ENDODONTICS EPT–stimulatesnerveendingswithlowcurrentandhighpotentialdifferenceinvoltage;stimulatesA

deltafibers;noglovesshouldbeusedbecausecausesfalsenegative. ResultsfromEPT: ‐chronicpulpitis=highercurrentthannormal

‐acutepulpitis=lowercurrentthannormal(acuteinflammationmediatorslowerthepainthreshold).‐hyperemia=lowercurrentthannormal,buthigherthanacutepulpitis.

Falsepositives–pus‐filledcanalornervouspatient. Falsenegatives–trauma,insulatingrestoration,orwearinggloves.

TraumacausingdeepintrusiontoapermanenttoothcausespulpnecrosisandconventionalRCT. SLOBRule–rootfarther(buccal)fromfilmwillmovetosamedirectionconeisdirected;lingual

surfaceisalwaysclosesttotheconesobuccalisalwaysfarthest. ReferredPain‐ Forehead:max.incisors

Nasolabial:max.caninesandPMs.Temporal:max.2ndPM.Ear:mand.molarsMentalis:mand.Incisors,canines,andPMs.

HemophiliaisNOTacontraindicationtoendo. Specialcase–traumawithpulpobliterationbutPDLnormal;asymptomaticandnoEPTresponse;

TX=observeaslongastoothasymptomaticandnoPAchanges.

ACCESS: mand.molar=trapezoidal,mostcommontoothforRCT;tippedMLsooverpreparedMLaccess;in

40%ofcases,mayhave2canalsindistalroot; maxmolar=triangular,highestRCTfailure,MBrootismostcomplexofallteeth,becauseunderMB

cuspandmustbeaccessedfromDLposition;M→Plineislongest;59%haveMB2;themostcommoncurvatureofthepalatalrootistowardthefacial.

Lingualwallofmandibularteethmostoftenperforated. U‐shapedradiopacityoverlyapexofpalatalrootofmax1stmolariszygomaticprocess. Facialaccessonprimarymaxincisorsrecommended. Mand.incisorsandmax1stPMsmostcautiousforaccessbecausecommoninperforations. Perforationsintofurcationsofmulti‐rootedteethhavethepoorestprognosis.

TEETHCHARACTERISTICS: Max.1stPM–lingualrootmaybewider;2roots=60%;thinovalaccess,commonperfonmesial

concavity. Max.2ndPM–moreaccessorycanalsthan1stpm;thinovalaccess;85%has1root;overfillingeither

max.PMswillenterthemaxillarysinus. Mand.1stPM–25%have2canalsand2foramen. Mand.2ndPM–97%have1canal. Mand.Canine–slightlabialinclinesoaccesstowardlingual;thinMD,wideBL;accessopeningisa

largeovalwithgreatestwidthplacedincisogingivally. Max.Canine–longesttooth. Max.lateralincisor–55%hasdistal/lingualrootcurvature. Max.Anterior‐teethhaveslightdistalinclines;allmax.anteriorsALWAYShave1root! Mand.Incisors–mayhave2canalswiththelabialbeingthestraighterone;mayhavedistal/lingual

curvature. VitalTeeththatdon’tneedRCT:1.Cementoma,2.Traumaticbonecyst,3.Globulomaxillarycyst. Pulpcapping:onlymostsuccessfulwithpinpointexposures;

Poorestprognosiswhenperforationintofurcationofmulti‐rootedtooth. Recapitulation:usingMAFaftereachincreaseinfilesizetoremoveanydentinfillingnotremovedby

irrigation. Obturationonly2ndtocanaldebridgement.

ENDOLiquids: SodiumHypochlorite(1%,2.6%,or5.25%)–germicidalsolventandantimicrobial;GPpointscanbe

disinfectedin5%NaOClfor1minute;toxictovitaltissues;3roles:1)goodtissuesolvent.2)antimicrobialeffects3)lubricant

HydrogenPeroxide(3%)–bubblysolutionremovesdebrisb/ccertainchemicalsphysicallyfoamsdebrisfromcanal(effervescenteffect)andliberatesoxygensodestroysanaerobes.

UreaPeroxide(Gly‐Oxide)–decomposition;betterthanhydrogenperoxideandfornarrow/curvedcanalsforslipperyeffectofglycerol;bettertoleratedbytissuethanNaOClandmoregermicidalthanH2O2soEXCELLENTfortxofcanalswithnormalPAtissueandwideapices.

Chloroform–thevaporisverydangerousandusedtodissolveguttapercha. GlassBeadSterilizer–sterilizedendofilesin15secat220oC. EDTA(17%)–ethylenediaminetetra‐aceticacid;notgoodirrigationsolution;decalcifyingprocessis

self‐limitingandstopsassoonaschelatorisusedup;canremainactiveupto5dayssomustirrigate/inactivatewithNaOClattheendoftheappt;chelatingagents–calcifytissuesinordertocleanrootsurfaceforguttaperchaandsealertoadapt;

chelatingagentactsbysubstitutingsodiumionsthatcombinewithdentintoformsolublesaltsforcalciumionsthatareboundinlesssolublecombinationcreatingsoftercanaledgestofacilitatecanalenlargement.

EDTAremovesthemineralizedportion(decalcify)ofthesmearlayer. EDTAC–EDTAandcetavlon;greaterantimicrobialactionbutgreaterinflammatorypotential;

inactivator–NaOCl. RCPrep–EDTAandureaperoxidesoBOTHchelationandirrigation;foradequateRCdebridgement,

mustachieveglassysmoothwallsofcanal;foamysolutionwithnaturaleffervescence. MostcommoncauseofRCTfailureisinadequatedisinfectedRC;2ndmostcommoncauseispoorly

filledcanals. MTA–mineraltrioxideaggregate;calciumandphosphorus;longsettingtimeanddifficultto

manipulate;increasepH;mostsuperiorretro‐filling/retrogradematerial. Mtasealsapicalportionofrootcanalandisalwaysafterapicoectomyalonewillnotyielda

goodresult. Advantages: 1)RO

2)hydrophilic3)biocompatible4)induceshardtissueformation.

BROKENFILES: Ifbrokenfilepastapex,surgeryisperformed. Ifbrokenfileinapical1/3andnoRL,thennosurgeryisneededbutrecallisamust. Ifbrokenfileinapical1/3butRLispresent,thensurgeryisperformed;prepareandobturatetothe

pointofblockageandthenperformanapicoectomywithout!retrofilling. BestprognosisifvitalandnoPAlesion. Easiertoretrieveaninstrumentifitwedgedcoronaloratthecurvatureofthecanalbutverydifficult

ifinstrumenthaspastcanalcurvature.

INSTRUMENTATION: 3typesofInstrumentation: 1.Filing(push&pull)–producesirregularshapedcanals.

2.Reaming(repeatedrotation)–producesroundshapedcanals.3.CircumferentialFilling(pushandpullwithemphasisonscrapingcanalwalls)–enhancespreparationforflaring.

NarrowestdiameteratDCJ(.5‐1.0mmfromapex);widestdiameter=orifice. Broaches–forpulptissueandsoftmaterialremovalnotforcanalenlargement. Files(stainlesssteel)–cutCOUNTERCLOCKWISE;strongestoffilebutcuttheleastaggressively. K‐File–mostusefulinstrumentsforremovinghardtissuetoenlargecanal;clockwise‐

counterclockwisemotionwhilepressureplacedapically;K‐flexfile=modifiedKtypefile. Reamers–fewerflutesthanfilesandremovesdebrisCLOCKWISEbutplacesmaterial

COUNTERCLOCKWISE;shavedentinusingonlyareamingactiontoenlargecanals. Hedstromstainlesssteelfiles–forfilingactiononlyandmuchfasterthanotherfilesbecausesharp

edgebutmustbecareful;modificationisS‐file. Verylightapicalpressureisappliedwhenusingnickeltitaniumrotaryfiles. Rotaryinstrumentsworkfasterandimproveaccessearlyintxcomparedtoheatedinstruments. Endofirstthenperio,unlessthecaseisofaprimaryperiodontallesion;commonclinicalfindingof

periodontalproblemispaintolateralpercussiononatoothwithawidesulcularpocket. ToothmustbeasymptomaticandDRYatthetimeofobturation. DebridementisthemostcrucialaspectofRCtx;wantglassy,smoothcanalwalls. MostcommoncauseofRCTfailureisinadequatedisinfectingofRCsystem;2ndmostcommoncauseof

failures(40%)isleakagefrompoorlyfilledcanals.OBTURATION: Ifanaccessorycanalisn’ttotallyfilledduringobturation,thenobserveandevaluateevery3mo. MainfctofRCsealeristofilldiscrepanciesbetweencorefillingmaterialanddentinwalls. ZOEBasedSealer–lubricant,bondingagent,andantimicrobialactivity;disadv:staining,slowsetting,

non‐adhesion,andsolubility; Allsealersareradiopaquefrommetallicsaltsinsealer. IfGPpastapex,fileusedbeyondapextoavoidbreakingcone;abrokenconeinPAareacancause

orthograderetxfailure. HowtoremoveGP: 1)rotary

2)ultrasonic3)heat4)heatandinstrument;5)fileandchemical.

Indicationsforusingsolvent‐softenedcustomguttapercha:1. Lackofapicalstop2. Abnormallylargeapicalportionofthecanal.3. Irregularapicalportionofthecanal.

Don’tuseiftugbackis<1mmandDOESN’TproducebetterapicalsealthannormalGP.VERTICALFRACTURES: diffuseRL/halosurroundingrootduetobonyattachmentapparatus;mostcommoncauseisdueto

toomuchcondensation;inlayshavebeenshowtocauseverticalfractures. Diagnosticaids: 1)fiberopticlight

2)wedgingthetooth3)persistentperiodontaldefects.4)patientbiteonbitestick.

Anadditionalradiographtakenwithsteep45overticalangulationinadditiontoconventional90o. Verticalfracturesthruroothaspooralmosthopelessprognosis. AnteriortoothrootfracturesusuallyinHORIZONTALplaneandmaybevisibleinxray.

BLEACHING: Superoxol:mostcommonbleachingagentforRCTteeth;30%solutionofhydrogenperoxideand

distilledwater;applytoheattosuperoxolcottontiltoothlightens;heatliberatesoxygen. bleachingeffectisduetodirectoxidationofstain‐producingsubstances. Complications:cervicalrootresorption,acuteapicalperiodontitis(#1complication),and

enamelanddentincolorchanges. Bleachingcausescolorchangeinenamelanddentin.

WalkingBleachTechnique–SodiumPerborateand2‐3dropsofsuperoxolintoothchamberfor4‐7daysandrepeatprn.

HydrogenPeroxide(30‐50%)–mosteffectivebleachingagent,inalkalinemedium.

FLAPS: SubmarginalCurvedFlap(semilunarflap)–notusedforanteriorrootendsurgery;

Disadvantages: 1)limitedaccess&visibility2)tearingofincisioncorners3)iflargelesion,thenincisionoccursoverdefectandscarringoccurs.4)incisionextentislimitedbyattachments.

Submarginaltriangularandrectangularflap–requires4mmofattachedgingivaandhealthyperiodontium;flapisraisedbyscallopedincisioninattachedgingivawith1or2verticalincisions;scarringbutaccessisgood;notasmuchrecession.

FullMucoperiostealFlap–maximalaccessandvisibilitysomostidealflap;raisedfromgingivalsulcus;difficulttorepositionandsutureandmayhaverecession.

IndicationsforPeriradicularSurgery: 1)non‐negotiablecanal,blockage,curvature.2)complicationsfromproceduralaccidents.3)failedtxfromirretrievableposts/rootfillings.4)horizontalapicalfracturescausingapicalnecrosis.5)biopsy.

LESIONS&BACTERIA: Blow‐outLesions(non‐vital)–allprobingnormaluntilswellingprobedandsuddenlydrops;tx=RCT. NarrowSinusTractLesions(non‐vital)–Probingnormalexcept1narrowarea;tx=RCT PeriodontalLesions–probingdefectisconicalshapeandneedsRCTandperioifneeded;painto

lateralpercussion;eventhoughperiolesion,mustdoendofirstthenperio. Pulp‐chamberretainedamalgammustbe3mmintoeachcanalforretention; RCTteethhavemorefracturesbecauselossofstructuralintegrity. Bacteriainfectedinrootcanals:1)eubacterium.

2)fusobacterium3)porphyromonas4)peptostreptococcus5)prevotella

StreptococcusinitiateslesiontopulpexposurebutSTRICTANAEROBESplayroleinperiapicalpathoses.

VirulenceFactorsinvolvedinperiradicularpathosis:1. Lipopolysaccharide‐foundongramnegativesurface.2. Enzymes–neutralizeantibodiesandcomplementcomponents.3. Extracellularvesicles–involvedinbacterialadhesion,proteolyticactivities,hemaglutination&

hemolysis.4. Fattyacids–affectchemotaxisandphagocytosis.

CYSTs–inflammatoryresponsewithepitheliallining;well‐definedRLlimitedbycontinuousROscleroticborderofbone;associatedwithchronicinfectedandsometimesmobileteeth.

Central,fluid‐filled,epithelium‐linedcavity,surroundedbyagranulomatoustissueand&peripheralfibrousencapsulation.

Osteomyelitis–FromPAinfectionwithdiffusespreadintomedullaryspaceswithnecrosisofbone;tx=drainageandantibiotic;

acutemax=welllocalizedinfection;acutemand=morediffuse&widespreadinfection; severepain,fever,andlymphadenopathywithlooseandsoreteeth. Progressesrapidlyandlittleradiographicevidentuntil1‐2weeksandthenappears“MOTH‐

EATEN”radiolucency. Tx=drainageandantibiotics.

PeriodontalAbscess–positiveforpalpationandpercussionandresponsefromEPT; Gramneg.rodslikeCapnocytophagia,Vibrio‐corroding,andFusobacterium.

GingivalAbscess–frommastication;tx=OHanddentaltx. ApicalScar–PAgranuloma,cystorabscessthathealswithscartissue;well‐circumscribedRL&non‐

vital;toothisnon‐vital,soneedsRCT. RadicularCyst–pre‐exitinggranuloma;NON‐VITALsoneedsRCT. THREEVITALTEETHLESIONSsoNORCT!–

1)Cementoma–anteriorareaofmandible;RLlesionthatcalcifies;disorderofproductionofboneandcementum‐liketissueintoothareasofjaw.2)TraumaticBoneCyst–noepithelialining;asymptomaticandRLappearsscallopedaroundrootsofteeth;intramedullaryhemorhage,bloodclotliquefiesandleaveemptyspace;3)GlobulomaxillaryCyst–jct.ofglobularandmaxillaryprocessesofmaxilla;pear‐shapedRLbtwL.I.andcanineroots;maybefissuralcystorOKC.

PhoenixAbscess(recrudescentabscess)–developsasgranulomatouszone;diagnosewithpercussionandxray;largePARLandisanacuteexacerbationofchronicapicalperiodontitis.

Granuloma–granulomatoustissuewithPDLduetopulpdeathsoRCTneeded;nosymptoms;canresultinabscessandonlydiffersfromcystbyhistologicexamination;well‐definedRL.

RADIOLOGY:5. Fasterfilm(E‐speed)requireslessradiationbutqualityimage.6. IncreasekVpcausesdecreasedpatient’sskindose;needstobe70kVporhigher.7. Collimation–restrictionofx‐raybeamsizesodoesn’texceed2.5inatpt’sskin.8. Maxradiationdoes–50mSvperyr/wholebody.9. Standatleast6’awayinareathatliesb/w90‐135otothex‐raybeam(anareaofminimum

scatterradiation).

PULP&DENTIN: Decreaseswithage–sizeofpulpand#ofreticularfibers(lesscellularandmorefibrous). Increaseswithage‐#ofcollagenfibersandcalcifications;apicalportionofpulpcontainsmore

collagenthanthecoronalportion. Pulpstonesareassociatedwithchronicpulpdiseasefromadvancedcariouslesionsandlarge

restorations. Pulphasmyelinated(sensory)andunmyelinated(motor)nervefibers–theyareafferentand

sympathetic;noproprioceptors! Pulponlyfreenerveendingwithonlyreceptorforpain! Predentin–adjacenttoodontoblastlayerofpulp,10‐47µmofdentinremainsunmineralized;iflayer

lost,predisposestointernalresorptionbyodontoclasts. MantleDentin–1stformeddentinbecauseodontoblastlayergetsorganized. CircumpulpalDentin–Mostdentinformed. SecondaryDentin–formsaftertootheruptionandduringlife. Tertiary/ReparativeDentin–irregulardentinformedinresponsetoinjury.

Primaryfunctionofpulpisdentinformation!Alsonutritionfordentinandinduction(formsdentintoenamel)

Inpulp,type1:type3collagenratiois55:45%;type5collageninsmallamts. Type1collagenpredominatesindentin;odontoblastsmaketype1and

fibroblastsinpulpmaketype1and2. 4PulpZones: 1)Odontoblasticlayer–outermostlayerw/odontoblasts(A);

adjacenttopredentin&maturedentin(F).2)Cell‐FreeZone(zoneofweil)–richinnerves(D)(inclnerveplexusofraschkow)&capillaries(C);3)Cell‐RichZone–innermostpulplayerwithfibroblasts(E).4)Centralzone(pulpproper)–largernervesandblood

vessels; Cellsinpulp–fibroblasts,odontoblasts,histiocytesandlymphocytes. Cellsindiseasedpulp–PMNs(afterpulpexposure),plasmacells,basophils,

eosinophils,lymphocytesandmastcells. Pulpalinflammationisachroniccellularresponsewithplasmacells,macrophages,andlymphocytes;

Afterpulpalexposure,PMNs(acuteinflammatorycells)areattractedtothearea. VitalPulpisresistantbutnon‐vitalpulpisfertilegroundformicro‐organisms. PulpNerveFibers: 1)A–deltaFibers=large,myelinatednervesthatperceivequick,sharp,

momentarypainanddissipatesquickly.2)CFibers=small,unmyelinatednervesthatperceivedullthrobbingachewithdiffusepainandcanbereferredpain;noteasilyprovokedbutsignifiesirreversiblelocaltissuedamage;

Unmyelinatedfibersregulatethelumensizeofbloodvessels.

PULPALDIAGNOSIS: Bestmethodtoelicitthemostaccuratethermalresponseistoindividuallyisolatethesuspectedteeth

witharubberdamandthenbatheeachtoothinhotorcoldwater. IrreversiblePulpitis–bendingover/lyingdownintensifiespain;oftennoPAlesion;

SPONTANEOUS,diffusepain;intensifieswithheatandreliefwithcold;tendertopercussion. Thermaltestarethebestaidtodiagnoseanirreversiblepulpitis.

ReversiblePulpitis–requiresirritanttoevokepainandpainremovedwhenstimulusisremoved;NOTSPONTANEOUS;painwithcoldnothot;usuallysedativefillingornewrestorationisenoughtx;mostcommoncauseisbacteria.

Pulpalhyperemiaisanexcessiveaccumulationofbloodinthepulpduetovascularcongestion. **mosteffectivewaytoreducepulpinjuryduringtoothpreparationistominimize

dehydrationofdentin!!! NecroticPulp–nosymptomsbutmaysometimesrespondtoheat;EPTisvaluableb/ctherewillbe

noresponseatanycurrentlevel; ChronicApicalAbscess(suppurativeapicalperiodontitis)–long‐standing,low‐gradeinfectionofPA

bonefromRC;painless;mayfollowanacutealveolarabscessorunsatisfactoryRCT. diffuseRL(unlikecystsandgranulomaswhicharewell‐definedRL)andPDLwidening;slightly

loose,tendertopercussion; oftencauseofsinustractingingivaltissueofkids;toothpainstopsupondrainage; NON‐VITALsoRCT.

30‐50%ofbonecalciummustbealteredbeforeRLpresents;thealterationoccursatthejctbetweenthecorticalandcancellousbone.

Periapicalabscessisthemostcommonofthealldentalabscesses. AcuteApicalAbscess–puscollectioninalveolarbone;sequenceofsymptoms:tendertoothtosevere

throbbingpaintopercussionwithswelling;loosetooth,fever;noresponsetoEPTorcoldbutmay

respondtoheat;tx=drainageanddebridethecanalsandthenatalaterdateperformRCTandgivePCNbutifnotpcnthenclindamycin=increasesbonelevelsbutchanceofpseudomembranouscolitis.

ERTx=drainage,antibioticsandanalgesiccsandthenRCTatalaterdate. HyperplasticPulpitis–red/cauliflowergrowthofpulpinandaroundcariousexposurecausedby

chronicirritationandvascularsupply. CariesspreadlaterallyatDEJtoincreaseorganiccontentandinvolvemanydentinaltubules,Tomes

fiber‐reactcausingfattydegenerationandlaterdecalcification(sclerosis);onceodontoblastsareinvolved,pulpalchangesoccur;

Onlyreliableclinicalevidencethatsecondarydentinasformedisdecreasedtoothsensitivity.RESORPTION: Pulpalinflammationoftencausesinternalresorptionwhendentinoclasts(undifferentiatedconnective

tissuecells)resorbthetoothstructureincontactwiththepulp. ExternalResorption–alwayswithboneresorption;

Etiology: 1)trauma2)pulpinflammation3)ortho4)impactedteeth5)bleaching6)non‐vitalteeth

Bowl‐ShapedResorption(inflammatoryresorption)–involvesdentinandcementum;tx–immediateRCT;CaOHevery3moandafter1yr,obturatewithCaOHsealer;

Pulpdoesn’tplayaroleincervicalrootresorption. SurfaceResorption–acuteinjurytoPDLandrootsurface;healsitself. ReplacementResorption–resorptionofrootsurfaceandbonecausingankylosis;oftenseenin

replantcases;accompaniesdento‐alveolarankylosis,characterizedbyprogressivereplacementofrootbybone(nopdl);signs:nomobility,metallicpercussionsound,andinfraocclusion.

Bowl‐shaped,surface,andreplacementresorptionallcanbecausedbyreplantation!All3aretypesofexternalrootresorption.

InternalResorption–asymptomaticbutseeninxraysasirregularRLanywherealongthecanal;oncepulpisremoved,resorptionceases;mayrespondtopulpvitalitytests;Tx=pulpectomy;

Undifferentiatedconnectivetissuepulpcellsareactivatedtoformdentinoclaststhatresorbthetoothstructureincontactwiththepulp.

Etiology: 1)trauma2)caries3)pulpcappingwithCaOH4)crackedtooth–pinktooth5)partialremovalofpulp(pulpotomy)

Pinktoothsyndromeisoftenasignofinternalresorptionandcervicalrootresorption;characterizedbypinkishtoothduetogranulationgrowthunderminingthecoronaldentin.

PULPTX: Apexification–inducefurtherrootdevelopmentinPULPLESStoothbystimulatingformationofhard

substanceatapex→CaOHcreatesalkalineenv’ttopromotehardtissuedeposition; Procedure–accesstooth,removepulptissue,CaOH‐methylcellulosepasteinjectedintothe

canaltocervicallevel;doublesealcementtoclosecavityandrecallafter3mo.;ifapexformsthenRCT.

Mayberequiredafterpulpectomy; Apexogenesis–maintainpulpVITALityduringpulptxtoallowrootdevelopment;forimmatureteeth

withincompleterootformationwithdamagedcoronalpulpbuthealthyradicularpulp. PlaceCaOH/MTAoverradicularpulpandrecallevery3motilrootformsthencompleteRCT;

RootSubmersion–resectionofatooth’sroot3mmbelowalveolarcrest;preventsresorptionandmaintainbetterproprioception;Indications: 1)rampantcaries.

2)periodontalconditions3)failureofprostheticcases4)requiringbetterdenturecontrol.

Crownlengtheningindications–subGcaries,perforations,andresorptions. PulpCapping:successisrecognizedbyformationofcompletebarrierofdentinatexposuresite;

Dycal=CaOH2 Ifpulpcappingfailsandtoothbecomessymptomatic,itmaybeimpossibletotreatwithroutine

endoduetoseverecalcificationsintherootcanal;perforationsmorecommonintheRCT. IPC–wait3‐4beforetoothisreopenedanddecayisremoved; DPC–verysuccessfulinimmatureteeth;performifsmallexposure(<1mm)andifexposure

was<24hrs;performpartialpulpotomyif>1mmand>24hr. Pulpectomy–removalofpulpandfillwithZOEifwantrootstoresorborplacetemporaryuntilRCT

canbecompleted. Pulpotomy‐Uncontrolledbleedingwithpulpotomy–performpulpamputationatamoreapicallevel.

Indicationsforpulpotomy: 1)cariousprimarytooth(healthyradicularpulps)2)cariouspermtoothwithunderdevelopedroots.3)ifRCTisntavailable.3)ERtxforperm.toothwithacutepulpitis.

Onlytemporaryprocedureforpermteeth. Apicoectomy–obliquelyresectingmostapicalportionofrootwithbuccalbonearoundapex

removed;retrogradeamalgamfilling;commonreasonforapicoectomyandretrofillingistoothwithpostandneedstoberetreated;

indications:reversefilling,gainaccesstopathosis,poorlyfilledapex; Retxforpost,core,andcrownrequirescurretage,apicoectomyandretrofill;

PeriapicalCurretage–sameasapicoectomybutdoesn’tremoveapex;removalandexaminationofdiseasedtissueanddeterminingextentoflesionareobjectivesofcurretage.

AVULSION: 5Factors:1)Time:w/in30min,littleresorptionvsover2hrswhichincreasesthefailurerate.

2)StorageMedia:influenceviabilityofPDLcells;milkbestb/cpH=6.5‐6.8;salineandsalivaisok.3)ToothSocket:nocurettageorforcedreplantation.4)RootSurface:noscrapping,dried,oraddedchemicals.5)SplintStabilization:splintformaximumof2wksforinitialPDLattachment.

IntentionalReplantation:extractanddoRCTandreplant;notasubstituteforendosurgery. Indications: 1)cantdonormalRCT

2) obstructionofcanal.3) Perforatinginternalandexternalresorption4) Previoustxfailed.

IfREPLANTw/in2hrs:RCT10‐14daysafterwithCaOH;replaceevery3moandthenobturateafter1year.

IfREPLANTafter2hours:RCTbeforereplant,soakin2.4%fluoride(fluorideslowstheresorptiveprocess)atpH5.5for20min,currettebloodclotandirrigatewithsaline,washtoothwithsaline,replantandsplintfor4‐6weeks.

Maincauseoffailureofreplantedteethisexternalrootresorption;ankylosiscanalsocausefailurebutbetterprognosisthanexternalrootresorption.

After60minofdrystorage(orwater)ofanavulsedtooth,fewPDLcellssurvive. Salivacanbestorageupto2hrsbutmilkcanstoreupto6hrs.

Transplantation–transferofatoothfromonealveolarsockettoanotherinthesamepersonorintoanotherperson;transplantingpartiallydevelopedrootteethhasbetterprognosis;

POSTS: Majordisadvofpostsistheyweakentoothstructure. Needatleast4mmofGPtopreserveapicalseal. Threadedpostsincreasechanceoffracturewhileparallel/taperedpostsarepreferred. Pinsincreasestressesandmicrofracturesindentin. Cuspsadjacenttolostmarginalridgesshouldberestoredwithonlay. RCTcausedestructionofcoronaltoothstructureandreducestructuralintegrity;minimum

preparationofRCTtoothisONLAY.

OPERATIVECARIES: Maincauseofcariesisbacteriaorplaqueformation;followingcleansingoftooth,newplaquegrowth

accumulatesmainlyoninterproximalsurfaces; Rateatwhichcariousdestructionofdentinprogressesisslowerinadultsthaninyoungpeople,dueto

generalizeddentinalsclerosiswhichoccursw/aging; ZonesofDentinLesion:frominnermosttooutermostlayers;

1. Zone1–normaldentinw/nobacteria;2. Zone2–subtransparentdentin–zoneofdemineralizationbutcapableofremineralization

andnobacteria;3. Zone3–transparentdentin–softerthannormaldentin&sameaszone2;4. Zone4–turbiddentin–bacterialinvasion&notabletoremineralize;5. Zone5–infecteddentin–decomposeddentinfilledw/bacteria;

ZonesofEnamelLesion:1. TranslucentZone–deepestzone;2. DarkZone–nopolarizedlight;demineralization;3. BodyofLesion–largestpartoflesionwhichalsohasdemineralization;4. SurfaceZone–unaffectedbycaries;

RootSurfaceCaries=senilecaries;spreadsonsurfaceratherthandepth;useGI; SecondaryCaries=recurrentcaries;marginsofexistingfilling; Defensemechanismsofpulptoirritation:

1. ScleroticDentin–peritubulardentinformation;INITIALdefense;2. ReparativeDentin–irritationdentinfromation;3. Vascularity­inflammation

Lactobacillusproducelevan(polymeroffructose)notdextran; StrepMutans,Mitis,Sanguis,&Salivariousinitiatedecay;theyproducedextransucrase

(glucosyltranferase)–catalyzesformationofglucansfromdietarysucrose;→ Glucans=dextrans&mutans;Glucanformsplaquewhichholdlacticacid,producedfrom

strep,againsttooth; StrepMutansproducesgreatamountsoflacticacid&stimulatedbysucrose; Cariostatic–stopscaries;Cariogenic–causescaries,likebacteriaStrepmutans&Lactobacillicasei; CariogenicBacteriamustbeacidogenic(produceacid)&aciduric(tolerateacidenvironment)&

abilitytoformprotectivematrix(dextran);→ StrepMutans&Sobrinusaretwomostcommoncariogenicbacteriafoundinman;

PredominantBacteriaFoundinPlaque: 1) StrepSanguis–foundearliestbutNOTprimaryetiologicalagentincaries;2) Actinomycesviscosus&naeslundii3) Strepmutans(primaryetiologicalagent),mitis,&salivarious4) Veillonella,Lactobacillicasie,&Fusobacterium

DemineralizationpH=5.5;RemineralizationpH>5.5; Salivahelpspreventcariesby: 1)dilutingacid

2)reservoirforCa&PO4ionsforremineralization3)reservoirforCa,PO4,&Fluorideions&otherionsforhypermineralizationofenamel;

Pit&fissurescaresaremostsusceptibleareasontoothforplaqueretentionsohighestprevalenceofallcaries;smoothsurfaceareasare2ndmostsusceptible;

AcuteCaries/RampantCaries–rapidprogressing,mostlychildren,lesionhassmallentrancebutdeep&narrowlargelesion;mayhavepain;

ChronicCaries–slowprogression;mostlyadults;darkpigmentw/leatherydentin&shallowlesion; RootSurface/SenileCaries–olderpatients&thatattackcementum&radiculardentin;spreadsmore

onsurfaceratherthandepth;bestpreventionistomaintainperiodontalattachement;

→ Gingivalrecessionismostrelatedtoinitiationofcariesinelderly; AnincipientcariouslesiononinterproximalsurfaceisusuallylocatedGINGIVALtothecontactarea; ResidualCaries–cariesthatremainsincompletedprepeitherbydentist’sintensionoraccident; Secondary/RecurrentCaries–decayappearingat&underrestorationmargins; Maxillary1stMolaristoothmostlikelytobenefitfromocclusalsealantplacement; LeastlikelymicrobialspeciesfoundindentalplaqueisStaphAureus;OPERATIVE: BWisbestxrayfordiagnosinglesionofDLofcanine;canusewedgetodiagnosealso; KissingLesions–preparelarger1st&fillsmaller1st;access&shadebetterwhendoneinbothappts; OcclusalReduction: Amalgam Gold PFM

o Workingcusps: 2.5‐3mm 1.5mm 1.5‐2mmo Non‐workingcusps: 2mm 1mm 1.5‐2mm

DirectPulpCap–CaOHhopefullystimulatesreparativedentinbridge; IndirectPulpCap–waitingtimeafterplacingCaOH&IRM=3‐4monthshopingforsecondarydentin

formation; Class1cariouslesionsareleastlikelytooccuronlingualsurfacesofmandibularincisors;INSTRUMENTS: CarbideBurs–slight(‐)rakeangle&edgeangleof90o;rotaterapidlybeforecontactingtooth;used

forcavitypreps&bestatHIGHSPEEDS;→ thegreater#ofbladescauseslessefficientcuttingbutsmoothersurface;

SteelBurs–usedmainlyforfinishingprocedures; Rotaryinstrumentthatproducesroughesttoothsurfaceafteruseiscross­cuttaperedfissureburat

slowspeed; Burblades–eachburbladehas2sides&3importantangles; Rakeface–facesdirectionofburrotation;Clearanceface–facesawayfromburrotation; EdgeAngle–angleformedb/wrakeface&clearanceface; RakeAngleofBur–angleb/wlineconnectingedgeofbladetoaxisofbur&rakeface;most

importantdesigncharacteristicofaburblade;→ (‐)angle=whenrakefaceaheadofradius;minimizesfractures;forhardmaterialslikeamalgam;→ (+)angle=whenradiusaheadofrakeface;forsoftmaterials,likeacrylic;

Morecuttingbladescauseslessefficiencybutsmoothersurface&viceversa; BurFormula= 10–85 – 8 – 14

=bladewidth(1.0mm)cuttingedgeangle(85o)bladelength(8mm)bladeangle(14o) Nib–workingendofnon‐cuttinginstrument(ballburnisher,condenser,etc.) Anglingtheshankofinstrumentsocuttingedgeofbladew/in2mmoflongaxisofhandle; Filesareusedtotrimexcessfillingmaterial,especiallyatgingivalmargins; The#ofbevelsthatmakeupcuttingedgecanclassifyhandcuttinginstruments:

→ hatchets&chiselshavesinglebevelwhileexcavatorsare2beveled; Excavators:removecaries&refineinternalpartsofpreparation;

1. HatchetExcavator–cuttingedgeofbladeinsameplaneashandle;primarilyforanteriorteethforpreparingretentiveareas;

2. HoeExcavator–cuttingedgeofbladeperpendiculartoaxisofthehandle;3. AngleFormer–cuttingedgeatanangleotherthan90degreestoblade;4. SpoonExcavator–canbesharpendw/handpiecestones;

Chisels:usedmainlytocutenamel;1. Stright,Slightlycurved,orBin­angle–primarilyusedforplaning/cleavingenamel;2. EnamelHatchets–chiselbladedinstrumentw/cuttingedgeinplaneofhandle;3. GMTs–similartoenamelhatchetbuthascurveblade&angledcuttingedge;

Handinstrumentstransferredtodentistheldbyassistantb/wthumb&forefinger;

AMALGAM: Themostfrequentcauseoffailureofdentalamalgamrestorationisimpropercavitydesign; Amalgamcoefficientofthermalexpansion2xthatofteeth; Amalgamtensilestrength1/5to1/8it’scompressivestrength;moreabrasionresistantthan

composite;Mostamalgamrestorationsshowslightsettingexpansion; Ifamalgamchipsduringcarving,it’sb/camalgamwascondenseAFTEritsworkingtimeelapsed; Vaporizationofamalgamduringcondensationofamalgam;greatestpotentialhazardofchronic

mercurytoxicitycomefrominhalingmercuryvapor; Amountofmercuryaftercondensationaffects: 1)Porosityofrestoration

2)Compressivestrengthofrestoration3)Corrosiveresistanceofrestoration4)Surfacefinish

Amountofmercuringinsetamalgamrelatedtohowmuchmercury‐richmatrixisleftaftercondensation;mostimportantconsiderationofamalgam’sstrengthisMERCURYCONTENT;

Thesmallerthecondenserpoint,thegreaterpressureexertedontheamalgam; Highmercurycontent(if>55%)showsseveremarginalbreakdown;ideally=43‐50%; Moisturecontaminationofamalgamresultsinsevereexpansionofamalgam&corrosion;Ifamalgam

w/moisture,thezincformshydrogengas;also↓compressivestrength; Amalgamcontaminatedbymoistureduringtrituration&condensationaretheMAINCAUSEof

fractures;amalgamcompressivestrengthgreatlyreducedwhencontaminatedw/moisture; ForAmalgam→↑triturationtime=↓settingexpansion;correcttrituration,↑strengthbut

inadequatetitration,↑corrosion;bettertoovertitratethanundertitrate;→ Properlytrituratedamalgamisshiny,wet,smooth,&homogenous;→ Purposeoftriturationiscoatthealloyparticlesw/mercury;objectiveoftriturationistobring

aboutanamalgamationofthemercuyr&alloy;→ Duringtritration,oxidefilmisrubbedoffandcleanmetalisreadilyattackedbymercury;

AMALGAM: ↓settingexpansion= ↓freemercury&particalsize↑triturationtime&condensationpressure

↑strength= ↑condensationpressure&triturationtime ↓voids&particalsize AmalgamRXN=Silver‐tinAlloy+Mercury→Silver‐tinAlloy+Silver‐Mercury+TinMercury

Ag3Sn(gamma) Ag3Sn(gamma)Ag2Hg3(gamma‐1)Sn3Hg(gamma‐2)→ Gamma(30%)–unreactedalloy;STRONGEST&LEASTCORROSION;Silver­Tin;→ Gamma­1(60%)–matrixofunreactedalloy;2ndstrongest;SilverMercury;→ Gamma­2(10%)–WEAKEST&softestphase;mostcorrosion;Tin­Mercury;addcopperto

reducegamma‐2;copperreactsw/tintopreventgamma‐2; Components: 1)Silver–40­70%;↓settingtime,↑expansion&strength

2)Tin(oppositeofSilver)–25­27%;↓expansion&strength,↑settingtime;componentinamalgamthatcausesCONTRACTION;3)Copper–6%/less;↓creep&corrision&gamma‐2formation,↑strength&lessmarginalbreakdown;4)Mercury–3%/less;initiates&activatesreactionw/alloys;5)Zinc–1%/less;↓oxidationofotherelements;6)Palladium‐1%/less;↓corrosion7)Indium–1%/less;↓surfacetension

Factorsthatinfluencefinalmercurycontentofarestoration: 1. OriginalMercury‐alloyratio2. Amountoftrituration3. Condensationpressure&time

Creep–deformationw/timeinresponsetostress;oneofthemaincauseofmarginalfracturesofamalgam;overtrituration&undertriturationcancause↑creep;time­dependent;

→ Highcopper&lowmercurycontent&↑condensationpressureall↓creep;→ Creepofmetalindicatesthatthemetalwilldeformunderstaticload.

