The structure of the oral mucosa is brief. Mechanical damage. Clinic and treatment. Functions of the mucous membrane

To describe the mucous membrane, characteristics such as color, shine, surface, structure, fold characteristics and secretion are used.

6.1. Color depends on the degree of vascularization, stretching, illumination and the distance from which observation is made.

Normal mucosa is uniformly pale pink in the esophagus and reddish pink in the stomach and duodenum. The border between the mucous membrane of the esophagus and the stomach is a clearly defined Z line. Differences between the color of the body of the stomach, antrum and duodenum poorly expressed, and the boundaries are unclear.

Pale mucous membrane occurs when acute blood loss, chronic anemia or atrophy.

Red (hyperemic) mucosa is a manifestation of inflammation, edema, congestion, increased vascularization or blood filling (for example, with portal hypertension or healthy person in the digestive phase of gastric secretion).

A yellowish-pink color of the mucous membrane is found in jaundice.

The variegated mucous membrane has a grayish-pink or grayish-red spotted color, and may be due to anemia or atrophy.

6.2. The shine is due to a continuous, uniform layer of mucus that covers the surface of the mucous membrane. Normally, the mucous membrane is shiny and reflects light; if mucus formation is impaired, it becomes dull and matte.

6.3. The surface is normally smooth, but with pathology it can be lumpy, granular, knotty, villous, etc.

6.4. The structure of normal mucosa with a faint vascular pattern and fine granularity, especially when observed at close range and with magnification. Fine-grained pattern for areas covered with columnar epithelium. However, when pathological conditions the character of the pattern becomes coarser, becomes coarse-grained, and the mucous membrane is described as granular.

6.5. The folds occur due to a discrepancy between the surface area of ​​the mucosa and the submucosal layer. A typical feature is plasticity (autoplasticity), that is, a change in the size and shape of the folds when the lumen is stretched. The degree of plasticity differs in different departments digestive tract.

6.5.1. Normal folds should correspond to the organ and location. In the esophagus, the folds are usually longitudinal and thin, and are not always easily distinguishable. In the stomach along the lesser curvature they are directed longitudinally, and along the greater curvature, anterior and back walls arranged in the form of a network of folds. In the air-stretched antrum, the folds are usually not visible. A typical feature of normal folds, plasticity, is best seen at the greater curvature. When inflated with air, the convoluted folds are flattened and straightened, and the folds along the lesser curvature can be completely smoothed out. In the duodenal bulb, the mucous membrane is usually flat with slightly pronounced folds.

In the remaining parts of the duodenum, circular (Kerkringer) folds are visible, which do not flatten when inflated with air.

6.5.2. Reduced (fuzzy folds) – reduction or disappearance of folds due to overextension or atrophy.

6.5.3. Enlarged - unusually large, but plastic folds covered with normal mucous membrane, usually not pathological.

6.5.4. Congestive enlarged hyperemic and edematous folds, sometimes with exudate and erosive lesions on the peaks. They are usually the result of some kind of irritation or inflammation, but such changes can also be secondary to a functional disorder.

6.5.5. Giant - wide, tortuous, curled, compacted folds, usually covered with normal mucous membrane. Typical for this type of fold is the absence of flattening when stretched.

6.5.6. Deformed folds serve important sign in the diagnosis of early gastric cancer at a preliminary stage and can look like bridges (jumpers), or be radial, converging, cone-shaped, abruptly ending, club-shaped, merging, with destroyed edges.

6.5.7. Postoperative folds are the result of twisting of the stomach wall by sutures and are similar to suture polyps.

6.6. Secretion during endoscopic examination can only be estimated approximately based on indirect evidence. At the same time, the composition of digestive juices is described, which should normally be presented according to the organ, the amount of contents, which depends on secretory activity, study time and psychogenic stimulation; the presence of pathological impurities. Changes in these parameters can serve as an indirect sign of secretory disorders.

When describing the mucous membrane, terms are also used that are characterized by a stable combination of features.

The atrophic mucosa is pale, thinned, and the vessels of the submucosal layer are clearly visible through it.

Erythema is focal redness of the gastric mucosa.

Stagnant mucosa is a combination of hyperemia, edema and exudation. The mucous membrane is red, swollen, vulnerable (increased contact bleeding), with increased secretion of mucus, plaques of white or yellow exudate, with enlarged folds. The vascular pattern is not visible.

The eroded or ulcerated mucous membrane is stagnant, hyperemic with multiple superficial or deeper defects.

Inflammation of the mucous membrane is characterized by hyperemia, edema, stagnation and other changes in color and structure. However, macroscopic differences between inflammatory and functional changes in the mucous membrane are not reliable.

The oral mucosa (ORM) is unique in its properties. It tolerates the influence of mechanical, chemical and other irritants, infectious agents well, and has a high regenerative ability. In some areas it is flexible and flexible, in others it is elastic and static. The area between them is called the transition fold. The unique structure helps the mucous membrane perform serious tasks.

Concept of oral mucosa

Normally, the mucous membrane lines the inner surface of the cheeks, lips, vestibular fold, alveolar processes, palate, fundus, and tongue. Tissue hydration is facilitated by the secretion secreted by the salivary glands. The structural features of the oral mucosa are that it is heterogeneous. Thanks to this, tissues can participate in many important life processes.

