Normal Oral Anatomy-DoctorSpiller.com

oralanatomy

If you have come here to look for images of lumps, bumps, sores or discolorations that you noticed in the mirror this morning, this is one of four pages with images you may find useful.  Start here.

Then proceed to three other pages on which you will find more images of both normal and abnormal oral structures and lesions. 

Have you ever wondered what that little thing that hangs down in the back of your throat is called?  A glance at the diagram above will tell you it is called the Uvula.  What’s it for?  It acts as a very effective valve that keeps food and drink from regurgitating up into the nasal cavity when eating or drinking (see diagram above).  It vibrates while snoring, and when it is removed (usually in a procedure to reduce snoring)  people seem to have minor problems immediately after the surgery with nasal regurgitation, especially when drinking carbonated beverages, but This problem goes away a few weeks after the surgery.

The other structures, labeled around the diagram are as follows:

The Labial Frenum is a little tag of tissue in the center of the upper and the lower lip that attaches the lip to the gums.  It too is not especially useful, and sometimes causes orthodontic or periodontal problems if the attachment on the gums is too close to the teeth.  If it becomes a problem, we usually simply cut it .  This is most often done on children if the attachment of the frenum is too “high” and causes a diastema (space) between the adult teeth.  The procedure is called a “frenectomy”.  An interesting thing to note is that a glancing blow to the face will generally rip this structure, and a ripped labial frenum, in combination with other “recurrent” bodily injuries is considered to be a legal indication of child abuse.

The gingiva are what most people call the “gums”.  These are covered in more detail below.

The roof of your mouth has two distinctive parts.  The Hard Palate is the tough, leathery, non movable part of the roof of your mouth that is attached to the inside of your teeth and curves up to make the vault of your palate. The Soft Palate lies behind the hard palate and is closer to the back of your throat.  You can feel the dividing line between the hard and soft palates with your tongue if you can draw it back that far.  The Uvula is attached to the back of the soft palate. The Hamuli (singular hamulus) are hard little bumps in the corners of the soft palate just where the soft palate meets the very back of the tuberosities.  If you press hard with the tip of the tongue to the inside and behind the gums behind the last top teeth, you may be able to feel them.  They represent the tips of little projections from the base of your skull called the hamular processes of the palatine bone.

The Maxillary Tuberosities are the tough, hard humps behind your top back teeth on both sides of the dental arch (note that both upper and lower teeth are arranged in “arches”).  These humps have underlying bone and hard gum tissue covering them, and they are persistent, permanent parts of the mouth, even if all the upper teeth are extracted. the piucture below does NOT show the tuberosities

SwollenTonsilsYour Tonsils are at the border between your mouth and your throat.  The Tonsils you can see at the corners of your throat are called the palatine tonsils.  They are, in fact, only a part of a ring of lymphoid tissue that lines your entire throat.  If you stick your tongue out really far, you can see some bumpy, pink (sometimes bluish) tissue toward the back on both sides.  These are called the lingual tonsils.  The lingual tonsils extend to the top (dorsal) surface of the tongue.  They are considered a paired mass of lymph nodes separated by a midline septum, (see diagram below) although ENT specialists tend to think of the pair as a large, single mass. .

AdenoidsAbove the soft palate, about even with the palatine and lingual tonsils lie two similar masses of tissue called the Adenoids.  These complete the tonsillar ring, so called because the palatine tonsils, lingual tonsils and adenoids form a complete ring of lymphoid tissue surrounding the throat. The tonsillar ring is composed of lymph nodes.  Lymph nodes are a part of a separate “circulatory system” called the lymphatic system which acts like a drain to help keep the hydrostatic system of the body in balance.  It keeps the various parts of your body from swelling up due to too much water pressure by allowing the water to redistribute itself.