Marginalleakageofamalgamrestorations↓w/age; Discolored,corroded,superficiallayerofamalgamisSULFIDE; AmalgamisBRITTLEbutpossesgoodcompressivestrength;brittlenessofamalgamiswhythe

occlusalmarginsaren’tbeveled; ClassVAmalgam‐ 1)Retentivegroovesongingivoaxial&incisoaxiallineangles;

2)Outlinedeformedtrapezoideorkidneyshaped;parallelarcsifpossible;3)NON‐PARALLELMDwallsbutPARALLELOGwalls;4)AllwallsDIVERGE;5)MDwallsPARALLELtotransisionallineanglesbutneverbeyondlineangles;directionofMDwallsdeterminedbydirectionofenamelrods;6)axialwallshouldbeuniformlydeepintodentin&CONVEXtoconservetoothstructure&minimizepulpirritation;

2mmb/wpulp&amalgampulpalfloor; MDwallsofClass1amalgamdiverge(sameasdirectgold&goldinlays)topreventunsupported

enamelatMDmarginalridges;widthofmarginalridgesforPMs=1.6mm,forMolars=2.0mm; Extendoutlineformbeforeexcavatinganycaries; Reverse“S”curveiscurveputintoBorLwallssowallmeetsexternaltoothsurfaceat90oangle; Allwallsmeettoothsurfaceat90oangle/buttjoint; Forclass2,B&Lwallsofproximalsectionconvergeocclusallybutisdeterminedprimarilyby

positionofadjacentteethinrelationtotoothbeingrestored; Whenpreppingclass2onmand.1stPM,burtiltedlingualtopreventhittingfacialpulphorn&

maintaindentinalsupportoflingualcusp; Gingivalcavosurfacemarginbeveledonlyifitisplacedinenamel;bevelisnowiderthanenamel; ConvenienceForm–formofcavitypreptakestoaidtheoperatorinpreparing,placing,orfinishing

therestoration; RetentionForm–resistdislodgementordisplacementoftherestoration;B&LwallsofClass2prep

CONVERGEocclusallytopreventamalgamdislodgement;→ Occlusaldovetail&retentiongroovesinproximoaxiallineanglesprovideresistanceto

dislodgement;groovesplacedinaxiobuccal&axiolinguallineangels&extendaxialwallheight; ResistanceForm‐taketoresistforcesofmasticationtopreventfractureofrestoration&tooth;flat

wallsatrightanglesoftooth’slongaxishelpachieveresistanceform;→ Whenrestoringcuspw/amalgam,requiresatleast2mmofcuspberemovedtoprovide

resistanceform; ForClass2prep,shouldhaveindependentretention&resistanceformforbothproximal&occlusal

portions; Mostdetrimentaltostrengthofposteriortoothinacavityprepis↑ inF­Lwidth; MatrixbandremovedPRIORtofinalcarving;mostdifficulttoothtoadaptmatrixbandismesialof

maxillary1stPM;matrixbandthickness=0.002inches;→ wedgingactionb/wteethshouldprovideenoughseparationtocompensateforthicknessof

matrixband;→ properproximalcontourisprovidedbycarvingrestoration&adaptingcontouredmatrix;→ primaryfunctionofmatrixistorestoreanatomicalcontours&contactareas;

Amalgamrestorationsshouldbefinished&polishedtoreducemarginaldiscrepancieswhichreduceschanceofrecurrentdecay;heatgenerationduringpolishingshouldbeavoided;

AmalgamisPOORTHERMALINSULATORsoexplainswhycoldsensitivityismostcommonproblemencounteredafterplacingamalgamrestoration;

PINS: Pins–1‐1.5mminsidecavosurfacemargin;>.5mminsideDEJ;2mmintodentin&2mmintoamalgam;

→ ShouldbeinsertedintoDENTINONLY;theyareretainedbydentin’sleasticity;→ shouldbeplacedPARALLELtoexternalsurfaceoftooth;→ Functiontoretainrestorativematerial;retentionofpin↑asthediameter↑;→ Onepinpermissingaxiallineangleisused;pinscanWEAKENrestorativematerialwhenused;→ Optimumpinplacementisatthelinganglesofthetoothwheretooth‐to‐rootmassisgreatest

&riskofperforationisminimal;→ ThreadedpinsusedtoretainamalgamshouldNOTBEPARALLELtoeachotherorlongaxisof

tooth; IndicationsforPins: 1)ClassIIamalgamprepwhere1/morecuspshavebeenlost

2)verylargeclassIIIamalgamprep3)ClassVamalgamprepthatfarexceedsminimaldimensions4)prepforamalgambuild‐upoverwhichacrownwillbeplaced

Contraindicatedforyoungteethw/largepulps&teethw/reversiblepulpitis; Ifpulpishitwhendrillpinhole,obtainhemostatis,dryw/paperpoint,placeCaOHandfindbetter

pinholelocation; PinsTypes: 1)Cemented–pinhole>pin

2)FrictionLock–NOTRCTTEETH;pinhole<pin;3)Self­Threading–mostcommon&mostretentive;holesizejustunderscrewdiameter;

TMSsystemhas4pinsizes(regular,minim,minikin,&minuta)whichareavailabeintitaniumorstainlesssteelplatedgold;

GOLD: Mostductile&malleablemetal; Chamferbevel=hollowgroundbevel;scoopedoutbeveltocreatemorebulkofrestorationmaterial; Gold–retentionfromdesignofprep&frictionb/wcavitywall&casting;

→ Retentiondirectlyproportionaltolength(3mm)&parallelismofaxialwall(6otaper); GoldConstituents: 1)Gold‐↓corrosion,↑ductility&malleability

2)Copper‐↑hardness;orangecolor;ranks3rdinmalleability;3)Silver–modifiedredcolor;↓temp,↑ductility&2ndinmalleability4)Platinum‐↑temp,↑tensilestrength,↓coefficientofthermalexpansion5)Palladium‐↑temp&hardness;absorbshydrogengas;whiteningeffect;6)Zinc–preventsoxidation7)Iridium–grainrefiner;↑tensilestrength&hardness;

HighGoldAlloys:1)Type1=83%noblemetal;soft&easilyburnishedb/c↑ductility;forinlays;2)Type2=78%noblemetal;medium,foronlays;3)Type3=75%noblemetal;hard,forcrowns;whenheatedtocherryredcolor&quenchedimmediately,↑inmalleability&ductilitybut↓hardness&strength;4)Type4=75%noblemetal;bridges&RPDs;

MediumGold=25‐75%gold/noblemetals;LowGold=25%orlessgold; GoldSubstituteAlloys–donotcontaingold,butcalledPASSIVEb/ctheyformprotectivesurface

oxidefilmlayerthatprovidesmaximumcorrosionresistance; Karat–thenumberofpuregoldpartsofagoldalloy,basedon24parts(100%gold)asunit; Puregoldisonlyusedingoldfoil; Fineness–measuredbasedonpartsofpuregoldper1,000=puregold; ClassVPrepforGold:

1. Sharpinternallineangles&smallretentiveundercutsataxio‐occlusal&axio‐gingivallineangles;thisismaincharacteristicinproperRETENTION;

2. M&Dwallsflare&meetthecavosurfaceat90o;M&Dwallsplacedatlineangles;M&Dwallsdivergefacially;

3. Convesaxialwallw/.5mmintodentin;occlusalwallslightlydeeperthangingivalwallb/cthereisathickerlayerofenamelinocclusalwall;

ClassVGold– Retentionform→sharpinternalline&pointangles;Resistanceform→flatMDwalls&convexaxialwalls;

BothRetention&ResistanceformofClassVgoldisSAMEforDirectGold; GoldFoil–oldesttypeofgoldformedbyrolling&beatinggoldintothinsheats,thiscauseselongation

whichgivefibrousappearance;availableinsheets,cylinders,&pellets;→ usedforbulkfilling&finishingveneerformatgold;→ alwaysmicroscopicvoidsduetoimpropercondensing&usingoversizedpellets;→ surfacehardness,tensilestrength,&yieldstrenghtareallincreasedduringcondensationof

goldfoil;goodcondensationwithlessforceisaccomplishedw/smallpoint/condenser;→ directgoldisheatedpriortocondensationtodriveoffmoisture&volatilecompounds;→ Indications: 1)IdealLesion–nogreaterthan1‐2mmintodentin

2)IdealPulp–atleast2mmofdentinb/wrestoration&pulp3)IdealPeriodontium–notoothmobility

DirectGold‐↑coefficientofthermalconductivity(12xamalgam);#1indicationfordirectgoldissmallclass3lesion;mostimportantinadaptationofgoldisdirectionforceisapplied;

ClassIIICavityPrepforDirectGold: (useLINGUALapproach)1) Outlineformishorizontalslotpositionedgingivaltocontactarea;2) Retentionformfromsharpinternalanatomy3) Resistanceformisprovidedbyflatwalls

MaterialofchoiceforclassIIIondistalofcanineisamalgamordirectgold; DisadvantagesofGold: 1)↑thermalconductivity(12xthatofamalgam)

2)expesive&non‐esthetic3)timeconsuming&techniquesenstive4)needtousecementwhichisweakestpartofcastgoldrestoration

Onlays–inferiorretentionthanfullcrownsduetocrown’sgreateraxialsurfacearea;restoreslargelesionsthatinvolvemorethan1/3intercuspaldimension&atleast50%ofcrownremainsorlossofcuspsw/atleast1mmdentinsupportingremainingcusps;

→ Parallelismofaxialwallsisprimaryretentivefeatureinonlyprep;sharppoint&lineanglesincreaseonlayretention;

→ ShoeingafunctionalcuspisNEVERINDICATED;itisminimal/partialcuspcoverageviaafinishingbeveloncuspcrest;Capacuspispreferredb/ccompletecoverageofcusp;

→ Fromfacialtolingual,theaxiopulpallineangleofanonlayprepislongerthantheaxiogingivallineangle;

Alwaysbevel/planemarginsorwalljunctionsofonlaycavitytoremoveunsupportedenamelANDcompensateforcastinginaccuracies;bevelDOESN’Tminimizeneedforgingivalextension;

→ Bevelusedmainlytoimprovemarginaladaptation;→ 3typesofbevels: 1)shortbevel–cutsonlyexternal1/3ofenamelprisms

2)fullbevel–involvesentirethicknessofenamel3)widebevel–involvesfullthicknessofenamel&somedentin

Mosteffectivemeansforverifiyingenoughocclusalclearanceiswaxbitechew­in; Inlay–lackofundercutsisthecharacteristiccommontoallclassIIgoldinlaypreps;anocclusal

lock/dovetailshouldbedonetopreventproximaldislodgement;marginalridgesneedtoberounded;→ Allmarginsarebeveledresultingin40omarginalmetal;

CrystallineGold/MatGold–formedbyelectrolyticprecipitationyieldingacrystallinestructureresemblingtrees/linksofchain;usedforbulkfillings;flow&adaptationnotasgoodasothergold;

PowderedGold–formedbyatomizing;granulesinthismateralhavesphericalshape;canbeplacedinveryshorttimeperiod;denserthanfoilthuseeasiertomanipulate&condense;

CohesionofgoldatroomtemperatureisexampleofATOMICATTRACTION;COMPOSITE: Dentaladhesion=dentalbonding; Adhesivejoint–adhesionofintermediatematerialw/2surfaces; AdhesivePotential–smallertheangle,thegreaterthewetting&potentialforadhesion; Composite<Amalgamforcompressivestrength&occlusalwear;seriouslimitationispolymerization

shrinkage; AmountofstressforcompositedependsonC­Factor=ratioofbonded:unbondedareas; Composite:↓wearresistanceisprimarycauseoffailureofclassIIcompositerestorations;difficulty

infinishingtheserestorationisthesoftnessoftheresin&hardnessofthefiller;→ Contraindicatedinptsw/heavyocclusionorbruxism;→ Themostdesirablefinishedsurfaceforcompositeisobtainedw/aluminumoxidedisks;

CompositeResins–aredimethacrylatemonomers&polymerizebyadditionmechanisminitiatedbyfreeradicals,whichgeneratebychemicalactivationorexternalenergy;

DisadvantageofMethylMethacrylate‐↓resistancetoabrasion&↑thermalcoefficientofexpansion; Incomparisontopoly(methyl‐methacrylateacrylic),compositehas↓coefficentofthermal

expansion,↓polymerizationshrinkage,↑compressivestrength,&↑stiffness; BiphenolA­glycidylmethacrylate–componentcommontomostcompositeresins,sealants,

bonding&glazingagents,&resincementsfororthobands; ChemicalActivated(self‐cure)Resins:2pastes=benzoylperoxide(initiator)+tertiaryamine

(activator); LightActivatedResin–(VLC)→diketonephotoinitiator(camphoroquinone)&amineactivator; VisibleLightCureComposites(VLC)‐haveα‐diketoneinitiatorwhichabsorbsenergyfromvisible

light(peakintensity=474nm;bluelight)andthenketonereactsw/aminetoproducefreeradicals;→ Incrementthicknessmostaffectscuringalight‐activatedcompositeresin;→ Mostpopularwaytopolymerizematrixmonomersusinganexternalenergysourcetoactivate

polymerizationprocess;VLChavecompletelydisplacedUVlightsystems;→ Lightenergyrange=410‐500nm;curinglightisusedatwavelengths400­500nm;→ Lightneedstobeheldw/in2mmofresintobeeffective;providesDENSERrestorationsthanself‐

cureresinsb/cnomixingrequiredsonoairbubbles;→ Mosthazardoustoretinasocancauseretinaldamage;Musthaveprotectionw/ptswhohad

recentcataractremoved;withdarkerresinshades,curealittlelonger;→ MostseriouslimitationisPOLYMERIZATIONSHRINKAGE;→ Advantages: 1)greaterdepthofresincanbecured

2)Resincanbepolymerizedthruenamel3)intensityofvisiblelightremainsrelativeconstant;

Thelightsourceaffectstherperceptionofcolorb/cthelightsourcemustcontainthecolor’swavelengthtobematchedinordertoseethatcolor;

CompositeComponents:1. Filler–bariliumsilicaglass/quartz/zirconiumsilica;combinedw/5‐10%weightofcolloidal

silica;reducespolymerizationshrinkage&increaseshardness;2. Matrix–difunctionalmonomers;

i. Bis‐GMA–highlyviscous(SealantsaregenerallycomprisedofBis­GMA)ii. UrethaneDimethacrylate(UEDMA)iii. Tri‐ethyleneGlycolDimethacrylate(TEGDMA)→addedtoreduceviscosity;

3. CouplingAgent–silaneprovidesadhesiveb/winertfiller&organicmatrix; CompositeFillers‐ 1)Macrofill=10‐100microns;firstcompositeresinsmade;

2)Midifill(smallparticle)=1‐10microns;3)Minifill=.1‐1micron4)Microfill(fineparticle)=.01‐1micron;SMOOTHESTFINISH&greatestresistancetoocclusalwear;5)Hybrid=mixture,usuallyMIDIFILLorMINIFILLw/MICROFILL;

HybridResinComposites–highlyfilledw/glass&SiO2;goodesthetics;usesilicafillersto↑hardness&wearresistancebuthighlypolishable;

↑fillerinrestorativecomposites&↓fillerinflowablecomposites; thehigherfiller&BIS‐GMA,thegreatlyreducedcoefficientofthermalexpansion; Onlyadvantageofunfilledresins=↓coefficientofthermalconductivity;commoncementbases;

unfilledresinshavehighcoefficientofthermalexpansion=7‐8xthatoftooth; UnfilledresinsaretheSOFTESTofallrestorativematerials;alsolowermodulusofelasticity; Unfilledresinshavethegreatesextentofmarginalleakagerelatedtotemperaturechange; DentinConditioner–primarilyremovesthesmearlayerofdentin&etchtheintertubulardentinto

producemicrospacesw/indentinsurface;placedafterenamelisetched Primer–hydrophilicmonomer(ie→hydroxyethylmethacrylate–HEMA);penetratessmearlayer&

fillsintertubulardentin; BondingAgent–unfilledresinadhesive(BIS‐GMA,HEMA); GenerationsofAdhesives: ‐‐4thGeneration–3stepetch&rinseadhesives

‐‐5thGeneration–2stepetch&rinseadhesives‐‐6thGeneration– Type1→2stepw/primer&adhesiveseparate; Type2→1step‐‐7thGeneration–1step

Bondingofcompositetodentindependsondifunctionalcouplingagents; AcidEtch–whenused,allenamelmarginsshouldbebeveldformoresurfaceareaandtoenhancethe

seal&retentiontoreducemicroleakage;purposeofacidetchismoresurfacearea&roughensurface;→ theacidcleanssurfacedebrissobetterwettingofenamelbyresin;→ acid‐etchcompositeshavebestinitialsealbutovertimesealweakenssoAMALGAMhasbestseal

overtime;→ itincreasesretention&adaptationby: 1)↑surfacearea;

2)conditioningsurfaceforbetterwetting;3)creatingsurfaceirregularitiesforbettermechanicallocking;

Inclass3compositeprep,retentionpointsshouldbeplacedENTIRELYindentinw/groovesplacedalonggingivo­axial&inciso­axiallineangles;smallroundedretentiveareasarepreferred;

OutlineforofcompositeclassVresemblesamalgamclassVexceptthatthecompositeinternalanglesaremuchmoreROUNDED;

Wheneverpossible,usedcompositesyringetoplacecompositetoreducetrappingairinrestoration; Mostimportantfactorinpreparing&restoringClassIIcompositeisMOISTURECONTROL; Materialmostlikelytocauseanadversepulpalreactionwheplaceddirectlyinadeepcavityprep! Normalwearmechanismoftheresinsisbestexplainedbyabrasionofmatrix,,exposureoffiller,&

dislodgementoffillerparticles;CEMENTS: ChelationofCalciumionsontoothbyionizedPolyacrylicacidside‐groupsisprincipalmechanismof

chemicaladhesiontotoothstructure; SolubilityofCements→ZincPolycarboxylate>ZincPhosphate>GICement; Cementsmainfunctionincastrestorationsissealthecavity,NOTretention;

Lowcoefficientofthermalconductivityispropertymostcharacteristicofcurrenavailablecements; GlassIonomerCement–goodthermalindicators;disadv–higherfilmthickness;limitedstrengthand

wearresistancebut↓strength;oftenusedforrootsurfacecavities;doesn’tpolishaswell;→ Powder=fluoroalumino­silicateglass;Liquid=PolyacrylicAcid(adhesive&biocompatible);→ ↑solubilitywhenfirstmixedsoverytechniquesensitive;→ micromechanicalbondw/compositeresins;alsoforClassVrestorationsw/composite

“sandwichtechnique”;onlyGICusedascement&permanentrestoration;→ goodthermalinsulator(sonopulpalprotectionneeded);→ “fluoride­sponge”–b/ccanabsorbfluoridewhenlocalionicconcentrationsarehigh,then

slowlyreleasefluoridewhentheenvironmentconcentrationdecreases;→ ↓compressivestrength,tensilestrength,&hardnesscomparedwithcomposite;→ 3Types: 1)ConventionalGIC–lutingagent

2)Light‐curedGIC–linerorbase;preferredb/cofextendedworkingtime;3)Resin‐modifiedLightCuredGIC‐Fuji

ZincPhosphate–Powder=ZincOxide;Liquid=orthophosphoricacid;acidic(pH=3.5)&cancauseirreversiblepulpaldamage;shrinksslightlyuponsetting;oldestlutingagent;

→ Retention=mechanicalinterlocking;SUPERIORSTRENGTH;→ ↓compressivestrengthwhenmixedfaster;coldslab‐↑workingtime&↓settingtime;→ settingtime↑whenlesswater;providesananti‐bacterialeffect;→ canbeusedasbaseorlinerifHIGHCOMPRESSIVEstrengthisneeded;→ ifzincphosphatecementbasedusedw/restoration,varnishisappliedPRIORtoplacingbase;→ CANbeusedundercomposite;→ ifhighpowder‐liquidratio,↓viscosity,strongerfinalset&↓solubility;powder­liquidratiois

mostimportantvariableofcement’sSTRENGTH(themorepowder,thestronger); ZincPolycarboxylateCement–chelationofcalciumionsprovideschemicaladhesion;NOTirritating

topulp;thick&shortworkingtime;firstcementdevelopedforadhesiontotoothstructure;→ Powder=ZincOxide+MagnesiumOxide;Liquid=Polyacrylicacid&copolymers;→ CompressivestrengthlessthanZnPO4buttensilestrengthgreaterthanZnPO4;

ZOE/IRM:↑strength&abrasionresistance;↓solubility;pHofZOE=7soleastirritatingofcements;Powder=ZincOxide&Liquid=Eugenol;provisionalsareusuallycementedw/ZOEcement!

→ eugenolhaspalliativeeffectonpulpbutnotathermalinsulator;→ placedondentin/enamelpriortobondingb/citcompromisesbonding;→ retainsabout20%byweightofpolymethylmethacrylateinpowdercomponent;→ ptsmaybeallergictooilofclovesineugenol;notforDPCb/ccanirritatepulp;→ Carboxylicacidisthecomponentthatcouldreplaceeugenolinazincoxidepaste;→ inhibitscompositepolymerizationsettingrxnb/cofeugenol;usedfor:

1. IntermediateRestorations2. Baseundernonresinrestorations3. Deciduousteethrestorations4. Restorativeemergencies

→ 4TypesofZOE: 1)TypeI=temporarycement2)TypeII=permanentcement3)TypeIII=reinforcedZOEfortemporaryfilling&thermalinsulatingbase4)TypeIV=cavityliner

LINERS&BASES: Bases–material1‐2mmthickthatfunctionasbarrieragainspulpallyirritatingagents,provide

thermalinsulation,&provideadequateresistancetocompressiveforcesofmastication;→ Serveasreplacementorsubstituteforprotectivedentindestroyedbycaries&cavitypreparation;

Primarybaseunderamalgam/compositeisCaOHbutundergoldisZnPO4/ZnPolycarboxylate/GI;

Primarybasenotusedunderpolycarboxylatecementsb/cdoesn’tirritatethepulp; MostcommonusedsecondarybaseisplacingZINCPHOSPHATEoverCaOHbasethathasbeenplaced

overpulpalexposure(DPC); Cementsusedasbasesshouldbemechanicallystrongersomixedwithmaximumpowdercontent; Onlydistinctionb/wbase,cement,&cavitylinerisfinalthickness:

→ Cement=15‐25microns,Liners=5microns,Base=1‐2millimeters; Themostimportantconsiderationforpulpprotectioninrestorativetechniquesisthethicknessof

remainingdentin;SelectingtheapproriatebaseorlinertorestoretheaxialwallofaClassIIrestorationdependsonthebiologicaleffectrequired&thicknessofremainingdentin;

Cavityvarnishreducesinitialmicroleakageofamalgamrestoration; CavityLiners→usedtosealdentintubules;3types:

1. Copalite(cavityVARNISH)→notgoodunderresin;cavityvarnish;solutionliner=1‐5microns;a. CavityVarnishFunctions:reducemarginalleakage,preventacidpenetration,protect

pulptissues,&preventmercurypenetration;2. Dycal(CaOH)→suspensionliner=20‐25microns;3. ZOE→suspensionliner;preventsthermalshock;

Suspensionlinersarethickerthansolutionliners; CaOH→abilitytostimulateformationofsecondarydentin;RADIOLUCENT;mostcommonlyused

suspensionlinerthatpreventsthermalshock; Whenusingacid‐etchtorestoreclassIVfracture,exposeddentinshouldbecoveredw/CaOHliner;MATERIAL’STRAITS&INVESTING: Brittlematerialshavehighcompressivestrengthbutlowtensilestrength; Alloy–mixtureof2/morematerialsmutuallysolubleintheliquidstate;solidifiesthruarangeof

temperatures; ModulusofElasticity–measuresstiffnessorrigidityofmaterial;Modulusofelasticityistheratioof

stresstostrain; Ductility–abilityofmetaltoeasilybeworkedintodesiredshapes;expressedinpercentelongation;it

dependsonplasticity&tensilestrength;ductility↓withtemp↑; Malleable–metalbeingabletobehammeredintoathinsheedw/orupture;dependsonplasticity;

malleability↑w/↑temperature; CoefficientofThermalExpansion:tendencyofmaterialtochangeshapew/temp.changes;

→ Tooth=11.4ppm/oC→ Gold=14.4ppm/oC→ Amalgam=22‐28ppm/oC→ Composite=28‐35ppm/oC→ UnfilledResins=81‐92ppm/oC

Consequenceofthermalexpansion&contractiondifferencesb/wrestorativematerial&adjacenttoothstructureispercolation;

Perculation–cyclicingress&egressoffluids@restorationmargins;→ ↑percolation=↑recurrentdecay;

ElasticLimit–greateststressamaterialcanbesubjectedtoandstillreturntoitsoriginaldimensionswhentheforcesarereleased;

ProportionalLimit–thegreateststressproducedinamaterialsuchthatthestressisdirectlyproportionaltothestrain;↑proportionallimit=moreresistancetopermanentdeformation;

→ Similartoelasticlimit;caninterchangetheterms; AdhesivePotential–predictedbymeasuringthespreading/wettingoftheadhesiveoverasubstrate

surface;donebydeterminingcontactangleofdropofadhesiveasitspreadsout;→ Smallertheangle,thegreaterwetting&potentialforadhesion→ 2typesofadhesion:physicalforces(vanderWaals)&chemicalforces(chemisorption)

whenaliquidwetsasolidcompletely,thecontactangleb/wtheliquid&soldis0o; Toughness–totalenergyabsorbedtothepointoffracture;itisaffectedbyyieldstrength,tensile,

strength,percentelongation,&modulusofelasticity;brittlenessisoppositeoftoughness; Resilience–energythatamaterialcanabsorbbeforetheonsetofplasticdeformation; Percentelongationofmetalismeasureofductility&isrelatedtopermanentstrainatfracture;

→ Propertythatmostcloselydescribesabilityofcastgoldinlaytobeburnishedispercentageelongation;

YieldStrength>ProportionalLimit>ElasticLimit Quenchingadvantages→ 1)MaintainsCastingsmalleability&ductility

2)castingeasiertoclean Annealing–softenmaterialbyheating;metalbecomestough&lessbrittle;

→ 3stages–recovery,recrystallizaiton,&graingrowth; Tempering–hardeningbyheattreatment; GypsumInvestmentExpansion↓when: 1)olderinvestment

2)↑water:powderratio3)↓spatulation4)↑timeb/wmix&waterbath

ComponentsofGypsumInvestments: 1. RefractoryFiller–silicondioxidelikequartzorcristobalite(60‐65%);providesthermal

expansionforinvestment;2. Binder‐α‐calciumhemihydrate(30‐35%);addsstrength;3. Modifiers–likemagnisiumoxide,NaCl,boricacid,graphite,orpotassiumsulfate

Thermalexpansionisthemaincauseofmoldexpansionwhichcompensatesforsolificationshrinkageofspecificalloy;VariablesthatInfluenceGypsumExpansion:

→ Olderinvestment=↓expansion→ ↑waterpowderration=↓expansion→ ↑spatulationtime=↑expansion→ ↑timeb/wmixing&immersioninwaterbath=↓expansion

Thinnermixofgypsuminvestmentcauses↓settingexpanion,↓strength,↑settingtime,&↑porosity; Sprue–diameter>1.5mm;diameterofsprueshouldbe>/=tothethickestpartofpatter;sprue

attachedat45oangletothickestpartofpattern; Investwaxpatternimmediatelytoavoidshapechangesduetorelaxationofinternalstressesinwax; TypesofInlayWax→TypeA(hard,lowflow),TypeB(mediumflow),TypeC(soft,highflow;for

crownsoronlays);→ Contains:Paraffinwax(soft&mainingredient),GumDammar(medium),&Carnaubawax(hard);

ZonesofFlame‐frominnertoouterzones →mixingzone(cool&colorless)→combustionzone(green/blue&surroundsinnercore)→reducingzone(hottestzone&onlypartofflamethatshouldbeusedtoheatthealloy)→oxidizingzone(ifcontactsmetal,adullfilmofdross–scumonmoltenmetal,developsovermetalsurface)

Example‐PorcelainatofPFMisseparatedatporcelain‐metalinterface,separationmaybecausedbydegassingmetalattoolowtemporfusingopaquecoatofporcelainattoolowatemp;

Propertiesusuallyfoundinmaterialsconsistingofionicbondsarebrittleness&highmeltingpoint(notweakness);

FLUORIDE&SEALANTS: Fluorideconcentrationincommunitywaterdependsonairtemperature&waterconsumption; Formsoffluorideinwater: 1)SodiumSilicofluoride

2)HydrofluorosilicAcid(wellwater)3)SodiumFluoride

Fluoridesupplementsrecommendedifcommunalfluoridewaterconc<.7ppmforupto13yo;

FLUORIDE: 1)CreatesFluoroapatite

2)Inhibitsacidproductionthatcausesdecay3)↑enamelremineralization4)Inhibitsproductionofglucosyltransferase(dextransucrase)5)BacteriocidalAction

Fluorideioneasilyexchangedforhydroxylioninenamelb/cfluorideisslightlysmallerthanhydroxylion&fluorideionhasgreateraffinityforhydroxylapatitecrystalthanhydroxyion;

Fluorosisisenamelhypoplasia;IRREVERSIBLE;doesn’toccuraftermostteetheruptedbutcanoccurinprimaryorpermanentteeth;