Structure

The structure of the sensitive mucous membrane of the oral cavity is quite complex. The trigeminal and glossopharyngeal nerve. According to the histology of the oral mucosa, 3 layers are distinguished:

• Flat epithelium facing the inside of the oral cavity. Includes keratinized and non-keratinized cells in equal proportions. The former line the membrane in places of stress - the hard palate, filiform papillae, dorsum of the tongue, and gums. The keratinized epithelium includes the basal, spinous, horny and granular layers. Non-keratinized cells cover the cheeks, soft palate, folds of the vestibule of the oral cavity, lips, and the lower part of the tongue. They have spinous, basal and superficial layers.
• The shell itself. It has reticular and papillary layers, the transition between which is blurred. The papillary layer is in contact with the overlying epithelium, the reticular layer consists of small lymph vessels, nerve plexuses, small salivary glands.
• Submucosal layer. It contains salivary and sebaceous glands, small vessels.

Functions

The oral mucosa has unique development and functions. The most significant of them:

Classification of diseases of the oral mucosa and their symptoms

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Diseases of the oral mucosa are divided into inflammatory, tumor, and pathologies similar to dermatoses. Their diagnosis requires knowledge of the anatomy of the tissues lining the mouth and the ability to analyze their condition taking into account the functioning of the body.

Separately, injuries due to accidents, bad habits, and unskilled actions of dentists, prosthetists, and oral surgeons are distinguished. In preventing diseases, knowledge of the prevention of the oral mucosa and periodontal disease is important.

Infectious diseases

The mucosa is often exposed to infectious agents that progress with weakened immunity. SORP classification:

• viral: foot and mouth disease, warts, aphthous stomatitis, herpes zoster;
• fungal: candidiasis, actinomycosis;
• bacterial: tuberculosis, streptococcal stomatitis;
• ulcerative necrotic stomatitis;
• venereal diseases.

Allergy

When allergies occur, the epithelium of the human oral mucosa undergoes changes. They can appear on the mucous membrane of the mouth and lips, possible hyperemia of the tongue, changes in the papillae, ulcers (we recommend reading:). Classification of such lesions in children and adults:

Injury

Mechanical injuries that lead to oral pathology and loss of sensory function are chronic and immediate. The latter occur under the influence of short-term factors (prick with a fork or other sharp object). Chronic damage occur under the constant influence of a traumatic factor (prosthesis, tooth fragment).

Pathologies are usually accompanied by an inflammatory process, which is provoked by pathogenic microbes. Treatment involves eliminating the traumatic factor, antibacterial therapy, rinsing with antiseptics, applying compresses.

Dermatoses

Row skin diseases in children and adults it manifests itself as pathology of the epithelium. For example, with pemphigus, bubbles with liquid contents form in the victim’s mouth. Bursting, they form foci of extensive erosions and necrotic ulcerations. Presumably, such ailments are autoimmune in origin. Complex treatment includes the use of immunomodulators, corticosteroids. Additionally use hormonal ointments, rinsing.

Heavy metal intoxication and drug poisoning

Such poisonings occur due to negligence. They are usually provoked by mercury and lead, which, if accidentally ingested, cause a metallic taste in the mouth. On examination, an inflamed mucous membrane is revealed, affected by ulcerations and areas of necrosis. Against the background of intoxication, stomatitis occurs, which requires symptomatic treatment, infection prevention.

Treatment comes down to detox therapy, use local anesthetics and rinsing with antiseptic drugs. Hormonal ointments and vasoconstrictors will help reduce swelling of the mucous membrane. Prevention of poisoning – compliance with safety measures when taking medications and working with chemicals.

Congenital developmental pathologies

Anomalies of the oral cavity concerning the pathology of the depth of the vestibule of the oral cavity, the small vestibule in children, occur regularly. They can serve as a symptom of a complex developmental defect and are often the dominant type of anomaly. The following pathologies are distinguished:

Reasons congenital pathologies genetic abnormalities and the influence of teratogenic factors during the formation of fetal tissues appear. Treatment is often surgical, requiring plastic surgery of the oral structures to restore the anatomical position. The operations are carried out in stages according to the schedule and require time for rehabilitation.

Independent cheilitis

Independent cheilitis is an inflammatory process on the lips that affects both the mucous membrane and the red border. It develops after exposure to wind, heat, low temperatures, other weather factors. Lips may become swollen, sore, covered in plaque, and cracked. During treatment, protect the lips and epithelium with special ointments. IN severe forms pathologies use antibiotics and hormones.

Precancerous conditions and oncology

Precancerous forms develop due to prolonged exposure tobacco smoke, regular inhalation by mouth of vapors of chemical and toxic substances, ultraviolet radiation. The time it takes for the oncological process to develop depends on the health and genetic predisposition patient.

Precancerous ones include leukoplakia, radiation stomatitis, papillomatosis, chronic ulcers and others. Bad habits dramatically increase the likelihood of precancer turning into cancer. Oncological diseases look like dense ulcers, tumors that grow quickly.

