Dental notesA complete note for the final year MBBS TABLE OF CONTENTS Table Of Contents....................................................... 1 Introduction to Dentistry ............................................ 2 Oral Cavity ................................................................. 2 Development of Teeth ................................................ 3 Dental Anatomy ......................................................... 5 Human Dentition ........................................................ 6 Clinical dental notation ............................................ 10 Oral Hygiene ............................................................ 11 Dental plaque........................................................... 15 Dental calculus ......................................................... 17 Dental Caries ............................................................ 18 Periodontal diseases and Gingivitis ........................... 22 Periodontitis ............................................................ 25 Dentoalveolar Abscess and Periodontal Abscess ....... 27 Impacted Teeth ........................................................ 28 Pericoronitis ............................................................. 29 Pulpitis ..................................................................... 30 Malocclusion ............................................................ 33 Chronic Injuries to Teeth .......................................... 34 Dislocation of Temporomandibular Joint .................. 37 Anesthetization ........................................................ 38 Tooth Extraction ....................................................... 43 Tooth Filling ............................................................. 45 Pulp Capping ............................................................ 46 Root Canal Treatment .............................................. 47 Maxillofacial Injuries ................................................ 48 Mandibular Fractures ............................................... 49 Maxillary Fractures ................................................... 52 Oral Cancer .............................................................. 54 Cysts of Orofacial Region .......................................... 56 Instruments.............................................................. 58 FAQ Examination Caries- Very FAQ Mandible Tooth extraction Dentine Gingivitis vs periodontitis - Very Very FAQ Antibiotics prophylaxis in ie and rhd Eruptions date for deciduous permanent dentition – FAQ Dental Notes by Sadichhya, Shooga & Sumesh Middle third fracture Nerve supply: inferior alveolar nerve Dental hygiene: tooth brushing FAQ Dental notation Dentigerous cyst Chronic injuries - FAQ False and true pocket Hypersensitive tooth: pulpitis Fluoride toothpaste - FAQ Medical assessment of dental procedure Calculus and plaque Dentoalveolar abscess Pericoronitis 1 Downloaded from DigitalMedicine.com.np INTRODUCTION TO DENTISTRY • • Definition: Diagnosis, prevention, and treatment of diseases of the teeth, gums, and related structures of the mouth and face including the repair or replacement. Branches of dentistry: 1. Oral medicine and radiology: Concerned with diagnosis and treatment planning of acquired and inherited disorders and diseases of the orofacial region 2. Conservative Dentistry and Endodontics: Deals with the prevention, diagnosis and treatment of the diseases affecting dental and periapical tissues 3. Orthodontics and Dentofacial Orthopedics: Study and treatment of malocclusions (improper bites) 4. Periodontics and implantology: Prevention, diagnosis and treatment of diseases of tooth supporting tissues and Implants for replacement of missing teeth 5. Maxillofacial Prosthodontics: Replacement of missing teeth, mouth, jaw and facial structures with artificial substitutes like dentures, crown and bridges. 6. Oral and Maxillofacial Surgery: Treats conditions, defects, injuries of the mouth, teeth, jaws, and face 7. Pedodontics and preventive dentistry: Deals with the treatment of children’s teeth 8. Community Dentistry: Public health aspect of dentistry like health programs, screening, etc. 9. Oral pathology Deals with investigation of causes, processes and effects of the diseases that affect the oral and maxillofacial tissues. 10. Forensic Odontology: Proper handling, examination and evaluation of dental evidence, which will be presented in the interest of justice ORAL CAVITY • • • • • Functions of the Oral Cavity o Mastication o Articulation of Speech o Partial Digestion o Accessory air passage o Deglutition o Sometimes defense Boundaries of the Oral Cavity o Anteriorly: Lips o Laterally: Buccal o Posteriorly: Palatoglossal Fold o Roof: Palate o Floor: Occupied by the tongue The roof consists of the hard palate and soft palate o Seven folds of mucosa called rugae: help in deglutition o Nerves: Nasopalatine Nerve: through incisive canal (seen as incisive papilla) Greater palatine nerve: greater palatine foramen Lesser palatine nerve: lesser palatine foramen. The floor o Structures: Tongue, sublingual papilla, lingual frenulum, sublingual fold, deep lingual veins. Frenula or Frena (singular: frenulum) o Superior labial frenulum, inferior labia frenulum. o Lingual frenulum. o Labial and buccal frenula. Dental Notes by Sadichhya & Shooga 2 Downloaded from DigitalMedicine.com.np com. 6th week: basal layer of epithelial lining of oral cavity forms a ‘c’-shaped structure called the dental lamina along the length of upper and lower jaw Lamina gives rise to 10 Dental Buds in each jaw: primordial of ectodermal component of teeth Buds for permanent teeth lie on lingual aspect of milk teeth. Cap Stage • • • • Invagination of dental bud by the mesenchyme 2 layers: outer and inner dental epithelium Central core of loosely woven tissue called stellate reticulum Mesenchyme which originates in neural crest forms the dental papilla 3. Bell stage • • • • • • Mesenchymal cells of dental papilla adjacent to inner dental layer differentiate into odontoblasts which later produces dentin Odontoblast layer persists throughout life and produces predentin Remaining cells of dental papilla form the pulp of the tooth Epithelial cells of inner dental epithelium differentiate into ameloblasts (enamel formers): form enamel that is deposited over dentin A cluster of these cells in the inner dental epithelium forms enamel knot: regulate early tooth development Enamel is first laid down at the apex of tooth then spreads toward the neck Dental Notes by Sadichhya. formed during3rd month of development 2.DEVELOPMENT OF TEETH STAGES OF TOOTH DEVELOPMENT 1. Bud stage • • • • Teeth arise from epithelial – mesenchymal interaction between overlying oral epithelium and underlying mesenchyme derived from neural crest cells.np . Shooga & Sumesh 3 Downloaded from DigitalMedicine. o As dentin increases. pulp chamber narrows forming canal o Mesenchymal cells on outside of tooth differentiate into cementoblasts which produce cementum o Outside the cementum. When dental epithelial layers penetrate in to underlying mesenchyme. root is forms o First epithelial root sheath is formed o Cells of dental papilla lay down a layer of dentin continuous with that of crown.np . mesenchyme gives rise to periodontal ligament Dental Notes by Sadichhya & Shooga 4 Downloaded from DigitalMedicine.com.• • When enamel thickens. temporarily leaving thin membrane called dental cuticle on the surface of enamel which sloughs off after eruption. ameloblasts retreat into stellate reticulum where they regress. 3 roots (mesiobuccal. grinding Helps in deglutition Articulation of Speech Cosmetic/ Aesthetic Defensive PARTS OF TOOTH • • • Crown Cervical Line Root OCCLUSAL LINE.com. cut food particles (4 surfaces+1 cutting edge) 1 root Prominence on the lingual surface of anterior teeth is known as the cingulum. pierce meat. Shooga & Sumesh 5 Downloaded from DigitalMedicine. incisal edge) DENTAL ARCHES • • Maxillary/ upper arch Mandibular/ lower arch CLASSIFICATION OF TEETH Incisors Canines (Cuspid) Premolars (Bicuspids) Molars Blunt. Mesial surface: Towards the midline along the arch Distal surface: Away from the midline along the arch Facial surface: i) Labial surface (anterior teeth) or ii) Buccal surface (posterior teeth) Lingual surface: In maxillary teeth. midbuccal and distobuccal cusps) . small size in F (4 surfaces + 1 cusp) 1 root Intermediate function of canines and molars (5 surfaces ) have 2 cusps: buccal cusp and lingual cusp (also called palatal cusp in maxillary premolars) st 2 roots (buccal and palatal) in 1 maxillary premolars.np . 4. all others have 1 root Elevated parts called cusps. it is also called as the palatal surface Occlusal surface (poorly defined in anterior teeth. MESIAL LINE AND THE FOUR QUADRANTS Mesial Line RUQ LUQ RLQ LLQ Occlusal Line ANTERIOR AND POSTERIOR TEETH • • • Demarcation line: junction of lips and cheek Central Incisors. piercing. 2 roots (mesial and distal) Dental Notes by Sadichhya. more prominent in the maxillary anterior teeth. 3. distobuccal and distal or mesiobuccal. distobuccal) but 5 in 1 molar (extra cusp known as cusp of Carrebelli). mesiobuccal. Grinds Food (5cusps + fossae + 5 surfaces) st • Maxillary molars: 4 cusps (mesiolingual. Pointed Edge(cusp). distobuccal and palatal) • Mandibular molars: 5 cusps (3 cusps along the Buccal surface: mesiobuccal. 2. 5.DENTAL ANATOMY FUNCTIONS OF TEETH • • • • • Mastication: cutting. distolingual. Depressed parts called fossae. knife edge like. Lateral Incisors and Canines are anterior teeth (they are adjacent to lips) Premolars and molars are posterior teeth (they are adjacent to cheeks) SURFACES OF TOOTH 1. Distal to lower canine • Dental Formula : 2102 Total = 20 2102 • Eruption Dates: Incisors: Lower central : 6 ½ mths o Lower lateral: 7 mth o Upper central: 7 ½ mth o Upper Lateral : 8 mth 1st molar: 12-16 mth Canines: 16-20 mths 2nd molar: 2-2 ½ yrs • First to shed off: Lower central incisor: 6 yrs • Last tooth to shed off: 2nd molar/canine: ~12 yrs Secondary Dentition (Permanent teeth) • Dental Formula 2123 Total = 32 2123 • First to appear: Lower central incisor/ First molar • Last to appear: Third molar • Eruption dates: Incisors: Lower central : 6-7 yrs o Lower lateral: 7-8 yrs o Upper central: 7-8 yrs o Upper Lateral : 8yrs 1st molar: 6 yrs 2nd molar: 12 yrs 3rd molar: 17-23 yrs Premolars: PM1: 9yrs . a primary and a permanent set) • • • • • Period of primary/ deciduous dentition: 6mth-6yrs Period of mixed dentition: 6yrs-12yrs 20 temporary teeth replaced by 32 permanent teeth Molars of temp teeth replaced by premolars of permanent teeth M1. M2. PM2: 10 yrs Canines: 11-12 yrs ERUPTION DATES OF DENTITION (THESE ARE ACCORDING TO CLASS PRESENTATION) Primary dentition Central incisor Lateral incisor First molar Canine Second Molar Lower Jaw 6 months 7 months 10 – 12 months 16 months 20 months Dental Notes by Sadichhya & Shooga Upper Jaw 7½ months 9 months 14 months 18 months 24 months Permanent dentition Central incisor First molar Lateral incisor Canine First Premolar Second Premolar Second Molar Third molar (Wisdom tooth) Lower Jaw 6-7 Yrs 6 yrs 7-8 yrs 9-10 yrs Upper Jaw 7-8 yrs 6 yrs 8-9 yrs 11-12 yrs (After PM2) 10-12 yrs 10-11 yrs 11-12 yrs 10-12 yrs 12 yrs 12 yrs 17-23 years 6 Downloaded from DigitalMedicine.com. M3 do not succeed their counterparts. Primary Dentition (Temporary Teeth) • Milk teeth: white as milk/ occurs during breastfeeding • Deciduous: falls of • Primate spaces: Mesial to upper Canine.Incisors Canines Premolars Molars HUMAN DENTITION Humans have diphyodont dentition (having two sets of teeth. they come behind deciduous teeth and are known as nonsucceedaneous.np . Rest of the teeth are succeedaneous. o On taking hot/cold substance – sensation taken by odontoblastic recesses. The pain disappears as soon as sensation is removed. o Alright after avoiding stimulus. • Sensation in dentine is due to odontoblastic processes and nerve endings. • Thinnest at cervical line and thickest at the cusps.INTERNAL STRUCTURE OF TOOTH • • • • • Enamel Dentine Pulp Radicular Pulp Cementum Dentine • Mesodermal in origin • Developmentally. • Softer (70% inorganic material) and elastic in comparison with enamel (96%) but harder than bone (45%). Dental pulp • Mesodermal in origin • Highly vascular delicate connective tissue derived from dental papilla. • Extends from crown to root and is yellow in color. • From pulp cavity minute papillary tubules called dentine tubules radiate (odontoblastic processes) to the periphery of dentine. severe pain (throbbing).np . • Dentine forms the main body of teeth.increases force during chewing) • Made up of 96% pure inorganic material calcium hydroxyapatite crystals (Ca phosphate. swelling.com. Nerve endings to pulpbrain-reacts and causes hyperemia-increased blood flow-increases pressure-nerves compressed – mild pain k/a sensitivity. • Loss of enamel: o Leads to exposed dentine. Shooga & Sumesh 7 Downloaded from DigitalMedicine. yet developmentally develops from cellular structures in the form of ameloblast (Ectodermal in origin) but ameloblasts die during eruption. • It is acellular. • Inorganic component constitutes larger proportion of matrix and dentine than that of bone and exists mainly in the form of calcium hydroxyl apatite crystals. exudation.B reaches pulp tissue: pulp reacts by full-fledged inflammation: hyperemia. Enamel: • Ectodermal in origin. • If dentine is exposed by any means: sensitivity felt d/t hyperemic condition at the pulp. • No dentine: F. a small amount of less organized secondary dentine continues to be laid down-progressive obliteration of pulp cavity with increased age (in kids pulp cavity is large) • Composed of calcified organic matrix similar to that of bone: glycolsaminoglycans with numerous collagen fibers. Ca carbonate) • Outermost covering and protective layer of crown • Color: Grayish white to yellowish white: depends on thickness of dentine which is yellow. avascular and aneural and is hence a dead tissue (can't be repaired. • After tooth formation is complete. cells responsible for dentine formation. • Contained within pulp cavity which includes: o Pulp chamber in crown: contains coronal pulp Dental Notes by Sadichhya. • Highly mineralized. odontoblasts differentiate as single layer of tall columnar cells on the surface of dental papilla (pulp) apposing amenoblast layers. not mobile and keratinized. • Oral aspect of gingiva: stratified squamous epithelium Cementum • Mesodermal in origin • Covering layer of root • Light yellow in color and avascular • Anchors to jaw bone by fibrous connective tissue • Periodontal membrane is regarded as periosteum of cement Dental Notes by Sadichhya & Shooga 8 Downloaded from DigitalMedicine. Pain of pulpitis Cannot localize Pain of periodontitis Can localize because periodontal ligament has nerves with proprioceptive fibers. PERIODONTIUM It consists of: 1. should not bleed. nerves and lymphatics. • Attached part provides a protective covering to upper alveolar bone. with orange peel appearance (stippling is normal). Alveolar Bone b. Functions of pulp: o Denture formation o Nutrition of all parts of tooth o Defense o Sensory (inflammation: swelling: press in pulp: very painful) Odontoblastic processes may act as sensory receptors in dentine. • Investing layer which gives protection to all attachment tissues. • Tip of free gingiva: thin layer of epithelial cells • Only 2 or 3 cells thick as the base of gingival crevice • The sulcal or crevivular epithelium is easily breached by pathogenic organisms and the underlying supporting tissues are thus frequently infiltrated by lymphoid cells. Investing tissue: a.5-1. • Parts: o Marginal(free) gingiva o Attached gingiva o Alveolar mucosa o Interdental gingiva(papilla) • Free gingiva forms a cuff around the enamel at the neck of tooth. o If depth >3mm it is called a pocket and is pathological: measured by periodontal probe: graduated in mm.