Fluorideconc>4mg/L=toxic;convertouncestograms=8.2ouncesx28.35(constant)=232grams; ProbableToxicDoseforFluoride=>5mgF/kg; Fluorideisexcretedbykidneys; PrenatalfluoridenotapprovedbyFDAbutDOESN’Tcrossplacenta; Fluoridemaycorrodesurfaceoftitaniumimplants; Systemicdistributionoffluoridemayaffecttoothmorphology; DailyUseFluorideGel=0.4%StannousFluoride&1%neutralNaFl;usedforrootcaries,xerostomia,

radiationtherapy,&teethforoverdenture; 3TypesofTopicalFluoride:

a. AcidulatedPhosphateFluoride­1.23%NaFl+1Morthophosphoricacid;pH=3­3.5;mostcommoninpractice;mayaffectexistingrestorationbyremovingtheglaze;

b. SodiumFluoride–2%;overthecounter0.05%recommended;pH=9.2;c. StannousFluoride–8%;poortaste&maycausestaining;pH=2.1­2.3;

Dailyapplicationof1.23%AcidulatedFluorideinfittedtraysfor4minisMOSTEFFECTIVEwaytoincreasethefluoridecontentintheexternallayersofteeth;

Lowviscositysealantswetacidetchteethbest(30‐50%PhosphoricAcid); Retentionoffissuesealantsischieflytheresultofmechanicalmicroretention; Fluoridetherapy&occlusalsealantsmodifytheHOSTthemost; SealantPropertiesclosertoUnfilledResins;Components:

→ Monomer→Bis‐GMA→ Initiator→benzoylperoxide→ Accelerator→amine→ OpaqueFiller→titaniumoxide

MISCELLANEOUS: WoodburryRDframehasmoreretractionbutYoung’sframe(u‐shaped)ismorepopular; Isolateaminimumof3teethw/RD;fortoothbeingclamped,holeis1sizelargerthantheholesover

teethwithoutaclamp;punchingholestooclosetogetherinRDmaycausedamagetogingivalpapilla; Whenusing#212clampforclassV,punchholelargerandslightlyFACIALtootherholesinarch; Pregnantptshavemoreinflamedgingiva; DENTIN­1)PrimaryDentin–forminitialshapeoftooth;depositedb/fcompletionofapex;

2)SecondaryDentin–formedafterapexcompleted(regulardentin–slowformationrate);3)TertiaryDentin–akaReparativeDentin–formedbyreplacementofodontoblasts;irregularshape&limitedtositeofirritation;compositionsameassecondarydentin;

4)ScleroticDentin–whendeadtracts/emptytubulescalcify; Dentinislessdensethangold,enamel,amalgam,&porcelain; GalvanicShock–brief&sharpelectricalsensationwhen2differentmaterialscontact(likeamalgam

&gold);1microamperes=500mV;graduallysubsides&disappearsinafewdays; PMcontactsfromfacialview→Junctionofocclusal&middlethird; Molarcontactsfromfaicalview→Middlethird; Posteriorteethocclusionviewofcontacts→slightBUCCALofmiddlethird;thiscreatesawide

lingual&narrowfacialembrasure; Inposteriorteeth,gingivaltissuesfillcervicalembrasure;itisnormally“col”shapedfromF‐Lcross

sectionview; HeightofContour–thickestportionorpointofgreatestcircumferenceofthetoothviewedfrom

occlusalsurface; Bleaching–In­Office=35%hydrogenperoxide(4‐10mincycles);

→ At­Home=10%carbamideperoxide;→ Extrinsicstains→vitalbleaching;bleachingaffectscolorchangeinbothdentin&enamel;→ Beststainsforbleaching:yellow>brown>orange>grey;→ Materialsfor“walkingbleaching”aresodiumperborate&30%aqueousHydrogenperoxide;

Green&orangestainsonmaxillaryincisorsareusuallyattributedtopoororalhygiene; Anticholinergicdrugscausexerostomiab/cblockreceptorsitesforacetylcholine; LAreducessalivainmouthb/creducesanxiety&sensitivity; ClinicalSignsofOcclusalTrauma:Mobility,ThermalSensitivity,Attrition,&FacialRecession; Glycerin,Kaolin,&SodiumFluoridecanalltreatrootsensitivity; HydrodynamicTheory–painresultsfromindirectinnervationcausedbydentinalfluidmovement

intubules,stimulatingmechanoreceptorsnearpredentin; ZincChloride–mostlikelytocauseNECROSISofthesulcularepithelium&adjacentlayerofCTwhen

impregnatedintocordforgingivalretraction;epi,alumsulfateoralumchloridedon’tcausenecrosis; Goodhygiene&fluoridationwillleastprotectgroovedefects; MostsensitiveareaoftoothduringcavitypreparationisDEJ; ahyperemicpulpmayrespondtolowlevelsofcurrentfromanEPT; ReversiblepulpitischangestoIrreversiblepulpitisprimarilyb/cofinvasionofmicroorganisms; Drugsthatactasanti‐sialogogues(anti‐salivaryagents)–Atropine&Methantheline(Banthine); UseofPropanthelineBromide(Pro‐Banthine)tocontrolsalivarysecretionsiscontraindicatedin

ptsw/glaucomaorcardiovasculardistress; ReversibleHydrocolloidshavetheLONGESTSHELF‐LIFE; ThesyringematerialthatismostrigidandmostdifficulttoremovefromthemouthisPOLYETHER; Mosteffectivewaytoreduceinjurytothepulpduringrestorationprocedureistominimize

dehydrationofdentinalsurface; Dentistadjuststheshadeofarestorationusingacomplementarycolor;thisprocedureresultsina

decreasedvalue! Dextranase–theenzymewhenincorporatedintoamouthwashismostlikelytointerferew/

microbialaggregationintheplaquemass;

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ORALSURGERY Erythromycinnotacceptableantibioticforprophylactic. IfallergytoPCN&clindamycin,usecephalexin,clarithromycin,orazithromycin. NormalPulse=72;BP=120/80 Temp:Oral=98.6,Axillary(leastaccurate)=97.6,Rectal(mostaccurate)=99.6,Aural=99.6. ASAClassifications:

1. Normalhealthypt.2. Mildsystemicdisease/significanthealthriskfactor(smoking,alcohol,obesity)3. Severediseasebutnotincapacitated4. Severesystemicdiseasethatisconstantthreattolife.5. Moribundpt.notexpectedtosurviveunlessoperation.6. Brain‐deadpt.whoseorgansremovedfordonation.

Testsforadmittingtohospitalforsurgery:CBC,WBCcount,urinalysis,andifG.A.thenchestx‐ray,andover40yrs,thenEKG.

PATHOLOGY: CBC: 1)Hematocrit:M=40‐54%,W=37‐47%;#ofRBCsinyourblood;

minimalforsurgeryis30%2)Leukocytes:5‐10,000/mm3;dentalinfection=15‐20,000/mm3.3)Hemoglobin:M=14‐18g/dL,W=12‐16g/dL4)TotalErythrocytes:M=5x106/mm3,W=4.5x106/mm3.5)TemplateBleedingtime=1‐9min;6)PTtime=11‐16min–besttesttodeterminifO.S.canbedonew/ptonCOUMADIN;Ptmustbew/in5‐7secsofcontrolsample.7)PTTTime=25‐36sec;besttestforhemophila;detectscoagulationdefectsofintrinsicsystem;8)Platelets=140,000‐440,000/mL

• Plateletsat50‐100,000isokifplateletfctishealthy.• Thrombocytopenia=<50,000/mm3whichiscontraindicatedforsurgery.

9)UrinepH=6;SpecificGravity=1.005‐1.025 Hydrocortisone(glucocorticoid)‐20mgsecretedbyadrenalcortex/day;stimulatedbyACTH(ant.

pituitary);increasesinconcentrationsunderstressbutdecreaseswithexcesssteroidsinsystem. Cushing’sSyndrome–hormonedisordercausedbyprolongedexposuretohighlevelsofcortisone

(glucocorticoid)causinghypercortisolism;rarebutmoreinfemalesages20‐50yrs.• 10‐15pploutof1millionaffectedeachyear;mostcommoncauseispituitaryadenomas.• Causesmoonface,fatpads,buffalohum,obesity,andpurplestriae.• Causesmuscleweakness,bruising,weightgain,andgrowthretardation,excesshair.• IncreaseinBP,osteoporosis,fractures,impairedimmunefct,glucoseintolerance,andpsychosis.

ErythemaMultiforme–hypersensitivitysyndromeofpolymorphouseruptionofskin/mucousmembranes;macule,papules,vesicles,“BULLS‐EYE”shapedbulla.

o Severeform=Steven’sJohnsonSyndrome.o Tx=corticosteroids(consultDRb/ftreatingthesepatients)

PtsonSteroids:• Smalldoses(5mg/dy)willhavesuppressionifbeenonregimenformonth.• 100mgcortisol/day(20‐30mgPrednisone/day)willhaveabnormalcorticalfctforaweek.• Shorttermtherapy(iehighdosesfor1‐3days)willnotaltercorticalfct.• Adrenalcrisis–IV/IMofhydrocortisoneandsupportivetxfordecreaseBP.• Personwhohasbeenonsupressivesteroidswilltake1yeartoregainfulladrenalcorticalfct.

Ptstakingchronicdailydoesofsteroids(>10‐20mg/dayofprednisone)shouldbeconsideredforsteroidsupplementationfororalsurgery.

• Ifcurrentlytakingsteroid,doubledailydoseofsteroidforsurgeryday.• Iflessthan2weeksaftersteroidsstopped,doubledoseofsteroidsonsurgeryday.

Asdehydrationprogress–turgor(fullness)ofskinloss,thenoliguria(decreaseinurine),thenseverecelldysfunction–watershiftsfromintracellulartoextracellularspace,particularlyinbrain.

o BPfallsw/continuousdehydration. DiabetesMellitus–mostlycarbs/glucose&lipidsowingtolackofinsulinsecretionbybetacellsof

pancreas;ifwell‐controlled,notsusceptibletoinfectionsbutdifficultycontaininginfections.o HypoglycemicSymptoms:tachycardia,sweating,nausea,tremulousness,hunger.o Diabetesismostcommonpancreaticendocrinedisorder/metabolicdisease.o Type1pt–absolutedeficiencyofinsulinduetodestructionofBcells.o Type2pt–resistanceofinsulin’sactioninperipheraltissues.o CausesPolydipsia(excessivethirst),Polyuria(excessiveurination),&Polyphagia(excessive

hunger).o Tx=forconsciouspt–oralcarbohydrate/sugaro Tx=forunconsciouspt–1mgglucagonIMor50mlof50%glucoseIV.o #1causeofKidneyDisease(40%);highbpis2ndcommoncause.o Well‐controlleddiabetesarenomoresusceptibletoinfectionsthanptsw/odiabetesbutit

ismoredifficultcontaininginfectionsduetotheiralteredleukocytefunction. Dypspnea:difficultybreathing;Apnea:transientabsenceofbreathing;Hyperapnea:deep&rapid

breathing. Hyperventilation–↓CO2frombloodcausingdecreaseBP&fainting;hypocapnea(lossofCO2). Hypoventilation–↑CO2inblood;hypercapnea(excessCO2) CHF–50%ofventricularejection;usuallyleftventriclefailsfirst;

o mostcommonsignofleftCHFispulmonaryedema;o mostcommonsignofrightCHFispedaledemaorabdominalswelling.o Earliest&mostcommonsign–ParoxysmalNocturnalDyspnea(ptwakesupgaspingforair).

Usuallyapost‐infarctionptisnotsubjectedtooralsurgeryw/in6monthsofhisinfarction. Ptstakingdiuretcis/vasodilatorsarepronetoorthostatichyptensionandavoidexcessiveEPI. NormalbloodpH=7.33‐7.44;normalbloodbicarbonatetocarbonicacidratio=20:1. Bicarbonate‐carbonicacidrationormalis20:1. Acidosis–deceasedbloodpH;CNSdepressed;10:1ratioindicatinguncompensatedacidosis–always

occursduringCPR; Alkalosis–increasedbloodpH;overexcitabilityofCNScausingtetany. MetabolicAcidosis=↓bicarbonate;toomuchacidortoolittlebase;causesCNSdepressionso

disorientation,thecomatosed;causesareChronicrenalfailure,diabeticketoacidosis,lacticacidosis,poisons,anddiarrhea.

RespiratoryAcidosis=increaseCO2b/cdecreasedresp.rateb/cpoorlungfunction. TxforMetabolic&RespiratoryAcidosis=sodiumbicarbonate. MetabolicAlkalosis–↑bicarbonate;toomuchbase/toolittleacid;causesoverexcitabilityofthebody.

o Etiology–diuretics,cusshing’ssyndrome,vomiting; RespiratoryAlkalosis–decreasedCO2b/cincreasedresp.rate. TxforMetabolic&RespiratoryAcidosis=aluminumchloride. StatusAsthmaticus–severeformofasthma;ifnottx,thenchronicpartialairwayobstructionwhich

mayleadtorespiratoryacidosis. RheumaticFever–SequelaofpreviousGroupA–β‐hemolyticStaphinfectionofUpperRespiratory

Tract;exudative&proliferativeinflammatorylesion(NOTINFECTION)ofconnectivetissue,esp.heart,joints,bloodvessels,&subcutaneoustissue;Tx=PCNandrest.• Commoninchildren5‐15yrs;Carditismaycausepermanentvalvedamage,likeMVP;• Diagnosismadewhen1major&1minorcriteria(JONESCRITERIA)aremet:

o Major–carditis,arthritis,chorea,erythemamargnatum,andsubcutaneousnodules.

o Minor–fever,arthralgias,historyofRFD,EKG,andlabtest. HemophiliaA&B–takeslongtimeforbloodtoclotandabnormalbleedingoccurs;sex‐linked

recessive(malesaffected&femalescarriers)A. Often<25yrs;deficiencyoffactorVIII(anti‐hemophilicfactor).B. (Christmasdisease)DeficiencyoffactorIX(plasmathromboplastincomponent).C. (Rosenthal’sSyndrome)DeficiencyoffactorXI(plasmathromboplastinantecedent).o **truehemophiliachasincreasedPTT,normalPT&bleeding;howeverptsonanticoagulant

therapy(wafarin,heparin,aspirin,orNSAID)willhaveprolongedPTandbleedingtime. VonWillibrand’sDisease–autosomaldominantbleedingdisordercausedbydeficiencyinvon

Willebrandfactor–bindstofactorVIIIandadhedesplateletstocollagen. Thrombocytopenia–mostcommoncauseofhemorrhagic/bleedingdisorders;abnormallylow#of

platelets(<150,000);Abnormalreductionsofplateletscausedbyanyofthese3processes:1. Plateletproductionbybonemarrow2. Trappingofplateletsbythespleen3. Fasterthanormaldestructionofplatelets.

• S&S–petechiae,nosebleeds,GIbleeding,tendencytobruise,urinarytractbleeding.• 2concernsw/thesepts–post‐ophemorrhageandadrenalinsufficiency(duetosteroidtx).• Excessivebleedingcausesformationofhematomaswhichincreaseschanceofinfection.• Drugsthatpotentiatebleedingafterextraction: 1)aspirin

2)anti‐coagulants 3)broad‐spectrumantibiotics 4)alcohol 5)anticancerdrugs. PtsonAnticoagulatedTherapy–stopdrugsfor5daysthenperformsurgeryandrestartthedrug

therapyTHEDAYAFTERsurgeryifnobleedingispresent. COPD–emphysema&chronicbronchitis&asthmaoranycombinationofthose3diseases;airway

obstructionthatischronic&progressive;causessecondarypulmonaryhypertension.1. BronchialAsthma–disordermarkedbydyspnea&wheezingexpirationfromnarrowingairways.2. Emphysema–oftenw/chronicbronchitis;laboredbreathingandincreasedchanceofinfections.3. Bronchiectasis–copiouspurulentsputum,hemoptysis,andrecurrentpulmonaryinfection.4. ChronicBronchitis–excessivebronchialmucousandproductivecough(universalsignofchronic

bronchitis)w/sputumfor3mo/moreinatleast2consecutiveyearsw/outanyotherdisease. COPD&aspirinmaycauseHemoptysis–burstingofRBC. ChronicBronchitis–causeshyperplasiaofbronchialsubmucosalglands&bronchialsmoothmuscle

hypertrophyquantifiedbyReidIndex;predisposedw/lungcancer;• associatedw/smoking;productivecoughw/wheezing;soneedtobeUPRIGHTduringO.S.• CORPULMONALE(enlargedRVofheart);• airwaynarrowing&obstructionofbronchialtree.

Emphysema–“BARREL‐CHESTED”appearance;b/cdistalairspacesbecomeenlarged&lungshyperinflated;destructionofairsacsinlungswhereoxygenexchanged;• shortnessofbreathanddifficultyexhaling.

End‐StageRenalDisease–perm.&almostcompletelossofkidneyfct<10%;toxinsslowlybuild‐up;• Onsteroidtherapy,increasedpost‐opinfections,increasedbleedingtendency.• Oralsurgeryperformed1dayafterdialysis;Consultdr.forprophylaxis.• DonotuseNSAIDS;avoiddrugsmetabolized/excretedbykidneys.

Atelectasis–mucous/foreignobjectobstructsairflowinmainstembronchuscausingcollapseofaffectedlungtissue;often36hrs.post‐opw/milddyspnea,lowgradefever,hypoxia,&canleadtopneumonia;• mostcommonANESTHETICCOMPLICATIONoccuringin1st24hrs.• Tx=incentivespirometer,pt.takeslongdeepbreathstoexpandthelung.

Pneumothorax–airleaksintopleuralspacecausinglungtorecoilfromchestwall;dyspnea,chestpain,needchestx‐ray;canoccuraspost‐opcomplicationsfromaspirationofvomitintotrachea.• Tx=removeairfrompleuralspacew/chesttube/smallneedle.

**Pneumonitis(inflammationoflungs)&atelectasis–2mostcommoncausesoffeverinpt.w/G.A. CalciumregulatedbyparathyroidhormonecausingincreasedboneresorptionwithincreasedCa

levels;calciumalsoregulatedbykidneytubulesandGImucosa(↓pH=↑Ca);• ↓Cacauseshyperirritabilityofnervesandmuscles.• ↑Ca=↓PO4• Caincreasedinhyperparathyroidism,glomerulonephritis,hypervitaminosisD,&malignant

diseases(iemultiplemyeloma);Cadecreasedindiabetesmellitus. Phosphorusconcentrationregulatedbyparathyroidhormone=↑PTH=↑Phosphorusinurine=↓

phosphorusinplasma. Goodhealth=Ca:Phosphorusratiois10:4. Insulin=↓glucose;glucagon=↑glucose. Fastingglucose>140andnonfastingglucose>200=diabetes;NormalGlucose–70‐120mg/dl. Glucoseregulatedbyliverw/hormonesfrompancreas,adrenalmedullaandcortex. Bloodglucoseincreasedw/glucagonanddecreasedw/insulin;glucosenotinurinebutfilturedb/c

reabsorbedinPROXIMALCONVOLUTEDTUBULEofkiney Osteomyelitis–inflammatoryprocessw/inmedullarybonethatinvolvesmarrowspaces;causedby

STAPHAUREUS;lessinmaxillab/crichbloodsupply;pusisproducedinbonesomaycauseabscess.• Suppurativeosteomyelitis–acute,chronic,orinfantileosteomyelitis.• Nonsuppurativeosteomyelitis–chronicsclerosing,Garre’sOsteomyelitisandactinomycotic

osteomyelitis.• Canaffectadults(vertebrae&pelvis)/children(longbones)–affectsadjacentendsofboneslike

femer&tibiaorhumerus&radius.• Garre’sOsteomyelitis–inchildren/youngadults;causesperiostealthickeningandperipheral

reactiveboneformationresultingfrommildirritation/infections;clinically‐bony,hardnon‐tenderswellingandassociatedw/painfulcarioustooth.

• AcuteOsteomyelitis–reducedbloodsupplypredisposesbonetoosteomyelitis;likeinmand. Dentigerouscyst–associatedw/crownsofuneruptedteeth;AKAfollicularorprimordialcysts;result

ofdegenerativechangesinreducedenamelepithethelium.o Unerupted2ndmand.molaron14y/ow/dentigerouscystaroundcrown…tx–uncover

crownandkeepitexposed.o Eruptioncystformwhentoothiserupting–tx=simpleincision/deroofing.

CharacteristicsofMalignancies: 1)erythroplasia–lesionred/speckledred&white2)ulceration3)duration>2wks;>40yrs.oldpt4)rapidgrowth,bleeding,induration,fixation.

Earlycarcinomafrequentlyappearsasareaoferythroplasia(redbutnotulceratedareaofmucousmembrane).

SquamousCellCarcinoma=90%oforalcavityandoropharyngealmalignancies;o mostcommonsiteisLIP(25‐30%,alsoGOODPROGNOSIS);oftenulcerated.o 2ndmostcommonsiteistongue,oftenanteriortongue(lateralborder).o 3rdmostcommonsiteisfloorofthemouth;oftenoldermenwhosmoke/drink.

EMERGENCIES: ReducingcardiacoutputisMAINFACTORinalltypesofshock; S&Sofshock:tiredness,cofusion,coldskin,sweaty,bluish,pale,rapidbutweakpulse,andBPdrops. CharacterizationsofShock: 1)increasedHR&vascularresistance

2)decreasedcardiacoutput

3)tachycardia4)adrenergicresponse5)ischemia/mentalchange

StagesofShock: 1)Compensatorystage–increaseHRandperipheralresistance.2)Progressivestage–metabolicacidosis3)Irreversible/Refractorystage–organdamage,survivalnotpossible.

CategoriesofShock: 1)HypovolemicShock–producedbydecreasedbloodvolume.2)CardiogenicShock–causedbymassiveMI;circulatorycollapsefrompumpfailureofL.V.;3)SepticShock–severeinfectionfromendotoxinofgram–bacteria.4)NeurogenicShock–severeinjury/traumatoCNS.5)Anaphylacticshock–severeallergicrxn.

Epinephrineisgivenduringshockb/cpreventsreleaseofsubstancesfrommastcells&antagonizestheactionofhistamine&leukotrienesofsmoothmuscle.

LAissedative/depressantonCNS;toxicitycausesdrowsiness,slurredspeech,coma,culvusions,resp.depression,decreasedcardiacoutput;initialeffectmaybestimulation,agitation,talking,↑BP,↑HR,↑Resp;Tx=oxygenanddiazepamIV.

FirstCLINICALSIGNofmildlidotoxicityisNERVOUSNESS! FirstCNSmanifestationofLAtoxicityisshortCNSexcitationthendrowsinessthenunconsciousness

andresp.depression/arrest;CVeffectsaredepressantcausingdec.BP. AllergicrxnstoLAisfromeithertheLAormethylparaben(preservative);ifthereisallergicrxntoLA,

usedipheynylhydramine/benadryl;allergicrxnstoLAcausedbyantigen‐antibodyrxn.o Presentsw/swelling,itching,andoralmucosaswelling.

Syncope=transientcerebralhypoxia;tx=oxygen3‐4L/min;• MOA=increasesamountsofcatecholaminescausingdecreaseperipheralresistant,tachycardia,

sweating;sosyncopecausedbyovercompensatingforincreaseBPsocreatesbradycardia.• Mostcommonearlysignofsyncope=pallor/paleness• OxygenindicatedforallsyncopeunlesscausedbyhyperventilationandcontraforCOPD.• Inhaledammoniumirritatesthetrigeminalnervesensoryendingscausingreflexstimmulationof

medullaryrespiratory&vasomotorcenters;• Types:Vasovagal,Neurogenic,Orthostatic,Hyperventilation.

Hyperventilationinanxiousdentalpt.leadstocarpopedalspasm=spasmofthehands,thumbs,foot,ortoes.

Asthma–dyspnea,cough,&wheezingcausedbybronchospasmwhichresultsfromhyperirritabilityoftracheobronchialtree;Ifbronchodilatordoesn’tworkduringasthmaattackuseEPI(.3mlof1:1000dilution),thenoxygen;Sitptinerectorsemi‐erectpositionduringasthmaattack.

Epinephrineisdrugofchoiceinacuteallergicrxnw/bronchospasmandhypotension. Ifasthmatic,avoid:aspirin,NSAID,barbs,narcotics,erythromycin;useB2‐agonist(albuterol)for

asthmatx. IfCPRiseffective,thenpupilsconstrict;**iftoomuchpressureonxyphoidprocess–liverinjured! Ifinterruptchestcompression–fallofBPto0andreducedbloodflow. ForBPcuff–bladderlengthandwidthofcuffshouldbe80%and40%ofarmcircumference. BP–5mgHghigherwhensitting;differenceinarmsbpis20%;inflatecuff30mgHGuntilpt.radial

pulsedisappears;thesphygmomanometershouldbereducedat2‐3mm/sec. MostcommonerrorinrecordingBPisapplyingcufftooLOOSELYandgivesfalseelevatedreading. ActivateEMSimmediatelyforadultsandafter1minforinfantandchild. Rescuebreathing(haspulsebutnotbreathing)‐1breathevery5‐6sec(every3secforchild)or10‐

12breaths/min(15/20forchild/infant). Forcompressions,depresssternum1.5‐2mm(1‐1.5child,.5‐1forinfant);30compressionq2breaths

foradult&kidsbut15compressionsq2breathsfor2rescuers;(80‐100/min)and5:1forinfant.

Inanaphylaxis,ptshouldbeinTrendelenburgposition–bodylaiddownandinclinedat45ow/feet&legsabovehead.

Meperidine/Demoral–narcoticusedtorelievemoderate/severepainandacoughsuppressant.o Mostwidelyusednarcoticinhospitals;o Mostabuseddrugbyhealthprofessionals.

ConcomitantadministrationofMeperidine&MAOinhibitors(likePhenelzine)cancauselife‐threateninghyperpyrexicrxnsthatcanendupinseizures/coma.

ANESTHESIA: Nitrous(bluetank!)=blood/gaspartialcoefficientof0.47sopoorlysolubleinbloodandlackof

potency;excretedunchangedbylung;onlyinorganicanesthetic;primarydisadv:lackofpotency.• MainlyeffectsreticularactivatingsystemandlimbicsystemandCNS;roomair=21%oxygenso

needpt.toreceivethismuchoxygenwhengettingNO.• Firstsymptomofnitrousistinglingofhands;goodfortimid/scaredkids.• Keepreservoirbat1/3to2/3full;onlyinoganicsubstance.• Inhalationanestheticw/fastestonsetofaction!Oldestgaseousanesthetic;• Nauseaismostcommonsideeffect;diffusionhypoxiaifnotgive100%O2atendofprocedure;

100%oxygenCONTRAINDICATEDinCOPDpt.• Mostcommoncomplicationofnitrousisbehavioralproblem.• Inconscioussedation,ptretainsallreflexesbutdoesn’tunderG.A.

Fullcylinderofoxygen=600Lat2000psi(greentank!) Spirometermeasuresrespiratoryairvolumes:

1. FunctionalResidualCapacity–amtofairremaininginlungsatendofexpiration;nitroustakeslongerifmoreFRC;FRC=ERV+RV.

2. TitalVolume–amtofairremaininginlungsatendofexpiration.3. ExpiratoryReserveVolume–amtofairforcedoutoflungsinmax.expiration.4. InspiratoryReserveVolume–amtofairinhaledatmax.inspiration.5. VitalCapacity=TV+ERV+IRV.6. ResidualVolume–volumeofairremainsinlungsatalltimes(can’tbemeasured)7. TotalLungCapacity=VC+RV

Pulmonaryvolumes20‐25%lessinfemalesthanmalesandlargerinathleticpplsonitrousadjustmentsneeded.

StagesofAnesthesia:I. Amnesia&Analgesia–administrationofanesthesia;verbalresponses(bestmonitor).II. Delirium&Excitement–lossofconsciousness&onsetoftotalanesthesia;maybecome

violentwithirregularBP&Respirations.III. SurgicalAnesthesia–regularpatternofbreathingandtotallossofconsciousness;eye

mvmtstops!;whensignsofresporCVfailurefirstappear;thisstagehas4PLANES!a. Pthasnopainreflexes.

IV. Premortem–signalsdanger;decreaseBP;cardiacarrestimminent;medullaryparalysis!a. Eyesaregreatlyenlarged/maximallydilatedpupils.

InductionPhase:StageI&IIofG.A.;MaintenancePhase:keepsptinsurgicalanesthesia;RecoveryPhase:beginswhensurgerycompleteandanestheticterminatedandendwhenanestheticeliminatedfrombody.

MostresistantpartofG.A.ismedullaoblongata(CV,vasomotor,resp.center) MostcontrollablerootofGAisinhalation;sedationcanbereversedrapidlywhenusinginhalation. EmergencymostoftenexperiencedduringoutpatientG.A.isrespiratoryobstruction. MinimumAlveolarConcentration(MAC)–alveolarconcentrationofanestheticwhere50%ofpt

unresponsivetosurgicalstimulus. MeyerOvertonTheory–anestheticbeginswhenreachescertainmolarconc.inhydrophobicphase.

SecondGasEffect–potentagentsadministeredwithnitroussoagentsdeliveredinincreasedamtstoalveoliasgasrushestoreplacenitrousabsorbedbypulmonaryblood.

Eyesgreatlyenlargeandnonreactivetolight–circulationtobrainhasstopped! EyestapedshutduringGAtopreventcornealabrasion. Cyanosis/↑Pulse–indicatesoxygenisneededduringGA. DuringG.A.,ptloseslaryngealreflexsoifblood&salivacollectnearthevocalcords,theyclose

(laryngospasm);thisisanadverseeffectofketamine;o Laryngospasm–acutespasmofvocalcordsandepiglottisthatcanresultinairway

occlusionanddeath.o Tx=oxygen&succinylcholine(cholinergic)–askeletalmusclerelaxant.

Stridor(CROWINGSOUNDS)–universalsignforlaryngealobstruction;cerebralbloodpermitsupto2minofconsciousnessandlackofoxygenbutneurologicdamageat3‐5min.

o Invasivetx= 1)Tracheotomy–forlong‐termairway,notERairways.2)Cricothyrotomy–forERairway(lastresort);foranaphylaxis;1stepi,thenoxygen,thencricothyrotomyiflosesconsciousness.

Commonbarbituatesforinductionofanesthesia:• Thiopental=2.5%solution;3‐5mg/kgproduceslossofconsciousnessw/in30secs&recoveryin

5‐10min;½life=6‐12hrs;IVisirritating.• Methohexital(Brevital)=1‐2mg/kgproduceslossofconsciousnessinlessthan20sec&recovery

time4‐5min;½life=3hrs;lesslipidsoluble&lessionizedatphysiologicalpH;o metabolizedinliver&excretedbykidney;causeshiccoughs–mostcommonsideeffect;o MOSTCOMMONDRUGforG.A.anesthesia.

PrimaryadvantageofIVsedationisabilitytotitrateindividualizeddosages. MaintargetofINHALATIONANESTHETICisbrain;Lipophilicmolecules;administrationofanesthetic

precededbyIV/IMbarbituatew/endotrachealintubation;5volatileliquidsthatrequirevaporization&mayirritaterespiratorytract&causemalignanthyperthermiaI;theycause↓inarterialpressure.

1. Enflurane–lesspotentbutrapidonsetwithrisksofseizures;CNSirritanteffect.2. Halothane–powerfulbuttoxininadultliver;sensitizeshearttocatecholamines.3. Isoflurane–combowithIVanesthetics;cancauseheartirregularities.4. Sevoflurane–goodforkids,lessirritatingwithrapidawakening.5. Desflurane–heatingcomponent;irritatingsousedw/IVagentsbutawakenfasterthan

anyotherinhalant;haslowblood:gaspartitioncoefficient,butnotusedtoinduceanesthesia.

Drugstoavoidinptstakingbarbituates:phenothiazines,alcohol,antihistamines,&antihypertensivesb/cthesedrugsenhanceCNSdepressionofbarbituates.

AtIVofbarbituate,lasttissuetobecomesaturatedasaresultofredistributionisFAT(notvascular). Barbituatesoverdosemayoccurb/citseffectivedoseisclosetothelethaldose;barbituatescancause

hyperanagesia(sensitivitytopain). Mosteffectivetxforresp.depressionfromoverdoseofbarbisoxygenunderpositivepressue. BestanesthetictechniqueusedinO.S.toavoidaspirationduringG.A.isendotrachealintubationw/

pharyngealpacks. EffectsSpeedofInductionofinhalationanesthetics: 1)Solubility

2)GasPartialPressure3)VentilationRate4)PulmonaryBloodFlow5)Arteriovenousconc.gradient

MalignantHyperthermia:autosomaldominant,pharmacogeneticdiseaseofskeletalmuscle;nosignstilgivenanesthesia;triggersareinhalationagentsanddepolarizingmusclerelaxants.

o suddenrapidriseoftemp,tachycardia,sweating,cyanosis,increasedCO2,andmusclerigidity;o Tx=Dantrolene–impairscalciumdependentmusclecontraction.

IVSedation‐optimumsiteismediancephalicvein(lateralaspectofant.ofelbow);avoidbrachialarteryb/cwillcauseburning,blotchskin&weakpulse.

o w/21gaugeneedle,usevalium=1ml/min=5mgofvalium(contraindicatedw/glaucoma);o injectiondiscontinuewheneyelidsdroop;Verrill’sSign=50%ptosis;o signssedationworking=blurryvision,slurredspeech,andverrill’ssign.