Elements of damage to the oral mucosa

Diseases manifest themselves on the mucous membrane in the same way as on the skin. However, due to special conditions(humidity, negative microflora) appearance morphological elements changes slightly. There is a classification according to the time of appearance of signs - primary and secondary. Primary ones appear on the mucous membrane that is clean and unaltered by the disease. Secondary ones often develop from primary ones, especially in the absence of timely treatment.

Primary

TO primary elements lesions include pustules, papules, plaques, spots, discoloration in the mucosal area. Pathologies are inflammatory and non-inflammatory in nature and arise as a result of injuries. Nodular papules are limited compactions up to 2 mm in diameter. Reaching large sizes, they turn into plaques. Fluid or pus accumulates in the vesicles of the epithelial layer. They burst and form erosions.

Secondary

To secondary damaging species include ulcers, erosions, cracks, crusts, scales. If a manifestation of one type is observed, a monoform lesion is diagnosed. With a combination of elements of the primary and secondary types, a polymorphic lesion is observed. The definition of morphological elements is additional method during diagnosis.

Prevention of diseases of the oral mucosa

Diseases in the mouth are often asymptomatic. However, paying close attention to your health helps you recognize the characteristics of the disease at an early stage. Especially it concerns congenital anomalies, such as the small vestibule of the children's oral cavity.

The main treatment is provided by a dentist, periodontist, infectious disease specialist and other specialists. Lead to the development of pathologies different reasons, and preventing them through regular prevention of diseases of the oral mucosa is always easier than treating the consequences.

Prevention of diseases of the oral mucosa should begin as early as childhood. Among the main events:

• the right choice of toothpaste, brushes, care products;
• regular dental examinations;
• protection with antibacterial rinses;
• prosthetics from an experienced specialist;
• using cream to fix dentures;
• quitting smoking and other bad habits;
• refusal of too cold and hot dishes (cause burns);
• correct technique medicines;
• elimination irritating factors, protection from injury.

The mucous membrane of the oral cavity, unlike other mucous membranes of the body, has its own characteristics.

1. It is resistant to impact

· physical,

· thermal,

chemical irritants, as well as

2. to the introduction of infection,

3. has increased regenerative ability.

In some areas the musculoskeletal system is mobile and pliable, in others it is immobile. Such properties of the SOPR are determined by its structure.

The structure of the oral mucosa is divided into three layers:

· multilayered squamous epithelium;

· the mucous membrane itself;

· submucosal layer.

Epithelium- directly facing the oral cavity.

About 50% of the total surface area of ​​the oral cavity is lined keratinizing epithelium, the next 50% - non-keratinizing.

keratinizing the epithelium covers the mucous membrane of the oral cavity in places of increased mechanical, thermal and chemical stress: the hard palate, the back of the tongue, filiform papillae, gums with alveolar processes and the tips of the papillae.

The keratinizing epithelium consists of four layers:

· basal;

· spiny;

grainy

· horny.

1.Basal layer . The boundary between the epithelium and the mucosa itself is basement membrane , which is formed by a dense network of argyrophilic fibers directed in various directions.

The deepest layer of the epithelium is located on the basement membrane germinal or basal . It is formed by cylindrical cubic cells arranged in one row on the basement membrane.

Regeneration of the epithelium occurs due to the cells of this layer.

2. Layer spinosum consists of several rows of cells irregular shape, having processes - spikes, with the help of which the cells are connected to each other, like a zipper.

3. Granular layer - thin, formed by several layers of flattened cells containing keratohyalin grains. This layer occurs where the process of keratinization is expressed.

4. Stratum corneum - surface layer, formed by flat horny scales.

The stratum corneum in the epithelium of the oral cavity can contain up to 20 layers of horny scales, the surface layers of which gradually peel off.

Non-keratinizing epithelium covers the surface of the mucous membrane

lips (except red border),

· soft palate,

lower surface of the tongue

fungiform papillae,

areas of the gum that form the gingival sulcus,

Transitional folds of the vestibule of the oral cavity.

Non-keratinizing epithelium is much thicker than the layer

keratinizing epithelium.

The non-keratinizing epithelium is represented by three layers:

1. basal;

2. spinous;

3. superficial.

1. Basal layer similar in structure and functions to the same layer of keratinizing epithelium.

2. Layer spinosum differs from the keratinizing epithelium only in its chemical composition.

3. Surface layer in the non-keratinizing epithelium it is not sharply separated from the spinous epithelium. It is formed by flattened cells, the outer cell membrane of which is thickened.

Located under the epithelium actual mucous membrane , which is divided into two vaguely demarcated layers:

· papillary and

mesh

Papillary layer in the form of papillary projections, it penetrates in waves into the overlying layer of epithelium.

Papillary projections increase the area of ​​contact between the epithelium and the mucous membrane itself, thereby improving the metabolism between them and a stronger mechanical connection between tissues. Therefore, in those areas of the mucosa that experience maximum mechanical loads, the papillae are high, and their number per unit area is maximum. Each papilla contains blood vessels and nerves, as a result of which it reacts to all types of inflammation.

Mesh layer located more deeply. The reticular layer contains small salivary glands (especially in the area of ​​the lips, soft and hard palate), lymphatic vessels, nerve plexuses.

The mucous membrane itself educated connective tissue.

Fibrous structures- collagen, elastic, argyrophilic fibers.

Cellular elements:

fibroblasts;

· macrophages;

· mast cells.