• • • • o Root canal in root: contains radicular pulp Pulp horn: pulp going towards the cusps At the apex of the root is an apical foramen thru which passes blood vessels. tooth structures. coral pink in color.np . Supporting tissues (Attachment apparatus): a. • Between enamel and free gingiva is a potential space called gingival sulcus which is normally 0. Gingiva or Gum Alveolar bone Periodontal ligament Cementum Gingiva • Surrounds alveolar bone. Periodontal Ligament 2.com. and has non-keratinizing epithelium. is firm. • Free gingiva is margin of gingiva which is not attached to underlying bone.5mm in size up to 3mm deep. periodontal ligament and cementum (attachment tissues) • It is epithelial tissue. Cementum c. cells cementoblasts present) while remaining coronal 2/3 is acellular. BV also acts as a shock absorber: part of force during mastication is dissipated by its ligament. Poorly organized collagen fibers and ground substance. Shooga & Sumesh 9 Downloaded from DigitalMedicine. plexus of myelinated nerve fibers.com.• • • • • • • Contains fibroblasts.e. Periodontal membrane fixes the tooth in its socket and contains numerous nerve endings. Cementum contains cells known as cementoblasts Function: Sharpey’s fibers hold teeth with periodontal membrane and have cushioning effect. reticulin fibers. rich network of capillaries. Alveolar Bone • • • Alveolar arch Interdental septum Intra radicular bone Periodontal Ligament • Functions o Support o Shock absorber o Propriocpetion o Formative o Nutrtion Dental Notes by Sadichhya. Cementum is thicker towards apex Softer than dentine (55% inorganic material but harder than bone 45%) rd rd Apical 1/3 is cellular (i.np . com. the left maxillary wisdom tooth. The continuous numbering from 1 to 32 is used for the permanent dentition and alphabets A to T are used for the deciduous dentition. First number denotes the quadrants: 1 | 2 R--------------------L 4 | 3 5 | 6 R--------------------L 8 | 7 Permanent Dentition • Deciduous Dentition The second number denotes the number of the tooth: 87654321|12345678 R -----------------------------------------------------L 87654321|12345678 Permanent dentition • • 54321|12345 R -----------------------------------L 54321|12345 Deciduous dentition Thus. is denoted by “28” and read as “two-eight”.4x lower left .2x 18 17 16 15 14 13 12 11 | 21 22 23 24 25 26 27 28 R --------------------------------------------------------------------L 48 47 46 45 44 43 42 41 | 31 32 33 34 35 36 37 38 lower right .CLINICAL DENTAL NOTATION PALMER NOTATION METHOD (ZSIGMONDY SYSTEM) • Hungarian dentist Adolf Zsigmondy 87654321 | 12345678 EDCBA | ABCDE R-------------------------------L R--------------------------L 87654321 | 12345678 EDCBA | ABCDE Permanent Dentition • • • Deciduous Dentition Used in Nepal.1x upper left . the permanent dentition will have the following notation: upper right .np .L 32 31 30 29 28 27 26 25 | 24 23 22 21 20 19 18 17 TSRQP | ONMLK Permanent Dentition Dental Notes by Sadichhya & Shooga Deciduous Dentition 10 Downloaded from DigitalMedicine.5x upper left .L 85 84 83 82 81 | 71 72 73 74 75 lower right .7x UNIVERSAL NUMBERING SYSTEM • A single number to denote each tooth.3x • Thus.6x 55 54 53 52 51 | 61 62 63 64 65 R ------------------------------------------.8x lower left . (Mostly used in the US) 1 2 3 4 5 6 7 8 | 9 10 11 12 13 14 15 16 ABCDE | FGHIJ R ------------------------------------------------------------------------L R --------------------------. similarly the right nd mandibular 2 molar is denoted by “85” and read as “eight-five” Thus. the deciduous dentition will have the following notation: upper right . but can’t be entered in computer Permanent teeth : 1-8 Temporary teeth: A-E FDI (FÉDÉRATION DENTAIRE INTERNATIONALE)/ WORLD DENTAL FEDERATION NOTATION • • Used two numbers to denote each tooth. 5 cm Bristles should be of even length (1cm) o Concave.ORAL HYGIENE INSPECTION OF ORAL CAVITY • • • Status of oral hygiene judged by inspection of oral cavity for: o Food debris o Teeth: Plaques Calculus Stains Caries o Gum: Gingival inflammation Gingival pocketing Gum recession o Breath On the basis of these characteristics the status of oral hygiene is labeled as: o FAIR o AVERAGE o POOR Fundamental requirement of oral aids: Aids to oral hygiene should be capable of removing dental plaques without any damage to hard and soft tissues METHODS OF CLEANING 1.np . 3. 4. rapid Should be well organized Should fit patient’s capabilities Dental Notes by Sadichhya. 2. Shooga & Sumesh 11 Downloaded from DigitalMedicine. convex or zigzag have no beneficial effect o Short bristles are rigid and can cause trauma o Tufts of bristles should be loosely packed o Each tuft should contain 30-35 bristles Texture of brush: o Soft: doesn’t remove plaque o Medium: preferred o Hard: cause gingival recession: good for smokers who have tobacco stained teeth Angulation: doesn’t have extra benefit REQUISITES FOR SATISFACTORY BRUSHING • • • • • Should clean all dental surfaces including gingival crevices Shouldn’t injure tissues and shouldn’t cause gingival recession Should be simple. Mechanical cleaning: • Brushing with a tooth brush • Dental floss • Massage to gum • Wood pecks Chemical cleaning • Chlorhexidine Change of diet: • Low sugar content Scaling: • Manual (conventional scaling) • Ultrasonic REQUIREMENTS OF A TOOTH BRUSH • • • • • Small Size: o for adults: head length 2.com.5cm o for children: head length 1. Vibratory 4. Bass method (sulcular method) 6. Horizontal 3. Modified Bass method 7. Fones method: Recommended for young child who wants to brush themselves 10.Each jaw should be divided into 2 quadrants. EFFECTIVENESS OF TECHNIQUE • • • • • Any technique is effective only if it can completely remove the plaque Effectiveness of plaque removal is assessed by disclosing solution or tablet which contains erythrosine which is a non-toxic dye and stains plaque purple or pink The tablet is to be chewed and/or rinsed with solution Especially effective in children Procedure: o Use after children have brushed o Rinse with solution o See in mirror o If plaque is present. Ineffective and leads to tooth abrasion and gingival recession Roll’s technique (sweep): o Especially for Interdental area o Side of brush is placed against the buccal aspect of teeth and gingiva o Back of brush should be at the level of biting surface o Bristles are parallel to long axis of teeth o Rotate the brush: downward in upper jaw and upwards in lower jaw o Side of brush cleans (sweeps) tooth and gingiva and bristles are forced into an Interdental area. Modified Stillman’s method: Recommended for cleaning areas with progressing gingival recession and root exposure to minimize abrasive tissue destruction 9. Vertical 2. vertical and circular motions. sugary or sweet. o Strokes are given for each of 6 segments in one half of each jaw o 5-10 strokes each for buccal and lingual aspect of each tooth o Lingual and palatal aspects of ANT segment are swept vertically by the width of brush and rotary movements for occluded surfaces Bass technique o Aka crevicular or sulcular technique o Imp for cleaning gingival sulcus 0 o Brush kept at 45 to long axis of teeth with bristle ends pointing into gingival sulcus across the gingival margin. o Brush is then pressed slightly towards gingiva to enter the sulci making vibratory or circular movements Modified bass technique o Roll and bass technique both combined Gingival sulcus is important especially in old age. sticky and stuck Dental Notes by Sadichhya & Shooga 12 Downloaded from DigitalMedicine. brush with modified bass technique to remove plaque: if not removed go to dentist BRUSHING FREQUENCY There are certain factors which determine the frequency of brushing: • It takes 8 hours for dental plaque to mature • 4 S: soft. each quadrant is further divided into: st • 1 segment: incisor and canine nd • 2 segment: premolars rd • 3 segment: molars BRUSHING TECHNIQUE: • • • • • Different techniques: 1. Roll’s method (sweep method) 5. Scrub method: Vigrous horizontal.np . Charter’s method 8.com. if the person is a child. the technique used is correct. mentally sound or subnormal • Scrub technique: to and fro movement of brush on the surface of tooth o Long scrub o Short scrub • Short scrub technique applied on molars and premolars for occlusal surface • Vibratory technique : tip of bristle fixed o • To clean sulcus.np .com.1-0. either vibratory or circular vibratory technique applied every 6-8 times with brush at 45 angle to longitudinal axis of tooth • Clean teeth in sequence so that no segment is missed • Do not damage gingiva by hard bristles or more by force (so hold brush far from head of brush) • In elderly: bristles parallel to buccal/palatal surface • Electrical brush available for physically or mentally handicapped but is expensive INTERDENTAL CLEANING • The interdental area is an important site of plaque collection and is inaccessible to tooth brush. paste or powder used to clean teeth Most commonly used: tooth paste Functions of tooth paste: o Detergent: helps in removal of dental plaque chemically o Refreshes breath Tooth powder is abrasive and removes plaque mechanically by abrasion CHEMICAL CLEANING OF TEETH • Chlorhexidine gluconate 0.must be present Teeth must be clean and gingiva must be totally healthy for it to be used Used at an angle following gingival contour to avoid trauma to gingiva If used straightly.2% mouthwash reduces salivary bacterial count by 20-50% and inhibits plaque formation over a prolonged period SCALING • Removes both supra and sub gingival calculi Dental Notes by Sadichhya. Used daily 18 inches long DENTRIFICE • • • • Any liquid. Interdental papillae will atrophy o Interspace brush: One bristles or little baby bottle brush used for irregular teeth. at least once a day brushing before going to bed: must and each time after taking soft. • Food particles accumulate especially in space between free gingiva and tooth called sulcus • Technique that reaches this sulcus is called sulcal • Technique not reaching this sulcus is called non-sulcal • If the teeth and gingiva are healthy on examination. Shooga & Sumesh 13 Downloaded from DigitalMedicine. forming caries During sleep BMR decreases so saliva production decreases: can’t wash away the food particles: cause decreases pH: minerals are dissolved : l/t caries Cultural factor: brushing in the morning Considering all these factors. Following methods can supplement normal brushing: o Dental wood stick Irregular in cross section and tapering Interdental space . food debris from Interdental spaces.• • • After these types of food. sticky and stuck food. have to brush immediately within half an hour o Polysaccharide: doesn’t cause problem o Disaccharide and monosaccharide: decreases pH immediately and cause dissolution of mineral. missing teeth. sugary. then vice versa • Teach accordingly. erosion o Dental floss A thread that is waxed or unwaxed Remove plaque. • • • • Two methods: o Manual/conventional scaling o Ultrasonic scaling Ultrasonic scaling: o Tip of instrument vibrates in high speed (20-20KHz) o Calculus is fractured o Use of water to nullify heat produced that can otherwise damage teeth and also for flushing action Scaling should be followed by polishing (otherwise rough surface can harbor plaque) Sublingual plaque maybe be left behind by ultrasonic scaling so check and mechanical scaling should be performed Dental Notes by Sadichhya & Shooga 14 Downloaded from DigitalMedicine.com.np . Initial colonization by bacteria o Occurs within 6-12 hours o The initial colonizers .g. loescheii. pyogenes (facultative) o Pneumococcus (facultative) • Gram positive bacilli o Lactobacillis acidophilus o Odentophytic.g. Streptococcus sanguis. albus. meningitides o Morexella cattarhalis Gram negative bacill (facultative) o Actinobacillus Actinomycetemcomitans o Campylobacter rectus o Eikenella corrodens o Enteric rods o Pseudomonas 15 Downloaded from DigitalMedicine.aerobic gram positive facultative microorganisms e. Fusobacterium nucleatum. majority of plaque can be detected Supra-gingival Sites: The plaque is formed everywhere especially on hard surfaces o Supra-gingiva Sub-gingival o Sub-gingival (in the gingival sulcus) o Gingival Gingival COMPOSITION: The plaque is composed of: o 70-90% microorganism o 10-30% organic and inorganic materials including interbacterial matrix (~10%) Microorganisms Bacteria: • Gram positive cocci o Strep mutans. Secondary colonization and plaque maturation o Secondary colonizers .DENTAL PLAQUE • • • • • • Definition: WHO (1978): Specific but highly variable structural entity resulting from sequential colonization & growth of micro-organism of various species & strains embedded in an extracellular matrix.np . Prevotella intermedia. Porphyromonas gingivalis.g. o Co-aggregation o After 48 hours. fermenti. Dental Notes by Sadichhya. virtually the whole layer is covered by bacteria o The plaque now becomes very much adherent to the tooth surface and can’t be removed by water rinsing or hand pressing (5-10 strong mechanical brushing strokes required) Growth of the plaque: o Adhesion of new bacteria/organism o Multiplication of existing bacteria o Accumulation of metabolic products of bacteria (fermented products of proteolysis) o Protein. 3. mitis o Staph aureus.anaerobic gram negative bacteria.com. milliri. Formation of dental pellicle: o Hydroxyapatite of enamel has an affinity for glycoprotein so that a thin adhesive layer is formed on the surface of tooth called glycoprotein pellicle o Glycoprotein pellicle is derived from : Saliva Crevicular fluid Bacterial and host tissue cell products Food debris 2. Brushing FORMATION: • • • The process of plaque formation can be divided into 3 stages: 1. e. carbohydrate from food debris Starts within 6hrs of thorough brushing In 24hrs. Thin plaques are invisible while the visible plaques are thick plaques Forms nidus for formation of dental calculus and bacterial growth Not removed by water rinsing Cleared by frictional force: e. Shooga & Sumesh • • Gram negative cocci (facultative) o Neisseria gonorrhea. viridians. Tenaciously adherent soft deposit composed of bacteria in an organic matrix. Actinomyces viscosus. Capnocytophaga species. P. np .1-0. K. leucocytes. Hexosamine. % Food habits o Avoid or restrict intake of 3S o Encourage fibrous foods. lipid. Na. food particles PREVENTION OF PLAQUE • • • • Mechanical method o Thorough brushing and suitable dentifrice o Dental floss o Interdental brush o Dental wood stick o Gingival massage Chemical method o Chlorhexidine gluconate: 0.15.2% o Providone-Iodine (1-2%) o H2O2 3% o Benzyl amine 0. -CHO. and galactose Fungi • Candida albicans Parasites (facultative) • Entamoeba gingivalis • Spirella • Leptotrichia • Buccalis 400 million organisms are found per milligram of dental plaque • Organic: protein. PO4 • Interbacterial matrix: Dextran. desquamated epithelium. and vegetables. And fresh fruits and vegetables Treatment o Tooth brushing o Scaling SEQUEL OF DENTAL PLAQUE • • • On the tooth dental calculus On the tooth dental caries Dentine exposure (sensitive tooth)pulpitisperiapical abscess (tender tooth On the gingiva gingivitis periodontitis Dental Notes by Sadichhya & Shooga 16 Downloaded from DigitalMedicine. soybean.com. methyl pentose. Levan. grains.