NeuroleptAnesthesia–andunconsciousnessproducedbycombiningNeuroleptic&Narcotic&NO;TheneurolepticandnarcoticprovideneuroleptanalgesiawhiletheneurolepticandNOprovideanesthesia&unconsciousstate;

o Pt.sedatedbutconsciousandcananswerquestions;inductionofanesthesiaisslowbutconsciousnessreturnsquickly.

o Nitrous&EthyleneareusefulONLYforsedation&analgesia. Post­opHypotensioncauses: 1)anesthesia/analgesiconmyocardium

2)intravascularhypovolemia3)rewarmingvasodilation4)hypothyroidism

o Tx=narcan(narcoticantagonist)oratropine(anticholinergic)ifbradycardia. Post­opHypertensioncauses: 1)post‐oppain/anxiety

2)hypercapnia(toomuchcarbon)orhypoxia(lackofoxygen) 3)overdistentionofbladder ForpsychogenicrxnusefollowingRx1hrb/fappt:

1. Diazepam(Valium):5‐10mgorally2. Pentobarbital(Nembutal):50‐100mgorally3. Secobarbital(Seconal):50‐100mgorally4. Promethazine(Phenergan):25mgorally

DissociativeAnesthesia–methodofpaincontroltodecreaseanxietyandproducetrancelikestatewhichfeelsliketheyareseparatedfromtheirbodybutnotasleep;usefulinchildren.

o Producesamnesiaduringprocedure.o Tx=ketamine–trancelikestatefor10‐30minbutpaincontrol30‐45min;sedativeoften

givenb/fketamintoreduceanxiety;ketamineincreasessaliva,BP,&HR&causesdelerium.

Enteralsedation:useofpharmacoligicalmethodtoproduceaminimallydepressedlevelofconsciousness.

SomatogenRxn:rxnfromorganicpathophysiologiccauses. Phlebitis‐irritation/inflammationofvein;maybecausedbypropyleneglycolinvalium;commonin

smokersandwomentakingBCP;Tx=elevatelimb,moistheat,IVantibiotics(Cefazolin–1g)oranti‐coagulants;S&S:

1. Vesselsfeelhard,thready,orcord‐like2. Extremelysensitivetopressure3. Surroundingareamaybeerythematousandwarmtotouch4. Entirelimbmaybepale,cold,andswollen.

LOCALANESTHESIA: NervelossoffctfromLAaffectsinorderfromfirsttolast:

• PAIN>TEMP(coldthenwarm)>TOUCH>DEEPPRESSURE>PROPRIOCEPTION>SKELETALMUSCLE. Lossofsympatheticfibersoccurfirst;smallerandmyelinatedfibersarethefirsttofailtoconduct. SensoryFibers(pain)–highfiringrateandlongactionpotentialduration.

o ie:AdeltaandCfibers–smalldiameterssoblockedsooner. Motorfibersfireatslowerrateandshorteractionpotential.

o ie:Aalphamotorfibers–toskeletalmusclesoblockedlast. Vasoconstrictorslikeepiactonalphareceptorstoconstrictarterioles;

o ie:cocaine–increasespressoractivityofepi&norepi.

VasoconstrictorinLA:1. limitsuptakeofanestheticintovasculaturessoincreasedurationofLA&decreasesystemic

effects.2. Reducestoxicityb/clessLAisneeded.(DOESN’TREDUCECHANCEOFALLERGICRXN!)3. Reducerateofvascularabsorptionthruvasoconstriction4. HelpmakeLAmoreprofoundbyincreasingconcentrationsofLAatnervemembrane.

Thepresenseofvasoconstrictordoesn’tpreventanintravascularinjection/systemicabsorption. Lidocaine,prilocaine,&etidocaineareforpregnant/lactatingwomen. Novocaine=procaine=esterLA;procainewasprototypeesterLAused. VolatileanestheticsnotconcernforCOPDbutnitrousis;nitrousisnotcontraindicatedforasthma. 1ccof2%lido=20mglido,.01mgepi,6mgNaCl,.5mgNa–metabisulfate(preservativetostabilizes

epi),1mgmethylparaben(preservative),NaOHtostabilizepH. 1.8ccof2%lido=36mglido,.018mgepi,10.8mgNaCL,.9mgNa‐metabisulfate,1.8methyparaben,&

NaOH. AmideLA–biotransformationinliverbut20%excretedunchanged.

o LongestDOA=bupivacaine(marcaine). EsterLA–biotransformationinbloodplasmabypseudocholinesterase.

o Tetracaineiscommonlyused; LA–producesanesthesiabyreversiblybindingto&inactivatingNachannels;stopsdepolarization;

siteofactionofLAislipoproteinsheathofnerves.• SoLAdecreasesmembrane’spermeabilitytoNaanddecreasesmembrane’sexcitabilityand

prolongsrefractoryperiod.• MoreeffectivewhenpH>7;effectivenessdependsonlipidsolubilityb/c90%ofnervecell

membraneislipid;potencyofLAincreasesw/increasedlipidsolubility.• LAinionized(cation)&non‐ionized(base)withnon‐ionizedforblockingNachannels;morenon‐

ionizedformhasfasteronsetofactionwhileionized/acidic,likew/inflammation,causesdelayinonset;pHofLA=7.8

• WheninjectionofLAinsolutionofincreasedpHduetobuffersinbodycausesincreasepercentofnonchargedLAsocanreadilypenetratelipidbarriers;↓pKa=↑pH=↑onsetofaction.

• Maxdoseof2%lidow/1:100kepi=3.2mglido/lb.;1kg=2.2lbs.• Forcarbocainew/oepi,maxdose=3.0mg/lb.• Maxdoseofepiincardiacpt.is0.04mgor.2mgoflevonordefrin.(equals1carpof1:50,000or2

carpsof1:100,000epi). TrismusiscausedbyIAinjectionbelowmandibularforamenintomedialpterygoidmuscle;arises1‐6

daysafterinjection;IAinjectionintotheParotidglandmaycauseBell’sPalsy. BuccinatorpiercedwhengivingIA. IfIAcausestinglingorcompletenumbessoflowerlip,maybeduetotrauma/piercingofnervetrunk

byneedle;moreoftenoccursw/mentalblock;maylast2wks‐6mosbutusuallycompleterecovery. PSA(AKA–tuberosityblock/zygomaticblock)‐blocks1st,2nd,&3rdmolarsbutneedgreaterpalatine

injforpalateandinfiltrationforMBcanalof1stmolar. MSA‐blockmax.PMs&MBof1stmolar. ASA–blocksmax.centrals,laterals,&canines. Longbuccalinj.mustbegiventoextractallmolarsand2ndPM,don’tneedtoforcanineand1stPMif

givingIA&lingualblock. GreaterPalatinenerve–branchofV2thatprofidessofttissueinnervationtotheposterior2/3ofthe

hardpalate;injectb/w2nd&3rdmax.molars,1cmfrompalatalgingivalmargintowardmidline.ANALGESICS: Analgesicsareunder2categories=NSAIDS&Narcotics. Phenothiazines(anti‐psychotic)aredangerouswhenmixedwithsedativedrugs(benzodiazepines/

tranquilizers)b/cphenothiazinescanpotentiatetheiraction.

ChloralHydrate–sedative/hypnoticforpedosedation. Proproxyphen(Darvon)–oralsyntheticopoidanalgesicstructuresimilartomethadone.

o DarvonCompound‐65=aspirin+caffeine+propoxyphene;AKATalwinCompound(noeuphoria).

Acetominophen+Propoxyphen=Darvocent+Wygesic;usedfortxofseverpainindentalprocedures. Analgesicstoavoidw/RENALdisease=aspirin,acetaminophen,NSAIDS,meperidine,morphine. BarbituateTherapeuticFunctions–anesthesia,anticonvulsant,anxiety;Rxinteractionswithbarbs,

CNSdepressors,alcohol,andopoids. Anticholinergics:Tertiary’smorereadilypenetrateCNSthanquaternary.

• Tertiary=atropine(penetratesCNSpoorly&mostcommonforDENTISTRY),scopolamine,benzotropine,dicyclomine,andtrihexyphenidyl.

• Quaternary=glycopyrrolate,ipratropium,probanthine.• Indentistry(oftenatropine),theyDECREASEsaliva,secretionsfromresp.glands(forG.A.),

bradycardia.• theyinterferew/bindingofAchatitsreceptor;

Ptspremedicatedw/ATROPINEwillexhibitmydriasis(dilatedpupils);atropineiscontraindicatedforglaucomaandnursingmothers.

Scopolamine(anticholinergic)–effectiveforpreventingmotionsickness;prolongsamnesia,psychicsedation,anddecreasessalivation;structurallysimilartoacetycholine;mydriasis(dilationofpupils).

o depressesCNSsousedassedativebeforeanesthesiaandadanti‐spasmodic.ANATOMY: LymphNodes:allpasstodeepcervicalLN.

• ParotidLN:lymphfromscalpaboveparotid,ant.wallofexternalauditorymeatus,andlateralpartsofeyelidsandmiddleear.

• SubmandibularLN:lymphfromfrontofscalp,nose,cheek,upper&lowerlip,ant.2/3oftongue,paranasalsinuses,floorofthemouth,max.&mand.teeth&gingiva.

o Paranasalsinuses–seriesofmucousmembranelinedairspacedthatlightenskull&enhancevoiceresonance;withinfrontal,ethmoid,sphenoid,maxillarybones.

• SubmentalLN:lymphfromtipoftongue,floorofmouthbelowtipoftongue,mand.incisors&gingiva,centerpartoflowerlip&skin&chin.

• Lymphdrainage:• SuperficialcervicalLN→DeepCervicalLN→Rt/LtJugularLymphtrunks→thoracicductor

↓→rightlymphaticduct. Lymphadenopathyismostcommonswellingofsubmandibulartriangle. Hardpalateperforatedbyfollowingforamina:

• Incisiveforamen:posteriortomax.incisors;nasopalatinenerves&sphenopalatineartery.• GreaterPalatine:medialto3rdmolar;greaterpalatinenervesandvessels.• LesserPalatine:posteriortogreaterpalatineforamen;lesserpalatinenervesandvessels.

PalatalNerves:o Sensory–suppliedbyCNV‐2‐ Ant.HardPalate=nasopalatinenerve.

Post.HardPalate=greaterpalatinenerveSoftPalate=lesserpalatinenerve.

o Motor–suppliedbymotorrootofCNV–tensorvelipalatinemuscle.‐othermusclesinnervatedbyCNXviapharyngealplexus.

FacialNerves:fromponstransversesfacialcanaloftemporalboneandexitscraniumthrustylomastoidforamen;4COMPONENTS:• BranchialMotor–musclesoffacialexpression,post.digastric,stylohyoid,andstapedius.• VisceralMotor–parasympathetictolacrimal,submandibular,andsublingualglands.• SpecialSensory–tasteonanter.2/3oftongue,palate.• GeneralSensory–generalsensationfromskinofconchaofauricleandsmallareabehindear.

PterygomandibularRaphe–wheresuperiorpharyngealconstrictorandbuccinatorinsert;passesb/wtipofhamulusandinternalsurfaceofmandibleatpointposterior/superiorlimitofmylohyoidridge.

o Lengthofrapheincreasesasmandiblemoves. DeeptendonoftemporalisandsuperiorpharyngealconstrictorformV‐shapedlandmarkforIA. GlossopharyngealNervesuppliesparasympatheticsecretomotorinnervationforPAROTIDGLAND;

• startfromlessersuperficialpetrosalnerveandleavesthruFORAMENOVALEw/V‐3;• thesepreganglionicfiberssynapseatoticganglionandjoinauriculotemporalnerve(V‐3)to

distributetogland. ParotidGland–largestglandandpurelySEROUS(likevonEbner’s);

dividedbystylomandibulartunnelintodeep“toramus”andsuperficial“toramus”lobes;• drainedbySTENSON’sDUCT=whichdrainsoppositemax.2nd

molarandpiercesbuccinatorbutcrossesmasseter.• ArteriesofParotidareexternalcarotid,superficialtemporal,

andmaxillaryarteries.• LymphdrainagetosuperiordeepjugularLNs.• Mumps=viraldiseaseofparotidgland

ExternalCarotidArterysuppliesmostofthehead&neck,exceptbrain(internalcarotid&vertebralarteries);Splitsinto…1. MaxillaryArtery–tomusclesofmastication,allteeth,and

palatal&nasalcavity.2. SuperiorTemporalArtery–suppliesscalp.

IAartery&Palatinearteriesarebranchesofmaxillaryarteries; MandibularteethsuppliedbyIAartery;Maxillaryteeth–post=PSAartery,ant=ASA&MSAarteries. LingualArteryBranches:

a. Suprahyoid–suppliessuprahyoidregion.b. DorsalLingual–suppliesdorsumoftongue.c. Sublingual–suppliesfloorofthemouth&sublingualgland.d. DeepLingual–suppliesanterior2/3rdsoftongue;*terminalartery.

Vertebralarteriesariseformsubclavianarteriesandjoinbasilararterywhichisbloodsupplytobrainstem&circleofwillis.

VenousreturnonbotharchesisPterygoidPlexusofVeins. SubmandibularGlands:locatedinsubmandibular/digastrictriangle;innervatedbyCNVIIwhichruns

inchordatympani&lingualnerve(V3)&synapsesinsubmand.ganglion(sameforsublingualgland).• Submandibular/WHARTON’sDuct–emergesfromanteriorendofdeeppartofglandandpasses

forwardalongsideoftongueandbeneathmucousmembraneoffloorofmouth.• Bloodsupplyfromexternalcarotidarteryandfacialartery.• MIXEDglandwithmucous&serouscells.

SublingualGland–numeroussmallducts(RIVIANDUCTS)thatopenintothefloorofthemouthsecretingmostlyMUCOUSaciniw/serousdemilunes;• smallestsalivaryglandthatcontainsmostlymucous.• Bloodsupplyfromsublingualartery.• consistsmostlyofMucousacinicappedwithserousdemilunes

andisthereforecategorizedasaMIXEDgland.• S‐timessublingualductsjointoformBartholin’sDuctwhich

drainsintosubmandibularducts. VonEbner’sGlands–aroundcircumvallatepapillaoftongueto

washfoodaftertasted;PURELYSEROUS–onlyglandw/parotid.

Genialtubercles(4ofthem)–lingualsurfaceofmandiblemidwayb/wsuperior&inferiorborders;areaofmuscleattachmentforsuprahyoidmuscles,ifremoved,tonguewillendupflaccid,sogenialtuberclesareneverremoved!

CarotidSheath–deeptoSCM,extendsfrombaseofskullto1stribandsternum;itcontains:1. Carotidartery2. Internaljugularvein3. CNX4. DeepcervicalLNs

Facial(3)&Retromandibular(1)VeinInternalJugular(6)+SubclavianbrachiocephalicSuperiorVenaCavaRightAtriumoftheheart.

MylohyoidMuscle–V‐3;inferiortosublingualglandbutsuperiortosubmand.gland;elevates:hyoidbone,baseoftongue,andfloorofmouth;• GetsinwayofdoingPAofmand.molars.• Mylohyoidandgenioglossusdetachedwhenfloorofmouthloweredsurgically.

OlfactoryNerve–senseofsmell OpticNerve–senseofsight OcculomotorNerve–motorsupplytoallmuscles,controllinglenseshape&pupilsizeEXCEPT

superiorobliquemuscle. TrochlearNerve–motorsupplytosuperiorobliquemuscleoftheeye. TrigeminalNerve–largestof12CNs;principalgeneralsensorynervetohead&face.

I. OpthamicDiv(SuperiorObliqueFissure)–sensorytocornea,scalp,eyelids,mucousmembraneofparanasalcavity.

II. MaxillaryDiv(ForamenRotundum)–sensoryforskinovermaxilla,upperteeth&gums,mucousmembraneofnose,max.sinus,&palate.

III. MandibularDiv(ForamenOvale)–innervatesEIGHTmuscles;motorofmusclesofmastication,sensoryfromskinoffaceovermandible,lowerteeth&gums,TMJ,mucousmembraneoffloorofmouthandanterioroftongue.

• V3innervation: o Cheek&Mand.buccalgingiva–longbuccalnerve(sensory)o TMJ,Auricle,&externalauditorymeatus–auriculotemporalnerve(sensory)o Floorofmouth,mandlingualgingiva,ant.2/3rdoftongue–lingualnerve(sensory)o Mand.teeth,skinofchin&lowerlip–IA(sensory&motor)

• 3NucleiofTrigeminalSensoryNuclearComplex:1. MesencephalicNucleus–mediatesproprioception(ie.Musclespindle)2. MainSensoryNucleus–mediatesgeneralsensation.(ie.Touch)3. SpinalNucleus–mediatepain&tempfromhead&neck.

• ProprioceptivefirstorderneuronsoftheTMJareinthemesenphalicnucleusoftrigeminalnerve.• Branchiometricmotorfibersinnervatemusclesofmastication,ant.digastric,mylohyoid,tensor

tympani,tensovelipalatini. Buccinatorfuctionistocompresscheeksagainsthemolarteethforsucking&blowing. InnervationoftheTongue‐ Motor–Hypoglossus(XII)

Sensory–Ant2/3rd‐Taste=chordatympani(VII) ‐Sensation=lingualbranchofV3 ‐Posterior‐Taste&Sensation=GlossopharyngealNerve(IX) AbducensNerve–motorsupplytolateralrectusmuscle. FacialNerve–facialexpression,submand.,sublingual,&lacrimalglands;tasteforant.partof

tongue(viachordatympani),palate,&floorofthemouthandsensoryinputforouterear;• exitscraniumthrustylomastoidforamen.• PassesTHROUGHparotidgland.• Facialnervetraumadestroysabilitytocontractfacialmuslesonaffectedsideoffaceandtaste.

VestibulocochlearNerve‐ 1)vestibulardivision=balanceandheadposition.

2)cochleardivision=senseofhearing GlossopharyngealNerve–motortostylopharyngeusmuscleandPAROTIDsalivarygland;tasteof

post.3rdoftongue;sensory–bpreceptorsofcarotidartery;sensorytotonsile,nasopharynx,&pharynx.

VagusNerve–motortopharynx,larynx,trachea,bronchi,lung,heart,esophagus,stomach,intestines,liver,pancreas,kidneys.

AccessoryNerve–motortoSCM&trapezius,musclesofsoftpalate,pharynx,&larynx. Hypoglossal–motorsupplytomusclescontrollingtongueEXCEPTpalatoglossusmuscle!!

• Injurytohypoglossalnerveproducedparalysisandatrophyonaffectedsidewhichwilldeviatetothatside;Dysarthria(inabilitytoarticulate)mayalsobefound;

• Thisinjuryisduetounopposedactionofgenioglossusmuscle(pullstongueforward);genioglossusmuscleariseslateralandinsertsatmandiblemidline.

• Ifgenioglossusparalyzed,tonguemaycausesuffocation. CN3,7,9,10allhaveparasympatheticactivity. LateralPterygoidInjury–mand.willdeviatetowardsideofinjury;whenankylosisofcondyleor

unilateralcondylefracture.o WilldeviateAWAYfromaffectedsidew/condylarhyperplasiafrommalocclusion.o Tx=closedprocedureinvolvingintermaxillaryfixation.o LateralPterygoids–open,protrude,andmovemandibleside‐to‐side!o ForRIGHTlateralexcursivemvmts–LEFTlateralpterygoidisprimarymover.

BoneofmaxillaMOREPOROUSthanmandiblesocanbeinfiltratedanywhere. MaxillarySinusopensintoHiatusSemilunaris–grooveinmiddlemeatusofnasalcavity&contains

frontalnasalduct&ant.ethmoidaircells.o Developsafterperm.teetheruptedandcontinuesgrowththruadulthood.o InnervatedbyV2–ASA,MSA,PSA&infraorbitalnerve.

Max.Sinusitis–paininmidface,cheek,&painonpercussionofmax.posteriorteeth. EthmoidSinusitis–painb/weyes&nearbridgeofnose. FrontalSinusitis–foreheadpain. SphenoidSinusitis–painbehindeyesorbackofhead. Txforsinusitis:AmpicillinifcauseisURI;PCN&amoxicillinifcausedbyodontogenicfoci. PterygomandibularSpace–b/wmed.Pterygoidmuscle&mand.ramusw/roofoflateralpterygoid

muscle;containsIAnerve&artery&lingualnerve.o Whendrainingabscessofpterygomandibularspaceintraorally,buccinatoroftenincised.

InfratemporalFossa–behindmaxilla;roof–greaterwingofsphenoid;medial–lateralpterygoidplate;limitedbycoronoidprocess&ramusofmandible;• Communicatesw/pterygopalatinefossathrupterygomaxillaryfissure(cleftb/wlateralpterygoid

plate&maxilla).• Communicatesw/orbitthruinferiororbitalfissure(b/wmaxilla&greatersphenoidwing).

containssomemusclesofmastication,max.artery,pterygoidvenusplexus,mand.nerve,oticganglion,&chordatympani.

Pterygopalatinefossa–smallspacebehind&beloworbitalcavity;maxillarynerve&arterypassthruit.

SubmandibularSpace–drainsinfectionfrommand.PMsandmolarb/cbelowmylohyoidmuscle.o Boundant.&medialbytongue.o Boundlaterallybydeepcervicalfasciao Boundinferiorlybyhyoidboneo Splitintosublingual(superior)&submaxillary(inferior)spacebymylohyoidmuscle;

medialpartofsubmaxillaryspace=submentalspace.o Submentalspacedrainsmedianoflowerlip,tipoftongue,andmouthoffloor;drains

infectionsofmand.incisors&caniniesb/capiceslieABOVEthemylohyoidmuscle.

MasticatorySpace=massetericspace,pterygomandibularspace,andtemporalspace;infectionsofthisspaceusuallydentalorigin(esp.mandibularmolarregion);needletractinfectionfromIAenterpterygomandibularspace.• S&Sofmasticatorspaceinfection–TRISMUS,pain,andswelling;signspeak3‐7daysw/

spontaneousintraoraldrainageon4th&8thday. Ludwig’sangina–mostcommonneckspaceinfection(sublingual,submental,&submandibular). Lymphadenopathyismostcommoncauseofswellingofthesubmandibulartriangletissues. CavernusSinusThrombosis–bloodclotw/incavernussinuswhichisalargechannelofvenusblood

andcontainsCNIII,IV,V1,V2,&VI;causedbyStaphAureusinfection.• Infectionsofthefacecancausesepticthrombosis(ofteninopthalmicveinb/cnovalves)of

cavernoussinus;furunculosis&infectedhairfolliclesarefrequentcauses.• TEofmax.anteriorteethw/infectioncancausethis;life‐threatening!• Pts.presentsw/proptosis,orbitalswelling,neurologicsigns,andfever.

TMJ: TMJnothyalinecartilage,justdenseFIBROUS

CONNECTIVETISSUE; TMJ:hasginglymoarthrodialjointmeaningithashinge‐

likerotationandglidingmvmts;4components:1. MandibularCondyle–functionalpartissuperior&

anteriorheadofcondyleandcoveredwithfibrousconnectivetissue;surfacecoveredw/vascularlayeroffibrousC.T.;longaxisorientedmediolaterally.

2. ArticularFossa–anterior3/4thoflargermandibularfossa;non­functionalpartofjoint;boundedinfrontbyarticulareminence&behindbytemporalbone;concave!

3. ArticularEminence–ridgeextendsmediolaterallyinfrontofmand.fossa;functionalpartofjoint;linedw/thickfibrousC.T.;convex!

4. ArticularDisc/Meniscus–biconcave,fibrocartilaginousdiscb/wcondyle&mand.fossa;glidingsurfaceofcondyleandcentralpointisavascularandNOnerves(onlyperiphery).

Articulardiscvariesinthickness;has2thickerbandthancentralbands:• Posteriorband–thickestbandandattachedtoretrodiscaltissue;RetrodiscalTissue(bilaminar

zone)–posteriorlooseconnectivetissue;highlyvascularized&innervated.• Anteriorband–contiguousw/capsularligament,condyle,&superiorbellyoflateralpteryogoid

muscle. Posterioraspectofcondyleisroundandconvexwhileanteriorinferioraspectisconcave. CondylesareNOTsymmetrical/identical; Palpateexternalposteriorsurfacew/mouthopenwhenexamining. Condyleheldinplacebycollateral/discalligaments(restrictsmvmtsofdiscawayfromcondyleduring

function)atmedialandlateralpolesofcondyle.• Heldinpositionanteriorlybylateralpterygoidmuscle.• Whencollateralligamentsbecometorn,condyledisplacedanteriomediallycausingclicking

sound&discdisplacement. ArteriestoTMJ: 1)superiortemporalartery

2)max.artery&externalcarotidartery3)smallermasseteric4)posteriordeeptemporal5)lateralpterygoidarteriesanteriorly

Venousdrainagethrudiffuseplexusaroundcapsule. FibrouscapsuleofTMJ–innervationAuricularTemporalNerve(V3) AnteriorregionofTMJ–massetericnerve(V3)andposteriordeeptemporalnerve(V3)

SENSORYinnervationofTMJ–trigeminalnerve;AnteriorTMJsuppliedbyMassetericnerve,PosteriorTMJsuppliedbyAuriculotemporalnerve;NOmotorinnervation.

TMJLigaments:1. TemporomandibularLigament(lateralligament)–

provideslateralreinforcement&preventsinferior&posteriordisplacementofcondyle;*mainstabilizingligamentandonlyligamentprovidesDIRECTsupport.

a. Fromarticulareminencetocondyle.b. Keepscondyleheadinplaceiffractured.

2. SphenomandibularLigament–attachestolingulaofmandible;mostoftendamagedinIAblock;limitsmvmt.

a. IAnervepasseslateraltothisligament.3. StylomandibularLigament–attachestoangleofmand

andstyloidbone. 3groupsresponsibleforDisplacingCondyle:

1) Masseter,med.Pterygoid&temporalis‐ELEVATEMANDIBLEsoupward&medialdisplacement.2) Digastric,mylohyoid,geniohyoid,andlateralpterygoid–DEPRESSMANDIBLEsoinferior&

posteriordisplacement.3) LateralPterygoid–forward&medialdisplacement;however,rightlateralpterygoidcantcontract

duringprotrusion. Crepidationfromdegenerationofcondyle(maybeosteoporosis). Dullthud–self‐reducingsubluxationofcondyle. Preauricular–bestsurgicalapproachtoexposingTMJ. SubmandibularApproach(RisdonApproach)–surgicalapproachforramusofmandibleandneckof

condyle. TraumaiscommoncauseofTMJankylosisbutankylosisismostcommoncomplicationofRheumatoid

Arthritis. DisordersofTMJ:

1. MyofascialPainDysfunction:maincauseofTMJpain;unilateraldullpainthatincreaseswithmuscularspasm;masticatorymusclespasmandlimitedjawopening;

a. Complaints:referredpain,headache,otalgia(earpain),tinnitus,burningtongue.b. Oftenduetostress;Tx=nightguard.

2. InternalDerangement:whendiscpulledanteriorlybysuperiorheadoflateralpterygoidmuscle;a. Withreduction–discanterioratrestbutreturnswhenopeningandclosing;painand

clickingmayoccur;1/3ofpopulation;normalopeningor“S”shaped.b. w/oreduction–discalwaysanterior,nosoundbutmaxopening<30mm.c. Subluxation/dislocation/openlock–ptcantcloseafterkeepopenforalongtimedueto

posteriorbandstretchingandjointtravelinginfrontofeminence;d. Tx=conservativefor4‐6wksandtheconsidersurgery;95%improvew/osurgery.e. Thereisntareproduciblereciprocalclick;mostdiscdisplacementsareANTERIOR&

MEDIAL.3. DegenerativeJointDisease(osteoarthritis):1o/2otrauma;oldpplb/cofwearandtear;

asymptomaticunlessitisinyoungpplwhereitismoresevere;BIOPSY: Aftertissueremoveforbiopsy,placein10%formalin(4%formaldehyde)that’s20xthevolumeofthe

tissue. Biopsies: Incisional–takeonlypartoflesion.

Excisional–entirelesionremoved.Needle–aspirationalbiopsyExfoliativeCytology–papsmear

Alloralulcerscausedbytraumawillhealin2wkssobiopsyneedediflongerthan2weeks; alsobiopsy:pigmentedlesions,tissueassociatedw/paresthesia,&whenalesionenlarges,

hyperkeratoticchangesinlesion,ifdoesn’tresponsdtoantibioticsfor14days,orpersistentswelling. Alwaysaspirateacentralbonelesiontoruleoutvascularlesion. Stethoscopeisusedtolistenforbruit(unusualsoundthatbloodmakeswhenitrushespastan

obstruction(calledturbulentflow)inanartery). Allleukoplakiasshouldbebiopsiedbecausetheyarepremalignant. Blockpreferredforanesthesiaratheraninfiltrationforbiopsy;anesthesia>1cmawayfromlesion. Getsomenormaltissueaswellasdiseasedforbiopsy.IMPLANTS: Bone­ImplantIntegration:

1. Fibrous‐OsseousIntegration:connectivetissueencapsulatedimplantw/inbone;successrate50%over10yrs;notseeoftenw/newermaterials.

2. Osseousintegration:directconnectionb/wlivingbone&implant(w/osofttissue);ONLYendosseous&transosseousimplant;mostpredictablelongtermstability;usesradiographic&lightmicroscopicanalysis;

3. Biointegration:implantinterfacew/bioactivematerials(hydroxyapetite)orbioglassthatbondsdirectlytobone;developbonefasterthannon‐coatedbutcanttellafter1year.

BesttimetoaugmentsofttissuetodevelopkeratinizedtissuearoundimplantisstageIIsurgery. GuidedTissueRegeneration:surgicallyeliminatedbonydefectaroundimplanttodecreaseC.T.

growthwhileincreasingbone;don’theatbone>116oF/47oC. Forsuccessfulimplant:

1. needadequatetransferofforceandbiocompatibility.2. Histologically35‐90%bonecontact,C.T.adhesionabovebone,andnon‐inflamedJE.

Forimplant,uselowspeedandhightorquehandpieces;usesuperfloss/yarn. Need10mmboneheighttoplaceendosseous/rootformimplant;need2mmb/wapexofmand.post.

implant&IAcanal;implantsplaced3mmapartand1mmapartawayfromadjacenttooth; Titanium/Titaniumalloyaremostcommonfor2‐stageendosseousimplants; Smokingaffectshealingofbone&tissuesoNOIMPLANTS! Pt.w/uncontrolledsystemicdisease–useextremecautionw/implantplacement. Max.ant.implants–highestfailurerate; Mobilityismostcommonsignofimplantfailure. Max.amountoftaperfordrawofoverdenture=15o. 2typesofImplantPlacement:

1. Submerged–2stagesurgicalproceduretouncoverfixture.2. Nonsubmerged–only1stage.

3CategoriesofImplants:1. EndosseousImplants–surgicallyinsertedintojawbone;mostusedimplant;2forms:

a. Root‐formedimplants–cylindricalshape,titanium;3phases–surgical,healing,&prosthetic.i. Mostpopular!80%ofallimplantsareENDOSSEOUS(intobone).

b. BladeImplants–flatterinappearanceforinsufficientbonewidthbutadequatedepth;titanium;eithersingle/2stage;

2. SubperiostealImplants–ridesonbone;fitsontopsupportingstructuresundermucoperiosteum.3. TransosseousImplants–insertedintojawbonebutpenetratesentirejawandemergesat

oppositeentrysite(usuallychin);indications:veryatrophicmandible.EXTRACTIONS: Maxillary3rdoccasionallydisplacedto: 1)Max.Sinus–usecaldwell‐lucapproachtoremove.

2)Infratemporalspace–mayneedoralsurgeon. Ifroottip2‐3mmorlessgetsintomax.sinusthenNOtxneeded.

Palatalrootofmax.1stmolarmostoftendislodgedintomax.sinus. Caldwell‐LucApproach–openingmadeintomax.sinusbyincisionintocaninefossaabovePMroots;

figure8sutures,antibiotics,nasalspray&decongestant. Mostfrequentlyimpactedteetharemandibular3rds,themax.3rds,thenMAXcanines. Roottipofmand.3rdmolardisappearsintosubmandibularspace. IAnerveoftenliesbuccaltorootsofmand.thirds; bonerarelyremovedfromlingualaspectofmandibleb/clikeihoodofdamaginglingualnerve. Whenremovingmylohyoidridge,becarefultoprotectlingualnerve. Mostcommoncausesofparesthesiatolowerlipisremovalofmand.3rdmolars. Extractmaxb/fmandandpostb/fant. Afterremovingmax.teeth,upperjawshouldbeatsameheightasdentist’sshoulders. Mandibulararchparalleltofloorwhendoingmand.extractions. ContraindicationsforExtractions: ‐acuteinfectionw/uncontrolledcellulitis

‐acutepericoronitisorstomatitisorANUG‐malignantdiseaseorirradiatedjaws.

DirectionofluxatingprimaryMax.molars–palatal;perm.maxmolars–buccal. IfpermPMwedgedb/wbell‐shapedrootsofprimarytooth–section&remove. DoNOTusecowhornsonmand.primarymolars. DeadSpace:woundinareathatremainsdevoidoftissueafterwoundclosure;usuallyfillw/blood

causinghematoma&highpotentialforinfection;• Tx=resolvesonitsownoropenanddrain.• Eliminateby:closewoundinlayers,applypressure,usedrainstoremovebleeding,placepacking

intovoidtilbleedingstops. Fractureofmaxillarytuberositymostcommonresultfromextractionoferuptedmax.3rdmolar;if

tuberosityfracturebutintact,repositionandsuture;• ***bewareoflonemolar–oftenankylosed&emitsatypical,sharpsoundonpercussion.

Whenremovingmand.tori–useenvelopeflapdesignw/noverticalcomponent. MaxillaryTorioftenseenb/fage30&moreinfemales;removalofmax.palataltori:

o Stentfabricated;UsedoubleY‐incisiono Useosteotometoremovesmallportionso Usebur/bonefiletosmoothareao Irrigate&looselyplacesutures&usestenttopreventhematoma&supportflap.o Mostoftenlocatedatmidlineofhardpalate.

ClassificationsofImpactions:w/difficultofremovalfromeasytohardw/MAND3rds:o Mesioangular(43%)o Horizontal(3%)o Vertical(38%)o Distoangular(6%)

• OPPOSITEformax.molars!!!Distoangulariseasiest!• Mostmand.3rdsangledinlingualdirection.

IfsinuscommunicationafterTE–noadd’lsurgicaltx…• Post‐op: avoidnoseblowingfor7days.

OpenmouthwhensneezingAvoidvigorousrinsingSoftdietfor3dys.