The mucous layer itself, without a sharp boundary, passes into submucosal layer .

Submucosal layer It is represented by loose connective tissue and contains accumulations of fat cells. This layer gives the mucous membrane mobility, looseness, and elasticity. In the mucous membrane tongue, gums and partially hard palate submucosa is absent , and in the area floor of the mouth, transitional folds, lips, cheeks- well expressed . Thus, we can conclude that in those places where the stratified squamous epithelium keratinizing - the submucosal layer is absent , and where the epithelium does not keratinize - the submucosal layer is pronounced.

The submucosal layer contains a large number of small vessels, minor salivary glands and Fordyce's sebaceous glands.

The mobility of the mucous membrane depends on the severity of the submucosal layer (except for the tongue, where mobility is caused by muscles).

In those areas where the submucosal layer is absent, the oral mucosa is directly fused with the periosteum.

Innervation mucous membrane is carried out trigeminal nerve , which is a common sensory nerve of the oral mucosa, lips, teeth and anterior 2/3 of tongue . Sensory nerve posterior third language is glossopharyngeal nerve.

Functions of the oral mucosa:

1. Protective- the mucous membrane protects the underlying tissues from the possible damaging effects of the contents in the oral cavity. When biting and chewing food soft fabrics oral cavity exposed mechanical forces (compression, stretching, tearing) and erasure (due to the presence of solid particles in food). In the oral mucosa, both the epithelium and connective tissue are adapted to withstand these stresses. The oral cavity normally contains microorganisms that can cause infection when introduced into tissues. Many of these microorganisms produce substances that have toxic effects on tissues. The epithelium of the oral cavity prevents these effects by playing barrier role . It is relatively resistant to not only mechanical but also chemical factors. The epithelium is constantly sloughed off, thereby removing attached microorganisms and preventing their penetration into the tissue.

Loss of surface cells due to intense and constant exfoliation (desquamation) of the mucosal epithelium in physiological conditions compensated by its active regeneration. Desquamation is further enhanced when the epithelium is exposed to unfavorable factors.

2. Touch- is carried out thanks to the presence receptors , perceiving temperature, tactile and pain signals. The oral cavity also contains specialized taste buds. Irritation

receptors located in the oral cavity, causes a number of reflexes associated with swallowing and salivation. The tongue and lips are able to perceive stimuli outside the oral cavity.

3. Secretory- surface of the mucous membrane wetted with saliva, which is produced by large and small salivary glands. Large glands lie outside the mucous membrane, but bring their secretions to its surface through ducts; small salivary glands are located in its thickness. In some areas of the oral mucosa there are also sebaceous glands, but their secretion apparently does not play a significant role. Saliva moistens food, softens it, preventing mechanical damage to the mucous membrane, facilitates the swallowing of bolus food, and has buffering properties. Constantly released, saliva helps remove microorganisms from the surface of the epithelium. It also contains nonspecific antimicrobial substances and antibodies that prevent the attachment of microbes to the surface of the epithelium.

4. Immune- the oral mucosa takes part in providing local immunity ; this function is apparently less pronounced than in the caudal parts of the digestive tract, however, it is in the oral cavity that the antigens contained in food and microbial antigens first affect the tissues of the body. The oral mucosa contains cellular elements involved in immune reactions (Langerhans cells, macrophages, lymphocytes, plasma cells).

5. Suction- despite the barrier properties of the mucous membrane, over its greater extent, in some areas it is permeable (this is due to the peculiarities of its structure). Thus, the thin mucous membrane in the area of ​​the bottom of the oral cavity is permeable to a number of substances, in particular iodine, potassium, sodium, and certain amino acids. Important clinical significance it is permeable to certain medications (for example, nitroglycerin, used to relieve an attack of angina, is placed under the tongue, from where it is quickly absorbed). In any areas (even those lined with keratinizing epithelium), the oral mucosa is more permeable than the skin.

6. Thermoregulatory- in some animals (for example, a dog), heat is given off by the body in significant quantities due to respiration. In humans, this function is unimportant.

The oral mucosa has its own characteristics that distinguish it from other mucous membranes. It is resistant to various irritants: mechanical, chemical, temperature, etc., has increased regenerative ability and is relatively resistant to infection. In some parts of the oral cavity, the mucous membrane is mobile and pliable, while in others it is immobile. Such qualities of the mucous membrane are determined by its structure.

In the structure of the oral mucosa, three layers are distinguished: stratified squamous epithelium, the mucosal layer itself and the submucosal layer.

The multilayered squamous epithelium lining the mucous membrane has different structure. In the area of ​​the lips, cheeks, soft palate, lower surface of the tongue, floor of the mouth and transitional folds of the vestibule, the epithelium of the oral mucosa consists of two layers of cells: basal and spinous. The absence of the stratum corneum explains its pink color and here it does not keratinize. In those areas where the mucous membrane is subject to the greatest friction and pressure during food intake, it is found in its superficial layers different stage keratinization of the epithelium. This is the mucous membrane of the hard palate and gums. Similar phenomena are observed at the tips of the filiform papillae of the tongue.

At histological examination Glycogen is found in the epithelium of the mucous membrane. An inverse relationship was found between glycogen content and the process of keratinization. Where the mucous membrane does not undergo keratinization, it contains a lot of glycogen, but where it undergoes keratinization, there is little glycogen. Obviously, it plays the role of a source of energy or plastic material in the process of formation of the stratum corneum.

