Healing of Oral Wounds Flashcards
Wound Healing
Early vascular response to injury
- Starts as inflammation through the following…
- Initial transient vasoconstriction followed by vasodilation.
- Vasodilation is caused by action of histamine, prostaglandins, and other vasodilatory substances.
- Dilation causes intercellular gaps to occur, which allows egress of plasma and emigration of leukocytes.
Wound Healing
Inflammatory stage of wound repair
- Wound fills with clotted blood, inflammatory cells and plasma.
- Adjacent epithelium begins to migrate into wound along edge of the wound.
- Undifferentiated mesenchymal cells begin to transform into fibroblasts.
Wound Healing
Migratory phase of fibroblastic stage of wound repair
- Continued epithelial migration under the fibrinous exudate.
- Leukocytes dispose of foreign and necrotic material.
- Capillary ingrowth begins.
- Fibroblasts migrate into wound along fibrin strands.
Wound Healing
Proliferative phase of fibroblastic stage of wound repair
- Proliferation increases epithelial thickness.
- Collagen fibers are haphazardly laid down by fibroblasts.
- Budding capillaries begin to establish contact with their counterparts from other sites in the wound.
Wound Healing
Remodeling stage of wound repair
- Epithelial stratification is restored.
- Fibrinous exudate resorbs, often leaving a depressed scar.
- Collagen is remodeled into more efficiently organized patterns.
- Fibroblasts slowly reduce and vascular integrity is re-established.
Wound Healing
Wound contraction
- Begins near the end of fibroplasia and continues during the early portion of remodeling.
- Wound contraction diminishes the size of the wound.
Indications for biopsy
- Any persistent pathologic condition which cannot be diagnosed clinically
- Any lesion thought to be malignant/premalignant
- To confirm clinical diagnosis
- Any condition not responding to routine management
- To allay cancer fears
Biopsy Types
- Excisional -
remove entire lesion (benign tumor)
- Incisional -
only take a small piece of lesion (only diagnostic)
- Punch -
- Needle -
ex. Fine Needle Aspiration (FNA)
- Aspiration -
Place Biopsy Specimen in 10% neutral, buffered formalin
Incisional biopsy
- If the lesion is larger than 1cm or in a hazardous location or whenever there is a great suspicion of malignancy.
- Is used to establish diagnosis.
- It is a diagnostic biopsy.
Excisional biopsy
- Is used to remove the lesion.
- It is a diagnostic and therapeutic biopsy.
- For lesions that are small and you are confident are benign
- Do not excise a lesion suspected of being malignant
Primary healing
- Healing by primary intention.
- When the margins can be approximated.
- Usually heals with minimal scar.
- Most Ideal
Secondary healing
- Healing by secondary intention.
- An open wound “granulates in”.
- Heals with scarring.
Cytology/Exfolative Cytology
the removal of individual cells, usually in order to determine microscopically if they appear normal or abnormal. It usually does not provide a definitive diagnosis.
- screening for cancer usually
Cytology Advantages and Disadvantages
Cytology Advantages
*Safe
*Bloodless
*Painless
*Quick
*Screening
Cytology Disadvantages
*Only for surface lesions affecting epithelium
*Cannot establish a definitive diagnosis
Cytology Grades
Grade I Normal (No biopsy)
Grade II Atypical (Biopsy)
Grade III Borderline (Biopsy)
Grade IV Suggestive (Biopsy)
Grade V Positive (Biopsy)
What is indicated for cytology?
*Premalignant/malignant lesions
*HSV
- Cytopathic viral effect
- “Multinucleation”
*Candidosis
Oral CDX Brush “Biopsy”
NOT A BIOPSY - NOT A DEFINITIVE DIAGNOSIS
- Cytological evaluation for premalignant/malignant lesions
- Improved cell harvesting
- All cell layers - Improved computer-based screening of specimen
- Improved diagnostic accuracy
- Atypical and positive results must be biopsied
- Does not provide definitive diagnosis
Immunofluorescence
Diagnostic technique to identify autoantibodies
- Direct (DIF)
- Autoantibodies in tissue
- Indirect (IIF)
- Circulating autoantibodies in blood
Immunofluorescent testing generally reserved for conditions that you suspect are autoimmune (pemphigus vulgaris, mucous membrane pemphigoid)
Most oral diseases are (+) on Direct but (-) on indirect IF.
DIF biopsies cannot be placed in traditional fixative, a transport media is required
Healing of Extraction Wound
First Week
- The blood clot begins to undergo organization by the ingrowth of fibroblasts and capillaries from the residual periodontal ligament and adjacent bone marrow.
Healing of Extraction Wound
Second Week
- The blood clot is becoming organized.
- PDL begins degeneration and the socket wall appears frayed.
- Epithelium proliferates over the wound surface.
Healing of Extraction Wound
Third Week
- The original clot is organized by granulation tissue.
- Early bone (osteoid) is formed by osteoblasts arising in the PDL and adjacent bone.
- The crest of the alveolar bone is rounded off by osteoclastic resorption.
- Epithelium completely covers the surface
Healing of Extraction Wound
Fourth Week
- Continued deposition of bone.
- Much of the early bone is poorly calcified and is not evident on radiographs.
- Radiographic evidence of bone formation is seen after six or eight weeks.
- Evidence of differences in new bone in the alveolar socket will persist for four to six months.
Localized Acute Alveolar Osteomyelitis (Dry Socket)
- Due to loss of the blood clot from extraction site.
- The socket appears dry and the bone is exposed.
- Produces a foul odor and severe pain but no suppuration.
Fibrous Healing of an Extraction Wound
- Results from a difficult surgical extraction accompanied by loss of lingual and labial or buccal plates of bone with accompanying loss of periosteum.
Radiographic - appears as a circumscribed radiolucent area at the site of previousextraction wound.
- may be mistaken for a residual cyst or granuloma.
Focal osteoporotic bone marrow defect
Radiolucency in bone from bone marrow expansion may not be pathologic
- Aberrant healing – many are in extraction sockets
- Hyperplasia due to chronic anemia
- ↑ Females 75%
- ↑↑ Md (posterior)
Asymptomatic, no expansion
Radiolucencies, often ill-defined but with faint internal trabeculation
Localized Tissue Overgrowth
- Often a fragment of bone will become lodged in the socket and induce tissue hyperplasia (pyogenic granuloma, peripheral giant cell granuloma, inflammatory fibrous hyperplasia - all covered later).
- Tissue growing from an extraction site can also represent malignancy growing along the course of least resistance.