• Meds:1)Afrin(localdecongestant),2)antibiotics(amoxicillin),3)actifed(systemicdecongestant) Ifsinusopeningmoderate(2‐6mm),placefigure8sutureoversocket. Ifsinusopeninglarger(>7mm),closesocketw/flapprocedure. ClassIIleverusedfortoothextractions. Luxation–looseningoftoothbyprogressiveseveringofPDL;luxationforcesperpendiculartolong

axisoftooth;canuserotationalforcesonsinglerottedteeth.

o Mvmtsfirmandprimarilytothefacialw/secondarymvmtstothelingual. Teethresistanttocrushbutnotresistanttoshearsobeaksappliedtolineparallelw/longaccessof

tooth. Idealtimetoremoveimpacted3rds–whenroots2/3rdsformedb/cbonemoreflexibleandnoroot

curves&rarelyfracture;aroundage17‐21yrs.old. Olderindividualhavemostpostoperativedifficulties. BiteonteabagifbleedingpersistsafterTE;thetannicacidpromoteshemostasis. Autotransplantingteeth–often3rdmolarreplacingcariousmand.1stmolar;

o Mostimportantcriteriaisadequatebonesupportinrecipientsign.o Bestresultifdonortooth’srootsare1/3to2/3completedrootdevelopment.o Mostlikelycauseoffailureischronic,progressiveexternalrootresorption.o Universalsequelaeofallogenictoothtransplantisankylosis&rootresorption.

Periocoronitis–causesfooddebris&bacterialwasteproductsandtissueoftentraumatizedduringmastication;max3rdsmostfrequentcontributingfactortopericoronitisofmand.3rds.• S&S–pain,badtaste,inflammation,pus;canbearecurrentconditionandanabscesscanform

unlesscauseisremoved.• Definitecriteriaforremoving3rdmolars;Tx=irrigatearea,placeonantibioticsandrinsewith

warmsalinesolutionsandoncesymptomsrelieved,thenextract. Post‐opEcchymosis–traumatounderlyingbloodvessels>1cm;commonafterTE’sinelderlyptsb/c

fragilevesselwalls;pt.complainsofdiffuse,non‐painful,yellowingdiscolorationofskin;mayfirstpresentasbluishlesion;morepredisposedinptsw/clotting&bleedingdisorders;tx=heat.

AnabscessshouldNOTbecontraindicatedtoaTEb/cinfectionsresolvequicklyaftertoothisremoved.

Conditionsthatrequireprophylaxispriortooralsurgery:(NOTpacemakers)1. Prostheticheartvalve2. RheumaticValvedisease3. Mostcongenitalheartmalformations.

INCISIONS&SUTURES: Advantagesofinterruptedsuture:mostcommon,independent,strength,&flexibility;ifonesuturesis

loose,theotheronesstayput;disadv:time. Advantagesofcontinuoussuture:easeandspeedofplacement,distributionoftensionoverwhole

suture;morewatertightclosure. SuturesshouldNOTbeclosedundertensionandshouldbe2‐3mmapart;sutureplacedfrommobile

tissueintofixedtissueandfromthinintothicktissue. Suturesizebasedonstrength&diameter;asdiameterdecreased,the0saddedornumbersfollowed

by0s=000=3‐0‐‐‐‐samesize;9‐0hasleaststrengthandsmallestdiameter. B/csuturesareforeignbody,smallestdiametersuturesufficient;mostOSuse3‐0or4‐0sutures. Resorbablesuturesevokeintenseinflammatoryrxn;notforskinwounds;recommendnon‐

resorbableforTEsitesandremovein5‐7dys. Monofilamentsuturesconsistofmaterialfromsinglestrandandresistinfections;RESORBABLE:

• Plaingut–sheepintestine,susceptabletorapiddigestionbutretainedfor5­7days;mostseveretissuerxnsw/thissuturematerial.

• Chromicgut–chromatizedtobemoreresistanttodigestionandretainedfor9­14days;moderatetissuerxn.

• PolyglycolicAcid–doesn’tenzymebreakdown,undergoesslowhydrolysis,lessstiffbutmoreexpensive.;minimaltissuerxn.

Polyfilamentsutures–multiplefiberseitherbraidedortwisted;NON‐RESORBABLE:o Silk–braided,black,inexpensive,goodhandlingbutseveretissuerxn.o Nylon–strong,notusedorallybutissuturematerialofchoiceforfaciallacerations.o Polypropylene–leasttendencyforinflammationbutfairhandling.

o Non‐resorbablesuturesshouldberemovedin5­7days. Verticalreleasingincisionmadeattoothlineangle. 3typesofincisions: 1)linear–straightlineincisionforapicoectomies.

2)releasing–addingverticallegtohorizontalincision;forTE&augmentations;incisionalongtoothlineangle.3)semi‐lunar–curvedincisionforapicoectomies.

#15scalpaluniversallyusedforOSprocedures. SuturesoversingleextractionsocketareNOTusuallyplacedunlesspapillaehavebeenexcised,

bleedingfromgingiva,orgingivalcufftorn/lose; Mostcommoncauseofpostextractionbleedingisfailureofpatienttofollowpost‐extraction

instructions. Osteoradionecrosis‐Mostseriouscomplicationafterextractionsfromareaspreviouslyirradaited;

conditionofnon‐vitalbonethatcanresultintissueinjury;HEALING: 5stagesofhealing–(sameassofttissue–inflammation→fibroplasia→remodeling)

1. Clotformation2. Granulationtissue(canberetardedbyGlucocorticoids)3. Connectivetissue4. Fibrillarbone5. Bonerecontouring.

StagesofWoundHealing:1. InflammatoryStage(vascular&cellularphase)–neutrophils&lymphocytespredominatew/

macrophages(mostimportantinflammatorycellforwoundhealing).2. ProliferativeStage(fibroblasticstage)–collagen&newbloodvesselsproduced;mediatedby

fibroblasts.3. MaturationStage(remodelingstage)–collagenfiberscontinuetoincreasetensilestrength.

Bonehealsbyprimaryandsecondaryintentionlikesofttissue:1. PrimaryIntention–endosteal(inbone)&periosteal(w/inconnectivetissuecoveringbone)

proliferation;occurswhenincompletefractureorreapproximatingfractureendsofbone;littlefibroustissuew/minimalcallousformation.(Ie–wellrepairedreducedbonefractures)a) Minimalre‐epithelizationandcollagenformation;allowswoundtobesealedw/in24hrs.

2. SecondaryIntention–endostealproliferation;usedwhenfracturebones>1mmapart;lotsoffibroustissue&callusisformed(whichossifies).(Ie–TEsockets,poorlyreducedfractures)b) Re‐epithelizationviamigrationfromwoundedges;sitefillw/granulationtissue;slower

healing; Bonehealingin3overlappingphases:

1. Hemorrhage–first10days.2. Callusformation–10‐20daysprimarycallous;20‐60dayssecondarycallous.3. FunctionalReconstruction–2‐3yearstocompletelyreformafracture.

3PhasesofHemostasis:1. Vascular–vasoconstriction,beginsimmediatelyafterinjury.2. Platelet–plateletsandvesselsbecomesticky;mechanicalplugofplateletssealoffcutvessels;

secondsafterinjury.3. Coagulation–bloodlossinsurroundingareascoagulatethruextrinsicandcommonpathways

whilevesselsinareaofinjuryuseintrinsicandcommonpathways;slowerthanotherpathways. 5waystoobtainhemostasis–hemostatonvessel,heatcutvessels,sutureligationofvessel,

pressuredressing,vasocontrictivesubstanceslikeepi. DrySocket–increasedfibrinolyticactivitycausingincreasedlysisofbloodclot;most

commonlyfollowingTEofmand.molars;causes:smoking,mouthrinses,hotliquids,trauma,oralcontraceptives.

• Symptoms–ptsdevelopssevere,dullthrobbingpain2‐4daysafterTE;foulodorandtasteandextractionsitefilledw/necrotictissuewhichdelayswoundhealing.

• Tx= ‐flushw/warmsalinebutnocurrettage.‐Placeeugenolsedativedressing&replaceevery48hrstilasymptomatic.‐AnalgesicsbutNOantibioticsneeded.

3%hydrogenperoxideagentfordebridementofintraoralwounds. Orderoftxforacuteinfection=localizeinfection,IND,thenculture;ifinfectionproduces

cellulitisofregioninvolved,calledinduration(appearshard,dense,andbrawny). Incision&Drainage–onlyperformedforacuteinfectioniflocalizationofinfectionhas

occurred.o CultureafterInDifantibioticsisnotsufficienttoresolveabscess.

FRACTURES: mostcommoncauseforfacialfractures=autoaccidents(80%);highestincidenceoffracturesin

youngmalesages15‐24. Fracturetypeprevalence: ‐Zygomaticomaxillarycomplex(40%)–tripodfracture

‐LefortFractureI(15%),II(10%),III(10%).‐Zygomaticarch(10%)‐Maxillaalveolarprocess(5%),SmashFractures(5%)

Controlofairwayisvitaltoanytreatofptw/facialfractures. 4reasonfracturedoesn’theal:

1. Ischemia–poorlyvascularizedsoischemicnecrosisafterfracture.2. Excessivemobility–healingprevented&pseudoarthritisorpseudojointoccurs.3. Interposition–ofsofttissueandoccurb/wfracturedends4. Infection–compoundfractureshavetendencytobecomeinfected.

Fatembolismoftensequelaoffractures. Inappropriatehealing:delayedhealing(>6wks),non‐union,mal‐union. Mandiblemustbeimmobilizedfor3‐6wksforfractures:(4forms)

1. BartonBandage–simplestform;used1staidmeasuretildefinitivetherapy.2. IntermaxillaryFixation–useprefabricatedarchbarsandwireteethtogether;classwayto

mobilizefractureafterclosedreduction;mostcommontechniqueforIMFistouseprefabricatedarchbars.

3. ExternalSkeletalFixation–ifIMFnotsatisfactory,usescrews,pins,andusecoldcureacrylicbartoholdscrewsinplace.

4. DirectIntraosseousWiring–combingw/IMFandtraditionallyusedafteropenreduction. Closedreductionsoftenforcondylarneckfractures;oftenusedwhenbothfragmentshaveteeth; Zygomaticarchfractures–bestseenbysubmentalvertexview;maycausedamagetosuperior

orbitalfissure;complications:parasthesia,hematomaofsinus,&impairedoccularmusclebalance. Zygomaticcomplexfracturesaremostcommonmidfacefracturebut2ndmostcommonfacialfracture

behindnasalbonefractures. InfraorbitalRimFractures:presentsw/numbnessofupperlip,cheek,andnose.

o Water’sviewbesttoevaluateorbitalrimareas. S&SofMand.Fracture: malocclusion,lowerlipnumbness,mobility,pain,bleedingatfracture. Openreduction–directexposureandreductionoffracturethrusurgicalincision;

• Procedure:openreductionthendirectintraosseouswiringwithIMFfor3‐6wks.• Mostcommonsiteisangleofmandible;Performedfordisplacedangleorbodyfractures.• Bestusedtoreduceafracturewhenteetharemissinginoneormoreofthefracturedsegments.

Fractureofangleofedentulousmandibleoftendisplacedanteriorlyandsuperiorly.

LeFortFractures:fromseverefrontalblows;associatedw/intracranialdamage,CSFleak;types:

I. Horizontalfracturethrumaxillajustabovemax.teeth;causingopenbite!II. Fracturewhichmaxillaseparatedfromfacialskeletonw/separatedbonebeingpyramidalin

shapeandincludespalateandmax.teeth;S&S‐edema,ecchymosis,hemorrhage,andnosebleeding.

III. Horizontalfracturewhereentiremaxillaand1/morefacialboneseparatedfromupperface;pts.haverestrictedmand.mvmt.

Blowstomaxillacausemaxillatobedrivenbackwardanddownwards;maycauseopenbiteorimpingementofairway.

Location&extentoffracturebasedondirection&intensityofblow&pointsofweaknessinmand.

Commonsitesforfractures: Body‐30‐40%Angle‐25‐31%Condyle–15‐17%Symphysis–7‐15%Ramus–3‐9%Coronoid–1‐2%

Bilateraldislocatedfracturesofcondylarneckscauseanterioropenbiteandcantprotrudemandible.

Unilateralfracturethruneckofcondylecausedforwarddisplacementofheadofcondyle. MandibularFractures:

1. Simple–dividesbonein2partsw/noexternalcommunication;it’saclosedfracturew/nolacerationofmucosa/facialtissue.

2. Compound–openfracturethatcommunicatesw/outsideenv’t;mayhavelacerationsoforaltissue;infectionsarecommon.

3. Communited–multiplefractureofsinglebone;maybesingle/compound.

4. Greenstick–fractureonlythrucorticolportionofbonew/ocompletefractureofbone;closedfracture;ofteninchildrenw/orbitalandfrontalfracturescommon.

Mostcommoncomplicationoffractureisinfection. Mostcommonsignofmand.fracture=malocclusion. Firststeptotreatmid‐facialfracturesistore‐

establishaproperocclusalrelationship. Lineoffracturedetermineswhethermusclewillbe

abletodisplacethefracturesegmentsfromoriginalposition: • favorablefracture–iffracturelinepreventsfracturedisplacementbymusclepull.• unfavorablefracture–iffracturelineresultsinmusclepulldisplacingfracture.

Maxillaryfractureshaveagreatertendencytoproducefacialdeformitiesthanmandibularfractures.GRAFTS: Idealgraftisreplacedbyhostboneandassistsosteogenicprocessesofthehost. 3formsofgrafts:

1. CorticalGrafts–withstandearlymechanicalforcesbutrequiremorerevascularizing.2. CancellousGrafts–increasehealingrate;mostabundantsupplyfromiliaccrest;disadv–inability

toprovidemechanicalstability.3. CorticocancellousGrafts–providesmechanicalstabilityandincreaseosteogenesisbutnotaswell

ascancellousgraftsb/clayerofnonporouscorticolbone. Iliaccrestprovidesbonemarrowforgraftingmandibleandmaxillaandridgeaugmentation. CostochondralribgraftforcartilaginouspartsimulatingTMJ&condyle.

Forfixatingbonegrafts–boneplates,biphasicpins,titaniummesh,andintraosseuswire. Greatestosteogenicpotentialoccurw/autogenouscancellousgraftandhemopoieticmarrow. ClassesofGrafts:

1. AutogenousGraft–tissuefromsameindividual;commoninOSbutfrequentlypresentsurgical/technicalproblems;

i. Mandibleismostcommonlyresectedforoncologicalsurgeryofallfacialbones.2. AllogenicGrafts–tissuefromindividualofsamespeciesbutnotgeneticallyrelated;oftenhuman

cadaverbone;3forms:i. Freshfrozen–rarelyusedb/ctransmissionofdisease.ii. Freeze­dried–osteoconductivebutnoosteogenicorosteoinductivecapabilities;usedin

conjuctionw/autogenousgrafts.iii. DemineralizedFreeze­dried–lackstrengthbuthasosteoconductiveandosteoinductive

capabilities;exposedbonemorphogenicproteins.3. XenogenicGrafts–tissuesfromdonorofanotherspecies.(bothxenogenicandallogenicgraftsare

mostcommongraftsforrejection).4. IsogenicGrafts–tissuefromsamespeciesandgeneticallyrelatedtorecipient.5. AlloplasticGraft–synthetic,inert,man‐madesyntheticmaterials;

i. oftenhydroxyapatiteisusedtoaugmentthemandible;granular/particleisused;itisbiocompatible&non‐resorbable;hydroxyapatitebondsphysicallyandchemicallytobone;

ii. Maycausechinprominenceerosionandunpleasantcoldsensationinimplantregion. 3processedbonerepairs/regenerates:

1. osteogenesis–abilitytoformnewboneingraftbytransplantingviableosteoblasts.2. osteoconduction–abilityofgrafttoallowvascularandcellularinvasionbyhost.3. osteoinduction–abilityofgrafttostimulatedifferentiationofmesenchymalcellsinto

osteoblastsatrecipientsite. SlidingGenioplasty–surgicallyimprovingaperson’schin;horizontalslidingosteotomy;

removinghorseshoeshapedpieceofchinboneandslidingeitherforward/backwardsandfixingitwithscrews.a. Problemswithalloplasticmaterialsforgenioplasty:migration,erosion,&coldsensation.

High‐speedhandpiecescancausetissueemphysemaorairemboluswhenremovingboneduringO.S.;thetissueemphysemacanbecausedbyairpressuresyringesoratomizingspraybottles.

Mainreasontousewaterirrigationwhencuttingboneisb/cheatgeneratedbydrillaffectsbonevitalityanddon’twanttoburnbone.Duh.

Marsupialization,decompression,andPartschoperationrefertocreatingasurgicalwindowinwallofcystwhichisuncoveredorderoofedandemptied.• Marsupializationistxforranulawhencystislargeandclosetovitalstructures;ifrecurrentranula

alsoexcisesublingualgland;cystliningmadecontinuouswithoralcavity. Enucleation–totalremovalofcystandpreferredtxofcysts;txfor

congenital&odontogeniccysts&mucoceles. Operculectomy–removalofoperculum–flapoftissueover

unerupted/partiallyeruptedtooth. Frenumprovidessupportorrestrictsmvmt;3FrenectomyTechniques:

1. Diamondexcision&2.Z‐Plasty–botheffectivewhenmucosal&fibroustissueisnarrow;thesetechniquesrelaxthepullofthefrenum.

3.V‐Yadvancement–preferredwhenfrenalattachmenthaswidebase;lessscarringandgoodforlengtheningtissue.

MandibularRamusSagittalSplitOsteotomy–commonperformedmand.orthognathicprocedure;usedtoeitheradvanceorsetbackthemand.;

o positionofcondyleUNCHANGED;o forcorrectingClass2malocclusion.

VerticalRamusOsteotomy–tosetmand.posteriorlyforprognathism. VerticalBodyOsteotomy–TEmand.teeth(PMs)bilaterallyandsetmand.back.;correctsclass3

malocclusion. LeFortIOsteotomy–mostcommontofixmax.retrognathia. StepOsteotomy–formand.prognathism,retrognathism,asymmetry,andapertognathia;3

independentpieces.

ORTHODONTICSOCCLUSION: ClassI–MBcuspofmax.1stmolarlinesupw/BUCCALGROOVEofmand.1st

molar;Orthognathicprofile;70%ofpopulation;→ MostprevalentcharacteristicofClassImalocclusionisCROWDING;→ Ifcrowding<4mm–stripsomeenameloffinterproximalsofmand.teeth.→ Ifcrowding>4mm–extraction;

ClassII–MBcuspofmax1stmolarb/wMand.2ndPM&1stMolar;max.caninemesialtomand.canine;retrognathicprofile(overbite);25%ofpopulation;convexprofile;

→ Div1–ALLmax.incisorsprotrudedinextremelabioverision&mand.incisorstippedforward;

→ Div2–Max.centralstipedpalatally&inretrudedposition(linguoversion)butLateralincisorstippedlabially&mesially(labioversion);ifthisonlyoccursunilaterally=SUBDIVISION;

ClassIII–MBcuspb/wmand1stmolar&2ndmolar;max.caninedistaltomand.canine;prognathicprofile(underbite);max.incisorstippedlingually.

→ “f”or“v”soundsaffectedbyClassIIImalocclusion; Pseudo‐ClassIIIMalocclusion–mandibularincisorsforwardinrelationto

maxillaryincisorswheninC.O.butcanmovemandiblebackw/outstrain.→ Mostinstancesedgetoedge;tx=eliminationofCO‐CRdiscrepancy.

SundayBite–forwardposturalpositionofmandiblewhichisadoptedbypeoplew/peoplew/ClassIIprofilesinordertoimproveesthetics;

PhysiologicalOcclusion–maynotbeidealocclusionbutitsanocclusionthatadaptstostressoffunction&canbemaintained.

PathologicalOcclusion–cantfunctionw/outcontributingtoowndestruction;maycause:1. Excessivetoothwear2. TMJproblems3. Pulpalchanges4. Periodontalchanges

BimaxillaryDentoalveolarProtrusion–inbothjawstheteethprotrude;Signsare1. Separationoflipsatrest2. Severelipstrain3. Prominenceoflipsinprofileview

Commondentalconditionthatcanbenefitfromorthotxpriortoprosthetictxislong‐termlossofmand.1stmolar;bettertotip2ndmolardistalthanmovemesial.

Onachild,ifpermanent1stmolarextracted,bestapproachistoallow2ndmolartomesialdriftintothatarea;

PRIMARY&MIXEDDENTITION: MixedDentitionAnalysis(TransitionalAnalysis)–determinesspaceavailablevsspacerequired;

basedontoothsize;Procedure:1. MeasureMDofmand.incisors&addtogether2. Measurespaceavailable3. Subtract#1from#2;anegativenumberindicatescrowding;4. Measurethespaceavailableforthecanine&premolarsoneachsideofthearch5. Calculatefromthepredictiontablethesizeofthecanine&premolars.6. Subtract#6from#5oneachside;negativenumberindicatescrowding.7. Thenaddthese3numberstogether(#fromincisorcrowding/space,#ofrightcanine&PM

crowding/space,#ofleftcanine&PMcrowding/space);(‐)=crowding,(+)=space!

Moyer’sMixedDentitionAnalysis–predictssizeofuneruptedcanines&PMsbylookingatMAND.INCISORSthathavealreadyerupted;theincisorsdeterminebothmand&maxposteriorteeth.

→ PredictstheamountofcrowdingAFTERthepermanentteetherupt.→ BothMAX&MANDspacedeterminedfromMAND.incisors.

Mandibularanteriorcrowdingusuallyresultsfromtoothsize‐archlengthdeficiency; Supervisionofchild’socclusionmostcriticalatages7‐10becausemalocclusionmostidentifiablein

children7‐9yo. LeewaySpace–servestoaccommodatePERMANENTCANINES(whicharelargerthanprimary);

→ thedifferenceinsumofMDwidthofprimarycanine,1stmolars,2ndmolars&permanentcanine,1stPM,&2ndPM.

→ Mand.leewayspace=3‐4mm;Max.leewayspace=2‐2.5mm. Permanentsuccessorsoftensmallerthanprimarysuccessors; LateMesialShiftof1stmolar–lossofarchlengthwhenprimary2ndmolararelost&1stpermanent

molarshiftsintoleewayspace. PermanentMAND.canineseruptFACIALLY/RIGHTINLINEtoprimarycanines; Inmax.&mand.arches,perm.toothbudsforincisorslieLINGUALLY&APICALLYtoprim.incisors

causingmandibularincisorstoeruptLINGUALLY; PermanentteethnormallymoveOCCLUSALLY&BUCCALLYwhileerupting; Maxarch=128mm;Mand.arch=126mm. Primarymolarrelationship=STEPrelationship; MesialStep(primaryteeth)=distalsurfaceofmand.2ndmolarismesialtodistalsurfaceofmax.2nd

molar;normallyresultsinClassIocclusionofperm.teeth; Flush‐TerminalPlane–theNORMALrelationshipofprimarymolarsinprimaryteeth;mostcommon

initialrelationship;whendistalsurfacesofmand.&max.2ndmolarsareendtoendrelationship;→ permanentteethdon’teruptimmediatelyinnormalocclusion,firstClassII,butaround10/11yo

(duringlatemesialshift),themoveintoClassIocclusion;→ iflatemesialshiftdoesn’toccur,thenstaysinClassIIocclusion.→ Terminalplanerelationshipdeterminesfutureanteroposteriorpositionsofpermanent1stmolars!

DistalStep–createspermanentClassIIocclusion; MesialStep,Flush‐TerminalPlane,DistalSteparealldeterminedbyobserving2ndPrimaryMolars! Childw/classIIImalocclusion,theywillhaveedgetoedgecontactw/primaryincisors; PrimateSpace–Max.arch=b/wLateralincisors&canines.

Mand.arch=b/wcanines&1stmolars.→ Spacingisnormalthruouttheprimarydentition,buttheseareasarethemostNOTICEABLE.→ Causedbygrowthofdentalarches.

Ifnospacing&primaryteethwereincontactb/floss,acollapseinarchafterlossofprimaryincisorsisalmostcertain;

→ nottrueforlossofperm.incisors–spaceclosureoccursrapidlywhetherspacing/not. Mostcommoncauseofmalocclusion–inadequatespacemanagementfollowingearlylossofprim.

teeth; Prematureexfoliationofprimarycaninemayindicatedarchlengthdeficiency&maycauselingual&

lateralcollapse/migrationofmandibularanteriorteeth; Prematurelossofprimarymax.2ndmolarproducesClassIImalocclusion; Aschildmatures,facebecomeslessconvex. Themostreliableindicatorofreadinessoferuptionofsuccedaneoustoothisextentofroot

development;OPENBITE&CROSSBITE: ThumbsuckingmaycauseClassIImalocclusion,unilateral/bilateralcrossbite,constrictsMAX.

arch,anteriorcrossbite,proclinationofmax.incisors,&retroclinationofmand.incisors.→ Asthehandrestsonthechin,itretardsmandibulargrowth,causingClassII.

→ Constrictionofthemaxilladuetopressuefrombuccinator,NOTnegativepressure; ANTERIOROPENBITE(APERTOGNATHISM)ismostcommonsequelaeofdigitalsuckinghabit;

assymmetricalw/normalposteriorocclusion;itisamalocclusion; Skeletalopenbite(longfacesyndrome)ismostoftenassociatedw/mouthbreathing. Ant.crossbiterareb/cmandibulargrowthlagsbehindmaxillarygrowth,unlessClassIIIrelationship;

mostoftenassociatedw/retentionofprimaryteeth; Crossbiteisassociatedw/jaw­sizediscrepancy,hereditary,reverseover­jet,&scissorbite; Neithercrossbiteoropenbitearecausedbytonguethrusting. AnteriorCrossbiteinprimaryteethisindicativeof1)SkeletalGrowthProblem&2)ClassIII

malocclusion;Resultsfrom: 1)Labialsituatedsupernumerarytooth2)Trauma3)ArchLengthDiscrepancy

→ shouldalwaysbetreatedinmixeddentitionstage;→ mostoftenassociatedwithprolongedretentionofaprimarytooth;→ mostessentialfactorincorrectionisamountofMDspaceavailable.→ Morecommoninafrican‐americans,whileopenbiteismorecommonincaucasians.

Delayedtreatmentofanteriorcrossbitecancauselossofarchlengthandthemostimportantfactorisspaceavailabilitymesialdistally.

Anteriorcrossbitebestretainedbynormalincisorrelationshipachievedbytreatment(theoverbite)notappliances;Anteriorcrossbite–easilyretainedafterorthotxbyoverbiteachieveduringtx.

Overbite(deepbite)–verticaloverlapping;Overjet–horizontaloverlapping. Reverseoverjet–ClassIIImalocclusionw/>2max.anteriorteethinlinguoversion; Scissorbite(bilaterallingualcrossbite)–fromnarrowmandibleorwidemaxilla;whenposterior

mand.teethlingualtomaxillaryteeth. Openbitemaycausetonguethrustswallowingbuttonguethrustswallowingdoesn’tcauseanterior

openbite; PosteriorCrossbite: ‐‐Transverseplaneproblem

‐‐correctedASAP‐‐Thoroughlydiagnosedasdental,functional,orskeletalorgin.‐‐maybecorrectedw/palatalexpansion–causesdiastema&expansionofnasalfloor;‐‐Maybeassociatedw/mandibularshift‐‐correctin1ststageoftxalongwithMILDant.crossbite(2ndstageissevere).‐‐skeletalcrossbitedemonstratessmoothclosuretoC.O.‐‐duetoprolongedthumbsucking&anteriorcrossbite!

TheMOSTCOMMONactivetoothmovementinprimarydentitionistocorrectaposteriorcrossbite–aTRANSVERSEplaneofspaceproblem.

1ststepoftreatmentforcrossbiteismaxillaryexpander–1‐2monthsofturnkeythenanother3months;thenbracesareusedb/ofspacingproducedbyexpansion;

Ananterioropenbitemaymakeitdifficulttomakesounds–th,sh,ch;alsos,&z(duetolisp). Largediastemacanalsocausealispsodifficulttoprodueces&zsounds; Irregularincisorscanmakeitdifficulttoproducesoundst&d. ClassIIIcancausedifficultywithF&Vsounds.

BONEGROWTH: Don’tconfusebonegrowthandboneformation;Onceboneisformed,itthengrowsbyappositional

growth=growthbyadditionofnewlayersontopofpreviousformedlayers; Boneformationbeginsinembryowheremesenchymalcellsdifferentiateintoeitherfibrous

membraneorcartilage;2pathsofbonedevelopment:1. IntramembranousOssification–inmembraneofCT;osteoprogenitorcellsinmembrane

differentiateintoosteoblasts&acollagenmatrixisformedundergoingossification.

a. Howmandible&maxillaareformed;alsoflatbonesofskull&clavicle.2. EndochondralOssification–takeplaceinHYALINECARTILAGE;cartilagecellsreplacedby

bonecells(osteocytesreplacechondrocytes),matrixislaiddown&Ca&PO4aredeposited;a. Formslong&shortbones–ethmoid,sphenoid,temporalbones;

Mandible&MaxillagrowDOWN&FORWARD; MandibleGrowth­ 1)growthincondyleincreasesanteroposteriordimensionofmandible.

2)increaseresorptionofanteriorborderoframus3)increaseappositionofboneonposteriorborderoframus4)appositionofalveolarboneincreasessuperior/inferiordimensionofmandible.

→ Spaceb/wjawsisprovidedbygrowthofcondyle–majorsiteofVERTICALGROWTHduetocartilageproliferation;

→ Resorptionoccursalonganteriorsurfaceoframuswhileboneappositionoccursalongposteriorsurfaceoframus;

→ Mand.maingrowthsite–CONDYLARCARTILAGE;The“VPrincipal”ofgrowthisillustratedwithgrowhtofmandibularramus;

→ Growthatmand.condyleduringpubertyusuallyresultsinincreaseinposteriorfacialheight.→ ThemaingrowththrustisUPWARD&BACKWARDdirectiongcausingthebodyofthe

mandibletomoveDOWNWARD&FORWARD,sameasMaxilla; MaxillaGrowth­ 1)growthatspheno‐occipital&sphenoethmoidaljunctions.

2)growthatnasalcartilaginousseptum→ Suturesforsecondarygrowth: 1)Frontomaxillarysuture

2)Zygomaticotemporalsuture3)Pyramidalprocessofpalatalbone4)Alveolarprocess.

→ Maxillaryarchelongates,movesposterior,andincreasesheight.→ Posteriormovementisduetoresorptionoflabio‐alveolarsufrace&appositionofthelingual

surface; Posteriorboneremodelingatramusceasesbefore3rdmolareruptionoftencausingimpaction; CartilageGrowth:

1. AppositionalGrowth–recruitfreshcells(chondroblasts)fromperichondralstemcells&addnewmatrixtosurface.a. Appositionalgrowthoccursbelowcoveringlayerofbone(periosteal);periosteumhasother

fibrouslayer&cellularinnerlayerofosteoblastswhichlaydownbone;2. InterstitialGrowth–mitoticdivision&depositionofmorematrix;chondrocytesalready

establishedincartilage;a. ie–Condyle(hyalinecartilage),nasalseptum,sphenooccipitalsynchondrosis;b. Hyalinecartilagediffersfromboneinthathyalinecartialgemaygrowbyinterstitialgrowth.

Atage6,greatestincreaseinmandiblesizeoccursdistalto1stmolars; Bonedepositionintuberosityregionresponsibleforlengtheningarch&posteriormvmt; Alveolargrowthresponsibleforincreaseinheightofmaxillarybones; IncisorcrowdingduetoLATEmandibulargrowth. Alveolarprocessboneexistsonlytosupportteethsoiftoothfailstoerupt,alveolarbonewillnever

forminthatarea;iftoothextracted,alveolusresorbs. Latemandibulargrowthistheorythatbestexplainswhythereisastrongtendencyformandibular

anteriorcrowdinginlaterteens&early20s;→ Theconceptisthatincisorcrowdingdevelopsasthemand.incisors&possiblytheentire

mand.dentitionmoveDISTALLYrelativetothebodyofthemand.lateinmand.growth;→ Mandibleundergoesmoregrowthinlateteensthaninthemaxilla;→ Lateincisorcrowdingoccursinpplw/o3rdssonotafactorincrowdingbutlatemandibular

growthisacriticalvariable.

Mostrapidlossesinarchperimeterareusuallyduetomesialtipping&rotationofpermanentfirstmolarafterremovalofprimarysecondmolar.

ORTHOPROCEDURES/TREATMENT: Mostimportantaspectofortho=RETENTION;accomplishedw/fixed/removableappliances; GradualwithdrawaloforthoapplianceisofNOvalue! IndirectMethodofBondingBracketsismoretechniquesensitiveandreduceschairsidetime;controls

FLASH(excessofresin);usedwhenvisibilityisaproblem; 35‐50%unbufferedphosphoricacidisusedasbondingagentbeforedirectbondingoforthodontic

brackets(for1min). topicalflourideshouldNOTbeusedbeforeetchingb/citdecreasessolubilityofenamel; IndicationsforusingBandsinsteadofBondingBrackets:

1. Betteranchorageforgreatertoothmovement2. Teeththatneedbothlingual&labialattachment3. Shortclinicalcrowns4. Toothsurfacesthatareincompatiblew/successfulbonding.