The thickness of the epithelial layer in various areas the mucous membrane is uneven. For example, at the bottom of the mouth, on the lip and the lower surface of the tongue, the layer of epithelium is thin. In other areas the layer is much thicker. With age, the thickness of the epithelium changes. In children, it is thin and delicate; with age, its thickness increases, and in old age, due to atrophy, it becomes thinner again. The epithelium performs a barrier function, protecting the mucous membrane from various damages. In addition, the surface epithelial cells are constantly exfoliated, along with them a large number of microorganisms are removed from the surface of the mucous membrane. This protective property of the epithelium is to prevent microorganisms from penetrating deep into the mucous membrane. The epithelium is connected to the underlying connective tissue by a basement membrane.

Under the epithelium is its own layer of the mucous membrane, which consists of dense connective tissue containing cellular elements, fibers and ground substance. The proper layer in the form of papillary projections is embedded in the underlying layer of epithelium. Each papilla contains blood vessels and nerves. Papillary projections increase the area of ​​contact of the epithelium with its own layer of the mucous membrane, which provides best exchange substances between them and a more durable attachment of the epithelial layer. In addition, the lamina propria contains lymphatic vessels, sebaceous glands and numerous salivary glands.

The proper layer of the mucous membrane passes into the submucosal layer without a sharp boundary. The latter consists of looser connective tissue and contains a deep vascular network and deeper-lying small salivary glands.

Language is a muscular organ, has powerful striated muscles. There is no submucous membrane in the tongue, and therefore the own mucous membrane passes into the intermuscular connective tissue, therefore the mucous membrane of the tongue is motionless and does not fold. The tongue has several surfaces: the front (back of the tongue), tip and root, side surfaces and the bottom, facing the floor of the mouth. The lower surface of the tongue is smooth, and the back is rough due to the presence of 4 types of papillae: filiform, mushroom-shaped, leaf-shaped and surrounded by a shaft, or grooved. The papillae of the tongue are nothing more than protrusions of the mucous membrane itself along with the epithelium covering it.

Filiform papillae are located along the entire back of the tongue. Superficial cells The epithelium tends to become keratinized and slough off in the form of whitish scales. In some diseases, especially of the digestive system, the desquamation of epithelial cells slows down and the tongue acquires a whitish color, which is clinically called a “coated” tongue. In some pathological conditions of the body, the surface layer of the epithelium can become completely keratinized, then the tongue takes on a “hairy” appearance. With old age, atrophy of the filiform papillae is possible, and then the surface of the tongue becomes smooth.

Fungiform papillae have a narrow base and a wider, rounded apex. The epithelium of the fungal papillae does not keratinize, therefore they have a bright red color and are scattered in the form of red dots among the filiform papillae in the region of the anterior 2/3 of the dorsum of the tongue.

Leaf-shaped papillae look like parallel folds 2-5 mm long, separated by a narrow groove. They are located on the lateral surface of the tongue. Their epithelium contains a large number of taste buds.

The papillae, surrounded by a shaft or grooved, are located in the form of a Roman numeral V on the border between the root and body of the tongue in the number of 8-15. The papilla has a rounded shape, is somewhat immersed in the mucous membrane and is surrounded by a shaft. They contain a large number of taste buds and are abundantly supplied with nerve receptors.

On the midline of the tongue, slightly posterior to the papillae, surrounded by a shaft, there is a blind fossa. Behind it and on its sides is the follicular apparatus, which is united under common name « lingual tonsil" Some of the follicles move to the lateral surface of the tongue. These follicles are mistakenly mistaken by some for pathology. This is followed by the left and right lingual-epiglottic folds, then the epiglottis and pharynx.

Lips consist of circular muscles covered on the outside with skin, their inner side is lined with mucous membrane. Its submucosal layer is tightly fused with intermuscular fibers, which determines its smoothness and prevents the formation of folds. The thickness of the mucous membrane contains many small salivary glands of a mixed (mucous-serous) nature. The red border has a transitional structure from the skin to the mucous membrane. There is no hair and sweat glands. Complete enclosure of the epithelium on the red border does not occur. Located under the epithelium, its own layer in the form of numerous papillae is embedded in the epithelium. Each papilla contains wide capillary loops that come close to the surface and are easily visible through the epithelium, which explains the red color of the lips.

The junction of the red border with the mucous membrane of the lip is called Klein's zone.

Upon examination, the mucous membrane of the cheeks and lips appears quite smooth. At the level of the upper second molar there is a papillary elevation, in the center of which is the opening of the duct of the parotid salivary gland. In the area of ​​the middle of the upper and lower lips, the mucous membrane forms folds (frena) dividing the vestibule of the oral cavity into the right and left half. The mucous membrane of the cheeks also contains salivary and sebaceous glands. Forming a transitional fold, the mucous membrane passes to the alveolar process, where it is called the gums. The edge of the gum is adjacent to the necks of the teeth and fills the interdental spaces, forming interdental papillae.

