS Pathogenesis of Retention Cyst Obstruction of duct -> Pooling of mucous glands -> Retention cyst is formed Pathogenesis of Extravasation Cyst Trauma to Duct -> Mucous escapes in surrounding tissues -> Chronic Inflammation -> Granulation Tissue formation around mucous without epithelial lining -> Extravasation Cyst HISTOLOGICAL FEATURES Retention cyst is surrounded by epithelial lining No epithelial lining is seen in case of extravasation cyst TREATMENT Excision of cyst is done completely with underlying salivary gland acini

LIP MUCOCELE

TONGUE MUCOCELE

7. RANULA
It is a form of mucocele but larger, specifically occur in the floor of mouth in association of ducts of submaxillary or sublingual glands CLINICAL FEATURES Unilateral Develops as a slowly enlarging painless mass on floor of mouth In superficial lesions, mucosa may have a translucent bluish color Deep lesion appear normal May interfere with speech & mastication HISTOLOGICAL FEATURES Similar to mucocele except that a definite lining is sometimes present TREATMENT & PROGNOSIS Treatment either marsupialization or more often excision of the entire sublingual gland

8. RETENTION CYST OF MAXILLARY SINUS (Secretory cyst of maxillary antrum, mucocele of maxillary sinus, mucosalcyst of maxillary sinus)
These are mucous retention cysts of mucous glands, lining the maxillary sinus CLINICAL FEATURES asymptomatic

RANULA

Discomfort in cheek or maxilla may be present Pain & soreness of face & teeth & numbness of upper lip RADIOLOGICAL FEATURES Lesion appears as a well-defined, homogenous, dome-shaped or hemispheric radiopacity, varying in size from a tiny lesion to one completely filling the antrum, arising from antrum & superimposed on it TREATMENT Cysts either persists unchanged or disappears spontaneously within a relatively short period No treatment is necessary

9. SIALOLITHIASIS (Salivary duct stone, Salivary duct calculus)

A stone in salivary ducts or glands is called Sialolithiasis Formed by deposition of calcium salts around a central nidus(formed by bacteria, debris, foreign bodies or epithelial cells) CLINICAL FEATURES Severe pain occurs during meal time especially when eating citrus fruits Salivary gland is painful & swollen On palpitation stone may be detected in ducts

Sialolithiasis is found mostly in submandibular gland because of: - Tortuous path of Wharton's duct - Mucinous secretion of the gland - Gravitational effect of saliva inside duct CHEMICAL & PHYSICAL FEATURES Round, ovoid or elongated Measure just a few millimeters or 2 cm or more in diameter Involved duct contain single or multiple stones Surface of calculi is rough, which may cause squamous metaplasia of duct lining Usually yellow & occasionally white or yellowish-brown in color Calculi consist of calcium phosphates & smaller amount of calcium carbonates, organic materials & water TREATMENT & DIAGNOSIS Small calculi may sometimes be manipulated or increasing the salivation by sucking a lemon, leading to expulsion of stone I.V. injection of antibiotic like nafcillin is given for bacterial infection due to persistent obstruction of duct Larger stones require surgical removal Piezoelectric shock wave lithotropsy is alternative to surgical removal

10. MAXILLARY ANTROLITHIASIS (Antral rhinolith)

Rare condition Defined as complete or partial calcific encrustation of an antral foreign body, either endogenous or exogenous, which serves as a nidus Endogenous nidus consist of a dental structure such as a root tip or may simply be a fragment of soft tissue, bone, blood or mucous Exogenous nidus is uncommon but may consist of snuff paper CLINICAL FEATURES Occur at any age in either sex May be a complete absence of symptoms Some cases are marked by pain, sinusitis, nasal obstruction, foul discharge & epistaxis TREATMENT Antrolith should be surgically removed

11. RHINOLITHIASIS
Are calcareous concretions occurring the nasal cavity This uncommon lesion is formed by calcification of intranasal endogenous or exogenous foreign material Reported in all ages

May present for years & frequently give rise to odorous discharge, symptoms of nasal obstruction, sinusitis, epiphora as well as pain & epistaxis

12. RADIATION INJURY (A) X-RAYS

Can ionized the water molecules present inside the cells & form highly reactive radicals. These radicals can damage the cell by various manners as: - They can cause mutation - They can damage enzymes - They may interrupt cell division EFFECTS OF X-RAYS ON ORAL MUCOSA Erythema of mucosa occurs initially Then Mucositis occurs Now mucosa becomes ulcerative with fibrinous exudation. Taste sense is also lost Taste sensation is returned 2 to 4 months after treatment of x-ray therapy EEFECTS OF X-RAYS ON SALIVARY GLANDS Xerostomia occurs due to loss of acinar cells, decrease in secretory granules & inflammation in connective tissue of salivary glands

May cause permanent dryness of mouth Artificial saliva (Methyl cellulose) should be prescribed EFFECT OF X-RAYS ON TEETH During formitive stage of teeth can cause andodontia or defective root formation After development of teeth, may cause cervical caries that may lead to fracture of crown at cervical third TREATMENT : Fluoride treatment & proper oral hygiene

EFFECT ON BONE
Have damaging effect on bone forming cells Blood vessels necrosed When these changes are associated with trauma & infection, OSTEORADIONECROSIS occurs This mostly occurs when infected tooth is present in the LINE OF FIRE

(B) LASER RADIATIONS

EFFECTS ON TEETH Enamel Chalky spots & craters with small holes are seen Dentin exhibit a burnt appearance Pulp Hemorrhagic necrosis present - Inflammatory cell infiltration is seen - Necrosis of odontoblastic layer

EFFECTS ON SOFT TISSUES Ulcers are formed in epithelium

13. CERVICOFACIAL EMPHYSEMA

Emphysema is swelling due to presence of gas or air in interstices of connective tissue CAUSES Blow of air in periodontal pockets or root canals with use of air syringe CLINICAL FEATURES Painful unilateral swelling with feeling of crepitus on palpation TREATMENT Antibiotics are given to avoid connective tissue infection, hydration, massages, sialogagues, & compression Puncture of subcutaneous tissues can be done with sharp needle Venous air embolism may occur as complication leading to death

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