• Anaerobic Gram negative rods o Porphyromonas gingivalis o Prevotella gingivalis o Bacteroids forsythus o Fusobacterium species • Anaeronic Gram positive rods o Eubacterium species • Anaerobic Gram positive cocci o Peptostreptococcus micros Organic and inorganic matrix • Inorganic: Ca. Protein.np . Greenish black or dark brown to black FORMATION: • • • Acquired pellicle dental plaque mineralization dental calculus Can form anywhere but is maximum over: o Lingual surface of lower teeth. fluorides Organic (10-30%) Bacteria (Streptococci. Desquamated epithelial cells. etc giving dark brown to black coloration In relation to gingival margin: dental calculi can be o Supra-gingival Coronal to gingival margin towards crown Hard clay like consistency White or yellowish white (Stain) st nd Abundant on buccal surfaces of upper 1 and 2 molars & lower lingual surfaces Formed in 2 weeks o Sub-gingival In gingival sulcus. PREVENTION • Prevent formation of plaque (Plaque can change into calculus in 15-20 days) and scaling. identified by probe and air syringe Thinner.DENTAL CALCULUS • • • Hard deposits formed on tooth or dental appliances due to mineralization of dental plaque Color: normally yellowish white but may get stained with tea. drugs. smoke. harder. Many calculi are formed at the opening of salivary gland ducts: 2+ o Duct opening: availability of Ca in salivary secretion. coffee. Mg3(PO4)2. Dental Notes by Sadichhya. Candida. CaSO4. Shooga & Sumesh 17 Downloaded from DigitalMedicine. COMPLICATIONS • Gingivitis and Aesthetic problems. Carbohydrate. Dead WBCs. MgCo2. Staphylococci) . Ca(PO4)2.com. o Buccal surface of upper teeth. COMPOSITION: • • Inorganic (70-90%) CaCo3. surfaces adjacent to tooth restorations and exposed roots are susceptible areas NATURAL HISTORY OF DENTAL CARIES 1. Stephan’s curve and cariogenic bacteria as well) • Widely accepted • According to this theory. 7. Proteolytic theory • In addition to acid production. Periapical granuloma c. 4. Acidogenic theory: (in exam write about demineralization & remineralization.com. Demineralization of dentine with dissolution of softened residue: acid affecting dissolution is obtained from starch and sugar fermentation by microorganisms which are mostly acidogenic • Dental plaque helps acid to stay in contact • Stephan’s curve shows the changes in pH in relation with the food (critical pH is 5. 2. Sinus tract formation b. the process cannot be reversed 4.5) 2.” • • One of the commonest diseases in the world Enamel. cavitation and soft consistency on probing (leathery feel) Dentinal caries: features of enamel caries + sensitivity Pulpitis: features of dentinal caries + pain (inflammation of pulp causes stimulation of Aδ & C-fibres) Periapical periodontitis: features of pulpitis + tenderness on percussion (periodontial ligament space is filled with exudate lifting the tooth) Periapical abscess: features of periapical periodontitis + swelling Sequel of periapical abscess: a. Cavernous sinus thrombosis • As dentine and enamel don’t have blood supply. the tooth surface remains intact and demineralization is reversible but once the tooth surface collapses to expose a cavity. The rate of demineralization is inversely proportional to the degree of saturation of calcium. 3. Initial enamel subsurface demineralization due to bacterial acid Extension of demineralized zone towards dentine Collapse of surface layer to form cavity Extension of caries lesion into dentine Extension of caries into pulp (with possible formation of apical abscess) Enamel caries: discoloration (asymptomatic chalky white soft spot on tooth). dental decay is a chemico-parasitic process consisting of 2 stages i. dentine. natural healing doesn’t occur • Aim of treatment is to stop progression ETIOPATHOGENESIS • • Demineralization and remineralization: 1. Ludwig’s angina e.np . plaque bacteria produce Proteolytic enzymes that destroys organic portion of tooth making it easier for microorganisms to invade enamel and dentine Dental Notes by Sadichhya & Shooga 18 Downloaded from DigitalMedicine. 1. 5. phosphate and fluoride ions in the saliva. and the pH of the solution 3. 6. Demineralization of enamel and its destruction ii. In the early stages. Periapical/Periodontal cyst d. Demineralization and remineralization is a dynamic process 2. catch on probing (if only stain no catch).DENTAL CARIES Definition: “Progressive irreversible damage to hard part of the teeth exposed to oral environment characterized by demineralization of inorganic constituents and dissolution of organic contents resulting in cavitation. Osteomyelitis and periostitis f. Remineralization occurs when the pH increases and calcium and phosphate from saliva together with fluoride form new hydroxyapatite crystals on the enamel surface and the body of the lesion Many theories regarding mechanism of evolution of caries. widely accepted • Bacterial attack on enamel is initiated by keratolytic microorganisms: breakdown of proteins and other organic portion of enamel especially keratin • This results in formation of substance which may form soluble chelates with mineralized portion of teeth: organic and inorganic portion of tooth undergo demineralization simultaneously • Chelation is complexing or freeing metallic ion Factors responsible for caries 1. Role of salivary flow (hypersalivation is protective against caries) STEPHAN’S CURVE AND CARIES The Stephan’s curve describes the pH change in relation to the food intake (Critical pH for caries formation is 5. Role of carbohydrates (sugary diet increase the risk of caries) 3. 4. it dilutes and carries away metabolites diffusing out of the plaque.5).3.. Role of teeth surface (less fluorhydroxyapatite and irregular teeth increase risk of caries) 6. Role of microorganism (E. Role of dental plaque (Acid that is formed is kept in contact with teeth surface for longer time) 5. The second figure shows the Stephan’s curve according to different salivary flow rate. 3. 2. long-term antibiotics use is protective against caries) 2. the nature of the fermentable substance.g. Role of acids to demineralize 4. the rate of diffusion of bacterial metabolites. salivary access to the plaque.np . Stephan Curves describe the changes in pH occurring within dental plaque when it is subjected to a challenge. The relationship of the shape of the Stephan Curve to the Critical pH can be used to assess the relative cariogenicity of foods CARIOGENIC BACTERIA: • • • Streptococcus mutans ( most potent) and S. 1. saliva flow rate Saliva exerts two effects. First. Strep sanguislactobacilli Main acids produced are: o Lactic acid o Acetic acid Dental Notes by Sadichhya. • Proteolysis-chelation theory (latest) • Latest theory. sucrose) into polysaccharides like polyglyans or dextrans which helps: Dental plaque to adhere to tooth Bacteria to adhere to tooth Streptococcus viridians. streptococcus salivarics. typically with a foodstuff When challenged with a fermentable carbohydrate the pH within plaque drops rapidly and then rises back to the resting pH more slowly Factors affecting the shape of the Stephan Curve include the microbial composition of the plaque. Second it supplies bicrabonate ions which diffuse into plaque and neutralise the by-products of fermentation (organic acids) in situ. 5. salivary components such as bicarbonate and the fermentable substance.com. sobrinu because of: o Its ability to produce aid by sugar fermentation o Its ability to polymerize sugar (esp. Streptococcus mitis. Shooga & Sumesh 19 Downloaded from DigitalMedicine. np . and pitted stained. periapical cyst enucleation/marsupialization Cellulitis.com.2% mouthwash o Mechanism: destroys cell membrane of bacteria o Disadvantages: not very effective as on stopping its use. • Ways of taking fluoride: Systemic and Topical.g. penicillin in long term with RHD Antiseptics: e. Ca phosphate to Cariogenic diet decreases caries in animals Increasing resistance of tooth to bacterial action • • • • Antibacterial measures o Antibiotics prevent caries but use is not advisable only for this purpose e. Chlorhexidine gluconate 0. more brittle. vaccine not yet developed as it is not practical since many organisms are responsible Roles of fluorides: (double edged sword) • Addition of fluoride to water 1PPM most effective means of increasing resistance of tooth to bacterial action • If addition of >2PPM fluoride: fluorosis: enamel mottling of teeth.g.• • o Propionic acid Disaccharides are more cariogenic than monosaccharides Glucose and fructose through unrefined foods can be severely cariogenic (less than sucrose) MANAGEMENT • • • • • Principles of Management Of Caries: o Removal of decayed enamel and dentine o Removal of adjacent stagnation surfaces e.1 mg (1/2 tab daily) Dental Notes by Sadichhya & Shooga 20 Downloaded from DigitalMedicine. • Systemic application of fluoride o Water fluorination (1PPM in water supply) o Salt fluorination(1/2 to 1/3 water concentration_ o Milk fluorination o Fluoride tablets Dual effect: systemic as well as local One tab: 2. pits and fissures o Protection of pulp (by putting an insulation lining to prevent sensitivity with a metallic filling like ZnSO4 or by indirect pulp capping) o Maintenance of water tight restoration o Restoration of original shape and form of tooth Enamel and dentinal caries restoration Pulpitis. and brushing once any food gets stuck (4’S’) (artificial sweeteners are not Cariogenic because they cannot be fermented by bacteria) Modifying plaque • Addition of Na. sugary and sticky diet. opaque tint.D) : equivalent to taking 1L of water containing 1PPM of fluoride Started immediately after birth Up to 2yrs: 1. periapical periodontitis root canal treatment Periapical granuloma. cavernous sinus thrombosis specific management PREVENTION OF CARIES Complete removal of plaque • • Brushing Scaling Denial of substrate to plaque bacteria • Avoid soft. osteomyelitis. causes growth of bacteria again o If long term use: extrinsic discoloration (staining) but no other harmful affect o Very unpleasant taste Immunization against caries: still in experimental stage.2 mg of NaF (O.g. non-fluoridated toothpaste because it can be toxic if swallowed. Changes in morphology of the teeth (esp.• 2-12 yrs: 2. Used everyday • Disadvantage: casual process. jaw and TMJ o Lateral cephalogram: growth-study and orthodontics o PNS view/Water’s view for PNS o Submento vertex view: for zygomatic process o PA skull o Transpharyngeal view for TMJ o Towne’s view and reverse Towne’s view o PA and lateral mandible o Lateral oblique view CT and MRI are generally reserved for complex maxillofacial surgeries involving cysts. powder. cancers. this will reduce caries incidence around 30% o Tooth paste of children formulation 125 to 580 ppm fluoride. root. alveolar bones o Occlusional radiograph: for sialolithiasis o Bite wing: Visualization of crown of upper and lower teeth For diagnosis of proximal or incipient caries Extraoral o Orthopantamogram (OPG): a screening radiograph showing teeth. 5.np . if fluoride is present during development of teeth) DIFFERENT TYPES OF X-RAY MODALITIES USED IN DENTISTRY • • • Intraoral o Intraoral Periapical (IOPA): Visualization of crown. periapical region. etc. only in accessible areas Mechanism of Action of Fluoride 1. periodontium. Shooga & Sumesh 21 Downloaded from DigitalMedicine. Dental Notes by Sadichhya.com. paste Shouldn’t rinse vigorously after brushing (residual fluoride after brushing) Fluoride tablets Fluoride in toothpaste • Most formulation contains NaF (sodium monoflouride) or capil (sodium mono fluorophosphates) or combination of both at a concentration of 1000 or 1500 ppm used twice daily. 2. Formation of fluorhydroxyapatite which makes enamel stronger and acid-resistant (Hydroxyapatite + fluoride -> fluorohydroxyapatite crystals which are larger and have few imperfections) Enhancement of remineralization at crystal surfaces of the tooth Reduce demineralization Inhibit enolase enzyme in glycolytic cycle of the bacteria thereby preventing acid generation. trauma. • Advantages: Directly in contact with teeth. 4. Up to 4 years. 3.2 mg daily one tab >12 yrs (1/2 tab daily) Topical application of fluoride o Get incorporated into superficial enamel which is available in the following forms Fluoride mouth rinse Fluoride containing dentifrice: gel. nifedipine. anemia. mouthwash TYPES • • Acute gingivitis Chronic gingivitis ACUTE GINGIVITIS 1. gingival abscess and pericoronal abscess) 7. sticky food.e. It is the sequlae of dental plaque and dental calculus CAUSES: • • Local factors: o Insufficient and inefficient tooth brushing o Stagnation of soft. fishbone. tumor. dallor. EhlersDanlos syndrome) 5. Gingivitis 2. leukemia. imbricated teeth (crowded teeth) o Badly restored teeth: rough surface. development of periodontal pocket and progressive loss of alveolar bone. It results in destruction of attachment apparatus.. cyclic neutropenia. Necrotizing ulcerative gingivitis/periodontitis 6.endodontic (pulp) lesions Gingivitis: Inflammation if gingival tissue associated with signs and symptoms of inflammation i. orthodontic appliances: irritable margin: food gets collected o Mouth breathers and incomplete lip seal (dry: inflammation) o Bacterial and viral infection o Trauma (traumatic bites. TB. Aggressive periodontitis 4.” 1999 Classification of periodontal diseases: 1. 2. 4. stomatitis. bacterioids and melaninoginicus Age groups affected o Children not usually affected o Adults and adolescents more Dental Notes by Sadichhya & Shooga 22 Downloaded from DigitalMedicine. Acute Necrotizing Ulcerative Gingivitis (ANUG) Herpetic gingivitis Non-specific or streptococcal gingivitis Leukemic gingivitis ACUTE NECROTIZING ULCERATIVE GINGIVITIS (ANUG) • • • Also referred to as Vincent’s angina or “trench mouth” Organisms o Borrelia vinceti (Treponema vinceti) o Bacillus fusiformis o Gram negative anaerobes o Other bacteria like vibrio. etc. Combined periodontic . fingernail ) Systemic factors: o Vitamin C deficiency: scurvy o Vitamin B complex deficiency B2: glossitis. Chronic periodontitis 3. brush.PERIODONTAL DISEASES AND GINGIVITIS • • • • Periodontal disease: “A group of diseases that affect all the periodontal structures. Periodontitis as a manifestation of systemic disease (eg. irritated gingiva o Prosthesis. 3. B3: pellagra: 3’D’ and gingivitis o Hormonal imbalance Puberty: increased estrogen Pregnancy: increased progesterone o Drug induced Phenytoin. OCP cause gingival hyperplasia o Diseases: DM.com. calor. Abscesses of periodotium (periodontal abscess. gingivitis. nephritis o Allergy to dentifrices. rubor. cyclosporine. tooth.np . tongue. cheek and palate o typical grayish ulcer with red margin o general: sudden onset fever. metallic taste. photophobia.In developing countries. later they join together to from big ulcer o site of ulcer-gingiva. Children are prime victims Clinical Features o no necrosis o Interdental papilla not involved o at first small vesicles are formed. also it is lethal to anaerobic bacteria) or Chlorhexidine gluoconate mouthwash o Metronidazole 250-400 mg TDS 5-7 days o Amoxicillin 250-520 mg TDS 5-7 days o Rest. malaise. painful o increased salivation o saliva can’t be swallowed: so trickle down from corner o no ulceration. ulceration. soft food o Analgesics o Antipyretics o • • • HERPETIC GINGIVOSTOMATITIS • • • • Due to Herpes Simplex Virus and Herpes Labialis Virus. malnutrition and malaria (3M) Risk factors o Smoking o Improper oral hygiene o Anxiety and stress o Alcohol use Clinical Features o Local (aka Vincent’s infection) o Sudden gingival inflammation. malaise.com. and increased salivation o General: fever. swelling of gum and spontaneous bleeding Anemia and lymphadenopathy Dental Notes by Sadichhya.np . irritability Management o Heals spontaneously within 7-14 days if no secondary bacterial infection o 3% H2O2 mouth wash o 250 mg tetracycline capsule dissolved in 30 ml H2o and wash 3-4 times a day for the prevention of secondary bacterial infection o Acyclovir and idoxyuridine for one week can be given o Bes rest o Soft food. and fetid halitosis o Ulceration and necrosis of Interdental papillae o Punched out ulcer-crater like formation covered with grayish white membrane or slough o Very painful o Halitosis. plenty of fluid o Mild analgesics STREPTOCOCCAL/ NON-SPECIFIC GINGIVITIS: • • • Due to streptococcal infection from oral commensals itself Clinical Features o beefy red lesions. incidence is high in children due to prevalence of measles. no necrosis Management o Tetracycline 250 mg OID 5 days LEUKEMIC GINGIVITIS • • Painful. lymphadenitis Management o Debridement wash in H2O2 ( it cleans necrotic tissue due to O2 release. bleeding. Interdental gingival necrosis. Shooga & Sumesh 23 Downloaded from DigitalMedicine. lips. gingiva may be detached from the neck of teeth. spongy. either it can recede downwards apically (gingival recession or apical migration) or grow coronally (coronal migration) to form pockets o Pain is the most common complaint with acute gingivitis but there is no pain in chronic gingivitis: so progresses to irreversible periodontitis Management and treatment plan: o Prevention of plaque calculus o Maintain good oral hygiene o Eliminate or treat the cause o Treat accordingly to type of disease Dental Notes by Sadichhya & Shooga 24 Downloaded from DigitalMedicine.np .