Elephantiasis(In Tropical climates, the bite of certain mosquitoes can transfer a nasty little parasitic worm which lodges in the lymphatic system thereby blocking it and causing enormous swelling of various parts of the body.  The condition is called “elephantiasis“)  The lymph nodes (including the tonsils) act as a sort of filtration system to keep the fluids in the lymphatic vessels free of germs so that a localized infection does not spread to distant parts of the body through the lymphatic system.

Should I have my child’s tonsils removed?

TonsilsThis image shows typical palatine tonsils in a young child.  (They shrink as we get older.)  You can see that tonsils can take up quite a bit of room in the throat, and while they are not removed as casually today as they were earlier in the 20th century, their removal has certain advantages.  They are a major factor in the constriction of the throat that causes snoring and obstructive sleep apnea, and when infected they can enlarge even more and add to the misery of a sore throat.  When infected with strep bacteria, numerous small yellowish-white plaques (white spots) appear all over them in the crevices (tonsillar crypts) that are visible over the surfaces of the tonsils seen in this image.  These plaques are active colonies of the Streptococcus organism.  Tonsils, like other lymph nodes, may enlarge during the course of viral and bacterial illnesses, and when this happens, constriction of the throat becomes more severe.

Of course the palatine tonsils do have physiological functions associated with the immune system.  However they are fairly redundant (that is, there are a lot of other lymph nodes in the area which have the same function), and while some parents and politically inclined health organizations would sooner see their children lose their heads rather than their tonsils, no one ever seems to suffer any permanent adverse affects from their removal.

Conversely, their physical absence has a number of distinct advantages relating to less constriction of the airway and fewer complications from chronic infections.  The major advantage of removing a child’s tonsils is that the operation is much less painful for children than it is for full grown adults.  If it becomes necessary to remove the tonsils during adulthood, the convalescence period is about two weeks of severe pain, especially upon swallowing.  (Adults tend to lose a lot of weight.  Children have fewer problems.)

Tonsilloliths (tonsil stones)

People with chronic sinusitis and post nasal drip may develop Tonsilloliths, which are tiny, white, foul smelling stones which lodge in the tonsillar crypts.  Sometimes a tonsillolith can be pried out of the surface of the tonsil with a pencil or other small pointed instrument leaving what appears to be a little “hole”  but is, in actuality, the tonsillar crypt in which it originally formed.  Tonsilloliths sometimes give the feeling of something lodged in the throat. They can also contribute to bad breath.   Some people have chronic problems with Tonsilloliths.  The only sure treatment for chronic Tonsilloliths is removal of the tonsils.  The operation is performed by an ear, nose and throat specialist (ENT) and is fairly simple and safe.  As noted above, in adults the operation causes a very serious sore throat for two weeks post-op.  Short of removing the tonsils, the bad breath can be treated with mouth rinses, and the condition itself may be lessened by gargling with Peridex® mouth wash which is available by prescription from your dentist or physician, and possibly by the use of decongestants to lessen the post nasal drip which is part of the cause of Tonsilloliths

Do you have Bad Breath?

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The Retromolar Pad is similar to the maxillary tuberosities discussed above, except that it is behind the last lower molars, and it is not underlain by a corresponding hump of bone.  Even so, it, like the tuberosity, is a persistent landmark and remains as a hump of tissue even if the lower teeth have all been extracted.

The Vestibule is the curvature of the tissue where the lining of the inside of the lips (labial mucosa) or cheeks (buccal mucosa)  meet the gingiva (the gums).  If you run your tongue around the outside of the teeth and extend it as far as it will go down (or up)  into the cheeks keeping it in contact with the gums, the tip is extended into the labial or buccal vestibule.