Normally, each papilla is quite dense and resembles a pyramid, the base of which is at the level of the necks of the teeth, and the apex is adjacent to the equatorial line of the teeth. The mucous membrane does not have a submucosal layer, so its own layer is directly fused to the periosteum, which ensures its immobility. It does not contain mucous glands and is rich in blood vessels and poor in nerves.

The relief of the mucous membrane of the floor of the mouth is uneven. Along the midline from the alveolar process to the tongue stretches a fold of the mucous membrane, or the frenulum of the tongue. To the right and left of the frenulum there are papillary elevations into which the ducts of the submandibular and sublingual salivary glands open. Somewhat posterior to the ducts lie the sublingual folds, on which the small ducts of the sublingual gland open.

Solid sky. IN anterior section The hard palate has transverse folds. Anterior to these folds, along the midline, not far from the central incisors, there is an incisive papilla, the position of which corresponds to the incisive foramen. Posterior to the transverse folds, along the longitudinal suture, is the palatine eminence. The mucous membrane in the midline and marginal zone does not have a submucosal layer and is firmly fused with the periosteum. In other areas, it has a submucosal layer, in which there is an accumulation of adipose tissue in the anterior part of the palate, and a large number of mucous glands in the posterior part.

The functional significance of the mucous membrane of the oral cavity and tongue is that it prevents the penetration of microorganisms into the underlying tissues, has absorption and excretory ability, and is involved in heat regulation. Thanks to the presence of receptors, the mucous membrane of the mouth and tongue perceives taste, pain, tactile, temperature and other irritations. The tongue is involved in the act of speech and chewing food. The mucous membrane of the oral cavity and tongue is highly reactive and with its changes often expresses the presence of certain painful conditions body.

healthy mucous membrane has a pale pink color in the gum area and pink in other areas. In the presence of various pathological processes, the color of the mucous membrane changes, its configuration is disrupted, and various elements of the lesion appear on it. Hyperemic areas indicate inflammation, which is usually accompanied by tissue swelling. Severe hyperemia is characteristic of acute inflammation, bluish tint - for chronic. If certain deviations in the color and structure of the mucous membrane are detected, it is necessary, through a survey, to establish the time of appearance of these changes, what sensations they are accompanied by, and determine the tactics for further examination, not forgetting about oncological alertness. For example, areas of increased keratinization can develop into a focus of neoplasm.

Elements of damage to the mucous membrane. Examination of the mucous membrane should be based on correct assessment local and general etiopathogenetic factors, since they can act not only independently, but also in combination. For example, the causes of symptoms such as hyperemia, bleeding, swelling and burning of the mucous membrane of the prosthetic bed may be: 1) mechanical injury; 2) disturbance of heat exchange of the mucous membrane due to poor thermal conductivity of a plastic prosthesis; 3) toxic-chemical effects of plastic ingredients; 4) allergic reaction to plastic; 5) changes in the mucous membrane in certain systemic diseases (vitaminosis, endocrine diseases, gastrointestinal tract); 6) mycoses.

The following elements of damage to the mucous membrane are found: erosion - surface defect; aphthae - small round areas of ulceration of the epithelium of a yellow-gray color with a bright red inflammatory rim; ulcers - a defect of the mucous membrane and underlying tissue with uneven, undermined edges and covered gray coating bottom; hyperkeratosis - excessive keratinization with a decrease in the desquamation process. It is necessary to use all outpatient and laboratory methods to identify the cause of the lesion ( colds, contact with an infectious patient, gastrointestinal disease, etc.). It should not be ruled out that probable reasons- trauma to this area by a sharp edge of a tooth, a tilted or displaced tooth, a poor-quality prosthesis, electrochemical damage to tissue as a result of the use (in the manufacture of prostheses) of different metal alloys with different electrolytic potentials (stainless steel and gold). It must be remembered that the traumatic areas may be located at a distance from the injured area of ​​the tongue or cheek due to the displacement of tissues or the tongue during conversation or eating. During the examination, the patient is asked to open and close his mouth, move his tongue - this will help clarify the traumatic area.

Traumatic injuries - ulcers - must be differentiated from cancerous and tuberculous ulcerations, syphilitic ulcers.

Long-term trauma can lead to hypertrophy of the mucous membrane. Are formed benign tumors: fibroma is a tumor of fibrous connective tissue, papilloma is a tumor developing from squamous epithelium and protruding above its surface; papillomatosis - the formation of multiple papillomas.

If petechial (petechiae is a spot on the mucous membrane with a diameter of up to 2 mm, formed as a result of capillary hemorrhage) rashes on the mucous membrane of the soft and hard palate are detected, even if the patient uses removable denture, first of all it is necessary to exclude a blood disease. Thus, with thrombocytopenic purpura (Werlhof's disease), areas of hemorrhage (bleeding) appear on the mucous membrane in the form of small pinpoints. bright red spots, sometimes having a purple, cherry-blue or brownish-yellow color.

You should remember about chemical and electrochemical damage to the mucous membrane, as well as possible allergic reaction to the base material.

Having assumed one or another form of the disease, it is necessary to conduct additional laboratory tests (blood test, cytological examination of fingerprint smears, bacteriological, immunological studies) or refer the patient to a dentist or surgeon, dermatovenerologist. It should also be remembered that the discrepancy between the clinical (presumptive) and cytological diagnoses serves as an indication not only for re-examination, but also for expanding research methods.