• Management o Symptomatic treatment o Prevent secondary bacterial infection o Gingivoplasty: reconstructing and reshaping (reconstructing) of gingiva o Gingivectomy: excision of diseased part of gingiva o Sequlae of gingivitis: periodontitis CHRONIC GINGIVITIS • • • Causes o Persistence of low grade inflammation due to presence of plaque.com. calculus o Incompetent lips: mouth breathing o Prosthesis and orthodontic appliances o Traumatic bites o If lower teeth continuously strikes palatal region of upper teeth o If acute gingivitis not treated Clinical Features o Cardinal Features Color change: red to purple Loss of stippling: becomes glossy Swelling due to inflammation Bleeding: on probing or spontaneous o Other: soft. especially in elderly Chronic infection of gingiva and anchoring structures begins with formation of bacterial plaque: begins above gum line in gingival sulcus Two types: acute and chronic ACUTE PERIODONTITIS • • • • Less common than the chronic form Causes o Injury Sudden blow. treatment is drainage CHRONIC PERIODONTITIS • • • • • • • Common type of periodontal diseases and is the main cause of teeth loss in adults If ignored it leads to deepening of physiologic sulcus and destruction of periodontal ligament Pockets develop and teeth become filled with pus and debris As periodontium is destroyed teeth loosen and exfoliate Eventually there is resorption of alveolar bone Causes o Untreated chronic gingivitis o Occlusal trauma o Excessive force applied during orthodontic treatment Main Pathological Features Are: o Destruction of periodontal membrane o Resorption of alveolar bone o Formation of periodontal pockets (3-6mm): slight 3-4 mm. etc. moderate 4-6 mm. Streptococcus.com. high fillings o Infections: Pulpitis Pulp necrosis Caries o Irritation: overfilled root canal which irritates the periodontal membrane o Impaction of FB: o Needles. Borrelia. and Fusiform bacilli Clinical Features o Pain o Feeling that tooth is extruded or elongated so that he cannot bite together due to inflammation and exudation o Fever. severe ≥6 mm o Loosening of teeth o Periodontal tissue can bear 100 pound weight equivalent to biting Dental Notes by Sadichhya. or analgesics o If infected: antibiotics(usually relived in a few days) o RCT in anterior teeth if possible in selected cases o If infection or inflammation become more severe: pain intensifies and becomes throbbing and if periapical abscess starts to develop .np . Shooga & Sumesh 25 Downloaded from DigitalMedicine. o Infection is usually because of Staphylococcus. bone.PERIODONTITIS • • • • Inflammation of periodontium Periodontal disease accounts for more teeth loss then caries. fall. trauma Sudden bite on hard object. malaise o Regional lymph nodes may be enlarged and tender o ANUG or Vincent’s angina: rapidly progressive and destructive diseases of periodontal tissue o Tenderness of percussion horizontal percussion is positive (vertical percussion positive with periapical lesions like periapical abscess or pulpitis) Treatment: o Removal of cause o Advise not to chew from affected side o Hot saline mouthwash o Soft food o Anti-inflammatory. Apical migration of gingiva exposing root (gum recession) 2. removal of soft and hard deposits from pockets 2. Gingivectomy or Gingivoplasty o Mucogingival flap operation: curettage of granulation tissue dead bone and damaged cementum beneath the flap Complications o Dentoalveolar abscesses (oral and intra oral abscesses): o Bacterial.np . removal of false pockets o To eliminate periodontal pockets: 1. Mobile teeth o All features of chronic gingivitis o Pus can be squeezed from around the neck of teeth (foul smelling) o Halitosis o Teeth may be mobile or loose ending on amount of alveolar bone resorption Diagnosis o Features of chronic gingivitis + at least one feature of periodontal ligament damage Principles of Management o To control gingival infection 1. Sub-gingival curettage of pocket to from normal attachment of gingiva 2.• • • • Clinical Features o Features Of Periodontal Damage 1. maintain oral hygiene 3. pyemia o Cellulites of face o Lymphadenitis (acute) o Osteomyelitis of jaw o Sinusitis (maxillary) o Scar on cheek and face Dental Notes by Sadichhya & Shooga 26 Downloaded from DigitalMedicine. True pocket 3.com. septicemia. Gingival abscess 2. Swelling is usually located opposite the midsection of the root & gingival border. Associted with pulp less or non vital teeth. On pressure. 4. Defn: It is collection of pus in alveolar bone of a tooth that originates from infection in at the root apex following death of the pulp.com.DENTOALVEOLAR ABSCESS AND PERIODONTAL ABSCESS • Dentoalveolar abscess: 1. Treatment : I & D Dental Notes by Sadichhya. 6. Lateral abscess: due to infestation of gingival sulcus due to impaction of food particles or trauma 3. Combined periodontal / endodontric abscess CLINICAL FEATURES OF PERIODONTAL ABSCESS • • • • Severe throbbing pain Patient cannot close teeth together due to slightest elongation (edema) Very tender to even light touch Fluctuant swelling in the buccal. Located opposite the root apex or beyound it. pus may exude near edematous tissue or through sulcus. Not 3. Pericoronal abscess (aka pericoronitis) 4. 5. Defn: Accumulation of pus along the root surface 1.np . 6. 5. 2. Treatment : RCT 27 Downloaded from DigitalMedicine. labial lingual or palatal region depending upon the teeth involved TREATMENT • • • • • • I and D of abscess through pulp or periodontal approach Drainage should be kept open if not properly drained Antibiotics Analgesics Hot saline water mouth wash Immediate extraction especially in periapical periodontitis Differences between two types of periodontal abscess: Lateral abscess Periapical abscess 1. Periapical abscess: due to infection around the root or root apex b. Shooga & Sumesh 3. 2. Generally associated with vital teeth. supporting structure of the tooth. Associated with periodontal pocket. Not 4. Periodontal abscess: a. np .IMPACTED TEETH • • • • • • Obstruction in normal mechanism of eruption of teeth Soft tissue overlying occlusal surface of teeth is called operculum Impacted tooth can be at certain angulations In erupting and impacted tooth tissues are present around the crown Impaction can be o Soft tissue impaction o Hard tissue impaction Space may not be available for tooth to erupt: impacted Dental Notes by Sadichhya & Shooga 28 Downloaded from DigitalMedicine.com. provides favorable media for bacterial growth and inflammation.g. etc. Conservative management: (continuation of antibiotics and maintenance of oral hygiene) o Indications: Adequate space available for tooth to erupt Angulation is favorable Teeth has good occlusion with antagonist teeth: Advice for intra oral periapical X ray and OPG (oralpanoramogram) if not inline: extraction is advised 2. halitosis due to inflammation Regional lymphadenopathy Abscess formation in extra or intraoral region (pericoronal abscess) rd Pterygomandibular space infection in impacted 3 molar and pericoronitis MANAGEMENT • Manage acute condition and definitive treatment Acute condition • Clean all area with H2O2 or Normal Saline (irrigation) • Antiseptic solution: Chlorhexidine gluconate. malaise. Vincent’s infection: can start from pericoronal pocket or spread to pericoronal pocket from other sites of gingiva Decreased resistance to infection e. Shooga & Sumesh 29 Downloaded from DigitalMedicine. Operculectomy: Surgical removal of pericoronal flap 3. • Hot salt water mouth wash 2-3 times daily • Analgesics and anti-inflammatory • Antibiotics started ASAP o Penicillin-amoxicillin (80% effective) o Metronidazole (25%) o Or both together o Soft food o Oral hygiene Definitive management 1. common cold. Diabetes Mellitus. Removal of upper teeth if pain Dental Notes by Sadichhya.PERICORONITIS • • • Inflammation of soft tissue around the crown of erupting tooth or impacted tooth. the rest of the crown is covered by a flap of soft tissue known as operculum rd Can occur un any tooth at any age but commonly occurs in lower 3 molar at the age of 18-24 years CAUSES • • • • • Impaction: food collection. When eruption is complete there is an opening through the membrane. TB Eruptive irritation: o Bouts of pain or attack of pain occurs in between every 2-3 yrs o After that for a few months or years: silent period: no pain o But in eruptive phase pain appears CLINICAL FEATURES • • • • • • • Soreness and tenderness followed by pain and swelling Due to inflammation there is spasm of muscles of mastication o Trismus: difficulty in opening mouth Dyshagia Systemic: fever. Anemia . Tooth extraction: o Indications: Recurrent pericoronitis Teeth doesn’t have good occlusion with antagonist teeth 4. stagnation inside the flap or operculum. Injury: if upper tooth is continuously traumatizing lower gum flap.np .com. Abrasion or Erosion leading to pulp irritation o Fracture of crown Cracked tooth: Splitting of tooth which usually occurs in Pre Molar due to masticatory stress Thermal effect (Iatrogenic) o E.g. Asymptomatic with pulp exposure Dental Notes by Sadichhya & Shooga 30 Downloaded from DigitalMedicine. onset. long duration On the basis of communication with external environment: o Open (Pulpitis aparta): pulp cavity and oral cavity communicate o Closed (Pulpitis clausa): no such communication exists On the basis of involvement: o Partial o Total On the basis of bacterial environment: o Sterile o Infected Grossman’s clinical classification of pulpitides (plural of pulpitis) 1. Very painful condition and is the most common cause of sever dental pain If untreated: death of pulp -> spread of infection to periodontal space -> periodontitis ETIOLOGY: • • • • • • Dental caries: extending up to pulp (most common cause) Traumatic: o Attrision. acid etching. thermal insulation. underneath filling Zn(PO4) is used as insulator Nonspecific infection: Due to streptococcus. other organisms via deep caries or via hematogenous route (bacterial invasion) Anachoresis and this pulpitis is called anachoretic pulpitis Chemical injury: Cements (silicate).PULPITIS • • • Inflammation of the dental pulp. Once pulp necrosis is complete. Acute ii.np .No pain without stimulus (hot or cold) 2. sever attrition or abrasion of tooth).: heat production during drilling especially when done without using water: over rapid cavity penetration: also in silver filling o To prevent thermal effect.com. If treated in early stage: reversible and localized tooth becomes sensitive to percussion and hot or cold and pain resolves immediately when irritating stimulus is removed Late stage: irreversible pain is severe and is sharp or throbbing worsening on lying down If infection spreads throughout the pulp: irreversible pulpitis occurs: pulp necrosis. Chronic a. mercury alum Aerodontalgia: mimics pulpitis pain but is due to decompression in high altitude PATHOGENESIS: • • • • • • • Sequence of events leading to pulpitis: o Dental caries -> Cavitation of enamel -> Penetration of tooth pulp -> Pulpitis Infection localized to pulp chamber (crown) and pulp cavity (root) which are closed. sever and of short duration o Chronic: slow development. fixed and rigid space -> accumulation of exudates in pulp space -> increased pressure (limitation for apical foramen) -> increased circulation -> impaired venous return and impaired arterial supply -> pulp necrosis. pain may be constant or intermittent but cold sensitivity is lost (differentiates irreversible from reversible pulpitis) Pulpitis is a nonspecific infection because multiple bacteria are involved: streptococcus and other bacteria present in carious cavity are mostly responsible TYPES OF PULPITIS: • • • • • On the basis of duration of onset: o Acute: rapid. Reversible pulpitis (chronic caries. Irreversible pulpitis – Pain even without stimulus i. cutting dentine during cavity preparation. e. Crown of tooth with pulp are destroyed and replaced by granulation tissue which may proliferate to fill the carious cavity and then undergoes epithelialization and fibrosis leads to formation of nodules called ‘pulp polyps’ CHP: irritation. Hyperplastic pulpitis Internal resorption ACUTE CLOSED PULPITIS • • • • • When virulent microorganisms enter the pulp in large numbers. reach periapical tissue Clinically acute and chronic pulpitis recognized by type and degree of pain: o Acute pulpitis: Early stage: tooth is hypersensitive to hot and cold Later: pain becomes more persisted and aggravated while lying down or sleeping Pain is due to: pressure on nerve endings by inflammatory exudates in the closed and rigid pulp chamber OR release of pain producing mediators (histamine. Shooga & Sumesh 31 Downloaded from DigitalMedicine. part of pulp becomes quickly destroyed resulting in an acute inflammatory reaction. epitelization and fibrosis Painless .com. occurs usually when apex is wide open and high blood supply maintain viability Pathophysiology of chronic open pulpitis: o Infection: chronic inflammation of pulp: formation of granulation tissue and proliferation: epithelization and fibrosis: nodule formation Dental Notes by Sadichhya. an acute inflammatory reaction ensues that leads to abscess formation and escape of pus thru to exposed part Pus escapes: pain relived Rapid spread of infection and destruction of pulp CHRONIC OPEN PULPITIS • • • • • • Occasionally widely exposed pulp survives in a stage of chronic open pulpitis especially in teeth with open apex Chronic hyperplastic pulpitis (CHP): It is a productive pulpal inflammation due to an extensive carious exposure of a young pulp and characterized by an overgrowth of the tissue outside the boundary of pulp chamber as a protruding mass. proliferation of granulation tissue. This reaction leads to acute hyperemia with escape of fluids and cellular exudates into the surrounding tissues A minute abscess is formed Rest of pulp is undamaged i. however inflammation doesn’t remain localized: it spreads quickly to pulp and progressively destroys it. c. ACUTE OPEN PULPITIS • • • • • • It occurs in late stage of caries Pulp chamber may open up due to destruction of part of crown Usually the pulp is already dead by this time but it may remain viable and proliferative Following an acute exposure and introduction of infection. destruction progresses slowly and finally thru apex. resulting from long standing.np . CHRONIC CLOSED PULPITIS • • • • • • Pulp destruction is seen at the entry at site of injection Mild hyperemia and abscess formation occurs Infection can remain localized for long periods with remaining part of pulp infected and healthy In other words.b. infection. chronic inflammation of pulp. low grade irritation. infection remains localized In severe cases. 