MaxMucogingival

MaxMucoLabeled2

The image above shows the actual anatomy of the gingiva, known commonly as the “gums”.  The lighter pink colored gum tissue is called the “attached gingiva” because it is firmly attached to the underlying bone.  It has the same consistency as the gums overlying the hard palate discussed above.  The darker pink tissue above it is called the unattached gingiva  also called the Alveolar Mucosa.  It is not firmly attached to the underlying bone.  The junction between them is called the mucogingival junction.  The small margin of tissue outlined in yellow on the lower diagram is called the free or marginal gingiva (sometimes called the free gingival margin), and it is the unattached, sleeve like portion of the gingiva that encircles the tooth to form the gingival sulcus.

The Vermillion border is the junction of the dry, pink part of the lip with the skin of the face.  The labial (lip) vestibule is marked on the diagram.  The Upper Labial Frenum is also visible.

The Throat Oropharynx2

The illustration on the right shows what is called a sagittal section of the face and neck.  Note the proximity of the back of the tongue, the soft palate and the epiglottis to the back of the throat.  The area between these structures and the back of the throat represents the narrowest parts of the airway and it is the narrowness of the airway in these areas that are of chief concern in the treatment of snoring and obstructive sleep apnea.  The throat is a dual purpose organ allowing both the function of breathing and of eating and drinking.  Air goes down the trachea to the lungs and food and drink go down the esophagus into the stomach.  A remarkable little organ called the epiglottis is the valve that determines into which tube the air or food flows.  This organ closes over the trachea blocking it off when anything but air is flowing through the throat.  It opens when the person is breathing.  You do have conscious control of the epiglottis.  You can get a sense of where it is by clearing your throat.  During this process, the epiglottis obstructs the trachea (airway) while you are exhaling, blowing air past the partially closed valve.

The Tongue (and its associated “bumps”)

LingualTonsil

The tongue is composed entirely of muscle and connective tissue covered with two types of mucosa (Mucosa is the pink “skin” in the mouth).  The image on the left shows part of the lingual tonsil on the lateral (side) surface.  The lingual tonsil is much larger than the portion shown here.  It curves up and around the posterior top surface of the tongue too (see the graphic below).  The ventral surface is the underside of the tongue and it is smooth and not involved with tasting food.  The dorsal surface is on top and is covered with a thin, pink velvet carpet.  The velvet surface is composed of tiny hair-like projections called “filiform papillae“.

FiliformPapillae2Large

The filiform papillae are a bit like hair in that they keep growing throughout your life.  The image above is a false color electron micrograph of the filiform papillae on a cat’s tongue.  Human filiform papillae are similar except they tend to be flatter and lie down instead of sticking up in little points. Click on the image to see a larger version.

Human_Filiform_papillaeThe image above is a micrograph of a section of a human tongue showing the flat filiform papillae surrounding a fungiform papilla which is better known as a taste bud. In healthy people, the individual hairs are shed before they get too long, and the natural red color of the underlying tongue tissue shows through giving the top surface of the tongue a velvety pink appearance.  In some disease conditions (mostly fever causing diseases), the hair does not shed easily and forms a white, or sometimes even a black “coat” on the dorsal surface of the tongue.  The filiform papillae are naturally white, but are often stained brown or black by foods or by dry mouth.  When the filiform papillae grow too long, they remain on the dorsum of the tongue like a thick mat. This condition is known as “white hairy tongue” or “black hairy tongue” (see images below).  A white or black coating on the tongue is NOT necessarily associated with any particular disease condition.  This overgrowth of “hair” is easily removed by scraping the surface of the tongue with a tongue scraper or an inverted spoon.  The filiform papillae are not associated with the sense of taste. White and black hairy tongue are not contagious conditions.  Click on either image below to see larger versions.

hairytongue

If you look at the surface of your tongue, you will notice many tiny bumps scattered in among the velvet along the edges of the dorsal surface.  The bumps are another type of papilla called “fungiform papillae” (named in honor of their mushroom-like shape).  These are small, slightly raised and slightly redder than the surrounding “velvet” filiform covered surface that surrounds them.  Foliate  papillaeare a third type located on both sides of the tongue in a small area just above (dorsal to) the lingual tonsils on the lateral surface of the tongue.  The fungiform and foliate papillae are associated with taste buds.  These papillae tend to be specialized with respect to the type of taste buds they contain.