GIcementsarereplacingZincPhosphatebecause1)Fluoridereleasing&2)RetentiveStrengths. FrozenSlabTechnique–allowsmorepowderintoliquidincreasingstrength. Cross‐Elastics–frommaxillarylingualtomandibularlabialcanbeusedtocorrectsingle‐tooth

crossbite; SerialExtraction–orderlyremovalofselectedprimary/permanentteeth;

→ ForsevereClassImalocclusioninmixeddentitionw/insufficientarchlength;if>10mm.→ 1stextractPrimaryCanines,2nd–Primary1stMolars,3rd–Permanent1stPMs;→ keytosuccessistoextractthe1stPMsbeforethepermanentcanineserupt.→ mustleave6‐15monthsb/wextractions;forsupport&retention,usefor…Mandible–

lingualarch,Maxilla–HawleyAppliance.ANGLES: FacialProfileAnalysis(Poorman’sCephAnalysis)–sameinfoaslateralcephbutlessdetailed;give

thefollowinginfo: 1)Anterior/PosteriorPosition/ProtrusionofJaws2)LipPosture&IncisorProminence3)VerticalFacialProportions4)InclinationofMandibularPlaneAngle

Withinlower1/3ofanteriorfaceheight,themouthshouldbeabout1/3ofthewayb/wnose&chin. SteepMandibularPlaneAngle–correlatesw/longanteriorfacialverticaldimension&anterioropen

bitemalocclusion; FlatMandibularPlaneAngle–correlatesw/shortanteriorfacialverticaldimension&anteriordeep

bitemalocclusion. Max‐MandPlaneAngle–angleb/wmand.plane&max.plane=27o(+/­4);greaterthevalue,the

longerthefaceheight. Highmandibularplaneangleismostsignificantcomplicationofmolaruprighting–cancause

increasedopenbite&lossofanteriorguidance; LongfacepredisposestoClassII,whileshortfacepredisposestoClassIII. SNAAngle–angleformedbylinefromSELLATURNICAtoNASIONtoPt.A;

→ SNA>82o=Max.Prognathism.→ SNA<82o=Max.Retrognathism.

SNBAngle–angleformedbylinefromSELLATURNICAtoNASIONtoPt.B;definessagittallocationofmand.denturebase;

→ SNB>80o=Mand.Prognathism→ SNB<80o=Mand.Retrognathism

ANBAngle: ‐ANBangle=2o=ClassI

‐ ANBangle<0o=ClassIII‐ ANBangle>4o=ClassII

Physiological/developmentalagejudgedbywrist/handx‐ray;Landmarks–1)UlnarSesamoid2)HamateBones

Frankfort‐HorizontalPlane–connectsPorion(midpointofuppercontourofmetalearrodofceph)&Orbitale(lowestpointoninferiormarginoforbit);bestrepresentationofnaturalorientationoftheskull;

SomeimportantCeph.Landmarks:• SphenocciptalSynchondrosis–junctionb/woccipital&basisphenoidbones.• Sella–midpointofcavityofsellaturnica;• Pt.A=subspinale=innermostpointofpremaxilla• Pt.B=supramentale=innermostpointoncontourofmandible;• Pogonion–mostanteriorpointofcontourofchin• Menton–mostinferiorpointonmandibularsymphysis(bottomofchin)• Gonion–lowestposteriorpointofmandiblew/teethinocclusion• Nasion–anteriorptofintersectionb/wnasal&frontalbones;

Cephincludesmeasurementsfromhard&softtissue; MoststableareatoevaluatecraniofacialgrowthisANTERIORCRANIALBASEbecauseofitsearly

cessationofgrowth. Cephsoftenshow7‐8%magnification;goodfortooth‐tooth,bone‐bone,&tooth‐bonerelationships.APPLIANCES: Band&Loop–haslimitedstrengthsoonlyreplaces1tooth;mostoftenusedwhenPRIMARYFIRST

MOLARprematurelyextracted. DistalShoe–usedwhen2ndPRIMARYMOLARSlostveryprematurily&priortoeruptionof1stperm.

molars;preventsmesialtippingofpermanentmolar; Lingualarchspacemaintainer–usediflossofbilateralmolarsbutincisorserupted;2bandsaround

eitherprim.2molarsorperm.1stmolars&wirerestsoncingulaofincisors;→ DOESN’Trestorefunction&shouldbecompletelypassive.

NanceAppliance–forprematurebilaterallossofmax.primaryteeth;smallacrylicbuttonthatrestonpalataltissuesthatareattachedtobandsthatarebilaterallycementedonpermantmax.molars;

→ PreventsMESIALrotation&driftingofperm.max.molarsitisattachedtoo. Removableappliancesarentusedoftenb/cappliancenotbeingworkoreasilybroken/lost. QuadHelixAppliance–fixedappliance,notfunctionalbutcontains4helices(2ant,2post);for

POSTERIORCROSSBITEw/digitsuckinghabit; FunctionalAppliancesareeithertooth‐borneortissue‐bourne; ToothBorneAppliances:

A. Activator–advancesmand.intoedgetoedgepostiontoinducemand.growth&inhibitmax.growth;improvesdeepbiteinClassIIcases;

B. Bionator–trimmeddownversionofactivatorapplianceforcomfort;C. Herbst–fixed/partiallyremovable;metalrod&tubetelescopicapparatusattachedbilaterally

tomax.1stmolar&mand.1stPM;usedtoposturemandibleforward&inducegrowth;D. TwinBlock–2pieceacrylicappliancetoposturemandibleforwardw/helpofocclusalincline

&guidingplanes&biteblocks(determinesverticalseparation); TissueBorneAppliances:

A. FrankelFunctionalAppliance–servestoEXPANDARCHbypaddingagainstpressureoflips&cheeks;protrudesmand.forward&downward;REMOVABLEfunctionalapplianceusedforabnormalsofttissuepatterns;

Bestmethodfortippingmax&mand.anteriorteethiswithFINGERSPRINGSwhichareattachedtoremovableappliance;mostcommonproblems: 1)lackofptcooperation

2)Poordesign/lackofretention

3)Improperactivation4)Rootapexmovement

ForceofSpring=Fα dr4/13;d=distanceofspring,r=radiusofspring;forceofspringisinverselyproportionaltolengthofspring.

ZSprings–canalsobeusedfortippingbutexcessiveheavyforce&lackofrangeofmotion; BuccalSprings–usedtotry&regainspacebypushingatoothmesial/distally,butmaycause

rotationofthattooth; Maxillaryincisorrotationnotfixedtilafterallpermanentteethhaveeruptedexceptforcrossbite

whichshouldbecorrectedASAP. Whip‐SpringAppliances–usedtode‐rotate1or2teeth; FixedOrthoappliancesoffercontrolledtoothmovementinall3planesofspace; 3planesofspaceinmalocclusion–Antero‐posterior,Transverse,&Vertical; RemovableAppliances–generallyrestrictedtotippingteeth;

a. AttachedRemovableAppliances:i. ActiveAppliance–containsextraoraltractiondevices(headgear),lipbumpers,activeplates,vacuumformedappliances;

ii. PassiveAppliance–containsbiteplanes,splints,&retainers.b. LooseRemovableAppliances.

IndicationsforRemovableAppliance: 1)Retentionaftercomprehensivetx2)Limitedtippingmovements3)Growthmodificationsduringmixeddentition

ComponentsofRemovableAppliance: 1) RetentiveComponent–retainsappliance’sfunctionw/clasps.2) Framework/Base–acrylic,providesanchorage3) Tooth‐movingelements–spring/screws4) AnchorageComponent–resistsactivecomponents5) Activecomponents–springs,screws,elastics;

Forappliancestobeeffective,mustbecapableofexertingtorque. 4basiccomponentsofFixedAppliances: 1)Bands

2)Brackets3)Archwires4)Auxilliaries(elastics/ligatures)

Alloysforortho–Stainlesssteel(canbesuppliedsoft&w/goodformability),Chromiun­Cobalt(increasedstrength&spring),&Titanium.

Idealwirematerialshouldpossess: ‐‐Increasedstrength‐‐Decreasedstiffness­­Increasedrange‐‐IncreasedFormability

Loops&helicesincorporatedinarchwirestoincreaseactivationrange; EdgewiseAppliance–bandsonallteeth,tubesonlastmolar&bracketsonallteeth;1labialusedasa

time‐.0125x.028indiameter,whichfitsinbracketslottof.022”widefromtoptobottom;→ Bestappliancefortxofcomprehensivemalocclusionsofpermanentdentitions;→ Variationsincludedouble/tandembrackets&narrow(.018)slottlebrackets.→ Components‐ 1)Siamesetwinbracket–maxillaranter.Teeth

2)Broussardbuccaltube–segmentedarchtechniquetointrudeteeth.3)Straightwirebracket4)Bracketw/.022x.028rectangularslot;

→ Straight‐wireAppliance–versionofedgewisew/featuresthatallowplacementofidealrectangulararchwirew/obends;

1storderbendinorthowireisHORIZONTALPLANE; BeggAppliance–usesroundwireswhichfitlooselyinverticalslotofbracket;

HawleyRetainer–incorporatesclaspsonmolarteeth&acharacteristicboww/adjustmentloops,spanningfromcaninetocanine;palatalcoveragew/acrylic–majorsourceofanchorage;

→ Txforptw/excessiveoverbite;canbemaxormand.→ MOSTCOMMONREMOVABLERETAINER.

HEADGEAR: Advantageofextraoralanchorage(headgear)isitpermitsposteriormovementinanarchanddoesn’t

touchopposingarch; Req’dforceforanchorage=250gfor10hrs/day;Req’dforcefortraction=500gfor14‐16hrs/day. Headgearextraoralcomponents–neckstrap,chincup,&headcap. Headgearintraoralcomponents–facebow. Facebow–intraoralheadgearcomponent;hasouter&innerbow;innerbowrelatestoresistanceof

tooth&effectsanchorage/traction; High‐PullHeadgear–produceddistal&upwardforceonmaxillaryteeth&maxilla;headcap&

facebow;Helpsw/ClassII,Div.IMalocclusionw/openbite. Cervical‐PullHeadgear–neckstrap&facebow;producesdistal&downwardforceonmaxillaryteeth

&maxilla;possibleextrusionofmax.molars;→ causesopeningofbite&1stmolarmovesdistally&forwardgrowthofmaxilladecreases;→ forClassII,Div.Imalocclusion.

StraightPullHeadgear–placesforceinstraightdistaldirectionfrommaxillarymolar;forClassII,Div1malocclusion;

ReversePullHeadgear–extraoralcomponentsupportedbychin,cheek,forehead;forClassIIImalocclusion,forprotrudingmaxilla.

PATHOLOGY: Hyperparathyroidism–causesprematureexfoliationofprimaryteeth; PrimaryFailureoferuptioniscausedbyeruptionmechanismitselftbutcanbecausedby:

1. HereditaryGingivalFibromatosis2. Down’sSyndrome3. Rickets

Localizedcausedoffailed/delayederuptionare: 1)CongenitalAbsence2)AbnormalPositionofCrypt3)Lackofspace4)Supernumerarytooth5)Dilaceratedroots.

Prolongedorthotxhaslongbeenassociatedw/caussationofinflammatoryperiodontaldisease; MouthBreathingcauses:

1. SkeletalOpenBite(longfacesyndrome)–worsensovertime;a. anterioropenbite=APERTOGNATHISM.

2. Narrowface3. Narroworopharyngealspace4. Chronicrhinitis,deviatednasalseptum.5. Tonsilitis,allergies

Conditionsw/multiplesupernumeraryteeth: 1)Gardner’sSyndrome2)Down’sSyndrome3)Sturge‐webersyndrome4)CleidocranialDysplasia

Supernumeraryteethhavepredilection2:1formales;mostcommonsiteisb/wCENTRALS; AnimpactedmesiodenscancausediastemabutanINVERTEDmesiodenscancausedelayederuption

ofcentrals; Oligodontia–absenceof1/moreteeth;morefemalesthanmales;smallerthanavgtoothsizeratio.

MISCELLANEOUS: Dentalarchformdeterminedbyinteractionofenvironmentalinfluencesongeneticpattern. MalocclusionisMOSTOFTENhereditary. 98%of6yearoldshavediastemawhile49%of11yearoldsdotoo; Diastemaclosesaftercanineseruptif<2mmbutif>2mmwilllnotclosesoneedtx:

→ Ifabnormalfrenum–doorthotxTHENdoafrenectomy.→ Uselingualarchw/fingersprings→ UseHawleyappliancew/fingersprings→ Cementedorthobandw/inter‐toothtraction.

Maxillarycanineismostcommonlyimpactedtoothafterthirds;inolderpts,thereisanincreasedriskthatimpactedtoothisankylosed.

Txofimpactedtooth–duringsurgicalexposure,flapsreflectedsotoothisultimatelypulledintoarchthruKERATINIZEDTISSUEnotalveolarmucosa;

EctopicEruption–tootheruptsinwrongplace;commoninMAX.1stMOLARS&MAND.INCISORS;→ CommoninClassIIin2‐6%ofpopulation&correctinin60%ofpopulation;→ Ifmax.1stmolar–txisplacebrasswireb/wprimary2ndmolar&permanent1stmolar;

Uprightingamolarcantake6‐12months:→ Tx–fixededgewiseorthoappliancew/.022”or.018”wiresizes→ Tipped2ndmolarshouldbebandedb/cmasticatoryforces;→ Severlylinguallytippedmand.molarMOREDIFFICULTtocontrol&upright.→ Highmandibularplaneanglealsomakeitverydifficulttouprightamolar(maycauseopenbite).→ Stabilizationshouldlasttillaminadura&PDLreorganize(2‐6months);→ Retentionw/well‐fittedprovisional.→ Slowprogressinmolaruprighting–duetoocclusalinterference;

6TypesofToothmovement:1. Tipping–crownmovesin1direction&roottipinoppositedirection(oftenw/appliance);

commonw/anteriorincisorteeth;2. Translation(bodilymovement)–rootmovementinsamedirectionastoothmovement;difficult!3. Extrusion–displacementoftoothfromsocketindirectionoferuption.4. Intrusion–movementintosocketalonglongaxisoftooth;difficult!5. Torque–rootmovementwhilecrownisstable;Mesialdistalrootmvmt=AKA‐UPRIGHTING.6. Rotation–revolvingtoothalonglongaxis;needadequateretentiontopreventrelapse.

Sidetowardtoothmovement=osteoclasts–breakdownbone; Sideawayfromtoothmovement=osteoblasts–boneformingcells. Collagenfibers(likerubberbands)insupra‐alveolartissueareresponsibleforrelapseof

orthodonticallyrotatedteethaswellasredevelopmentofspacesb/worthodonticallymovedteeth→ Primarycomponentofgingiva&getstretchedduringorthotx.

CircumferentialSupracrestalFibrotomy–simpleincisioninsulcustobone;incisescollagenfibersinsertedintorootoftooth;eliminatespotentialrelapse&allowsnewfiberstoforminnewposition.

→ Goodcandidateforprocedureisarotatedmaxillarylateralincisor. CollagenfibersinSUPRA‐ALVEOLARtissueareprimarilyresponsibleforrelapseoforthodontically

rotatedteeth&forredevelopmentofspacesb/worthodonticallymovedteeth.→ Collagenfibersaremaincomponentofattachedgingiva.

OSHA&PATIENTMANAGEMENTBEHAVIORALSCIENCE: Behaviorisdetermined,purposefulunitofactivity; 4majorfieldsofbehavior: PersonalSocial,Motor,Language,&Adaptive; Mostresearchersbelievechangesinbehaviorareaprerequisitetochangesinattitude; Themosteffectivewaytoteachoralhygieveskillsisbyhavingptparticipateinrepeatedsupervised

traininingsessions; Maintaininga4yearoldchild’shealthydentitionstartsw/educatingtheparent; BehaviorModification–typeofpsychotherapythatattemptstomodifyobservable,maladjusted

behaviorpatternsbysubstitutinganewresponseorsetofresponsestoagivenstimulus;5Types:1. ClassicalConditioning(pavlovian/respondentconditioning)–aformoflearninginwhicha

previouslyneutralstimuluscomestoelicitagivenresponsethroughassociativetraining;a. Operatesbyassociatingonestimulusw/another;

2. OperantConditioning–consequenceofabehaviorisinitselfastimulusthatcanaffectfuturebehavior;aformoflearningwherethepersonundergoingtherapyisrewardedforcorrectresponse&punishedforincorrecresponse;a. 4types:Positive&Negativereinforcement,omission,&punishment;b. BehaviorShaping(successiveapproximation)–anoperantconditioningtechniqueinwhicha

newbehaviorisproducedbyprovidingreinforcementforprogressivelycloserapproximationsofthefinaldesiredbehavior;sometimescalledStimulusResponseTherapy;

3. AversionConditioning–techniqueinwhichpunishmentorpainfulstimuliareusedinsuppressionofundesirablebehavior;ie–Handovermouthtechnique;

4. ObservationalLearning(modeling/behaviorshaping)–behavioracquiredthroughinitiationofabehaviorobservedinasocialcontext;

a. 2stages–observationallearningacquisitionandactualperformanceofbehavior;5. SystemicDesensitization–atechniqueusedtoeliminatemaladaptiveanxietyassociatedw/

phobias;constructionbythepersonofahierarchyofanxietyproducingstimuli&generalpresentationofthesestimuliuntiltheynolongerelicitaninitialresponseoffear;

Flooding–intense&prolongedexposuretoafearedstimuluswhileusingcopingskills; Biofeedback–teaching1tohavecontroloverhisorherphysiologicalarousalthrutheuseof

auditory/visualmonitoringofarousallevel; CognitiveCoping(reframing)–assistingptsinchangingtheirthinkingaboutsomethingtoamore

adaptiveorrealisticthinkingstyle; ThePremackPrinciple–makingabehaviorthathasahigherprobabilityofbeingperformed

contigentupon(usedareinforcement)theperformanceofalessfrequentbehaviormayincreaseperformanceofthelessfrequentbehavior;

Extinction–identifyingthepositiveconsequencesorreinforcementsthatmaintainabehavior&ceasingorwithholdingthesereinforcmentsorconsequences;

Incompatiblebehavior/stimuluscontrol‐useofanincompatiblebehaviortodecreasethefrequencyofanundesirablebehavior;

Eyecontactistheprimarynon‐verbalcuethat2/morepeopleusetoregulateverbalcommunication; Thebestwaytoshowaptyoucareaboutwhattheyaretellingyouistouseeyecontact; Whenpresentingtreatmentplansalwaysuseopen‐endedquestions;theyaretheMOSTEFFECTIVE

waytohelpptsunderstandtheproposedtxplan; ConstructiveAggression–anactofself‐assertivenesinresponsetoathreatenedactionforpurpose

ofself‐protection&preservation; DestructiveAggression–actofhostilityunnecessaryforself‐protection/preservationdirected

towardanexternalobjectorperson; Anxiousptsareusuallyconsideredthemostdifficultpts;mostptswhoareanxioushaveatraumatic

experienceindental/medicalsetting;

Fear–anticipationofathreatelicitedbyanexternalobject;itisdistinguishedfromanxietyonthebasisoftheperson’sabilitytolocatethethreateningagent&recognizethepresenceofabehaviorthatwillreduceperceiveddanger;

Stress–generaldisturbanceinpsycho‐physiologicaladaptation;mostlyassociatedw/responseaspects;

Overprotectiveparentsusuallyhavechildrenwhoareshy,docile,&manageable; HealthBeliefModel‐conceptualframeworkthatdescribesaperson’shealthbehaviorasan

expressionofhis/herhealthbeliefts;suggeststhatindividualswillacttopreventdiseaseonlywhentheybelivetheyaresusceptibletodisease;Componentsofthemodel:

1. Person’sownperceptionofsusceptibilitytoadisease/condition.2. Likelihoodofcontractingthatdisease/condition.3. Person’sperceptionofseverityofconsequencesofcontractingthecondition/disease.4. Perceivedbenefitsofcare&barrierstopreventivebehavior.5. Internal/externalstimulithatresultinappropriatehealthbehaviorbytheperson.

OSHA: Standard/UniversalInfectionControlPrecautions–methodofinfectioncontrolwhichallhuman

blood&certainbodyfluids(salivaindentistry)aretreatedasifshowtobeinfectiousforHIV,HBV,HCV,&otherbloodbornepathogens;firstrecommendedbyCDCin1987;

OccupationalSafety&HealthAdministration(OSHA)–federalagencycreatedbycongressin1970toprotectworkersfromhazardsintheworkplace;theyareconcernedw/REGULATEDWASTEindentaloffice;

HazardousWaste–wastecausingharm/injurytoenvironment;doesn’thavetobetoxic/poisonous; InfectiousWaste–wastethatcontainsstrongenoughpathogensinsufficientquantitytocause

disease; AIDSpromptedOSHAtoadoptBloodbornePathogensStandardforDentistry–acomprehensiverule

thatsetsforththespecificrequirementsOSHAbelieveswillpreventthetransmissionofbloodbornediseasestoEMPLOYEESnotpatientsoremployers;

OSHAdirectsthatuniformclothingwornindentalofficeislaunderedatdentalofficeorbyanoutsideservice,NOTemployee’shome;

OnlyindentalproceduresisSALIVAconsideredapotentiallyinfectiousmaterial; Fluid‐resistantgownsarenotrequiredunlessitisanticipatedthatlargeamountsofblood,saliva,or

otherbodyfluidswillsoakthrugowntotheemployee’sclothing; Whenhandlingchemicalagentsorcleaningadentaloffice,alwayswearprotectiveeyewear,mask,&

heavydutyutilityornitrilegloves; CDCsuggestsnewmaskforeachpatient;masksshouldhaveatleast95‐99%filteringefficiencyfor

smallparticleaerosols1‐3m; HIVisMOSTINFECTIOUSTARGETofstandard/universalbloodprecautionsbutHBVisMOST

INFECTIOUSBLOODBORNEPATHOGEN,notmostinfectiousagent; HBV–posesthegreatestoccupationalhealthcareworkerriskforbloodborneinfection;

→ HBVconcentrationsinbloodofachroniccarriercanrangeb/w1‐100millionvirions/ml,incontrasttosignificantlylowerviralloadsshownforbothHIV&ADSinfectedpts;

→ ExposedemployeeswhohavedeclinedtheHBVvaccinecanchangetheirmindatanytime&receiveFREEvacination;

→ ExposedemployeeswhohavebeguntheirHBVvaccineseriescanworkattheirjobeventhoughtheseriesisnotcomplete;

→ Dentistmustprovide“at‐risk”employeesw/protectionfromHBV;federalstandardforoccupationalexposuretobloodbornepathogensREQUIREemployerstoprovedtheHBVvaccine;

→ EmployemayrefusevaccinationbutOSHAwillrequireproofthatemployeehasrefused;→ Employersmustofferthevaccinationtoanewemployeew/in10workingdaysofinitial

assignmenttoapositioninvolvingexposure;Trainingmustbeprovidedpriortoofferofvaccine;

→ HBVinfectioncommonlyoccursbysex,prenataltransfer,&percutaneousinoculation; HCV–transmittedprimarilyininfectedbloodviaaccidnetalneedle‐sticks,bloodtransfusions,ordrug

addictssharingcontaminatedsyringes;→ Historically,drugusers,pplreceivingtansfusions,organrecipients,&hemophiliacsreceiving

FactorVIIorIXareathighriskforthevirus,butnowpplgettingtattoos&piercingsareatrisk;→ ViralconcdetectedinHCVinfectedptsrangeb/wnumbersforHBV&HIV;

OccupationalExposure–anyreasonablyanticipatedskin,mucosal,eye,orparentalcontactw/bloodorotherpotentiallyinfectiousfluidsduringthecourseofone’sdutieswhileatwork;→ Infectioncontroltrainingrecords&medicalrecordsifemployeeinvolvedinoccupational

exposuremustbemaintained;→ Medicalrecordsmustbemaintainedfordurationofemployementplus30years&strictly

confidential;→ ifyougooutofbusinessornewowner,mustnotifyDirectorofNationalInstituteofOccupational

Safety&HealthyatLEAST3monthsb/fyouintendtodisposerecords&offertotransmittherecordstoNIOSH;

ExposureIncident–specificoccupationalincidentinvolvingeyes,mouth,othermucousmembranes,non‐intactskin,orparenteralcontactw/bloodorpotentiallyinfectiousmaterials;→ Anyinjuryfromacontaminatedsharpisthemostcommonexposureincident.→ EmployERmustprovideEmployEEwithanymedsneededafterorbeforeexposure,CONSELING,

andevaluationweeksafterincident; ExposureControlPlan–requiresthateveryemployerhaveawrittenexposurecontrolplanto

elimate/minimizeemployeeexposuretobloodbornediseaseas;→ MustbeupdatedatleastANNUALLY&whenevernecessarytoreflectofficechanges;→ TheplanmustbeprovidedtoOSHAuponrequest;

EmployersmustensurethatALLemployeesw/occupationalexpsosureparticipateintrainingprogramatNOcost,duringworkinghours,w/materialforeducation,literacy,&languageoftheemployee!

Contaminatedsharpsareanyobjectthatcanpenetrateskin,likeneedles,scalpels,brokenglass,brokencapillarytubes,&exposedendsofdentalwire;

Anti­RetractionValves–usedonhandpiece&air‐watersyringehosestopreventretractionoffluidbackintothetubing;preventsptsfluidfromgettingintowaterlines;

→ CDCrecommendsminimumof20‐30secsofflushingwanterlinesb/wpatientsandseveralminutesifthesystemhasbeenidleforawhile,likeovertheweekend;

FDA–branchofHealth&Humanservicesthatdetermineswhichdrugs&medicalservicescanbemarketedinUS;alsoresponsibleforregulatinghandpieces&recommendingsterilizationprocedurestoCDC;

DEA–branchofDepartmentofJusticethatdeterminesdegreeofcontrolforsubstancesw/abusepotential;

ThemostcommonlyuseddentalmaterialsdeemdhazardousbyOSHAaremercury,nitrous,&chemicalsusedtodevelopfilm;

Amalgamscrapisstoredintighlysealedcontainerscoveredw/sulfidesolution; AcceptablemaxexposurelevelallowedbyOSHAfornitrousis1000ppm; MaterialSafetyDataSheet–documentthatcontainsinfoconcerninghazardouschemicals;chemica

manufacturers&importersarerequiredtoobtainaMSDSforeachhazardouschemical;→ Mustbereadilyaccessibletoemployees

EPA–regulateswasteTRANSPORATIONfromdentaloffice; OSHAconsiderspart‐time,temporary,&probationalworkersasemployees;PUBLICHEALTH: QualityAssessment–measureofthequalityofcareprovidedinaparticularsetting;limitedto

appraisalofwhetherornotstandardsofqualityhavebeenmet;

QualityAssurance–measurementofqualityofcare&IMPLEMENTATIONofallnecessarychangestomaintain/improvesthequalityofcarerendered;contains3Concepts:

a. Structure–layout&equipmentoffacility;b. Process–theactualservicethedentistprovidesforpts;c. Outcome–changeinhealthstatusthatoccursb/cofcaredelivered;

Sensitivity&SpecificityareINVERSELYproportional;asthespecificityofatestincreases,thesensitivitydecreases;

Sensitivity–abilityoftesttodiagnosecorrectlyacondition/diseasethatactuallyexists;measurestheproportionofpeoplew/adiseasewhoarecorrectlyidentifiedbyapositivetest;

→ Definedas#oftruepositive(TP)dividedbytotal#ofpotentialpositivefindings(truepositives&falsenegatives)insample;Sensitivity=TP/(TP+FN)

Specificity–abilityoftesttoclassifyhealth;definedby#oftruenegativeresultsdivedbytotal#offalsepositive&truenegativeresultsinsample;Specificity=TN/(FP+TN)

Prevalence–#ofOLDcasesofdiseasepresentinpopulationatriskataspecificperiodoftime;theproportionofpersonsinpopulationsufferingfromparticulardiseaseatgivenpointintime;

→ Expressedaspercentageofpopulation; Incidence–#ofNEWcasesofspecificdiseaseoccurringw/inapopulationatcertainamountoftime;

expressedasarate(cases)/(population)/(time);incidenceisaratethatrequiresaunitoftime;→ IncidenceisaRATE&prevalenceisaPROPORTION;

Frequency=acount; Abuse–dentistaremorally,ethically,&legallyobligatedtoreportasuspectedcaseofchildabuse;

dentist’sfirst&immediateresponsibilityistoprotectthechild;→ Dentistalsoethicallyobligatedtoidentify&refercasesofdomesticviolence;→ 68%ofbatteredwomeninjuriesinvolveface,45%theeyes,&12%theneck;

ManagedCare–arrangementwhere3rdpartypayermediatesb/wdoctors&patientsnegotiatingfeesforservices&overseeingtypesoftxprovided;types=HMO,PPO,&IPA;

→ PPO(preferredproviderorgnaization)–typicallyinvolvescontractsb/winsurers&dentistandpatientscanchoosetheirdentinstdependingonifthedentistparticipatesinPPO;

→ ParticipantsofHMOaremuchmorelimitedintheirdentistselectionb/ctheyhavetostayw/innetwork;

Capitation­fixedmonthlypaymentpaidbycarriertoadentistbasedon#ofptsassignedtodentistfortreatment;feeissameregardlessofhowmuchorhowoftencareisdelivered;

→ Mostpopularmanagedcarepaymentmethod; HMO=capitation;PPO=reducedfeeforservice; DentalIndex–datacollectioninstrumentusedtonumericallyexpressoralhealthstatusof

population;8Indices:1. DMFTIndex(Decayed‐Missing‐FilledTeeth)→irreversibleindex(measuresthatcantbe

reversedlikecaries)appliedonlytoPERMANENTteeth;i. Ityieldsagroupscariessusceptibility;receiveduniversalacceptance&isprobablythebestknownofalldentalindices;

2. DEFTIndex(Decayed‐Extracted‐FilledTeeth)→usedforPRIMARYTEETH;3. DMFSIndex(Decayed‐Missing‐FilledSurfaces)→sameasDMFTbutrecordsinvolvetooth

surfaces;4. GingivalIndex(GI)–reversibleindexusedtoassesseverityofgingivitisbasedoncolor,

consistency,&BOP;i. Gingivitismostcommonlyscoredw/GingivalIndexofLoe&Silnesswhichgradesgingivaon4surfacesofeachtoothbasedoninflammation&bleeding;

ii. GI,Papillary,Marginal&AttachedGingivalIndex(PMAIndex)–measurementw/ingingiva;recordstheprevalence&severityofgingivitisinschoolchildren;

5. PeriodontalIndex–reversibleindexthatmeasuresconditionsthatcanbechanged,likeplaque&bleeding;conditionofgingival(lessweight)ANDBONE(moreweight)estimatedforeachtooth;

6. SimplifiedOralHygieneIndex–reversibleindexusedtomeasureoralhygienestatusbyestimatingtoothsurfacecoveredw/materialalba&/orcalculus;

7. PlaqueIndex(PI)ofSilness&Loe–reversibleindextoassessTHICKNESSofplaqueatthegingivalmargin;scoresfrom0to3; 0=toothsurfaceisplaquefree

1=plaquenotobservedontoothbutisonprobe2=thinplaqueobservedontooth3=heavyaccumulationofplaqueontooth;

→ Extensivelyusedbutnotuniversallyaccepted;→ 80‐90%ofchildrenhaveperiodiseasebyage15;mostcommonformislocalizedacute

gingivitis;8. SulcusBleedingIndex–usedtodeterminebleeding&gingivalhealth;

VitalStatistics–quantitativemethodstomonitor&evaluatethelifehistoryofaspecificpopulation;→ identifiescommunityhealthneeds,estimateshealthcarecosts,&evaluateshealthprogram

effectiveness;→ datamonitoredismortality,morbidity,natality,birth‐deathratio,&crudedeathratio;

3PrinciplesofPublicHeath–problemexists,solutionsexists,&solutionstoproblemisapplied; mostimportantconceptofWinslow’sdefinitionofpublichealthispromotionthroughorganized

communityheath; Dentalpublichealthisaformofdentalpracticethatservesthecommunityasapatientratherthan

servingtheindividual; Fundamentalprinciplesofpublichealthareprevention,cost­efficiency,&teamwork; Preventionismajorobjectiveofpublichealthprograms;moreethicaltopreventdiseasethancureit; RandomizedStudy–studywhereALLsubjectshaveequalchanceofbeingassignedtoeitherthe

studyorcontrolgroup; BlindStudy–studywheresubjectsareunawareiftheyareinatestorcontrolgroup;thisisachieved

byusingplacebos; Cross‐SectionalStudy–studyinwhichthehealthconditionsinagroupofpeoplewhoare,orare

assumedtobe,asampleofaparticularpopulation(across‐section)isassessedatonetime; CaseControlStudy–peoplew/acondition(case)arecomparedw/peoplew/oit(control)butwho

aresimilarinothercharacteristics; CohortStudy–2types:prospectivecohortstudy&retrospectivecohortstudy;

→ ProspectiveCohortStudy–ageneralpopulationisfollowedthrutimetoseewhodevelopsthedisease,&thenthevariousexposurefactorsthataffectedthegroupareevaluated; Ie–studyingasampleofsubjectswhodon’tyethavecancerbutmeasuringtheriskfactorsof

eachsubjectthatmaypredictthesubsequentoutcome.→ RetrospectiveCohortStudy–usedtoevaluatetheeffectthataspecificexposurehashadona

population;measuringtheriskfactorsofsubjectswhohadtheoutcomeofinterest; TheethicalprinciplesfoundintheADA’sPrinciplesofEthics&CodeofProfessionalConductare:

1. Justice–thequalityofbeingimpartial&fair;2. Autonomy–toinformpatientabouttreatment,betruthful,&protecttheirconfidentiality;3. Beneficence–tobekind&givehighestqualityofcareoneiscapableofproviding;

GoodSamaritanLaw–lawenactedinallstatesthatprovidesIMMUNITYfromsuitforspecifiedhealthpractitionerswhorenderemergencyaidtovictimsofaccidens,providedthereisnoevidenceofgrossnegligence;NotallstatesincludedentistsinGoodSamaritanLaw;

Mean=average;Median=middlemeasurementinsetofdata;Mode=mostfrequentmeasurement; Range=thesimplestmeasureofvariability;Variance=methodofascertainingthewayindividual

valuesarelocatedaroundthemean;StandardDeviation=typical/avgdeviationfromthemean; Chi‐squaretest–measureassociationbetween2categoricalvariables; T‐test–usedtoanalyzethestatisticaldifferenceb/w2means;

INFECTIONCONTROL: OpportunisticInfection–infectioncausedbynormallynon‐pathogenicmicroorganismsinahost

whoseresistancehasbeendecreased/compromised;→ Percentageofppllivingw/widevarietyofimmuncompromisedconditionscontinuestoincrease;