Establishing the nature of lesions of the oral mucosa, the reasons that caused or maintained this lesion, is important for choosing a treatment method and the material from which dentures and appliances must be made. It has now been proven that when chronic diseases oral mucosa (lichen planus, leukoplakia, leukokeratosis), orthopedic measures occupy a leading place in complex therapy.

An increase in the size of the papillae, the appearance of bleeding gums, a bluish tint or sharp hyperemia indicate the presence of subgingival calculus, irritation of the gingival margin by the edge of an artificial crown, filling, removable denture, the absence of interdental contacts and injury to the mucous membrane by food lumps. These symptoms may occur when various types gingivitis, periodontitis (Fig. 44). The presence of fistula tracts and scar changes on the gums confirms the presence inflammatory process in the periodontium (Fig. 45). Painful areas, swelling (bulging), and sometimes fistula tracts with purulent discharge. They arise as a result of inflammatory (acute or chronic) processes in the periodontium.

On the mucous membrane of the cheek and tongue, you can sometimes notice tooth marks and areas of hemorrhage from biting the mucous membrane during chewing. These phenomena arise as a result of tissue edema, which in turn develops in diseases of the gastrointestinal tract. Traces from biting the tongue and cheeks can be detected when the occlusal height decreases, violations of the occlusal relationships of individual teeth; finally they can appear during epileptic seizure, dyskinesia (a disorder of coordinated motor acts, consisting of impaired spatial coordination of movements) of the tongue with damage to the nervous system.

The degree of hydration of the mucous membrane is also subject to assessment. Dry mucous membrane (xerostomia) is caused by hyposecretion of the salivary glands, which occurs as a result of diseases of the parotid and sublingual glands; noted in diabetes, candidiasis. If you complain of dry mouth, it is necessary to palpate these glands and determine the quantity and quality of saliva. Normally, a few drops of clear secretion are released from the ducts.

Topographic and anatomical features of the structure of the mucous membrane of the prosthetic bed. When examining a patient in need of orthopedic treatment, the study of the topographic and anatomical features of the structure of the mucous membrane of the prosthetic bed becomes of great importance. Special meaning this has implications for the selection of impression materials, the use of removable prosthetic structures, dispensary observation for persons using dentures (assessment of the quality of treatment).

Rice. 46. ​​Oral mucosa.
a - upper frenulum; lips; b - buccal-gingival fold; c - transverse palatal folds; g - seam of the sky; d - blind fossa; e - pterygomaxillary fold; g - palatine tonsil; z - pharynx; and - language; j - lower buccal-gingival fold.

Rice. 47. Scheme of the location of the mucous membrane of the alveolar process.
a - actively mobile; b - passively mobile; c - immobile mucosa; d - transitional fold; d - valve zone.

In the vestibule of the mouth, both the upper and lower jaws have frenulums upper lip And lower lip(Fig. 46). As a rule, the frenulum ends on the mucous membrane of the alveolar process, not reaching the gingival margin by 5-8 mm. The other end connects to the aponeurosis of the orbicularis oris muscle. Sometimes the frenulum reaches the level of the gingival margin, attaching to the gingival papilla between the central incisors. Such an abnormal attachment, as a rule, leads to the formation of a gap between the central incisors - a diastema, and over time to retraction of the gingival margin of these teeth. V

On the vestibular side in the area of ​​the premolars on both the upper and lower jaws on the right and left there are lateral buccal-gingival folds.

Inspect and determine the boundaries of the frenulum and folds by moving the lip, and then the cheek forward and upward with the mouth half open.

With the loss of teeth, the place of attachment of the frenulum and folds does not change, but due to atrophy of the alveolar process, it seems to approach its center. When examining the vestibule of the mouth, it is necessary to determine the boundaries of the transition of the fixed mucous membrane into the mobile one, and in the latter - the boundary of the transition of the passively mobile mucous membrane into the actively mobile one.

Passively mobile mucous membrane is a section of the mucosa that has a pronounced submucosal layer, due to which it can move in different directions when external force is applied (the concepts of “mobile” and “compliable” should not be confused. The mucous membrane is always pliable, but the degree of compliance varies greatly , but the pliable mucous membrane is not always mobile). The zone of passively mobile mucous membrane on the vestibular side in orthopedics is called the neutral zone (Fig. 47).

Actively mobile mucous membrane is a section of the mucosa that covers the muscles and moves when the latter contract.

The place of transition of the actively mobile mucous membrane of the alveolar process into the same mucous membrane of the cheek is called the transitional fold. It is the top (for upper jaw) and the lower (for the lower jaw) border of the arch of the vestibule of the mouth.

The vault of the oral vestibule has a variable volume in length and, as a rule, is narrow in the anterior section and widens in the distal direction. Both the volume of the vault and its vertical size decrease when the mouth opens, since the contracting muscles of the cheek or lip seem to be pressed against the alveolar process.

In orthopedic dentistry, the special term “valve zone” has been adopted. It extends from the transition point of the fixed mucous membrane to the actively mobile one on the cheek.