Tongue2The image above shows the areas on the tongue which contain the fungiform and foliate papillae with taste buds specialized to taste the four basic tastes.  (Our sense of smell is intimately linked to our sense of taste, and it is in our nose that we taste everything besides salty, sweet, bitter, and sour.)    Notice that on this little image the back of the dorsal surface of the tongue contains a series of large bumps.

TongueTasteIf you stick out your tongue, you can see them on your tongue too.  These large bumps on the top surface of the back of the tongue are a fourth type of papilla called circumvallate papillae.  They are located along the “circumvallate line” and contain taste buds that confer the sense of sour and bitter to the back of the tongue.  They can actually be quite prominent and are often mistaken by patients for cancerous growths.

FiliformPapillae

No, this child does not have Blue Tongue Disease!  (There is no such thing–in humans anyway.  Such a disease does exist, but it only affects cattle, goats, sheep and deer.)  A few drops of blue food coloring were applied to demonstrate the general size and location of the (otherwise pink) fungiform papillae which are the little bumps scattered all over the top surface of the tongue.  They are usually difficult to see unless an overgrowth of filiform papillae causes the ordinarily pink velvet of the tongue to turn white, in which case the fungiform papillae.

Macroglossia (large tongue)

Macroglossia

The tongue normally resides on the inside of the arch formed by the lower teeth.  Most people’s tongues fit neatly into this space, however, a minority of people have tongues which are a bit larger than the space available.  This does not mean that the patient cannot actually fit their tongue into this space.  The tongue is a very flexible organ, and can accommodate itself to the prevailing conditions easily.  On the other hand, once fitted into the space, it relaxes and presses up against the teeth.  This causes the tongue to fill up the space available.   Tongues like this have scalloped edges like the one pictured to the left.  The scallops reflect the shape of the teeth as well as the spaces between them.  This condition is sometimes associated with burning around the edges of the tongue.  Click the image to see why, and for larger images.

Fissured tongue (scrotal tongue)

Fissured_tongue

Fissured tongue, also known as scrotal tongue is characterized by folds and fissures in the dorsal (top) surface of the tongue.  The fissures are of variable depth and usually extend laterally from a median groove as is pictured in the thumbnail to the right.   This condition does not cause any symptoms, unless food particles and debris lodge in the depths of the fissures causing a mild glossitis (inflammation of the tongue).  It is considered to be a normal form of tongue anatomy.  Click on the thumbnail to see a larger version.

The floor of the mouth

LingualFrenum

The image above shows the undersurface of the tongue.  The thin strip of tissue that runs vertically from the floor of the mouth to the undersurface of the tongue is called the lingual frenum.  It tends to limit the movement of the tongue, and in some people, it is so short that it actually interferes with speaking.  It is a simple matter to “snip” this chord under local anesthesia.  It is most often done when a child is between 5 and 9 years old.  The procedure is called a lingual Frenectomy.

The “V” shaped hump of tissue in the floor of the mouth houses a series of saliva gland ducts.  The two largest ducts are in the center just in front of the attachment of the lingual frenum and are called Wharton’s Ducts.  They empty the submaxillary saliva glands (also known as the submandibular salivary glands).  These ducts can be quite active in some persons, and upon occasion, a “fountain” of saliva may erupt from them while the patient is talking causing one of those embarrassing moments.  The Sublingual saliva glands glands empty through a series of tiny ducts in the tissue on either side of Wharton’s ducts.

If you look carefully at the above image, you will note some blue tinted tissue under the tongue and in the floor of the mouth.  These represent the presence of superficial veins that run in this area, and they are called varicosities.  Their presence is normal, becoming more and more prominent as the patient ages.

kaposis_thumb(Many people who inquire about “bumps on the tongue” are worried about HIV and AIDS.  Please click on the icon to the right to view a complete explanation of AIDS and its oral manifestations.) 