Exposureisnotsynonymousw/infection;Donotdisinfectwhenyoucansterilize; Itisnotpossible/necessarytosterilizeallenvironmentalsurfacesthatbecomecontaminated

duringpatientcare; Sterilizationofallclincalinstruments&inanimatesurfacesNOTmanditory; Bactericidalagentspreferredoverbacteriostaticchemicals; Sanitization–typeofantimicrobialtreatment(usedfordrinkingwater)tolowertotalmicrobialload

tosafepublichealthlevels; Sterilization–processofkilling/removingallmicroorganisms,includingspores,onanobject/ina

material;limitingrequirementisdestructionofheat‐resistantspores;abscessofalllivingforms; Heatismostefficient,reliable,&biologicallymonitorablesterilizationmethod; Pre‐Cleaning–MOSTIMPORTANTSTEPininstrumentsterilizationb/cdebrisactsasabarriertothe

sterilant&sterilizationprcces;→ Ultrasonicinstrumentcleaningissafest&mostefficaciousmethodofprecleaning;

Immersionofdentalinstrumentsincolddisinfectantswillnotdestroyspores/hepatitisviruses; Liquidsaregenerallysterilizedbyfiltration;mostcommonfilteriscomposedofnitrocellulose&has

poresizeof0.22m; RapidHeatTranferSterilization–veryfastcycletime,nodullingofinstruments&drys

instrumentsaftercycle;forcedair,dryheatconvectionovensareareappropriateforsterilizingheat‐stableinstruments&otherreusuableitemsusedinpatientcare;→ Highertempthanotherdryheatunits;cansterilizemuchfasterthantraditionaldryheat

sterilizers;→ Requires375oF(191oC)for12minforwrappedinstruments&6minforunwrappedinstruments;

DryHeatSterilization–Dryheatdestroysmicroorganismscausingcoagulationofproteins;→ requires320oF(160oC)for2hoursor340oF(170oC)for1hour;→ instrumentsmustbedrybeforeusingthissterilization&ethyleneoxidesterilization;→ doesn’tdullorcorrodeinstrumentsbutlongcycle&poorpenetration;

Autoclave–destroysbacterialbydenaturationofhighprotein‐containingbacteria;→ Requires250oF(121oC)for15‐20minunder15psior270oF(134oC)atpressueof30psifor3min

(flashcycle);flashcyclebestindicatedforunwrappedinstruments;→ thepressuregreatlyspeedsuptheproteindenaturationprocess;only10minrequiredtodestroy

allbacterialbutincreasedtimeallowspenetrationwheninstrumentswrappedinthicktowels;→ SporetestingforautoclaveunitsrecommendedWEEKLY;thesporesBacillusStearothermophillus

areused;→ Sporesareresistanttoboiling(100oC)sotempincreased&pressureneeded;→ ThiskillsevenhighlyheatresistantsporeslikeClostridiumBotulinum;

UnsaturatedChemicalVaporSterilization–requires270oF(132oC)for20‐40min;yields20lbsofsterilizingvaporpressure;Doesn’trustorcorrodeinstruments;→ doesn’tusedistilledwater,usessolutionofalcohol,formaldehyde,ketone,acetone,&waterto

producethesterilizingvapor; Glutaraldehyde(2%)–analkalizingagenthighlylethaltoessentiallyallmicroorganisms;takes10

HOURStokillSPORESwheninstrumentplacedin2%glutaraldehydesolution;→ longtime,allergenic,&extremelytoxictotissues;→ usedinhospitaltosterilizerespiratorytherapyequipment;→ Faceshieldsdisinfectedw/IodophorsorGlutaraldehydes;→ Thisdisinfectiantoften28‐30daylifespan;

EtheleneOxideGasSterilization–killsbyalkylatingproteins&nucleicacids&proteins;usedextensivelyinhospitalstosterilizeheat‐sensitivematerialslikesurgicalinstruments&plastics;

→ Slowprocesstaking10‐16hours;toxictohumans&flammable,solimiteduse;→ Highlypenetrative,doesn’tdamageheat‐sensitivematerial,evaporatesw/oleavingresidue;

Antiseptics–chemicalsafetobeadministeredtoexternalbodysurfacesormucousmembraneto↓microbialnumbers;canttakeinternally;similartodisinfectantsbutcanbeappliedtolivingtissue;

→ Bestrelatestohandwashagentlikechlorhexidinegluconate,parachlorametaxylenol,idophors,&triclosan;

→ AlcoholisMOSTWIDELYUSEDANTISEPTIC&reducesthenumberofmicroorganismsonskinsurfaceinwoundedarea;itactsby: 1)denaturingproteins

2)extractsmembranelipids3)dehydratingagent

→ Evensomeviruses(lipophilic)areinactivatedbyalcohol; → Alcoholsarebactericidal,tuberculocidal,&economical;NOTsporicidal;itevaporatestoo

quicklyanddiminishedactivityagainstvirusesindriedblood,saliva,&othersecretions; → Isopropylalcoholismajorformusedinhospitals;→ Ethanol–widelyusedtocleanskinpriortoimmunizationorvenupuncture;→ Iodine–MOSTEEFFECTIVEskinantisepticusedinmedicalpracticethatactsasan

oxidizingagent,&irreversiblycombinesw/proteins;→ Phenolwasoriginaldisinfectantbutrarelyusedtodayb/ctoocaustic;

Disinfection–processofreducingthe#orinhibitinggrowthofmicroorganisms,especiallypathogenstothepointwheretheydon’tposeathreatofdisease;notallpathogensorspores!

Disinfectants–antimicrobialchemicalagentsusedtodestroy/killmicroorganismswhenappliedtoinanimateobjects/surfaces;notsafeonlivingtissues;

→ Ie–Alcohol,Chlorhexidine,&QuaternaryAmmoniumCompounds;→ Water‐baseddisinfectantsarebetterthanalcohol‐baseddisinfectants;→ Pumpspraydisinfectantsarebetterthanaerosolspraydisinfectants;→ QuaternaryAmmoniumCompounds–cationicdetergentsusedasdisinfectant&antiseptic

againsgram(+)bacteriawhicharemostsusceptibletodestruction;inactivatedbyanionicdetergents(soaps&ironfoundinhardwater);ie–BenzalkoniumChloride;

→ CleaningsurfacespriortodisinfectionisrequiredtoREDUCEconcentrationofpathogens;→ MycobacteriumTuberculosisisthemarkermicroorganismforintermediatesurface

disinfection;→ ChlorhexidineGluconate&Triclosan­handwashagentsw/broadantimicrobialeffect;

havesubstantivityorresidualactiononwashedtissuesforextendedperiodsoftime; Chlorine–powerfulOXIDIZINGagentthatinactivatesbacteria&mostvirusesbyoxidizingfree

sulfhdrylgroups;activecomponentofhypochlorite&usedasdisinfectant; Pasteurization–txofdairyfoodsforshortintervalsusingHEATtokillcertaindisease‐causing

microorganisms;targetofpasteurizationistodestroyMycobacteriumTuberculosis; Concentration&Timearecriticalfactorsthatdetermineeffectivenessofantimicrobialagent; IndividualspredisposedtoreadilydevelopinghypersensitivityrxnscanbecomeSENSITIZEDtolatex

allergnesmorereadilythanpeoplew/fewornoallergies; HeveaBrasiliensis–water‐solublemacromoleculesthatcanleachoutoflatexgloveswhenaperson

perspiresormaybedetectedonsurfacesofotherproductcontainingnaturalrubberlatex;→ TheseproteinscauseTypeIV,IgEmediatedreactionstonaturalrubberlatex;→ ProductsdesignatedHYPOALLERGENICarenolongerlabelledlatexalternativessincethey

containlatexw/achemicalcoatingoverthelatex; IrritationDermatitisisMOSTCOMMONformofanadverseepithelialrxnnotedforhealthcare

professionals;20‐30%ofhealthcareworkerssufferoccasionalorchronicdermatitisontheirhands;

Americansw/DisabilitiesAct–bothstate&federalstatuesdefinedisabilityashaving“aphysicalormentalimpairmentthatsubstantiallylimitsone/moremajorlifeactivitiesoftheindividual,arecordofsuchimpairmentexist,&thepatientisregardedashavingsuchimpairment.”

→ DentistsCANNOTdenyanyonecareduetodisability&cannotdismissemployeesduetodisability.

→ Dentalofficesmustundergostructuralchangestoallowaccessforthedisabled.→ HIVptsareprotectedunderthisact;

PEDIATRICDENTISTRYTOOTHANATOMY: Primarymand.1stmolar–likenoothertooth;difficulttodoaClassII,nocentralfossa; Primarymand.2ndmolar–greatestFLdiameterofallprimaryteeth. Primarymax.centralincisor–NOMAMELONS;incisocervicalheight<MDwidth. Primarymand.centralincisor­similartopermanentLATERALincisor. Primarymand.lateralincisor–similartopermanentCENTRALincisor. Primarymax.1stmolar–FLdiameter>MDdiameter(differentthanotherprimarymolars);5th

cusp;oftenresemblespermanentmax.PM;obliqueridge;MB–largestpulphorm;MBcusp>MLcusp;groovesformHpatternw/3fossa;has3Roots,resemblingperm.1stmaxmolar.

Primarymax.canine–mesialcuspridge>distalcuspridge&mesialcusplonger&sharper;bothfactsdifferthanpermanentcanines.

PermanentMax.Canines–mostlikelytobecrowdedoutofmaxillaryarch. PermanentMand.2ndPMs–mostlikelytobecrowdedoutofmandibulararch! Facialpartofremainingprimaryrootislongest. Labial&Lingualcervicalridgesprominentonallprimaryincisors! Largestprimarytooth–mand.2ndmolar;Smallestprimarytooth–mand.lateralincisor. Largestpermanenttooth–Max.2ndmolar;Smallest–mand.centralincisor. Primarymolars– 1)B&Lsurfacesareflatter

2) Shorter&narrowerMDatcervical1/33) Longer&slenderroots.

PrimaryAnteriors‐ 1)WiderMD&shorterIC2)roottapersmorerapidly

Enamelendsabruptlyatcervicallineonallprimaryteeth; LateralincisorismostcommonPRIMARYcongenitalmissingtooth. Primaryteethlessopaqueonxraythanpermanentteethb/c>inorganic(Ca+,Phosphorus,

hydroxyapatite)content;Organiccontentiscollagentype1. Enamelonprimarymolars=1mmwhilepermanentmolars=2.5mmofenamel. SumofMDwidthsofprimarymolarsinany1quadrantis2‐5mmgreaterthanperm.teeththat

succeedthem(premolars); Lastprimarytoothtobereplacedbypermanenttoothismaxillarycanine. Occlusaltableonprimarymolarsarenarrowerfaciallingually. Cementum(thickerapicallythancervically)&PDLfibersincreaseasyouage; ChildGingiva‐ 1)morered,2)lessstippling,3)flabbiertissue,4)rounded/rolledgingiva,5)PDL

runsparalleltoteeth,6)alveolarbonethinner;ERUPTION&CALCIFICATION: Primaryteethbegintoformat6weeksinutero;Permanentteethbegintodevelop4monthsinutero. Whentootherupts,½‐2/3ofrootformed;apexfullyformedin2‐3yrs(permteeth);rootcompletely

formsin18monthsforprimaryteeth. all20primaryteethbegincalcificationat4‐6monthsinutero;10monthsforcompletecalcification; primaryteethbegintoformat6weeks;AllPrimaryteethcalcificationinutero! Afterpermanentteethhavereachedfullocclusion,smalltoothmvmtsoccurtocompensateforwear

oncontacts(mesialdrift)&occlusalsurfaces(depositionofcementumatrootapex). Hardtissueformationofprimaryteethat18weeks; Succedaneoustooth–permanenttooththatmovesintopositionformerlyoccupiedbyprimary

tooth;NEVERMOLARS! Toothbudsgenerallyinitiatedafterbirth–PMs,2ndmolars,&3rdmolars. BesttxforpermanenttoothtryingtoeruptbutprimarytoothisstillinplacesisEXTRACTION; Primarytoothtakes1.5to2monthsfromeruptiontoocclusion;CANINEStakethelongest;

Calcificationofrootsbyage3or4;Calcificationofprimaryteethduring2ndTRIMESTER. Afterprimaryteethfallout,extraspaceonMand=3.1mm/quad(6.2)&Max=1.3mm/quad(2.6). Mand.3rdmolarsarelasttobegincalcificationat8‐10years. Girlsteetheruptbeforeboys;girlsreachpuberty2yearsbeforeboys.

TOOTHDEVELOPMENT: Toothdevelopmentinitiatedbymesenchyme’sinductiveinfluenceonoverlyingectoderm; Enameloftoothfromectodermwhileothertissuesoftoothfrommesenchyme. Ectodermalcellsresponsibleforcrownroot&shape; HistogenesisofTooth:onceectomesenchymeinfluencesoralepitheliumtogrowinto

ectomesenchyme&becometoothgerm:1) Elongationofinnerenamelepitheliumcellstoenamelorgan2) Differenciateintoodontoblasts3) Depositionoffirstlayerofdentin4) Depositionoffirstlayerofenamel5) Depositionofrootdentin&cementum

Korff’sFibers–rope‐likefibersatperipheryofpulpdealingw/formationofdentinmatrix. Lobes – primary centers of calcification; separated by developmental grooves in posterior teeth&

developmentaldepressionsinanteriorteeth.→ Anteriorteeth–3labial&1linguallobe→ PMs–3labial&1linguallobe(Mand.2ndPM–3labial&2Lingual)→ 1stMolars–5lobes–1foreachcusp.→ 2nd&3rdMolars–4lobes–1foreachcusp.→ Nomamelonsinpermanentteethunlessmalocclusionlikeanterioropenbite!

Hertwig’sEpithelialRootSheath–determines#,size,&shapeofroots;inductorofdentinformationindevelopingroot;

→ Uniformgrowth=singleroottooth;Medialgrowth=evaginations/multi‐rootedteeth;→ formedwhenouterenamelepitheilium&innerenamelepitheliumcombineatcervicalloop

regiontoformthisbilayeredstructure. 6stagesofToothDevelopment:

1) Induction–induction,5thweek,formationofdentallaminafromepithelium&mesenchyme.2) BudStage–proliferation,8thweek,dentallaminainto10budsperarch;shapeoftooth

evident&enamelorganforms;3) CapStage–proliferation&differentiation(eithermorphodifferentiationor

histodifferentiation),9th&10thweek;a. toothgermcompletew/enamelorgan,dentalpapilla(pulp&dentin)&sac.

4) BellStage–11th&12thweek;dentalpapilla(eitheroutercellsorcentralcells);dentalsachasincreaseincollagen;4celltypesinenamelorgan:

i. OEE–cuboidalii. IEE–columnariii. StelateReticulum–star‐shapediv. StratumIntermedium–flattocuboidal

5) AppositionalStage–depositespecificdentaltissues(enamel,dentin,cementum,&pulp).6) MaturationStage–mineralizationatDEJ&continuestiltoothdevelopment2yearslater.

FRACTURES: EllisFractures­1)ClassI–little/nodentin;tx–enamelplasty/bonding.

2)ClassII–fracturecrownw/lotofdentinbutnopulp;tx–restorew/CaOH&GI.3)ClassIII–fracturew/pulpexposure;tx–Pulptherapy&restore.4)ClassIV–fractureentirecrown;tx–pulpectomy&SSC.5)ClassV–toothavulsed.6)ClassVI–fracturerootbutnotcrown.7)ClassVII–displacementoftooth.8)ClassVIII‐fracturecrownenmasse(asawhole).9)ClassIX–injurytoprimaryteeth.

Prognosislessfavorableinhorizontallyfractureprimaryteethversuspermanentteeth; Fracturedmaxillaryanteriorteethmostofteninkidsw/ClassII,Division1malocclusion. ChiefcauseoffailureofreplantationofpermanentteethisEXTERNALRESORPTION. Thicknessofdentininprimaryteeth=½ofdentininpermanentteeth.VITALPULPTHERAPY: Pulpotomy:

→ Nopulpotomyiftoothpainful/swelling.→ FormocresolPulpotomy–txforprimaryteethw/cariousexposure;successofformocresol

pulpotomyforprimarytoothdependsprimarilyonvitalroottip;• ZOEisplacedoverchamber&restored;• allowsresorption&exfoliationofprimarytoothbutpreservesspacemaintainer;• formocresolcausessurfacefixationofpulptissueaccompaniedbydegenerationof

odontoblasts.→ CaOHPulpotomy–notoftenusedonprimaryteethb/calkalinepHcanirritatepulpcausing

internalresorption;mustbesymptomfree;formsNECROTICdentinlayerunderCaOH.• forpermanentteethw/cariousexposurebutimmaturerootdevelopment&healthypulpin

rootcanals. Pulpectomy–canalsdebrided,enlarged,&disinfected;filledw/ZOEsoitwillresorbwhenroots

resorb;txofchoicewhenthereisperiapicalpathology. Apexogenesis–vitalpulptoencouragephysiologicaldevelopment&formationofrootend;MTA

used;

ContraindicationsforIPC‐ 1)SpontaneousPain2)Furcationinvolvement3)PulpInvolvement;4)Primaryteeth

Chronicpulpinfectioninprimarymolarsisnotedinx‐raysasachangeinbonyfurcation.OPERATIVE: Primary molars have exaggerated cervical constriction & enamel rods in gingival 1/3 extend

OCCLUSALLYfromDEJsonogingivalbevel!!ButAxio‐pulpallineangleBEVELED! Class2Amalgamonprimaryteeth‐ 1)Boxbroadercervicalthanocclusal

2)B/L/Gwallsbreakcontact&canfitexplorerthruit.3)B&Lwallscreate90oanglew/enamel.4)Flatpulpalfloor5)isthmus=1/3ofintercuspalwidth.

Ifamalgamfractureoccurs,itismostlikelytooccurhere;preferroundedanglesinprep! “ExtensionforPrevention”–onlyforamalgam,becauseyoucanusesealantforcomposite; ForSCC,reducecusp1‐1.5mm,whileproximalsurfacesarereduced&cariedgingivallytoextentthat

contactw/adjacentteethisbroken;2types–PretrimmedSSCorPrecontouredSSC;o Removesharplineanglesanddistinctbuccalbulgeespeciallyinprimary1stmolar.

Largerpulpalspaceinprimaryteethlimitsdepthofamalgamprep.Duh. Cervicalconstrictioninprimarymolarsmakegingivalfloornotideal&difficulttoadaptmatrixband

tothetooth. Facial&lingualwallsofproximalboxshouldbeparallestoexternalsurfaces&convergeslightly.LA/DRUGS/MEDS: Mandibularforameninchildisslightlybelowplaneofocclusionandmoreanteriorthanadults; Maxdoseoflidoinkids=4.5mg/kgperappointment. Bupivacaine/MarcaineshouldNOTbeusedonkids. Mostfrequentinhalationagentforsedatingpts=NITROUS;earliestsymptomofconscoussedationis

LightHeadedness;

EMERGENCYTREATMENT: EmergencyTreatmentforFracturesofPermanentteethw/immatureapices:

1. ClassI–smoothenameledgesandrestore.

2. ClassII–applyCaOH&restore.3. ClassIII–applyCaOH&placetemporary;iflarge,performCaOHpulpotomy;afterapexcloses,

dopulpectomy;4. ClassIV–CaOHpulpotomyandafterapexcloses,duepulpectomy;

Intrudedprimaryanteriortooth–NOTX;repositioningofprimaryteethnotrecommended;However,iftheintrudedincisoriscontactingtheperm.toothbud(takexray),thenprim.toothshouldbeTE’ed.

Darkerprimaryteethfromtraumaisduetopulpbleeding&diffusionofBILIVERDINindentintubules;ifdiscoloredprimaryteethisasymptomatic&noradiographicchanges,theNOTX.

Underdevelopedmotorcoordinationismostcommoncauseofdentaltraumainkids1.5‐2.5yrsold. RootfracturesofprimaryteethareUNCOMMONb/cmorepliablealveolarbone;However,ifroot

fracture,sametxaspermteethbutLESSfavorableprognosis;SplintingisNOTrecommendedforprimaryteeth;

THERMALtestismostreliableinprimaryteethbutpulpvitalityisntcommonlytestedintheseteeth.FLUORIDE: CDCrecommendsatleast0.7ppmoffluoridebepresentindrinkingwater;maxamt=1.2ppm. Waterfluoridation&supplementsmayaffecttoothmorphology; Typesoffluorideaddedtowater: 1)Sodiumfluoride

2)Hydrofluosilicicacid3)Sodiumsilicofluoride

Asfluorideconcentrationincreasesbeyond1ppm,thenincreaseinfluorosisprevalencebutnoincreaseinreductionofdentaldecay;

43stateshavewaterfluoridation,62%ofpopulation;Fluoridationcost72cents/person/year. Schoolwaterfluoridationconcentrationis4xthecitywaterduetolesswaterconsumptionatschool. Themostcost‐effectivemethodofdeliveringfluorideto6‐12yearoldchildren(innon‐fluoridated

community)isthroughschoolwaterfluoridation. Overthecounterfluoriderinces:ACT,Fluoriguard,Prevident;allcontain0.2‐0.5%NaF. Fluorideintoothpastes:1)StannousFluoride

2)SodiumMonofluorophosphate3)SodiumFluoride4)SodiumFluoride&CalciumPhosphate

FluorideconcentrationinUSAis0.1%(1,000ppm)=.22%NaF=.76%NaMFP=.4%SnF2. MostdesirableformofFl‐isfluorohydroxyapatite(lessacidsoluble,moreresistanttocaries)&most

efficientmeansofformingthisrxnisprolongedexposureofenamelto↓concentrationoffluoride. Majormechanismoffluorideiscariesinhibitionwhichincreasesremineralizationofenamel; Fluoridealsoinhibitsglycolysis(wheresugarisconvertedtoacidbybacteria); FluorideisBACTERICIDAL;decreasesenamelsolubility;leasteffectiveonrootsurfaces; FluorideworksbystoppingorevenREVERSINGtoothdecay;greatesteffectonnewlyeruptedteeth. EnameldemineralizationstartsatpH=5.5. Greatestconcentrationoffluorideionsexistonoutermostlayerofenamel; Acutefluoridetoxicitytx=syrupofIPECACtoinducevomiting&call911;calciumbindingproducts

likemilkdecreaseabsorption. Deathbyacutefluoridetoxicityiscardiacfailure&respiratoryparalysis;fluoridetoxicityshowsupin

thebonesasOSTEOSCLEROSIS; Childlethaldose=15mg/kg;Adultlethaldose=4‐5gm;completelyweightdependent; Fluorideabsorbedthrustomach&smallintestine&excretedbykidney; Fluoride’smaineffectoccursAFTERthetoothhaseruptedabovethegingiva! 3typesofTOPICALFLUORIDE:

SodiumFluoride(NaF)–2%;neutral/basicpHof9.2;acceptabletaste;29%efficacy; StannousFluoride(SnF2)–8%;doesn’tetchporcelain;BADTASTE&stainssilicate

restorations;pH=2.1‐2.3;mainadvantage–SINGLEAPPTbutnotusedinU.S.

AcidulatedPhosphateFluoride–1.23%;acceptabletaste(bitterw/oflavoring)butdamagesporcelain&contraindicatedinimplantrestorations;

a. MOSTCOMMONLYusedinpractice;

Fluorosis–irreversiblediffusesymmetricHYPOMINERALIZATIONdisorderofameloblastsduring

CALCIFICATIONperiodoftoothdevelopment.SEALANTS: Fissuesealantssucceedbyalteringhostsusceptibility. Lowviscositysealantswetacid‐etchedtoothsurfacesthebest; SealantsneedMICRO‐MECHANICALRETENTION; Acidetchedw/30‐50%phosphoricacid; Propertiesofsealantsareclosertounfilleddirectresinsthanfilledresinslikecomposite; Sealantsarebestretainedonmax&mandPREMOLARS! Theprincipalfeatureofasealantrequiredforsuccessisadequateretention. ComponentsofPit&FissureSealants:

a. Bis‐GMA–monomerdilutedw/TEGDMAtoreduceviscosity.b. Initiator–BenzyolPeroxideinself‐curedsealants&Diketoneinvisible‐likecured.c. Accelerator–amineisself‐cured.d. OpaqueFiller–smallamountsoftitaniumoxidetomakedifferentcolorthanenamel.

PEDSPATHOLOGY: CleftPalate&LipareMOSTCOMMONcraniofacialmalformation,accoutingfor50%ofalldefects! CleftPalate–failureoffusionofpalatalshelvesofMax.processw/primarypalate;moreFEMALES;

impairsspeech&swallowing;occursduring1sttrimesterofpreganancy(6‐9wks)4classes:1) ClassI–onlysoftpalate2) ClassII–Soft&hardpalate3) ClassIII–Class2&alveolarprocess4) ClassIV–Class3&throughalveolusonbothsidesofpremaxilla.

CleftLip–failureofmedialnasalswellings&maxillaryswellingtofuse;Left>Right;moremales;lip&primarypalatedevelop@4‐5weeksgestationperiod;during4‐6wksofpregnancy;4classes:

1) ClassI–unilateralnotchingofvermillion2) ClassII–Class1&extendstolip.3) ClassIII–Class2&extendstofloorofnose.4) ClassIV–bilateralcleftingoflip.

AtrophicGingivitis–recessionw/outalveolarboneloss;minorgingivalinflammation; Cretinism–HYPOTHYROIDISMduetoabsenceofthyroxinefromthyroidgland;defectivemental&

physicaldevelopment;curvedspine&pendulousabdomne;featuresarecoarse;thickenedlips.→ Underdevelopedmandible&overdevelopedmaxillaw/enlargedtongue;→ Anterioropenbite&flaring;delayederuption;uneruptedbutfullydevelopedperm.teeth.

ADHD–M:F=10:1;3‐5%ofchildren;childdoesn’tusuallyneedspecialdentaltreatment;→ Tx=Methylphenidate(Ritalin)–CNSstimulant;Amphetamines(Dextropamphetamine).

ScarletFever–EXOTOXIN‐mediateddiseasearisingfromgroupAβ­hemolyticstrepinfections;mostlyin4‐8yrsold;strepthroat,fever,headache,nausea,vomiting,pain,&fatigue;

→ Strawberrytongue–enlargementofFUNGIFORMpapillaeabovethelevelofdesquamatingfiliformpapillae;appearanceofunripedstrawberry;tx=PCN.

Diptheria–acutecontagiousdiseasecausedbyBacteriumCorynebacteriumDiptheria,characterizedbyproductionofsystemictoxin;damagingtoheart&CNS;immunizationavailable.

NursingBottleCaries/BabyBottleToothDecay–mostaffectMAX.INCISORS;rampantdecayfromsleep‐timebottlefeeding&activityofstrepmutans;

CongenitalPorphyria–autosomalrecessive;skinbecomelightbrown&sensitivetosunlight&photosensitivityexpressedaslargebullouslesions;→ teetharepink/brownbutscarletunderUVlightduetoexcessiveporphyrinsinbloodduring

mineralization;3complaints: 1)Photodermatitis2)Neuropsychiatriccomplaints3)Visceralcomplains(abdominalpain/cramping)

Down’sSyndrome–underdevelopedmidfacialregions;ClassIII;openbite;chronicmouthbreathing,delayedtootheruption,↑rateofmissingteeth;rootsshort&conical;heartdefectsarecommon;

→ Needcomprehensivepreventiveplan;difficultyacceptingdentalcarebutcooperationimprovedbyusinggradualexposuretodentaloffice;

Type1Diabetes–bodycantproperlyuse/storeglucose;bodycompletelystopsproducinginsulin;Xerostomia,infections,poorhealing,↑periodontaldisease,burningmouthsyndrome,blindness;

ApertSyndrome–cranial/limbanomalies;skull,midface,hands,&feetmalformations;Shovel‐shapedincisors;Lefort3surgeryforretrudingmidface;supernumeraryteeth,ClassIIImalocclusion.

Autismpresentsinthefirst3yearsoflife;neurologicaldisorderthataffectsbrainfunction;4xmoreprevalentinmalesthanfemales;

CrouzonSyndrome–autosomaldominantcraniofacialdisorder;maxillaryhypoplasia,crossbite;dysmorphicfacialfeatures;

Rieger’sSyndrome–delayedsexualdevelopment&hypothyroidism;hypodontia,underdevelopedpremaxilla,cleftpalate,&protrudinglowerlip;

TreacherCollinsSyndrome–mandibularfacialdysostosis(disorderofdevelopingbone);autosomaldominant;sunkencheekbones,recedingchin,malformedears,mandibularhypoplasia,narrowface.

Seizures–grandmal(2‐5min)ismostcommon(90%);3phasesofseizures:1) Aura–smell,taste,vision,hearing,emotions2) Ictus–largerevent;tx=supineposition,BLS,oxygen(ifcyanotic)3) Postictal–drowsiness&confusion;brainrecovery;tx=IVof25‐50mlof50%dextrose,

then10mgIVofDiazepam; Hemangiomaismostcommonbenigntumorofinfants;vascularbirthmarksthatarebiologically

activesoindependentofchild’sgrowth;5xmorecommoningirls; 3stagesofOdontogenicInfection:

1) PAosteitis–inflammationw/inalveolarbone;NOsofttissueswellingbutsensitivetopercussion.

2) Cellulitis–infectionspreadsfrombonetosofttissue;inflammation&edemaoccurs;sensitivetopalpation;maybecausedbynecroticprimary/permanenttooth;discoloredtissue;bacteria–GroupAStrep&StaphAureus.a. OftenLudwig’sAnginainkidswhichcausesDEHYDRATION!

3) Supparation–inflammationlocalizedtodiscrete,fluctuantabscess; ConditionscausingDelayedExfoliation&DelayedEruption:CleidocranialDysostosis,Ectodermal

Dysplasia,Down’sSyndrome,Gardner’sSyndrome,OsteogenesisImperfecta,Rickets,severecongenitalheartdisease,&mentalretardation;Hypothyroidism,Hypopituitarism,Hypoparathyroidism,&genetics(mostcommonreasonformissingteeth);

MISCELLANEOUS: ChildshouldhavePANObyage6;frequencyofxraysdependsonchild’sriskofdecay; 1stBWsshouldbetakenwhenthespacesb/wtheposteriorteethhaveclosed. Within6monthsof1sttootheruption–dentalvisit(b/f1stbirthday!); 30‐60%lossinmineralizationb/fcariesisradiographicallyevident.

Atage6,childsheadis90%ofadults. Atbirth‐ 1)jawcanaccommodateallprimaryteeth

2)widthoffaceatgreatest%ofadults3)palateisflat4)can’tdifferentiatesour,salt,orbittertaste5)cranialvaultverynearsizeofadult6)brain&cranialbasefullydeveloped.

Tonsilsinearlylifefunctiontofilterbacteria&programproductionofantibodies; Age6‐12,lymphtissue200%ofadulttissue;lymphtissuedecreasesatpubertywhilegenitaltissueis

developing; Ifpermanenttoothbudisaccidentlyextractedwhileremovingprimarymolar,immediatelyorientthe

toothbud,replantthebudusingdigitalpressure,&suture. HydrodynamicTheory–painresultsfromindirectinnervationcausedbydentinalfluidmovement

intubuleswhichstimulatesmechanoreceptorsnearthepredentin. Themostpersonalbehaviorbythedentististouchingthepatientgentlyinthearm. ThemainadvantageofusingrubberdamisitAIDSinchildmanagement;itworksforvery

nervous/anxiouspts; AveryyoungchildisbestmanagedunderGA;premedicationw/barbituatemaycauseparadoxical

excitementinayoungchild. Post‐anestheticlipbitingiscommonpost‐treatmentcomplicationinchildren;

PERIODONTICS TxofPerio‐EndoAbscess: 1)RCT–re‐evaluatein2‐3mo.

2)Antibiotic3)Sc/Rp4)Periosurguryifneeded2‐3mo.afterRCT

PeriodontalCyst–cantbedifferentiatedradiographicallyfromperiodontalabscess;commoninmand.Canine/PMarea;teethvital;noperiodontalpockets;presentsasalocaltenderswelling;tx=excision.

PeriodontalAbscess–vitalteethwithdeeppockets;acutepainthatisconstant,severe,andthrobbing;increaseinmobility;tx=PCN.

PeriodontalTxPlanning:I) OHI,extractionofhopelessteeth,SRP,Occlusaladjustments/Nightguard,Splinting;RE‐Eval.II) PerioSurgeryIII) RestorativePhaseIV) MaintenancePhase

POCKETS: GingivalPocket–noapicalmigrationofjunctionalepithelium;coronalexpansionofmarginaltissue; PeriodontalPocket–Junctionalepitheliumtomigrateapicallyalongcementum;attachementloss!

• Suprabonypocket–baseofpocketcoronaltocrestofbone;horizontaldestructionofbone;notintraosseous.

• Infrabonypocket–baseofpockeapicaltocrestofbone;periodontalosseousdefect;angular/verticaldestructionofbone;**contraindicationofMucogingivalSurgery!

Infrabony/Intrabonypockets–verticalboneloss;classifiedas:1. 1‐walled=hemiseptum(onlyprox.wallspresent)orramp(onlyF/Lwallpresent).2. 2‐walled=interdentalcrater3. 3‐walled=intrabonydefect;contraindicationformucogingivalsurgery.4. 4‐walled=circumferencial/moatdefects.

• 3and4walleddefectshavebestprognosisfortreatment!• 0(zero)walleddefect=dehiscencesandfenestrations;NOTXwithosseoussurgery!

Dehiscence–lossofbuccal/lingualboneoverlayingrootportionoftoothleavingareacoveredbysofttissueonly.

Osseouscraters–concavitiesincrestofboneconfiedwithinfacialorlingualwalls;1/3ofalldefectsand2/3ofmandibulardefects;TX=osseoussurgeryandrecontouring.