5-HT) from damaged site o Chronic pulpits: May develop without symptoms However there may be bouts of full pain with hot and cold stimuli spontaneously Pain of both acute and chronic pulpitis is poorly localized due to lack of proprioceptive fibers in the pulp and because individual pulp is not represented in sensory homunculus. np . Dental Notes by Sadichhya & Shooga 32 Downloaded from DigitalMedicine. indirect pulp capping (IPC) is done o In recently exposed pulp cavity with opening <1mm without any infection or pain: pulp capping is done (direct pulp capping or DPC) Ca(OH)2 applied at exposed parts o If pulp cavity opening >1mm: needs extirpation and RCT. however it is undertaken when patient cannot afford RCT o In severe pulpitis. in children with incomplete development) and RCT is not possible o Newly exposed pulp cavity is treated with pulpotomy instead of RCT which is done later if pulp dies Root canal treatment (RCT) is the ultimate solution for all types of pulpitis in which there is no indication for teeth extraction Extraction: effective but destructive way of treating pulpits o Not always treatment of choice. LA may not work o However it is safe in that there are no complications like spread of infection TREATMENT MODALITY FOR DIFFERENT TYPES OF PULPITIS Reversible Pulpitis Superficial caries: restoration Deep caries: restoration with base Very deep caries: IPC Exposed pulp: DPC or Pulpotomy Acute pulpitis DPC Post and core RCT Extraction Chronic pulpitis Post and core RCT Extraction Chronic hyperplastic pulpitis Elimination of polypoid tissue (with periodontal curette or spoon excavator) followed by RCT Extraction TREATMENT OF PULPITIS IS OFFERED BASED ON PATIENT • • • • Attitude: whether he wants to preserve or remove the tooth Financial status: RCT is expensive Latest technique for desensitization : iontophoresis (back to condition of sensation) Once irreversible pulpitis occurs: RCT is necessary and contents of pulp chamber and root canals are removed followed by thorough cleaning antisepsis and filling teeth with an inert material COMPLICATIONS OF PULPITIS • • • • If pulp infection doesn’t decrease: periapical abscess formation (pain on chewing) If mild and chronic infection: periapical granuloma or eventually periapical cyst which produces radiolucency at root apex When untreated a periapical abscess can erode into the alveolar bone producing osteomyelitis. penetrate and drain through the gingiva (parvis or gumboil) or track along deep fascial planes producing a virulent cellulits (Ludwig’s Angina) involving submandibular space and floor of mouth Elderly patient with DM and pt taking glucocorticoids may experience little or no pain and fever as these complications develop.g. Pulpotomy o Partial removal of pulp o Coronal pulp is amputated leaving the remaining radicular pulp to heal o Pulpotomy is an intermediate treatment modality when apex is wide ( e.INVESTIGATION AND DIAGNOSIS • • Thermal test (see by applying hot and cold): Initially tooth is sensitive to both hot and cold but later the cold relives while hot aggravates Electric pulp tester: o First test in a healthy tooth o Start with low current and raise it till response comes o Then test in affected tooth o Low current produces responds in early stage and high current in late stage o Helps to judge the extent of pulpitis MANAGEMENT OF PULPITIS • • • • Pulp capping: o In very deep caries without exposure of pulp cavity.com. np . Shooga & Sumesh 33 Downloaded from DigitalMedicine.MALOCCLUSION NORMAL OCCLUSIONS • • • Incisor occlusion o Overjet: horizontal distance between upper and lower incisor normally is 2-3 mm o Overbite: vertical displacement of upper incisor over lower.com. normally it is 2-3 mm Canine o Upper canine fits in the groove behind distal margin of lower canine Molars: o Cusps of upper molars fit in the grooves of fossa of lower molars ANGLE’S CLASSIFICATION OF OCCLUSION Based on the relationship of mesiobuccal cusp of upper first molar to buccal groove of lower first molar Class I occlusion The mesiobuccal cusp of the upper M1 fits with the buccal groove of lower M1 Class II occlusion The mesiobuccal cusp of the upper M1 behind the buccal groove of lower M1 Class III occlusion The mesiobuccal cusp of the upper M1 in front of the buccal groove of lower M1 MALOCCLUSION • • • Increased overjet. Increased overbite Class III or class II occlusion Requires orthodontic treatment: braces TREATMENT • • • Photography Dental caries prepared Separators placed and Braces Kept Dental Notes by Sadichhya. known as bruxism o Chewing pipe o Marked malalignment or malocclusion o Loss of posterior teeth Sites o Anterior: incisor edges o Posterior: occlusal surface of teeth Affected sites appear smooth and polished but in advanced attrition. abrasion and erosion ATTRITION • • • • • • • • Definition: ‘The physiological wearing away of the tooth surface as a result of tooth to tooth contact’ as in mastication Causes: o Coarse gritty diet o Nervous habit (grinding teeth in anxiety) o If at night. Excessive intake of carbonated drinks: developmental caries o Intrinsic: Chronic regurgitation of acidic gastric juice e. vigorous tooth brushing using tooth powered. etc.com. highly polished in labial surface Dental Notes by Sadichhya & Shooga 34 Downloaded from DigitalMedicine. 1st trimester of pregnancies.CHRONIC INJURIES TO TEETH • • Conditions that are taking place over a long period of time especially in the elderly Include attrition. incisor edges and cusps are worn away and become peg like.np . occlusal surface becomes flat and even hollows out Attrition is a slow process so even in advanced cases pulp may not be exposed due to dentine formation The dentine may be exposed and stained Attrition is not compatible with caries and periodontal problems because the latter two leads to destruction and mobility of teeth because of which attrition does not occur Attrition helps in preventing caries by destroying stagnation areas of occlusal surface ABRASION • • • • • • • • Definition: ‘The abnormal wearing away of tooth tissue by a mechanical process’ Causes: chewing tobacco.g. shiny often yellow/brown areas at the cervical margin EROSION • • • Definition: The loss of tooth tissue by a chemical process that does not involve bacteria It is progressive dissolution of tooth usually by acid solution but sometimes due to unknown causes (non-carious pathological loss of teeth tissue) Causes o Extrinsic: Occupational: common among workers of battery/acid factories due to exposure to acid fumes Habitual sucking of citrus fruits for long duration Soft drinks have high H3PO4. certain professions like cutting thread. in APD. Hard tooth brushing with horizontal sweeping action is the commonest cause of abrasion Site: neck of teeth near cervical margin usually after gingival recession (because cememtoenamel junction is the most susceptible to abrasion) A major degree of gingival recession is also seen but no gingivitis occurs due to effective plaque removal Corner teeth are the most severely affected First cementum and then dentine are exposed: groove is found Appearances: o Worn ‘notches’ on the incisal surfaces of the anterior teeth o Worn. erodes especially the palatal surface of teeth Excessive vomiting o Erosion of unknown caries: shallow. GERD. F) ABFRACTION • • • Definition: ‘The pathological loss of enamel and dentine due to occlusal stresses’ Occlusal forces which cause the tooth to flex. inducing the abrasive lesions Usually wedge shaped lesions with sharp angles found at the cervical margins SECONDARY DENTINE • • • • Secondary dentin is formed in response to a normal or slightly abnormal stimulus after complete formation of the tooth. Shooga & Sumesh 35 Downloaded from DigitalMedicine. Secondary dentin is less mineralized.) and its avoidance o Coatings o Fluorinated tooth paste o Inotophorosis (Na .np .com. Causes o Normal ageing process o Injury to dentin by caries or abrasion PULP CALCIFICATION • • • • • • Calcification within the pulpal tissue Chief morphological forms Discrete pulp stones (denticles) o True denticles: resembling dentin o False denticles: not resembling dentin Diffuse calcification Causes o Increased incidence with age o Exact cause not known Clinical significance o Sometimes painful o Otherwise no significance RESORPTION • • External resorption o Periapical inflammation o Reimplantation of teeth o Tumors and cysts o Excessive mechanical or occlusal forces o Impaction o Idiopathic Internal resorption o Idiopathic Dental Notes by Sadichhya. cause small enamel flecks to break off. Types: o Physiologic secondary Dentin Laid down throughout the life of the tooth Produced slowly o Repairative secondary Dentin Formed as a result of irritaion or attrition DENTINAL SCLEROSIS • • • Calcification of dentinal tubules Decreases the conductivity of the odontoblastic processes. etc.• Treatment: o Identification of course (occupational. 6-10% less mineral than primary dentin. DIFFERENT TYPES AND CAUSES OF RESORPTION Internal resorption gross appearance Cyst Internal resorption in x-ray Periapical inflammation Impacted teeth Dental Notes by Sadichhya & Shooga 36 Downloaded from DigitalMedicine.np .com. DISLOCATION OF TEMPOROMANDIBULAR JOINT TYPES: • • Acute dislocation Chronic dislocation CAUSES • • Acute dislocation o Yawning with excessive wide open mouth o Biting hard substances with high pressure o Traumatic fracture Chronic dislocation o Idiopathic o Laxation of muscles and ligaments o Atrophic changes of muscles and ligaments o Osterpanthroapthy CLINICAL FEATURES • • Acute dislocation o Aim o Open mouth o Pt is panicky o Painful closure of mouth Chronic dislocation o Painless or mild pain o Open mouth MANAGEMENT • • Acute dislocation: o Relaxing the patient o Counseling the patient o Analgesics o Diazepam( to relax the muscles) o Gauze piece over the last molar tooth: apply pressure first downward and then backward and upwards usually the joint will reduce o If above procedure fails try the same again under GA Chronic dislocation o Results of management are not good and recurrence occurs very often o Some maneuver or in a cute TMJ dislocation o Teach the patient how to reduce o Advice to avoid wide yawning Dental Notes by Sadichhya.np .com. Shooga & Sumesh 37 Downloaded from DigitalMedicine. o Frontal nerve: Supratrochlear: supplies conjunctiva and skin of the medial aspect of the upper eyelid and skin over the lower and mesial aspects of the forehead. Zygomatic nerve • Zygomaticotemporal branch – supplies skin on the side of the forehead. eyelids & nose Branches of ophthalmic nerve: o Lacrimal nerve is the smallest branch of the opthalmic division. temporalis. supplies scalp as far back as the parietal bone. Upper lip o MUCOUS MEMBRANE: Nasopharynx. Lower eyelid. SUPPLIES o Eyeball. • • • • • Fifth cranial nerve Largest cranial nerve Mixed nerve with 2 roots: Sensory: Skin of the face and mucous membrane of cranial viscera and oral cavity Motor: o Masticatory muscles. Hard palate o MAXILLARY TEETH & PERIODONTAL TISSUES Branches of maxillary nerve: Branch within the cranium: 1. o Nasociliary: Anterior ethmoidal: branch.ANESTHETIZATION TRIGEMINAL NERVE AND ITS BRANCHES • • • • • I. secretary fibers from the sphenopalatine ganglion to the lacrimal gland 2. Middle meningeal nerve: SUPPLIES Dura mater in the middle cranial fossa Branches in the pterygopalataine fossa: 1.internal nasal: supplies the mucous membrane of the anterior part of the nasal septum and the lateral wall of the nasal cavity.com.massetter. temple • Zygomaticofacial branch – supplies skin on the zygomatic prominence of the cheek. External nasal Infratrochlear MAXILLARY NERVE nd 2 branch of trigemineal nerve Purely sensory Leaves the cranium through foramen rotundum Supplies: o SKIN: Middle portion of the face. It supplies the lateral part of upper eyelid and a small adjacent area of the skin. conjunctiva o Lacrimal gland o Parts of the mucous membrane of the nose & Para nasal sinuses o Skin of the forehead.np . Pterygopalataine nerve • Orbital branch. medial pterygoid. Side of the nose. carries.supplies periosteum of orbit Dental Notes by Sadichhya & Shooga 38 Downloaded from DigitalMedicine. Maxillary sinus. Supraorbital: sensory to upper eyelid. Tonsil. lateral pterygoid o Mylohyoid o Anteriror belly of digastric o Tensor tympani o Tensor veli palatini OPHTHALMIC NERVE Purely sensory Smallest branch Leaves the cranium and enters the orbit through superior orbital fissure. • • • • • II. Soft palate. com.Sensory innervation of the skin and mucous membrane of the upper lip.skin of the lower eyelid 2.np .Greater (anterior) and lesser (middle and posterior) palatine nerve Pharyngeal branch-mucous membrane of the nasal part of the pharynx Posterior superior alveolar nerve • Buccal gingiva in the maxillary molar region and adjacent facial mucosal surfaces. preferred technique as small area anesthetized. Superior labial. o Block: Anesthetization of larger terminal branch (field block) or main nerve trunk (nerve block). • Sensory innervation to the alveolar bone. Palatine branch. Dental Notes by Sadichhya. Middle superior alveolar nerve: Supplies:-adjacent mucosa of maxillary sinus. MANDIBULAR NERVE • Largest division of trigeminal nerve • Both sensory and motor • Exits the skull through foramen ovale • Branches of the mandibular nerve: Branches from the undivided nerve Branches of the anterior division Nervus spinosus. o Nasopalatine nerve: supplies palatal mucosa in the region of premaxilla.• • • 3. mastication except medial Nerve to medial pterygoid pterygoid: • Nerve to lateral pterygoid • Nerve to masseter • Nerve to temporalis Buccal nerve: sensory to buccal mucosa and skin of cheek Branches of the posterior division Auricotemporal nerve Lingual nerve Inferior alveolar nerve • Incisive branch • Mental nerve Mylohyoid nerve ANESTHETIZATION • • • To block pain during dental procedures Can be done by two methods o Infiltration: Anesthetization of small terminal nerve ending in the area. Infiltration onto sub mucus layer: local anesthetic has to pass through cortical plate right up to pulp. done if infiltration is not possible or susceptible. the two premolars & mesiobuccal root of first molar 2. Nasal branch-supplies mucous membrane of the superior and inferior concae. Large area or unwanted areas maybe anesthetized.Skin of the lateral side of nose 3.supplies dura Nerves to all muscles of mater and mastoid air cells. Shooga & Sumesh 39 Downloaded from DigitalMedicine. second and first molars (except the mesiobuccal st root of 1 molar) Branch in the infraorbital canal: 1. Inferior palpebral. Wait for three minutes after injection. Anterior superior alveolar nerve: Supplies: central incisors. so cortical plates must have enough pores. lining of the posterior ethmoidal sinus and posterior portion of the nasal septum. Wait for 5 minutes. periodontal ligaments and pulpal tissues of the maxillary third. Lateral nasal. III. lateral incisors & canine Branch on the face (terminal branches): 1. np .com. a) infiltration.• If infiltration under periosteum it diffuses only to periosteum and it will be lifted up from bone causing pain. o Greater palatine N comes thru greater palatine foramen: o Supplies palate behind PM1 Local infiltration to anesthetize the teeth and the buccal gingiva: Dental Notes by Sadichhya & Shooga 40 Downloaded from DigitalMedicine. b) field block. Methods of anesthetization: From above downwards. and c) nerve block MAXILLARY LOCAL ANESTHESIA (NERVE SUPPLY OF UPPER JAW) • • Summary of nerve supply: o SUP alveolar N: POST SAN: M1 M2 M3 except mesiobuccal root of M1 Middle SAN: PM1 PM2 root of M1 ANT SAN: 3 Ant teeth CI LI C o Nasopalatine nerve: comes out thru incisive foramen st Supplies ANT palate till the level of start of 1 premolar. 