Burning mouth syndrome (BMS) (also known as burning tongue syndrome)

HitchhikersA small percentage of older men and women (mostly women), generally at, or around the age of menopause develop a problem with chronic burning pain and phantom tastes in their mouths.  It often centers on the tongue. The tongue itself looks perfectly normal.  It just develops a burning sensation that progresses throughout the day.  These patients may have seen numerous doctors to try to rid themselves of the annoying, and sometimes painful symptoms, but generally to no avail.  The problem has been ignored for centuries because there seemed to be no physical reason for the symptoms, and because it was believed that it was a hysterical symptom brought on by emotional distress.  In fact, the problem sometimes does respond to antidepressant drugs like Elavil.

Recent research has revealed a hypothesis which might explain BMS (Burning Mouth Syndrome).  It involves actual damage of the seventh cranial nerve which supplies the taste buds in the anterior 2/3 of the tongue. This may be caused by either (or perhaps both) the change in hormonal balance due to menopause and/or a viral infection.  The theory is that these persons have lost much of their ability to taste, even though many do not realize their loss since the brain is good at amplifying small signals.  The loss of the function of the 7th nerve leaves the trigeminal nerve (which allows the tongue and mouth to experience pain sensation) in a position of dominance.  This theory assumes a sort of balance between the two nerves, and if a patient suffers a loss of ability to taste because of damage to the 7th cranial nerve, then the brain exaggerates the impulses from both the trigeminal and the 7th cranial nerve causing a constant burning sensation because of exaggerated trigeminal sensitivity.  In addition, due to exaggeration of impulses from the 7th cranial nerve, the brain begins to generate phantom taste sensations.  This sort of taste hallucination is similar to the tactile “fat lip” sensation that a patient feels when the conduction of the trigeminal nerve is blocked by a shot of a local anesthetic to numb the lower teeth.

Sometimes people develop this problem due to a hypersensitivity to some toothpaste or oral rinse that they have recently begun using. The first line of defense is to change your toothpaste to a type with only fluoride (Tom’s of Maine is a reasonable choice) and cut out mouth rinses.  The type of toothpaste most often involved with this type of hypersensitivity are those containing pyrophosphates which are added to reduce the buildup of calculus (like Crest Complete or Colgate Total) Also try to determine if you have recently been taking a new medication whose introduction coincided with the onset of the symptoms.  A simple change of medication could make the difference.

It was discovered, quite by accident, that patients suffering from epilepsy who also suffered BMS experienced relief from the symptoms of both of these ailments by the administration of the epilepsy drugs clonazepam (Klonopin) and gabapentin (Neurontin). Thus a small, once or twice a day oral dose of of one of these drugs has been found to relieve the symptoms of BMS in most patients.  Alternatively, clonazepam may be dissolved in the mouth using 1/2 of a .5 mg tablet twice a day.  Another drug which has been found to be useful in treating BMS is Chlordiazepoxide (Librium) not to exceed 10 mg three times per day.

Another treatment that may work (or at least reduce the symptoms) in about 1/2 of sufferers is capsaicin desensitization.  Capsaicin is the ingredient in hot peppers that makes them hot.  The regimen is dilution of one part Tabasco sauce in two or three parts water with the patient rinsing and expectorating (spitting out).  This is done every 2-3 hours at first, and tapering off over a day or two to once or twice a day.  Be careful.  Some people are hypersensitive to capsaicin, so if the burning is too severe, stop immediately!

Bald tongue (Atrophic glossitis)

AtrophicGlossitisAs people begin to reach their senior years, sometimes they notice that their tongue begins to burn when eating sharp tasting foods.  A look in the mirror reveals a beefy red tongue lacking the filiform papillae which, in health, give the top (dorsal) surface of the tongue a normal, light pink, velvet appearance.   The loss of the filiform papillae is known as atrophic glossitis, and it may be caused by several different factors.