To define boundaries various areas of the mucous membrane, palpation and inspection are used. During the examination, by retracting the lip and then the cheek, the examinee is asked to slowly open and close his mouth and strain individual muscle groups. To determine the boundaries of the transitional fold on the oral side on the lower jaw, they are asked to move the tongue. These tests are described in detail in Chapter 7. Behind the tubercle of the upper jaw, a pterygomandibular fold is identified, running from the pterygoid hook to the buccal protrusion (ridge) on the lower jaw. The fold is well defined when the mouth is opened wide. Sometimes a small mucous fold runs from the tubercle in the distal direction to the pterygomandibular fold. The latter, like all of the above, must be taken into account both when taking an impression and when determining the boundaries of a removable denture: the denture must have recesses that exactly correspond to the volume of the folds.

In the vestibule of the mouth, on the mucous membrane of the cheek at the level of the crown of the second upper molar, there is an excretory duct parotid gland, having the shape of a rounded elevation.

From the oral side, all areas of the hard and soft palate are subject to inspection and examination. The condition (severity, position, color, pain) of the incisive papilla (papilla incisiva), transverse palatine folds (plicae palatinae transversae), palatal suture (raphe palati) and the presence of the palatine ridge (torus palatinus) are determined. In different individuals they can be significant or, conversely, weakly expressed or completely unnoticeable, but this is not a pathology. At the same time, determine the height of the vault of the sky, which depends on vertical size alveolar process (this value varies depending on the presence or absence of teeth, the cause of tooth loss) and the development of the entire jaw. Thus, with a narrow upper jaw, the vault of the palate is almost always high, while with a brachycephalic shape of the skull and a wide face, it is flat.

At the border of the hard and soft palate, on the sides of the median palatal suture, there are palatine blind fossae, which serve as a guide in determining the boundaries of removable dentures.

Rice. 48. “Dangling” alveolar ridge according to Supplee.

Along the line of location of these pits, the normally pale pink mucous membrane of the hard palate passes into the mucous membrane of the soft palate, which has a pinkish-red color. The mucous membrane of the hard palate is covered with stratified squamous keratinizing epithelium and is tightly connected to the periosteum almost throughout its entire length (alveolar process, palatine suture and small areas to the right and left of it). In these areas, the mucous membrane is stubborn and immobile. In areas in the anterior part of the hard palate in the submucosal layer there is a small amount of adipose tissue, which determines its vertical compliance (compression during palpation, compression from hard object). The palatal folds and incisive papilla can also move horizontally.

In the posterior third of the palate, at the level of the second and third molars, there are large and small openings through which neurovascular bundles emerge, directed anteriorly, with a well-defined submucosal layer. In the area from the base of the alveolar process to the area of ​​the palatal folds and the median suture, the mucous membrane is very pliable.

Taking into account the structure of the submucosal layer, the following zones are distinguished in the immobile or limitedly mobile mucous membrane, based on varying degrees of compliance: the region of the alveolar process, the region of the median suture, the region of the transverse palatal folds and incisive papilla, the region of the middle and posterior thirds of the palate.

Changes observed after tooth extraction mainly affect bone tissue, but can also be observed in the mucous membrane; in the center of the alveolar process it loosens, has an irregular configuration, longitudinal folds appear, zones of inflammation and hypersensitivity, as well as areas of mobile mucosa - the “dangling” alveolar ridge (Fig. 48).

These changes occur due to poor oral hygiene, poorly manufactured prosthesis, as a result of resorption bone tissue and replacing it with connective tissue during periodontitis.

In the lower jaw, in the oral cavity itself, the frenulum of the tongue, the floor of the mouth, the retroalveolar region and the mandibular tubercle are examined. The mucous membrane lining the floor of the mouth passes from the tongue, and then into the mucous membrane of the body and the alveolar part of the jaw. Several folds form here. The frenulum of the tongue is a vertical fold of mucous membrane that runs from the lower surface of the tongue to the floor of the mouth and connects to the oral surface of the gums. The fold is clearly visible when the tongue moves. The frenulum may be short and limit the movement of the tongue, causing tongue-tiedness. If the fold is attached close to the gingival margin of the incisors, gum retraction may occur. After removal of the incisors, due to bone tissue atrophy, the fold seems to move to the center of the alveolar part of the body. On the sides of the frenulum, the ducts of the submandibular and sublingual salivary glands open, from which distally there is an elevation (ridge) formed by the duct and the body of the gland.

A feature of the mucous membrane of the floor of the mouth is the presence of a well-developed submucosal layer with loose connective and adipose tissue and underlying muscles: mylohyoid and chin hypohyoid. This explains the high mobility of tissues during tongue movements. The retroalveolar region is limited by the posterior edge of the mylohyoid muscle, posteriorly by the anterior palatine arch, on the sides by the root of the tongue and the inner surface of the lower jaw. This area is important because it is where there is no muscle layer. Its absence determines the need to use this area for fixation of a removable denture. Mandibular tubercle is a formation of mucous membrane in the center of the alveolar part, immediately behind the wisdom tooth. The pterygomaxillary fold is attached to the distal end of the tubercle, so this zone seems to rise upward when the mouth is opened wide.

The mucous mandibular tubercle has different shape and volume, can be mobile and always malleable.

Orthopedic dentistry
Edited by Corresponding Member of the Russian Academy of Medical Sciences, Professor V.N. Kopeikin, Professor M.Z. Mirgazizov