6 cm through labial sulcus at the apex of PM1 and LA is injected. see fig below. artery and vein. inject LA at ‘x’ to anesthetize palatal gingiva of PM2 or M1). Shooga & Sumesh 41 Downloaded from DigitalMedicine. thereby avoiding the need for multiple injection o Infraorbital foramen is palpated from outside just below the inferior orbital border but needle is inserted by about 1. MANDIBULAR LOCAL ANESTHESIA (NERVE SUPPLY OF LOWER JAW) • 3 nerves blocked: o Lingual N: lingual gingiva of all the mandibular teeth o Inferior alveolar N: all the mandibular teeth. mental nerve.6 cm at 45 to maxillary buccal sulcus above the M2 to pass above and behind maxillary tubercle. Dental Notes by Sadichhya. labial alveolar mucosa and gingiva and skin of chin are also anesthetized because they are supplied by mental N. Post sup alveolar N block o Used sometimes to anesthetize the premolar and molar together 0 o Needle inserted by about 1.np . Nasopalatine or greater palatine block to anesthetize the palatal gingiva: o Palatal surface also gets nerve supply from greater palatine and nasopalatine nerves so that palatine N block is also required o Greater palatine nerve is blocked as soon as it emerges from greater palatine foramen (between the M2 and M3 ‘*’ in the figure below) and nasopalatine nerve is blocked by injection just posterior to incisive papilla. However.. when multiple anterior teeth and/or premolars are to be dealth with. and buccal gingiva of incisors. Skin and mucus membrane of lower lip. When this nerve block is successful all the mandibular teeth are anesthetized to median plane. canines and premolars o Long buccal N: buccal gingiva of all 3 mandibular molars Inferior Alveolar Nerve and Lingual Nerve Block: • • • • • • INF alveolar N enters the mandibular foramen and courses through mandibular canal on the medial aspect of the ramus of the mandible forming INF dental plexus which sends branches to all mandibular teeth on its side Mandibular canal gives passage to INF alveolar N. o A needle is inserted at the reflection of alveolar and vestibular mucosa and passed along central axis of tooth to be anesthetized. branch of inferior alveolar N. o Needle is angled towards bony surface into soft tissue so that its tip lies opposite the periapical region. o • • • Infraorbital N block o To anesthetize both anterior and middle sup alveolar nerve. rd Lingual N lies 0.Maxillary teeth are anesthetized by local infiltration with injection of LA into tissues surrounding the roots of teeth and allowing solution to infiltrate the tissues to reach dental N branches that enter the roots (done so because Sup alveolar N are not accessible). Another branch of the plexus.com. passes thru mental foramen and supplies skin and mucus membrane of lower lip. in practice LA is injected midway between palatal midline and gingival margin of the teeth to be anesthetized to avoid unnecessary anesthetization of larger area (e. floor of mouth and lingual gingiva) and enters mouth between medial pterygoid muscle and ramus of mandible and passes ANT under cover of oral mucosa just inferior to M3. skin of chin and vestibular gingiva of mandibular incisor teeth.5cm antero-medial to INF alveolar N (sensory to ANT 2/3 of tongue.g. Mandibular Nerve Block: • • LA injected near mandibular N where it enters infratemporal fossa Anesthetizes auriculotemporal. o Withdraw the needle by about 1mm and aspirate. lingual and buccal branches of CNV3. COMPLICATIONS OF BLOCK: (@ PANT) • • • • Trismus Transient facial nerve Paralysis Allergic reaction Needle break Dental Notes by Sadichhya & Shooga 42 Downloaded from DigitalMedicine. To find out if block is effective or not: o Ask whether the lips or chin on ipsilateral side are anesthetized or not.com.5 cm deep till bony resistance is encountered.5cm and depositing additional 0.25ml of LA.np . lacated disto buccal to the 3 mandibular molar between the anterior border of the ramus and the temporal crest. INF alveolar. This point is directly above the mandibular foramen hence inferior alveolar block is achieved (and the mental nerve which is its branch is also blocked). deposit 0. If no blood is aspirated slowly deposit 1. to supply buccal gingiva of all the 3 molars Procedure: o Mouth is kept wide open. o Aspirate and if no blood is aspirated. o Prick in gingival surface (dental probing) Buccal Nerve block • • rd Buccal Nerve courses in the retromolar fossa.5ml LA.25 ml of LA to produce buccal nerve block. o Lingual block is ensured by withdrawing needle 0. o Insert the needle disto-buccal to the last molar and enter 2-4mm until contact with bone is made.• • Procedure: o Mouth is kept wide open o Put one finger in retromandibular space medial to which is the internal oblique line o Needle inserted between internal oblique line and pterygomandibular raphe o Barrel of syringe is placed in occlusal surface of opposite premolars: needle is inserted 2-2. Agranulocytosis Addison’s Disease Patients on Corticosteroids (Require dose adjustment) Jaundice and Liver Disease a. osteomyelitis. Gravid uterus uncomfortable c.g. TB b. Severe anemia b. Cor pulmonale c.TOOTH EXTRACTION Definition: Exodontia or tooth extraction is defined as painless. Vitamin K Deficiency b. Nephritis Psychosis Neurosis Allergy to LA Incorporative patients During Menstruation Local Contraindications 1. CONTRAINDICATIONS General Contraindications 1. tumors. especially upper. If tooth lies in fracture line. o In orthodontic cases where arch is small or teeth are crowded (extractions are done to make space for correction. o If longitudinal fracture of tooth o In case of jaw fracture. 11. 2. Traumatic tooth injuries: o If coronal half of root is fractured.: Cysts. Acute periodontitis c. o Acute/Chronic pulpitis where RCT is not possible. IHD d. b. o Supernumerary teeth causing overcrowding or eruption disturbance. in case of oral cancer. 13. Fibrinogen Deficiency 6. Acute cellulitis Dental Notes by Sadichhya. Acute pericoronitis d. Patient on Anticoagulants Blood Diseases a. 8.np . Hemophilia d. Any acute infections like a. o Malposition or impacted teeth (which makes dental arch crowded and cause carries and damage to adjacent teeth. o Retain deciduous teeth ( Permanent successor present) o If tooth is hurting soft tissue Miscellaneous: o In case of bone lesions where tooth is involved. o Preparation of oral cavity for radio therapy. Asthma d. Leukemia c. INDICATIONS • • • • • Any tooth not useful for proper function should considered for extraction Periodontics/Endodontics: o Gross carries of tooth which cannot be restored. 17. 10. Cardiac disease a. 3. atraumatic removal of tooth from its investing structures. 12. Valvular heart disease. E. o Periodontal disease where bone loss is more than half of normal alveolar bone. 5. Abortion and Premature Delivery b. Shooga & Sumesh 43 Downloaded from DigitalMedicine. 14. Diabetes Mellitus (Healing delayed) Thyrotoxicosis Pregnancy during first and second trimester a. Less Stamina for opening mouth Very Old Age Epileptic patients Presence of fever Debilitating diseases a. 7. HTN f. Blood Clotting Factors c. 15. Orthodontics/prosthodontics indications: o For aesthetic purposes (if protruding teeth.com.) o Prosthetic consideration where teeth are interfering with fitting or designing of denture. Prothrombin d. RHD c. Acute gingivitis b. 9. 4. 16. CHF e. lips.np . maxillary tuberosity.2. o Displacement of root into soft tissues or maxillary antrum i. Traumatic extraction: o Fracture of crown. two to three times a day. lingual nerve.com. inferior mental nerves and its branches. 2. pain. Same for right and left Lower anterior teeth forceps: Small gap where ends meet Upper right molar and premolar forceps: Elevated edge on tip of forceps on left side Upper left molar and premolar forceps: Elevated edge on tip of forceps on right side Upper anterior teeth forceps PROCEDURE 1. alveolus. contact hospital Don’ts • Do not spit or rinse as far as possible: Clot might get dislodged • Do not take hot food or drink for 24 hours. lukewarm or cold food: Causes vasoconstriction • Cold compression with ice pack from outside: With pack from outside it decreases surgical edema • Warm saline mouthwash from next day for two to three days. Postoperative or intraoperative hemorrhage and hematoma formation Orodental communication Allergy or systemic complications Infections Dental Notes by Sadichhya & Shooga 44 Downloaded from DigitalMedicine.. sinus cavities o Damage to gingiva. • Do not take caffeine: Causes vasodilatation • Do not smoke or drink COMPLICATIONS • • • • • • • • • Dry socket (common complication of tooth extraction that can cause severe pain). Complications related to anesthesia: o Failure to secure anesthesia o Other complications of LA (@PANT) o Prolonged pain Failure to extract Incomplete extraction: A portion of the tooth may be left in the jawbone. e.e. and mandible.g. • If any bleeding. However. there are some instances where a small root tip is intentionally left in the jaw because removing it would be too risky (e. increasing the risk of infection. o Dislocation or damage of adjacent tooth or TMJ. tongue. Hemangioma AV malformation ( because bleeding that cannot be stopped) (If such condition occurs put teeth on socket and press) Relative Contraindications: all other contraindications INSTRUMENTS (LAST CHAPTER FOR PHOTOS) • • • • • • • Straight Elevator Root Elevator Lower molar and premolar forceps: They have wide gap that does not meet. Give Local Anesthesia After sensation is obtunded extract tooth by mobilizing root and extracting with forceps POST EXTRACTION INSTRUCTIONS • White Cotton Pad or Gauze for 30 minutes (it takes 20 to 25 mins for fibrin mesh to form) ‘Do’s • Rest • Take prescribed medicines • Soft. Acute osteomyelitis Malignancy Irradiated Jaw: Acute osteoradio necrosis can occur due to end-arteritis obliterants Absolute Contraindications 1. potential for damaging a major nerve). 2. 3. or complaint. palate. therefore do not allow to drink for 2 hrs.TOOTH FILLING • Temporary or permanent. 2. Self-cure composite: Sets on its own. 4. 6. • There will be a dull chalky white discoloration Bonding liquid (organic monomer) added • Flows into the pores formed by etching and fills the pores Composite material added over this Light (intense blue visible light) passed • Polymerizes organic monomer and sets the composite material After filling patient is asked to bite so that any extra filling material is removed and material fits the shape of teeth THERE ARE TWO TYPES OF COMPOSITE: • • Light cure composite which requires light for setting (Light source used is halogen). Shooga & Sumesh 45 Downloaded from DigitalMedicine.np . 5. wash. Acid etch applied on surface of enamel • 34% orthophosphonic acid • Dematerializes surface of tooth creating pores After few seconds. CHARACTERISTICS OF GOOD CEMENT • • During application: o Easy preparation o Easy to manipulate o Fast setting Physical characters: o Good attachment o Color matching with teeth o Hard o Not undergoing corrosion o Coefficient of thermal expansion equal to teeth SOME FILLINGS Restorative material 1. 3. Miracle mix • Silver and glass ionomer cement (GIC) • Silver amalgam: hard but not sticky • GIC: Sticky but not hard • Takes 2 hr to set. GIC filling 4.com. Composite filling: Light and strong and good color match Cements (Temporary) ZOE (Zinc oxide eugenol) Zinc phosphate Zinc polycarboxylate Silicate Silicophosphate STEPS 1. use waterproof cream to prevent from action of saliva 2. Silver amalgam filling 3. sets before finishing the filling Dental Notes by Sadichhya. but disadvantage is that while working in high room temperature. or near exposure. o Pulp cavity is covered with Dycal and then temporary filling with Zn3(PO4)2.np . o Dycal helps to regenerate secondary dentine. which even if soft and removed causes exposure of pulp. after 3 to 4 weeks thin layer of dentine develops o Soft dentine is removed and filling is done on hard dentine o But if there is a thin layer of dentine. o Fill with GIC temporary filling Dental Notes by Sadichhya & Shooga 46 Downloaded from DigitalMedicine. then secondary dentine formation has taken place o Remove the temporary filler and then replace with permanent filler Direct pulp capping (DPC) o When pulp cavity already exposed.com. leave the soft dentine and line with Dycal because it helps to calcify.PULP CAPPING • Capping done when pulp is closed. but exposure is less than 1mm and chance of infection is less. already exposed in order to save pulp from infection TWO TYPES: • • Indirect pulp capping (IPC) o When pulp cavity is not exposed IPC done o Pulp cavity is covered with Ca(OH)2 (Dycal) and temporary filling with zinc phosphate o If no symptoms for 6 weeks. com. anti-inflammatory analgesic used Restorative material: o Amalgam o Composite o Glass Ionomer Cement (GIC) Cements: These are used to make the base for filling the restorative materials o ZOE (Zinc Oxide Eugenol) o GIC o Zn polycarboxylate o Silicate o Silicophosphate o Zn phosphate.np .ROOT CANAL TREATMENT INDICATIONS: • • • • Non-vital teeth Irreversible pulpitis (When pulp cavity is exposed >1mm with infection and pain or when the pulp is necrosed and irreversibly destroyed with infection) Periapical periodontitis Periapical abscess PROCEDURE: • • • • Steps in procedure: o Access pulp cavity by making hole or opening o Biomechanical preparation: Extrication of dead pulp. Shooga & Sumesh 47 Downloaded from DigitalMedicine. antiseptic. steroid (septadont dexamethasone acetate). cleaning repeatedly o Working length estimation(radiological) o Obturation (filling of root canal or pulp cavity) Gutta-parcha is used for this purpose. and the opening is sealed initially with temporary filling If no pain after few weeks permanent filling is done o Crowning While cleaning. calcium hydroxide INSTRUMENTS USED IN RCT (LAST CHAPTER FOR PHOTOS) • • • • • Files Burr Reamers Brouch: spikes present GP points (gutta perhca points): (absorbent point papers) Absorbs pulp cavity contents POST AND CORE • • Indications: Root intact but crown damaged either due to trauma or caries Procedure: o Extirpation of radicular pulp and sealing of the apical foramen using gutta-percha o A ‘post’ is placed in the radicular pulp cavity o Then a ‘core’ is placed on top of the ‘post’ on the remains of the crown o Finally a prosthetic crown is placed on top of the ‘core’ Dental Notes by Sadichhya. This procedure is necessary to reestablish the proper dentoskeletal relationships.MAXILLOFACIAL INJURIES CLASSIFICATION Maxillofacial injuries have been classified into three parts: • • • Upper third (roughly above the eyebrows) Middle third (above the mouth): An area bounded superiorly a line drawn across the skull from Z-F suture. MMF should be completed prior to reduction and fixation of other segments of the maxilla. and ensure normal postoperative occlusion. no need for surgical tissue damage • No foreign body/material in the body • DISADVANTAGES • Cannot obtain absolute stability • No compliance from the patient due to long period of fixation • Loss of patient to follow up • Difficult nutrition • Complete maintenance of oral hygiene not possible • Problematic for patients with premorbid pulmonary function. immobilize the fractured bones. psychological disorders. so early treatment within 1 week is necessary to prevent malunion o Permanent tooth buds are present along the roots of primary teeth.np . no great operative skill required • Biologically conservative. In general. followed by restoration of