The first factor is nutrition.  Atrophic glossitis is most often caused by a lack of B vitamins in the diet.  The addition of daily doses of folic acid, niacin, vitamin B12, pyroxidine, riboflavin, and even Iron, all in the form of a simple daily multiple vitamin tablet may help to restore the tongue and relieve the burning on eating.

The second factor is an oral yeast infection known as thrush, also known as candidiasis.  In older patients with weak immune function, the mouth acts as a good incubator for yeast cells.  These accumulate under a denture and often cover the tongue leaving a white coating that is easily scraped off revealing red tissue underneath.  This is easily treated with Mycelex troches, or a single Diflucan tablet.  Both of these are anti-fungal medications.

The third factor is mechanical abrasion of the tongue against a rough dental appliance, or occasionally on the teeth themselves, producing a more localized, persistent area of smooth surface on the tongue.  This is treated by building a new denture and repairing or removing rough, broken teeth.  Sometimes it is as easy as scraping hardened dental calculus off the insides of the lower front teeth.


The Saliva glands

SalivaGlandsGraysThere are three pairs of major saliva glands.  The Parotid glands are on the sides of the jaw just below and in front of the ears.  They are the “pickle glands” that create that funny feeling on the sides of your face when you first taste something really sour.  The reason you feel it is that the parotids are contracting, expressing a sudden burst of saliva into the mouth. The glands empty through tiny holes in little bumps on the inside of the cheeks.  These bumps are called Stenson’s Ducts and you can feel them with the tip of your tongue on the cheeks on either side of your mouth beside the upper back molars.  The sublingual and submaxillary (also called the submandibular) glands empty into the mouth through ducts under the tongue.  For a more detailed diagram and explanation of the anatomy of the major salivary glands, see my page on dry mouth.

Sometimes one of the ducts to a gland will become blocked, generally due to a calcium deposit called a sialolith, or a salivary stone.  When this happens, the patient may notice a transient swelling in the face that comes whenever he eats, or thinks about food.  The swelling corresponds to the time when the salivary gland is producing saliva.  The sialolith causes the saliva to back up in the duct or in the gland itself.  Ordinarily, saliva always flows from the gland into the mouth, and this keeps germs from the mouth from progressing up the duct into the gland.  But when the flow of saliva is blocked, bacteria can now enter the duct.  Infections of this nature are called retrograde infections because the lack of flow of body fluid in the normal direction allows the germs to flow backwards (retro) into the organ that produces it.  This problem is treated by an oral surgeon who clears the duct or removes the stone, and administers antibiotics.

There are also about 600-1,000 minor salivary glands, which occur just under the mucosa (pink skin) all over the inside of the mouth, except on the top surface of the tongue. They are located beneath the lining of the lips, the undersurface of the tongue, the floor of the mouth, the hard and soft palate, inside the cheeks, nose, sinuses, and the larynx (voice box).  These glands are susceptible to retrograde infections and blockages of the duct just like the major salivary glands.  When this happens, the patient may notice a small reddish (inflamed) lump or bump, sometimes sore, sometimes not.  These small lesions can happen anywhere on the smooth pink mucosa lining the lips, cheeks or undersurface of the tongue and floor of the mouth, as well as on the hard palate.  Duct blockages often cause the swelling to take place at or around mealtime.  The swelling generally subsides between meals.

If you have come here to look for images of lumps, bumps, sores or discolorations that you noticed in the mirror this morning, there are three other pages with images you may find useful.  Start on this page.Then proceed to three other pages on which you will find more images of both normal and abnormal oral structures and lesions. 

Oral cancer
Lumps, bumps and sores and discolorations
Disease processes that affect the mouth

The index on this page includes links to subjects covered on the cancer and lumps & bumps pages.