the dentition to normal occlusion and then tying the two arch bars together with interdental wire. and these can be easily destroyed by use of hardware o The growth centres may get injured leading to asymmetrical growth o Even immobilization of few weeks can causes TMJ to become fixed Dental Notes by Sadichhya & Shooga 48 Downloaded from DigitalMedicine. In edentulous patients (patients without teeth).com. across F-N suture to Z-F suture on opposite side. and the pterygoid plates of the sphenoid Lower third (the mandible) CLINICAL FEATURES • • • • • • Pain (which is usually sever when patient moves the jaw) Swelling Deformity of face and especially of occlusion of teeth clicking Diplopia Abnormality of mobility: Difficulty in opening the mouth( inability to close the mouth) Anaesthetized of face and lip AIMS OF MANAGEMENT • • To restore the face (both aesthetically and functionally) To prevent complications (disfigurement. malocclusion and diplopia) that result from improper management of facial injuries STEPS OF MANAGEMENT • • • • • • • • • • Airway maintenance Bleeding control and appropriate fluid resuscitation Pain management Infection management Repair of soft tissue injuries Evaluation for the presence of brain injury : observe for 24h Specific management: Maxillo-Mandibular Fixation (MMF) or Intermaxillary fixation (IMF): Operative reduction of maxillary/mandibular fractures with placement of arch bars to the maxillary and mandibular dentition. seizures Issues in children: o Fractures heal within short time. inferiorly the occlusal plane and posteriorly as far as the frontal bone above and the body of sphenoid below. dentures or surgical (acrylic splints with circumzygomatic and circummandibular fixation helps in restoring the occlusion (MMF will lead to gum ischemia and necrosis in these patients). ADVANTAGES • Inexpensive • Short procedure/limited operating time • Generally easy. np .com. unfavorable fracture • • • • Direct violence Indirect violence Excessive muscle contraction • Favorable fracture: vertically and horizontally undisplaced Unfavorable fracture: vertically and horizontally displaced According to site of fracture: (most commonly used) o Condyle o Coronoid o Ramus rd o 3 molar and Angle o Body: Molar Mental Cuspid or canine o Symphysis (parasymphysis) CLINICAL FEATURES • • • • • • • • Swelling and ecchymosis Deformity in the bony contour of mandible Derangement of occlusion Unilateral/bilateral posterior gagging Anterior open bite Abnormal mandibular movement: unable to open or unable to close Anesthesia/paresthesia of lower lip Loose teeth RADIOLOGICAL EVALUATION • • • • • • Paranomic view (unobstructed clear view). orthopantamogram (OPG) commonly done Towne’s view PA view and Lateral view of mandible CT scan Occlusal view of maxilla and mandible CM view of right and left side of mandible MANAGEMENT OF MANDIBULAR FRACTURE Aims: • Anatomic reduction of fracture • Stabilization of fracture • Preservation of cranial nerve function • Functional rehabilitation Dental Notes by Sadichhya.MANDIBULAR FRACTURES ETIOLOGY • • • • • Assault: 55% Fall 21% RTA 15% Sports 4% Industries 3% CLASSIFICATION American system of classification (according to type of fracture) • Simple • Compound • Communicated • Open / Close • Pathological fracture • Undisplaced / Displaced • According to cause Favorable vs. Shooga & Sumesh 49 Downloaded from DigitalMedicine. this method is used either with or without MMF.e. nowadays open reduction with rigid fixation is becoming more popular.2-3 weeks Favorable fracture: simple fixation is employed Unfavorable fracture: prolonged fixture is employed Antibiotic prophylaxis to patient with h/o RHD (no longer recommended according to NICE guidelineKumar and Clarke for further information) OPEN REDUCTION Internal fixation: After open reduction.Approach: • MMF is secured initially • Then based on different factors. only MMF) • Non-displaced angle fracture (tooth in proximal segment) • Ramus fracture • Non-displaced symphysis fracture(mobile body) • Non or minimally displaced high condyle fracture • Intracapsular condyle fracture • • • • Open reduction with rigid or non-rigid fixation • Non-displaced vertically modified symphysis/body • Displaced angle fractures • Condylar occlusion • B/L severe condylar displacement with comminuted mid face fracture Duration of immobilization with MMF: o Teen/adults: 5-7 weeks o Children: 4-6 weeks o Infants. with rigid fixation) • Because of early return of function and because of need for prolonged immobilization with MMF. ADVANTAGES • Early return to normal jaw function.np . seizures. normal oral hygiene and avoidance of airway problems • Can get absolute stability. Non-rigid fixation Rigid fixation (MMF should be continued after fixation) (MMF can be removed after fixation) Circumferential wiring Bone plate (common): • SUP border wire • Compressible • INF border wire • Non-compressible Transfixation with Kirschner wire or skeletal pins • Mini-plates Lag screws Indications for open reduction with non-rigid fixation and MMF: • Occlusal discrepancy • Associated alveolar fracture ADVANTAGES AND DISADVANTAGES OF OPEN REDUCTION WITHOUT MMF (i. normal nutrition. choice is made between: (indications for closed and open reduction) Closed reduction (i. psychiatric disorders DISADVANTAGES • Need for an open procedure • Significant operating time and great skill required • Expensive • Risk of neurovascular damage • Scarring MANDIBULAR CONDYLAR FRACTURE • • • • If the condyle is avulsed : open reduction If the fracture is intra-capsular: closed reduction and occlusal range of movement exercised In a growing child: immobilize the fracture site early In edentulous fracture : liquid diet. potential airway problems.e.com. promotes primary bone healing • Bone fragments re-approximated with direct visualization • Avoids MMF for patients with occupational benefits. minimal displacement minimal pain EDENTULOUS MANDIBULAR FRACTURE • • • • Avoidance of mandible-maxillary fixation ( MMF) Rigid internal and skeletal fixation 6wks mobilization Bone grafting (if severe atrophy has occurred) Dental Notes by Sadichhya & Shooga 50 Downloaded from DigitalMedicine. com.• Condylar fixation COMPLICATIONS OF MANDIBULAR FRACTURE • • • • • • • Infection Delayed union Malunion Malocclusion TMJ problems If complications occur the whole management procedure will have to be repeated. Shooga & Sumesh Regimen Children 50 mg/kg 50 mg/kg IM/IV 50 mg/kg IM/IV 50 mg/kg 20 mg/kg 15 mg/kg 50 mg/kg IM/IV 20 mg/kg IM/IV 51 Downloaded from DigitalMedicine. nose and throat procedures and bronchoscopy) – Genitourinary tract (including urological. they should receive appropriate antibacterial therapy that includes cover against organisms that cause endocarditis. ■ If patients at risk of endocarditis are undergoing a gastrointestinal or genitourinary tract procedure at a site where infection is suspected. ■ Patients at risk of endocarditis should be: – Advised to maintain good oral hygiene – Told how to recognize signs of infective endocarditis and advised when to seek expert advice. and mandibular fracture immediately reduced Indications for tooth extraction: (infection can lead to malunion) o Tooth fracture o Grossly mobile o Excessive tooth exposure o Infection has occurred Endocarditis (NICE guidelines for adults and children undergoing interventional procedures March 2008) ■ Antibacterial prophylaxis and chlorhexidine mouthwash are not recommended for the prevention of endocarditis in patients undergoing dental procedures. ■ Antibacterial prophylaxis is not recommended for the prevention of endocarditis in patients undergoing procedures of the: – Upper and lower respiratory tract (including ear.np . Any infection in patients at risk of endocarditis should be investigated promptly and treated appropriately to reduce the risk of endocarditis. gynaecological and obstetric procedures) – Upper and lower gastrointestinal tract. Antibiotics prophylaxis for dental procedure in patients with Infective Endocarditis: Situation Agent Oral Unable to take oral medication Amoxicillin Ampicillin Cefazolin or ceftriaxone Adults 2g 2 g IM/ IV 1 g IM/IV Allergic to penicillins or ampicillin Oral Cephalexin 2g Clindamycin 600 mg Azithromycin /clarithromycin 500 mg Unable to take oral medication Cefazolin or ceftriaxone 1 g IM/IV Clindamycin 600 mg IM/IV All regimen are single dose to be given 30 to 60 minutes before procedure Dental Notes by Sadichhya. com. Clinical features: • Can occur as single entity or with II & III • Gurien’s sign: Ecchymosis in greater palatine foramen (low level fracture) • Often associated with midline split in the palate • Mobility of the teeth bearing segment of maxilla • Slight swelling of the upper lip • Ecchymosis present in the buccal sulcus • Derangement of occlusion beneath the zygomatic arch • Gagging of occlused (ANT open bite) as maxilla falls down posterior teeth clutches so ant mouth remains • Ecchymosis in upper vestibule open causing lengthening of face LEFORT II AND III FRACTURES Lefort II fracture Lefort III fracture Introduction • Pyramidal fracture • Starts at or just below naso-frontal suture. crosses below the zygomatico-maxillary junction. After traumatic fracture. travels horizontally above the teeth apices. extends inferolaterally through lacrimal bones and inferior orbital floor and rim. LEFORT I FRACURE • Transverse fracture of maxilla: a part of body of maxilla separated from the base of the skull above the level of palate and below the attachment of Zygomatic process • The fracture extends from nasal septum to the lateral pyriformis rim. and traverses the pterygo-maxillary junction to disrupt the pterygoid plates.np . through anterior wall of maxillary sinus and below Zygomatic buttress and through the pterygoid plates Clinical features: • Step deformity at infra-orbital margin • Mobility of midface detectable at nasal bridge and infra-orbital margins Introduction • Cranio-facial disjunction (causes elongated face) • It is a high fracture that starts at nasofrontal & frontomaxillary suture and extends across the floor of orbit along inferior orbital fissure and continues along lateral orbital rim • Extends posteriorly along the nasolacrimal groove to involve the ethmoid. intact buttresses provide a valuable rigid support to fix the fractured part: (from anteromedial to posterolateral) o Fronto-maxillary o Zygomatico-maxillary o Pterygo-maxillary Lefort fractures are the fractures of the middle third of the face. but spares the strong sphenoid • Extends inferiorly along perpendicular plate of ethmoid to vomer and through the pterygoid plates Clinical features: • Tenderness and separation at frontozygomatic sutures • Tenderness and deformity of zygomatic arches • Lengthening of face Dental Notes by Sadichhya & Shooga 52 Downloaded from DigitalMedicine.MAXILLARY FRACTURES FRACTURE OF MIDDLE THIRD OF THE FACE Middle third of the face consists of following structures: • Two maxillae • Two zygomatic bones • Two zygomatic process of the temporal bones • Two palatine bones • Two nasal bone • • • • • • The vomer The ethmoid and its attached conchae Two inferior conchae The pterygoid plates of the sphenoid Maxilla has 3 paired vertical buttresses which resist the forces of mastication. through or near the infraorbital foramen. • Anesthesia or parasthesia of cheek • Possible diplopia • Pupil tend to be level unless there is gross unilateral enophthalmos • Nasal bones move with midface as a whole but often otherwise intact • • • • • • • • • • • • • • • • • • Depression of ocular levels Enophthalmos Hooding of eyes Lengthening and sometimes extreme disorganization of nasal skeleton Often profuse CSF rhinorrhoea Tilting of the occlusal plane with gagging on one side only Lateral displacement of midline of upper jaw Mobility of whole face as a single block Clinical features common to both Lefort II and III: Gross edema of the face Characteristic moon face appearance Circumorbital ecchymosis Subconjuctival hemorrhage Limitation of ocular movement with possible diplopia and enophthalmos Bleeding from the nose and CSF rhinorrhea Cribriform fracture: CSF rhinorrhoea: tram like effect: salty taste Dish-face deformity of the face with occasional lengthening of the face Retroposition of maxillae, so that anterior teeth do not meet, and there is gagging on the posterior teeth • Difficulty in opening mouth, and sometimes inability to move the lower jaw • Mobility of upper jaw • Haematoma of the palate • Cracked pot sound on tapping the teeth • Telecanthus: widening of medial anthus : globe is attached laterally to the bone by a suspensory ligament of locaud if fracture occurs above the attachment: eye drops down: diplopia • Enophthalmous: fracture in orbital rim • INF orbital rim fracture: entrapment of inferior rectus: difficulty in upward gaze RADIOGRAPHIC VIEW • Occipitomental view/PNS view , lateral view, Occlusal view, fronto-occipital view, CT scan MANAGEMENT: • • • • Supportive measures: o Antral pack o Antral balloon The objective of definitive surgical treatment of maxillary fractures should be fixation of unstable fracture segments to stable structures usually in the areas of the vertical buttresses. In isolated maxillary fractures, the stable cranium above and occlusal plate below provide sources of stable fixation. In general, restoration of dental occlusion with MMF (with Arch bars and interdental wiring) should be completed prior to reduction and fixation of other segments of the maxilla. In edentulous patients, dentures or surgical splints with circumzygomatic and circummandibular fixation helps in achieving the occlusal stabilization (MMF will lead to gum ischemia and necrosis in these patients) Internal fixation: direct and indirect osteosynthesis Direct osteosynthesis Internal wire suspension • Transosseous wiring • Frontal-central or lateral • Miniplates • Circumzygomatic • Tranfixation with K-wire • Pyriform aperture • • • External fixation Craniomandibular o Halo frame o Box frame Craniomaxillary halo frame Suspension from the cranial vault COMPLICATIONS IMMEDIATE COMPLICATIONS • Airway • Nasal hemorrhage • Ophthalmic • Cerebral • Inaccurate reduction • Insecure fixation Dental Notes by Sadichhya, Shooga & Sumesh LATE COMPLICATIONS • Complications arising from head injuries • Complications arising from fracture • Bony deformity • Lacrimal system • Ophthalmic • neurological • Non-union 53 Downloaded from DigitalMedicine.com.np ORAL CANCER • • • • Quite common in SE Asia Usually arises in parts of oral mucosa Oral ca constitutes of about 1% of all malignancies but erosive LP makes up to 50% DESTRCUTIVE ORAL LESION 95% OF AL ORAL CA ARE SQ CELL CA, 5% SARCOMAS ETIOLOGY • • Exact etiology is unknown but it is supposed to be multi-factorial Following are considered to be the predisposing factors: o Irritation due to dentures o Betel nut chewing o Tobacco and alcohol o Ageing o Role of genetics o Viral irritants o Premalignant conditions o Syphilis WHO CLASSIFICATION • • • • Grade 1 : ca in situ Grate 2: well differentiated Grade 3: moderately differentiated Grade 4: poorly differentiated C/F: • • DX: • • • • All oral cancer appear as white red ulcers Neck nodes spread: poor prognosis FNAC Biopsy: most reliable Toluidine blue staining Imaging CT scan SQUAMOUS CELL CARCINOMA • • • • • HISTOLOGY: o Marked cellular pleomorphism o Loss of polarity o Hyperchromatic nuclei, variable in size, shape and number o Abnormal mitotic figures o BM intact or invaded PROGNOSIS: o If localized at the time of Dx : survival rate: 75% o If regionalized: survival rate: 50% o In distant metastasis: survival rate: 18% RISK o Is more among males and after 49 yrs o Smokers, tobacco chewers, betel nut chewers have increased risk o Heavy alcohol consumers and always at increased risk C/F o symptomatic growth o mucosal discoloration o pain and non-healing ulcer o constitutional symptoms TREATMENT: o chemotherapy alone o radiotherapy alone Dental Notes by Sadichhya & Shooga 54 Downloaded from DigitalMedicine.com.np surgery: radical resection palliative surgery removal of tumor o relief of pain and anxiety o rehabilitation and follow up Toluidine blue staining: o it recognizes epithelial dysplasia and oral cancers o thus aids in DX o stain binds to cells with increased DNA synthesis o stain binds to sulphated mucopolysaccharides o by the staining it points out the accurate site for biopsy Lateral border of tongue is the most common site of ca o • • MALIGNANT MELANOMA • • • • • • Peak incidence between 40-60 yrs Usually appears as black or brown patches Amelanotic melanomas appear red Histologically consists of neoplastic melanocytes, often surrounded by a clear halo within epithelium and invading deeper tissues Neoplastic melanocytes are round to spindle shaped and typically speckled or intensely pigmented with melanin Shoud be widely excised but median survival probably not>2yrs PREMALIGNANT LESION OF ORAL CAVITY Common premalignant conditions include: • Leukoplakia: 6% has chance of malignant transformation • Chronic hyperplasic candidiasis (50%) • LP (1%) • Sub mucus fibrosis (0.2%) • Erythroplakia (50%) • Sublingual keratosis (erosive LP) 50% LEUKOPLAKIA • • • Any white patch of mucosa which is adherent and cannot be given any other clinical diagnosis is a leukoplakia according to WHO White color is due to locked water On high power examination: Hyperkeratoiss; Acanthosis; Dysplasia Rx: • Regular check-up for changes of colour and ulceration • Excision • Cryosurgery LICHEN PLANUS • • • • • These are lesions of unknown etiology seen in pts (20-60 yrs) Commonly occurs in cheek, mucosa tongue and lips Lesions appear as white lesion of oral mucosa in reticular pattern On histopathology o Saw tooth appearance of rete ridges o Infiltration by lymphocytes in connective tissue o Thickened keratinized layer Rx: observation and excision LOCALLY INVASIVE TUMOURS OF JAW • • • Amenoblastoma Adenoid cystic ca Pleomorphic adenoma Dental Notes by Sadichhya, Shooga & Sumesh 55 Downloaded from DigitalMedicine.com.np Odontogenic Keratinizing Primordial cyst/Keratocyst Extrafollicular dentigerous cyst • • • • • 2. 1974): Pathological cavity containing fluid. semi-fluid.CYSTS OF OROFACIAL REGION • • • Definition (Kramer. Cyst is a cavity occurring in hard or soft tissues with a liquid or semi-solid or air only It is surrounded by a definitive connective tissue wall or capsule with/without the epithelial lining 1. frequently but not always lined by epithelium.np . Bone cyst Solitary bone cyst Stafne’s idiopathic bone cyst Aneurysmal bone cyst Symptoms: o Pain and swelling o Salty discharge in mouth o Mobility/Loosening of teeth (d/t bone resorption) o Inability to wear dentures o Missing teeth (teeth won’t erupt) Signs: o Cortical expansion o Eggshell cracking (d/t destruction of bone) o Pathological migration of tooth (gap between teeth) o Alteration in sensation (if neurovascular structures involved) Radiological features: o Radio-opaque sclerotic border (sharp) o Resorption of root o Dark shadow where cyst has eroded into the soft tissue Diagnosis: o Aspiration biopsy using wide bore-needle: Straw colored fluid containing cholesterol crystal dentigerous cyst Yellowish pus like cheesy material keratinizing cyst Blood hemangioma Treatment: o Marsupialization: Decompression Chances of re-epithelialization and recurrences Done in case of large cyst or if cyst is near the neurovascular structure or if chances of fracture of jaw bone Healing is very slow o Enucleation: Always preferred Remove the entire cyst with its lining PERIAPICAL CYST • • It is an epithelium lined sac containing liquid or semi-solid inflammatory exudates and necrotic products It originates from dental granuloma of infected periapical tissues Key features: • Forms in alveolar bone in relation to root of non-vital tooth • Arise by epithelium proliferation on an apical granuloma • Usually asymptomatic unless infected Diagnosis • Radiographic appearance of non-vital tooth • Histological appearances Dental Notes by Sadichhya & Shooga 56 Downloaded from DigitalMedicine. gas but not pus.com. Non-odontogenic Non-keratinizing Periodontal cyst o Lateral o Apical o Residual Dentigerous cyst Eruption cyst Nasopalatine cyst Nasoalveolar cyst Globulomaxillary cyst Median palatine cyst 3. dental cyst. most frequently in post alveolar ridge is angle of mandible. tooth seen in the cyst. so should be differentiated from normal dental follicle. The cyst is enucleated when it is small enough. unerupted (or partially erupted) teeth.com. etc Radiology: OPG. X-rays (a well-demarcated radioluscent lesion attached at an acute angle to the cervical area of an unerupted teeth. smooth and hard swelling on the jaw o Painful only if infected o Growing cyst can cause problems of malocclusion. soap bubble like appearance due to trabeculations) Aspiration with wide bore needle: Straw colored fluid containing cholesterol crystal Differential diagnosis: adamantinoma. PRIMORDIAL CYSTS • • • • • • • • It is formed due to regression of satellite reticulum in the enamel organ which takes place before any calcified teeth structure is formed It contains keratin tissue Usually multi-locular From intraosseoulsy. osteoclastoma Treatment: o Small: excision o Large: initially marsupialization and later enucleation o Unerupted teeth should be extracted Complications: adamantinoma Dental Notes by Sadichhya. and by its enucleation we risk a discontinuation in mandible The cyst is large Certain vital structures are involved by the cyst.Treatment Enucleation: Do not recur after complete enucleation OR Marsupialization: Indications of marsupialization: • • • The cyst has eroded into the mandible. Frequently recur after enucleation Do not respond to marsupialization Radiological appearance usually multi-locular frequently mononuclear Histologically: epithelial lining of uniform thickness’ and attached weakly to the fibrous wall DENTIGEROUS CYSTS • • • • • • • • • It is a non-keratinizing odontogenic cyst thought to be of developmental origin. Shooga & Sumesh 57 Downloaded from DigitalMedicine. The cyst/abscess cavity is dressed daily. incidental finding in many cases o Symptomatic cysts present as painless.np . involvement of neurovascular structure. thus creating a passage for draining of glandular secretions. Marsupialization is a procedure whereby a new orifice is created by excising a 1 to 2 cm ellipse of tissue that includes the epithelial surface and the roof of the cyst. commonly in relation to premolars and molars Arising in relation to dental epithelium. The incision is made where the cyst protrudes into the oral cavity. which encloses the crown of an impacted or unerupted tooth at its neck portion Associated with impacted. such that the crown of the unerupted or impacted tooth lies in the cystic cavity but the root lies outside Clinical features: nd rd o Age: mostly in 2 and 3 decade o Common in lower jaw than upper jaw (2:1) o Asymptomatic. The edge of the cyst wall is then grasped with fine forceps and everted onto the epithelial surface where it is sutured with interrupted absorbable sutures. the periosteal elevator is needed to separate a bone or tooth from the fibrous membrane.INSTRUMENTS PERIOSTEAL ELEVATOR During extraction.np . Straight root elevator: Its working ends are in line with the handle and have a concave surface. A root elevator has three functions: • To loosen the teeth in their sockets.com. 1. • To remove parts of teeth (broken root tips or retained roots). called the periosteum that covers it. The dentist may also use it to gain access to retained roots and surrounding bone. These are used when the root are deep-seated. At least one (and sometimes more) is used in every tooth extraction. ROOT ELEVATORS Root elevators come in many sizes and shapes. Which elevator or elevators that are used will depend upon the desire of the dentist. Dental Notes by Sadichhya & Shooga 58 Downloaded from DigitalMedicine. • To remove a complete tooth. The inner surface of each of the two beaks is concave and the outer surface is convex. this forceps allows maximum mobility and application of force.com. They can be divided into following parts: • A beaks • A neck and • Handles The beaks of tooth extracting forceps are designed to grasp the tooth with maximum contact on the facial-lingual surface of the root(s) just below the cervix.and Z-shaped forceps are used in maxillary teeth while right angled and Cshaped forceps are used for mandibular teeth. These are used to either lift the root or move a large root fragment. Angled root elevator: In these sets of elevators. Dental Notes by Sadichhya. the straight. Because of the straight line of beak and handle. the handles are in line with the shank. S. whose sharp working tip makes an obtuse angle with the shank. As a general rule. but the working ends are set at an angle. The picture here is of the Cryer root elevator.2.np . Maxillary incisors and canine forceps: (Forceps # 1) The beaks are in a straight line with the handle. TOOTH EXTRACTION FORCEPS There are several types of tooth extracting forceps. Shooga & Sumesh 59 Downloaded from DigitalMedicine. Thus. the forceps used for their extraction are also unique. The tip of one of the beaks of this forceps is pointed while the other is rounded. The thin. is also called universal maxillary premolars. with the tip of the beak fitting between the mesiobuccal and distobuccal roots. while holding the forceps with its concave surface on the palm. and can be used for all types of maxillary teeth. The maxillary molars have 3 roots: lingual. Therefore.Maxillary Premolars These are Z-shaped and when closed resemble the Bayonet (the blade at the tip of the muzzle of a rifle). The size of the beak varies to accommodate different sizes of the maxillary premolars. the given forceps is right sided and vice-versa. To identify whether the given forceps is right or left. we have a formula: “Beak towards cheek” i. this forceps is an anatomical forceps. This arrangement allows for snug fitting of the beaks with the root of the molars: the beak with pointed end is placed towards the buccal side. The forceps #65 which is a kind of maxillary premolars. Dental Notes by Sadichhya & Shooga 60 Downloaded from DigitalMedicine. if the pointed beak is towards the right side. and while holding the concave surface of the handle should lie on the palm of the dentist.np . unique in the sense that there are separate forceps for the left and right side. these are also called the Bayonet. mesiobuccal and distobuccal. Maxillary Molars Because of the unique anatomy of the root of the maxillary molars.e. This forceps is S-shaped. slender forceps can also be used for extracting root fragments and are also called root forceps. The rounded beak grasps the single lingual root.com. some have wide beak while others have long and slender beaks. np .Right sided maxillary molar forceps Rigth and left maxillary molar forceps Dental Notes by Sadichhya. Shooga & Sumesh 61 Downloaded from DigitalMedicine.com. Mandibular Incisor. Unlike the rounded end of the beaks of these forceps. And these differ from the mandibular molars in that the shape of the free-end of the beaks. the ends of both the beaks of the molars are pointed. they have wide beaks and the free-end of the beaks is pointed so as to fit snugly between the two roots (mesial and distal) of the mandibular molars. Which of the mandibular teeth they are used for is decided by the size of the beak. Canine and Premolars Forceps The mandibular forceps are all right-angled. Dental Notes by Sadichhya & Shooga 62 Downloaded from DigitalMedicine. Mandibular Molar Forceps The mandibular forceps are also right angled.np .com. np . but not with silicate cements (plastic spatulas should be used for silicate cements).DENTAL SPATULA Cement spatula is used to mix and handle cements and is not used in the mouth. CEMENT PLACING AND PLUGGING INSTRUMENT The flattened end is used for transporting the cement while the flat-topped.com. WAX SPATULAS These spatulas are heated and then used for handling of wax. Shooga & Sumesh 63 Downloaded from DigitalMedicine. rounded end is used for plugging the cement in the prepared cavity. Dental Notes by Sadichhya. Stainless steel spatulas are used to mix various dental cements. Dental Notes by Sadichhya & Shooga 64 Downloaded from DigitalMedicine.BALL BURNISHER Burnishing (polishing) means making a surface shiny or smooth by friction. This action will polish and level the margins of restorations. the filling material will be pushed harder so that any small discrepancy between the restoration and the tooth is closed.np . EXCAVATOR It is used to remove any caries and other debris from the tooth cavity while preparing for restoration.com. By using a burnisher. np .com. Shooga & Sumesh 65 Downloaded from DigitalMedicine.EXPLORERS Pigtail explorer Periodontal probe and pigtail explorer Dental Notes by Sadichhya. Explorers are sharp. Locating of faulty margins on dental restorations PERIODENTIAL PROBES (look at the pigtail explorer for the picture) These are non-cutting instruments with blunted working ends.np . They are used to measure the depth of the periodontial sulcus or pockets and are therefore provided with marking for measurement. These instruments are used for diagnostic purposes based on the tactile sensation and on mechanical penetration of defects in tooth surfaces.com. Locating caries and other defects on various surfaces of the teeth ("the catch” is diagnostic of caries) b. cotton gauze or other things into and out of the mouth. pointed instruments for reaching the various surfaces of teeth conveniently. DENTAL MIRRORS OR ODONTOSCOPE Used for clear visualization of those areas of teeth which are beyond the direct line of vision. Some of their functions are: a. they are used for transporting cotton rolls. They can either be plane mirror (image of same size) or magnifying mirror (magnified image). Dental Notes by Sadichhya & Shooga 66 Downloaded from DigitalMedicine. COTTON PLIERS These are metallic forceps whose working ends make an acute angle with the handle. As their name suggests. Locating subgingival calculus c. The process is continued until a tight seal is achieved. Gutta-percha points are used as a root canal filling material. gutta-percha maintains its shape. Its major advantages are: a. They shrink when used with a solvent b. Shooga & Sumesh 67 Downloaded from DigitalMedicine. Then the spreader is withdrawn and a suitable sized gutta-percha cone is inserted in its place. and are easy to remove from the root canal d. milky exudate of trees in the Malay peninsula. They do not shrink unless used with solvent c. For example. When cool. They have a high thermal expansion. are impervious to moisture. conduct heat poorly. They may be kept sterile in antiseptic solution. and are bacteriostatic (prevent the growth or multiplication of bacteria) The major disadvantages are: a.np .RCT FINGER SPREADERS They are used to mobilize the cones for achieving tight seal of the cones.com. coagulated. GUTTA-PERCHA POINTS Gutta-percha points are made from the refined. They are radiopaque. Gutta-percha is pink or gray in color. It is softened by heat and is easily molded. They are not always easy to introduce into the root canal Dental Notes by Sadichhya. at first a master cone is inserted and then finger spreader of suitable size is inserted into the root canal and then the master cone is pressed to achieve tight seal and also to create space for accessory cones. b.