HorizontalbonelossparallelsCEJ’sofadjacentteethandisusuallygeneralizedwhileverticalbonelossisoftenlocalized.

Onlywaytodetermine#ofwallssurroundingtoothisexploratorysurgery. 2mostcriticalparametersinprognosisoftooth–mobilityandattachmentloss. Pseudopocketing–pocketingw/oattachmentlossandmarginaltissuemovescoronally;pseudopicks

aresuprabony. Firstdetectablesignofinflammationisincreaseinsulcusfluid;bleedingisthemostreliableindicator

ofgingival/periodontalinflammation. BestcriteriontoevaluatesuccessofSRPisNOBLEEDINGonprobing! IfafterSPRptreturnsin1wk,w/hard&blackdepositsofcalculusaroundgingivalmargin,indicates

reductionininflammationandoldcalculusisnowexposed. WhenthegingivalmargincoincideswiththeCEJ,thelossofattachment=thepocketdepth.FURCATIONS&MOBILITY: ClassesofFurcations:(GLICKMANFURCATIONCLASSIFICATIONS)

I. Incipientboneloss;probefeelsdepressionoffurcationopening.

II. Partialboneloss;probetipunderroofoffurcation;lesionisCul­de­sac,nottunnel!III. Totalboneloss;thruandthrufurcation(TUNNEL);furcationentranceisntvisible.IV. GradeIIIfucationbutentrancevisible.

Tx=guidedtissueregeneration;GradeIIfurcationshavegoodprognosis. Max2ndMolarshavepoorestprognosis. MobilityClasses:

0. NoMobility1. Barelydistinguishablemvmt.(.5‐1mm)2. Mvmt1‐2mm3. Mvmt>2mmORteethdepressedorrotateinsocket.

PERIODONTIUMANATOMY: Gingivalunit=freegingiva+attachedgingiva+alveolarmucosa AttachmentApparatus=PDL+cementum+alveolarbone Freegingivalgroovedemarcatesjctb/wfreegingivaandattachedgingiva;onlypresentin33%of

adults. AttachedgingivaandfreegingivaisKERATINIZED!Gingiva

coronaltothemucogingivaljunctioniskeratinizedandgingivaapicalisnon‐keratinized.

WidthoffacialattachedgingivagreatestonfacialsurfaceofMAX.L.Incisorsandnarrowestb/wMAND.Caninesand1stPMs.

Attachedgingivaiscoralpinkcolorbutitdependsondegreeofkeratinization,thicknessofepithelium,presenceofmelanin,and#ofbloodvessels.

Attachedgingivaismeasuredbysubtractingpocketdepthfromwidthofgingivafromfreegingivalmargintomucogingivalmargin.

Stippling–irregularsurfacetextureofattachedgingiva;intersectionofepithelialridgesthatcausedepressionandinterspersingconnectivetissuepapilla.• Inhealthyattachedgingiva,itshowssignsofstippling=orange‐peel

appearance. Gingivalapparatus=gingivalfibers+epitheliaattachement. GingivalLigament=dentogingival+alveologingival+circularfibers. IndifferentFiberPlexus=inPDL;smallcollagenfibersthatrunindifferent

directions. Gingivalfibersaretype1collagenfibersthatextendfromcervical

cementumintogingiva;justfreegingivabutpartofPDL;supportsgingivaandkeepsitcloselyadaptedtotooth.• A‐CircularFibers–resistrotationalforces;encircletootharoundmost

cervicalpartofroot;insertintocementum,laminapropria,andalveolarcrest

• B‐DentogingivalFibers–extendfromcementumapicaltoepitheliaattachementandcourselaterally.

• C‐DentoperiostealFibers–fromcervicalcementumoveralveolarcresttoperiosteumofbone;

• D‐AlveologingivalFibers–insertincrestofalveolarprocessandspreadintofreegingiva.

GingivalcollagendifferentthanrestofbodywiththecollagenturnovernotasrapidasPDL;collagenis60%of

gingivalprotein;butgingivalcollagenhassignificantlygreaterturnoverratethantendonsandpalate! EpithelialAttachement–mediatesattachmentofreducedenamelepithelium(1oattachment)or

junctionalepithelium(2oattachment),namelyinternalbasallaminaandhemidesmosomes;joinsfreegingivatotoothsurface.• TheattachmentapparatusthatjoinsJEtotoothsurface.

Junctionalepithelium(.25‐1.35mm)‐stratifiedsquamous,non‐keratinizedepitheliumthatsurroundstoothlikecollar;2basallaminas;inhealthygingiva,JEisentirelyonenamelaboveCEJ.• Firmlyattachedtotoothbyhemidesmosomes;DOESN’Tcontainretepegswhilefreegingivadoes.• 10‐12cellsthicknearsulcusand2‐3cellsthicknearapex.• HasaproliferativecelllayerresponsibleformostcelldivisionsandincontactwithC.T.• JEhaddesquamative/sheddingsurfacelocatedatcoronalendandformsbottomofgingivalsulcus.• LongJEreferstoJEindisease.

ThePDLishighlyvascular&cellularconnectivetissuethatsurroundstherootsofteethandbridgesrootcementumwithalveolarbone;PDLisspecializedromofC.T.derivedfromdentalsac.

PDLPrincipalFibers(type1collagen):connectrootcementumtoalveolarbone.A. Transeptal–toothtotooth;keepsteethaligned;notinfacialaspect.B. Alveolarcrest–cementum–alveolarcrest;slantsapicallyandresists

LATERALmvmtandcounterbalanceocclusalforces.C. Horizontal–runsperpendicularformbonetocementum;resists

LATERALmvmt.D. Oblique–slantsocclusallyfromcementumtobone;resistantto

MASTICATORYforces;1/3offiberssomostnumerous.E. Apical–radiateapcialfromcementumtobone;INITIALresistantto

OCCLUSALforces.F. Irradicular–cementum‐furcation;onlymulti‐rootedteeth.

Sharpey’sFibers–terminalportionsofthecollagenfibersthatinsertintocementumandalveolarbone;diameter>onbonesidethancementumside.

ThePDLishour‐glassshapedw/narrowestpartinthemiddleoftheroot. PDLfuctions: ‐formative(connectivetissue)

‐remodeling(resorbcementum)‐sensory(proprioceptiveandtactilesensitivity‐physicalandnutritive

• .2mmwideanddecreasewidthasyouincreaseinage;immatureelastin=oxytalan+eluanin;• Oxytalanfibersrunparalleltorootsurfaceinverticaldirectionandbendtoattachtocementumin

thecervicalthirdoftheroot;regulatesvascularflow.• MajorcellsofPDL: 1)FIBROBLASTS,macrophages,andectomesenchymalcells.

2)cementoblastsandclasts3)osteoblastsandclasts4)cellrestsofmalassez5)vascularandneuralelements.

• NerveendingsinPDL= 1)freeunmyelinatednerves–conveypain2)encapsulatedmyelinatednerves–conveypressure.

4traitsthataffectPDLhealth: 1)ant.teethhaveslight/nocontactinMIC.2)occlusaltable<60%ofoverallF/Lwidthofteeth3)occlusaltable90ototooth’slongaxis.4)mandibularcrownsinclined15‐20%towardthelingual.

EpithelialRestsofMalassez–groupsofepithelialcellslocatedinPDL;remnantsofepithelialrootsheaththatremainfollowingdisintegrationduringrootformation.

PDListhickerinfunctioningteeththannon‐functioningteeth. CEJcurvestowardtheapexF/LandawayfromapexM/D;curvaturegetssmallerasapproachmolars.

• greatestcontourofcervicallinesandgingivalattachementsoccurontheMESIALsurfaceofanteriorteethwiththegreatestcervicallinecurvatureonthemesialofthemax.centralincisor.

Attachedgingivacanwithstandfrictionalforcesbutalveolarmucosacant. FunctionalAdequateZoneofGingivaiskeratinizedandfirmlybondtobone;2mmor>inwidthand

resistanttoprobing. KeratinizedTissue(allstratifiedsquamousepithelium)–hardpalate,vermillionborderoflips,

dorsumoftongue,andgingiva. MasticatoryMucosa–free&attachedgingivaandhardpalate;keratinized; Lining/ReflectiveMucosa–mucosathatlinesmostoftheoralcavity;non‐keratinizedepithelium. SpecializedMucosa–coversdorsumoftongueandtastebuds;keratinized. JunctionofliningmucosawithmasticatorymucosaisMucogingivalJunction. AlveolarProcess(2Parts).

1) AlveolarBoneProper–partofalveolarprocessthatimmediatelysurroundstherootoftoothandPDLfibersareattached;

a. PerforatesCribiformPlate(2layers)– 1)CompactLamellerBone(spongyandcompact)2)Layerofbundlebone(PDLfibersinsertintoit)

2) SupportingAlveolarBone–surroundsalveolarboneproperandsupportsthesocket;2layers:a. CorticolPlate(thickerinmand.)b. Spongybone(fillsinb/wcorticolplateofbone);itisnotinant.regionorradicularbuccal

boneofmax.post.teethwherecorticalplatefusedtocribiformplate.• Compactbone‐ 1)cribiformplate(socket)–bundlebone(PDLattaches)

2)corticalplate(undergingiva)‐bothareseparatedbyspongybone.

Epithelialattachementhasnoretepegs. HydrodynamicTheory–rootsensitivitycausedfromindirectinnervationfromdentinalfluidmvmtin

tubules,whichstimulatesmechanoreceptorsinpulp. VitaminCisneededforcollagenformationforhydroxylationofprolinetolysine. CEMENTUM–thicknessfrom0.05‐0.6mm;radicularcementum(thickerthancoronal)iscementum

onrootandcoronalcementumiscementumonenamel;depositionofnewcementumcontinuesperiodicallythroughoutlifesorootfracturescanberepaired.• Cellularcementumcontainscementocytesandmostlyinapical1/3ofrootandfurcations;formed

aftertoothreachesocclusalplane.• Acellularcementumiscementumw/ocellsandmostlyincoronal2/3ofrootandthinnestatCEJ;

majorroleistoothanchorage;firstformedcementum.• Mainfunctionofcementum:1)canresorbbutcantremodel!

2)theattachementsofprincipalfibersofPDL3)protectsrootsurfacefromresorption4)compensatesforlossoftoothstructurefromocclusalwearbyapicaldepositionofcementum.5)reparativefctthatallowsreattachmentofC.T.afterperiotx.

• 2collagenfibersincementumaresharpey’sfibers(perpendiculartocementum)andtype1collagen(paralleltocementum).

PLAQUE&CALCULUS: Layerofbiofilmcoverscalculuswhichcausesplaquetoattach. Plaquebacterialdevelopment:gram⊕facultativetogram–anaerobicbacteria. Plaque‐accumulationofmixedbacterialcommunity(>1010bacteria/mg)inaDEXTRANMATRIX; PLAQUE=80%water&20%solids(95%bacteria);alsocontainscalcium&phosphorus(fromsaliva) PlaqueismostlikelytoaccumulateonINTERPROXIMALtoothsurfacesfirst. Plaque–small#ofepithelialcells,leukocytes,andmacrophages;cellscontainextracellularmatrix

withproteins,polysaccharides,andlipids;

• Extracellular/dextranmatrixisinsolubleandsticky;• Gram⊕Facultative=S.MutansandSanguisandActinomycesviscosus.• Gram–Anaerobic=Aa,Capnocytophypaspecies,EikenellaCorrodens,P.Gingivalis.• Pellicle–glycoproteindeposite(plaque).• Formation: 1)Formationofpellicle–albumin,lysozyme,amylase,IgA,proteins,&mucins.

2)BacterialColonization– 1)primarycolonizers=gram⊕‐S.Sanguis&Mutans&Actinomycesviscosus.

2)secondarycolonizers=gram–at1‐3daysofplaque ‐‐Fusobactium,Prevotella,Capnocytophaga

3)tertiarycolonizers‐‐P.Gingivalis,Campylobactar, Eikinella,Aa,&Treponema.

3)MaturationStage–bacterialintercellularadhesionresults.4)Day1‐2=cocci5)Day2‐4=coccidominantwithfilamentsandrods.6)Day4‐7=increaseinfilamentsandmixedflorabegins.7)Day7‐14=vibriosandspirochetsw/WBC’s,moregram–anaerobes; ‐signsofinflammation.8)Day14‐21=vibriosandspirochetsinolderplaquewithfilamentousforms; ‐gingivitsevidentclinically.

Calculus=inorganiccontentof70‐90%withCalcium,Phosphate,MagnesiumandCarbonate. ‐2/3oftheinorganicmatterishydroxyapatite;‐organiccomponentsaremicroorganisms,epithelialcells,leukocytes,andmucin.‐CalculusFormationtakesabout12days;itisformedbybathingtheplaqueinhighlyconcentrationsolutionofcalciumandphosphorusfromsaliva.

Supra‐GCalculus–white/yellow;lingualofmand.Incandbuccalofmax.molarsthemostb/csalivarygland;attachesbysalivarypellicle;attachedortoothassociated;Saliva&Dietalteritsbacterialcomposition.• Grampositivefacultativecocci–S.SanguisandMutans,ActinomycesViscosus.

Sub‐GCalculus–darkcolorb/cbloodbreakdownproductsandmoredensethanSupra‐Gcalculus;formedfromgingivalfluidsecretions;attachesbyirregularitiesinCementum;unattachedorlooselyadherent;Saliva&DietDON’Talteritsbacterialcompostion.• Gramnegativeanaerobicrods/spirochets–P.Gingivalis,FusobacteriumNuclatum,Prevotella

Intermedia,Bacteroides.• Sub‐Grootsurfaceroughnessdoesn’tinterferewithhealingafterSRP.

MicrobiologicetiologicfactorinperiodontaldiseasesisPLAQUEwhilecalculusisthemostsignificantLOCALcontributingfactor.

Primaryreasontoremovecalculusisb/citharborsplaqueorganisms. S.Viridinsisanalpha‐hemolyticstreptococcithatarecommonoralflora!INSTRUMENTS: Mosteffectiveinstrumentofsub‐GSc/Rpissharpcuret;workingangle<90oor>45o. RPpromotessoft‐tissueattachement/re­epitheliazationwhichoccursin7­10days. Mostimportantfactortodetermineamountofshrinkageisdegreeofedema. Healingbeginswithbloodclotformationandneutrophilspredominateimmediatelyaftercurettage

(1st12hrs). Chiselisbestforremovingsupra‐Gcalculusinterproximalforant.teeth;singlestraightcuttingedge

withflatbladebeveledat45o. Currettage–removalofsulcularepitheliumandinflammedconnectivetissue;NEUTROPHILS

predominateimmediatelyaftercurrettage;incidentalcurrettageoccursduringSc/Rp.• Objective:Maximumshrinkageaftergingivalcurrettageoftissuethatisedematous.• ContraindicationsforCurrettage: 1)acuteperioinflammation

2)fibrotictissue3)infrabonypockets4)mucogingivalinvolvements5)whenlaterwallistoothin.

• Inorderfornewattachment,needenoughundifferentiatedmesenchymalcellspresent,completeremovalofcalculus,andcompleteremovalofjunctional/pocketepithelium.

• GraceyCurets:(60otocuttingsurface)I. #1/2&3/4–shortshankdistanceandforant.proximalsandB/Lposteriors.II. #5/6–2differentshanklengthsbutsameas#1/2.III. #7/8–universal(cuttingsurfaceis90o)IV. #9/10–B/LofPM&molars;longcontra‐angledesign.V. #11/12–mesialofpost.teeth.VI. #13/14&#15/16–distalofposteriorteeth.

Graceys: 1)offsetbladebeveled60‐70o.2)curvedin2planes.3)1cuttingedge.‐lowershankisparalleltotoothsurface.

Universal:1)notoffsetwith90otoshank.2)2cuttingedges.3)curvedin1plane.

‐lowershankslightlytiltedtowardthetooth. Curettesaresmallerthanscalersandhavegreatertactilesensitivitythanscalerssobestinstrument

forSub‐Gcalculusdetection&removal. whensharpening,avoidproducing“wire‐edge”byfinishingwithdownstroke. ProperlysharpedinstrumentwithNOROUNDSURFACESwillnotreflectlight. whensharpening,lubricantallowsmetallicparticlestobesuspendedinlubricantsoprevents

scratching/glazingofstone;useoilwithnationalstonesandwaterw/artificalstones. manualsharpeningispreferred; instrumentswhosecuttingedgeis>90owillslipoverthecalculus. Sharpeninggraceyanduniversalcurettesareessentiallythesame. Curet–greatertactilesensitivitythanscaler;cuttingedgeparallelandcurved;smallerthangracey;

firstdoshortstrokesandthenlongstrokes. Rootplaningstrokesarelongerandlighterthanscalingstrokes. PeriodontalFiles:(cuttingedge90o)crush/fractureaccessibleSupraGcalculus;bestonB/Lsurface;

goodfordistaloflastmolar;useVerticalPull‐typestrokesandcanreduceamalgamoverhands. Hoes:(singleandstraightcuttingedge90o)onlyverticalpull‐typestrokes;B/Lsurfacesarebest; HoesandFilesareusedexclusivelyforHEAVYSupra‐Gcalculusremovalbutmaybeusedsub‐Gif

grosscalculusonlyandtissueisflexibleandeasilydisplaced;bothhavethickbladesandlackoftactilesensitivityandadaptability;curettesusedafterhoeandfilesareused!

Mostimportantplaqueretentivefactoriscalculus! Probeangle10otodetectcraterbutmostlyparalleltolongaxisoftooth;probehas0.5taperedshaft. PeriodontalprobeisadaptedinproximalareassotouchescontactareawithtipangledSLIGHTLY

BELOW&BEYONDthecontactarea. Clinicalprobing>histologic/pocketdepth;accuracy+/=1mm. MostimportantreasonforusingperiodontalprobeistodetermineATTACHMENTLOSS! Naber’s2NorHampProbeareusedtodetectfurcations. Correctprobeforceis10‐20gsodepressesthumbpad1‐2mm. Recordpocketdepths>3mmandwhengingivalcrest<2mmat/belowCEJ. Inhealthygums,crestofalveolarboneis1‐2mmbelowCEJ. MostcommonerrorduringprobinginEXCESSIVELYANGLINGtheprobeinterproximally. ProbeshouldalwaysbeincontactwithtoothandFLATagainstthetooth.

Recession(gingivalatrophy)ismeasuredaspositivevaluesoifgingivalmargincoronaltoCEJthenrecessionisnegative.

Bacteremiacanoccurevenwithmasticationorbrushing,somustpremedicateifprobing. Toothbrushtrauma(abrasion)–usuallyoccursoncanineandPMs;mostcommonisleftcanineof

righthandedpeople;MOSTCOMMONetiologyfactorforgingivalrecession.• Dentinabraded25xmorethanenamelandcementum35xmore.• GingivalClefts–narrowgrovesthatextendfromcrestofgingivaltoattachedgingiva.

MostdifficultarearstoSc/RparetrifucationsofMax.Molars. Cementum,dentinandcalculusareallremovedduringSc/Rp. InRP,workingstrokebeginsatapicaledgeofjunctionalepithelium(baseofsulcus/pocket). Probing/WorkingStrokeisupward&downwardmovementw/inpocket. ScalingstorkeisshortandpowerfulPULLstroke;themotiontoinitiateascalingstroekisfromthe

FOREARM. Commonclinicalchanges1wkafterSRPincludereducedpocketsandgingivalinflammation. 3BasicStrokes: 1)Exploratory/AssessmentStroke

2)ScalingStroke–shortandpowerfulpullstroke.3)RootPlaningStroke–longoverlappingpullstrokes.(lesspressure)

OrderofstrokesforSc/Rp=vertical,obliqueandthenhorizontal. Correctangulcationofcurrettefacialsurfacetotoothis70­80o. straightshanksforanteriorareasandcontra‐angleshanksforposteriorareas. Afterperiotx,the1strecalshouldbein3mo.andthencanbelengthenedto4‐6months. Mostdifficultareastoscaleare: 1)mesialofmax.PMs

2)proximalsofmand.Incisors.3)trifurcationsofmax.molars.(MOSTDIFFICULT!)

BestclinicalaidtodeterminifSub‐Gcalculushasbeenremovedisexplorer&BWs. IfCurettetipbreaksoff: 1)useanothercurretteinaspoon‐likestroketopullthefragmentoutof

sulcus;2)takePAandplacept.UPRIGHT.3)checkfloorofthemouthandmucobuccalfold.4)bestwaytopreventcurettebreakageispropersharpeningtechnique.

Power‐DrivenScalers:useeithermagnetostrictive(ELLIPTICALVIBRATIONPATTERN)orpiezoelectrictechnology(LINEARVIBRATIONPATTERN)toconvertelectricalenergytophysicalenergyattip;basedonuse/principalofHIGH‐FREQENCYSOUNDWAVES;• vibratesfrom25,000‐40,000cycles/secandamplitude=10‐13µm.• Usesideoftipwithwaterforcoolingwhichcauseswater“cavitation”whichreleasesdissolved

gases. Sonicintrumentsdonotreleaseheatthewayuntrasonicsdo,theyareair‐turbineintrumentsthat

useairpressuretoproducetipvibrationsform2,000‐6,000.OHI: Theprimarycauseofdiseaserecurrenceisdentistteamfailuretomotivatepttopracticeeffective

plaquecontrol. Dentinalhypersensitivity(coldsensitivity)iscommonafterperiosurgeryduetoclinicalexposureof

rootsurfaces;besttx=diligentOH! Orange,green,andbrownstainsonanteriorteetharecausedbypoorOH! ExtrinsicDentalStains: 1)brownstain–duetopellicle;colorfromTANNIN.

2)blackstain–chromogenicbacteria(actinomyces)3)green/green‐yellowstain–commoninkidsduetofluorescentbacteria.4)metallicstain–varyfromgreentoblackdependingonmetal.

Toothbrushmusthavesoft,nylonbristlesandasmallhead. Methodsfortoothbrushing:

1. BassMethod/SulcularTechnique–brushbristlesplace45ototoothandbrushmovedinbackandforthmotionfor20strokes;PREFERREDMETHODFORBRUSHING!

2. ModifiedStillmanMethod/RolledTechnique–brushrestingpartialonteethandpartiallyongingiva;gingivaisblanchedbytoothbrushandmovedbackandforthstrokeswithbrushmovingcoronallysimultaneously.

3. Charter’sMethod–brushpointedawayfromgingivalmarginat45o. 3componentsofSUPERFLOSS:1)stiff‐endthreader–forunderappliances

2)spongyfloss–b/wwidespaces3)regularfloss–forinterproximalplaque.

ToothPasteIngredients: 1)Fluoride2)abrasives–calciumphosphateorcalciumcarbonate‐removesstain&plaque3)surfactants/detergents–sodiumlaurylsulfate(forfoam)4)humectants–glycerin/water(fortexture/moisture)5)binder/thickener–cellulosegum6)flavoringagentsandsweeteners7)coloringagent–titaniumdioxide

ChlorohexidineGluconate12%(peridex/perioguard)–30secfor2x/day;helpscontrolgingivitsandgreatestrisidualconcentrationinmouthafteritsuse;NOTteratogenic.• Causesreversible,yellow‐browntobrownstainsinteeth,tongue,andresinrestorations;impairs

tasteperception;thestainisduetopresenseofaldehydes&ketones.• Retentionpropertiesthatareconcentrationandtimedependent.• Itseffectivenessduetogreatestresidualconcentrationinmouthafteritsuse.

GingivitisdecreaseswithPhenol­basedmouthrinses–LISTERINEandQuaternaryAmmoniumcompounds–SCOPE&CEPACOL;

o Phenolbasedrinsescontain20‐27%alcohol;essentialoilsareflavoringagents. PerioAid–taperedroundtoothpickfortracingmotionalonggingivalmargins;cleansclassII

furcations. Stim‐U‐Dent–balsawoodwedgesforgingivalmassage,interdentalrecession,anddislodging

interproximaldebris. Proxabrush–forinterproximalbrushing. Interdentalstimulator–rubbertipofsmooth/ribbedconicalshape;massagesandstimulates

circulationofinterdentalgingiva;don’tuseifnormalandfilledgingiva. WaterIrrigationDevices–aroundbridgesandorthoappliances;doesn’tremoveallplaque.

• Oralirrigationdevicesarecontraindicatedinptswithperiodontalinflammationandptsrequiringantibioticpremedication.

Polishingteethiscontraindicatedin: 1)communicabledisease2)respiratoryproblems3)greenstains4)newlyeruptedteeth5)ptatriskfordentalcaries

Disinfectants/Antibiotics:1. Actisite–ethylenevinylacetateflexiblefiberimpregnatedwith12.7mgoftetracyclineHCl;for7‐

10daysSubGthenremoved.2. Atridox–biodegradablecontrolledreleasegel(7dy)containingdoxycycline;deliveredviasyringe.3. PerioChip–gelatinchipcontains2.5mgofchlorohexidinegluconate;bio‐absorbableover8days.4. Periostate–2x/daytabletof20mgdoxycline.

PERIODONTALDISEASE: periodontaldiseasemaybeautoimmunedisorder;periodontitisalwaysbeginsw/gingivitis! BWsaremostaccuratetoassessalveolarboneresorption

Smoking/nicotine–increaseinflammationbyreducingoxygeningingivaltissueandtriggeroverproductionofcytokines;smokingcancausebonelossandrecessioneveninabsenceofperiodontaldisease;riskofperiodontitisisdirectlyaffectedby#ofcigarettessmoked.

o Smokingcigarsandpipescarriesequalriskascigarettes. Patientswithdiabeteshave15x’sincreaseriskofperiodontaldiseasethannondiabetics;theyhave

higherlevelsofspecificinflammatorychemicalslikeinterleukins. Periodontaldiseasesisassociatedwith: 1)Down’ssyndrome

2)HIV/AIDS3)Hormoneimbalances4)uncontrolledType1&2diabetesmellitus5)WBCdisorders&Autoimmunediseases6)Medications7)Smoking8)Osteoporosis

Osteoporosis(lossofbonedensity)‐associatedwithperiodontaldiseaseinpost‐menapausalwomen. CriteriafordiagnosisGingivitis‐ ‐color(mostcommoncolorchangeiscyanosis‐bluish)

‐contour(gingivashouldbescalloped)‐tone(normalconsistency)‐size(knifeedgethickness)‐plaque/calculus

• GingivitisisthePREDOMINANTperiodontaldisease.• Bestwaytoevaluateamtanddistributionofplaqueiswithdisclosingsolution.• IgGismostabundantimmunoglobiningingivalexudatesandcommoningingivitis.

3stagesofGingivitis: 1. TransientStage–2‐4daysaftercessationofOH;marginationofleukocytesonjunctional

epithelium.2. DevelopingStage–collagendestructionincreasesandfluidfillsindestructionwithIgG;

lymphocytespredominateandmacrophages.3. ChronicStage–Plasmacellspredominantinlaminadura;IgG(fromplasmacells)andIgA(from

salive)andIgM(rarely). Agranulocytosis&neutropeniaassociatedwithperiodontaldisease. LocalizedAcuteGingivitisismostcommonformofgingivalperiodontaldiseaseinschool‐agedkids. PregnancyGingivitis–commonsignisgingivalhemorrhagetogentlepressue;

• increaselevelsofPrevotellaIntermedia–thisbacteriacravesprogesteroneofitsmetabolism.• Gingivalchangescommoninpregnancybecauseincreaseprogesteroneandincreaseinmasts

cells.• Sc/Rp,polishingandOHIokduring1stand2ndtrimester.

RadiographicchangesinPeridontitis: 1)lossoflaminadura2)horizontal/verticalboneloss3)wideningofPDL

InflammatoryGingivalEnlargement–significantincreaseinpocketscausingpseudopockets. DilantinHyperplasia=progressiveproliferationresponsetogingivaassociatedwithuseofsodium

dilantin/Phenytoin;causedbyplaqueaccumulationandincreasedaccumulationofinflammatorycells;50‐60%ofpeopleondilantinwillgethyperplasia;ifOHisgood,prollywontobtainhyperplasia.

20%ofpeopleoncalciumchannelblockerswillgetgingivalhyperplasia. 20‐30%ofpeopleoncyclosporinA(immunosuppressant)willgetgingivalhyperplasia. HereditaryGingivofibromatosis–raregeneticdiseasescausinggeneralizeddiffusegingival

enlargement,enoughtocovertheteeth;lackofinflammatorycellsandproliferatingcapillaries.o Erythmatouschangesareresultofsecondarybacterialinvolvement.

TxforInflammatoryGingivalEnlargementandHereditaryGingivofibromatosisisGINGIVECTOMY. AggressivePeriodontitis(formerlyJuvenilePeriodontitis)–2forms:

1. Generalized–12‐25yrsold;rapidsevereperiodontaldestructionaroundmostteethandsevereattachmentloss;PrevotellaIntermediaandEikenellaCorrodens.

2. Localized–12‐19yrsold;rapidandsevereattachementconfinedtoincisorsor1stmolarswithabsenceofplaque;etiology–geneticsorneutrophildysfunction;AaandCapnocytophaga(botharealsoassociatedwithperiodontitisinjuvenilediabetes.

• GoodtxforPeriodontitiswithAabacteriaisTETRACYCLINE! PeriodontitisprogressesslowlyandpainlesslybutisARRESTEDwithpropertherapy. Atleast30%ofbonemassatthealveolarcrestmustbelostforachangeinboneheighttobe

recognizedinxray;reductionin.5‐1mmthicknessofcorticalplateissufficienttoseebonedestructioninradiograph.

Periodontitiscantbediagnosedw/oxraysbutxraysarenotdefinitivediagnostictoolwithfurcationinvolvementorinterdentalcraters.

DesquamativeGingivitis–fieryredmarginalandattachedgingivawhichdemonstratesulceratedandnecroticepitheliumthatsloughsoffwithairblasts.• Maybemanifestationoflichenplanusorvesiculobullousdisorderlikepemphigoid.• Atrophic/erodedgingiva;lossofstippling;middle‐agedtoelderlyfemales.• AffectsB/Lattachedtissue;retepegsshort/abscent.• OtherEtiologies–allergy,crohn’sdisease,psoriasis,orchroniculcerativestomatitis.• Tx=steroids/corticosteroidsdependingonetiology;ifdermatologicetiologythenusuallyresolves

whenskindiseaseresolves. ANUG–18‐30yrs;AKA–vincent’sinfectionortrenchmouth;acuterecurringgingivalinfectionof

complexetiologywithnecrosisofpapilla;noattachmentloss;• Historyofsoreness/painandbleedinggumsformeating/brusing;fetororis(odor),low‐grade

fever,lymphadenopathyandmalaise.• interproximalnecrosisandpseudomembraneformationonmarginaltissue;• PrevotellaintermediaandTreponemaspirochetesandFusiformspirochetes.• DominantWBC=neutrophils;predisposedifsmokeorneglect.• Tx=debridgement,hydrogenperoxiderinsesandantibiotics(PCNV,ifnotPCN,then

tetracycline);ptswithHIVandANUGrequiregentledebridementandantimicrobialrinses.BACTERIA: ThemostlikelysourceofbacteriafoundindiseasedperiodontaltissueisSub–Gplaque! Inhealthymouth,morethan350speciesofbacteria,w/periodontalinfectionslinkedto<5%. PeriodontalHEALTH=grampositiveNONMOTILEFACULTATIVEANAEROBES.

• S.Gordininii&Actinomyces PeriodontalDISEASE=gramnegativeMOTILESTRICTANAEROBES. Aggressive&LocalizedAggressivePeridontitis‐ActinobacillusActinomycetemcomitans(Aa) ChronicPeriodontitis–PorphyromonasGingivalis DeepPocketsandANUG–PrevotellaIntermedia,Treponema,Denticola,Sokranskii AlsoassociatedwithPeriodontitis–BacteroidsForsythus Endotoxin–Lipopolysaccharidebaseincellwallofgramnegativebacteria;existsinplaqueand

gingiva;promotesboneresorptionbydecreasingosteogenesisandchemotaxisofneutrophils; PlaqueBacteriaproducesenzymesthatinitiateperidontaldisease:

1) Collagenase–catalyzesdegradationofcollagen(producedbyBacteroides)2) Hyaluronidase(producedbyS.Mitans&Salivarius)&3)ChondroitinSulfatase(producedby

Diptheroids)–leadstodestructionofamorphousgroundsubstance. Acutegingivitis=gram⊕bacterialikeActinomycesandStrep. Chronicgingivitis=gram–bacterialikeFusobacterium,Prevotella,andCapnocytophaga. Oxygenismajordeterminingfactorindifferentbacteria. Oralcavityissterileatbirthbutbacteriapresentat10‐12hrsafterbirth;

• After1yr–S.Salivarious(mostabundent),Staph,Neisseria,Actinomyces,Fusobacterium.

• Atage4‐5,oralfloralikeadults.INFLAMMATION: PMNs(neutrophilicleukocytes)arethefirstlineofdefenseandfirstcellstomigratetogingivalsulcus

wheninflammationiscausedbyplaqueformation;whilePolymorphonuclearLeukocytesaremaincellcomponentsinCHRONICinflammation.

bacteriathatformsplaque/calculusrelasetoxinsthatstimulateimmunesystemtooverproducepowerfulinfectionfightingfactorscalledCYTOKINES:• cytokinesarerelatedtoallperiodontaldisease:ie–TNFα,IL–1B,IL–4,andprostaglandinE‐2.• Cytokinesareforhealingbutcancauseinflammationfromoverproducingcollagenasewhich

breaksdownproteinsincludingconnectivetissuearoundteeth;• oftenhavehyperinflammatorymonocyte/macrophagephenotype.

Lymphocytes:1) B‐Cells–wbcthatmatureinbonemarrowandmigratetolymphoidorgans;antibody‐producing

plasmacellsinvolvedinantibody‐mediatedimmunity;travelstospleen/lymphtodifferenciate.2) T‐Cells–wbcthatmatureinthymusandbecomethymocytes;importantincell‐mediated

immunityandtype4hypersensitivityrxnsandmodulationofantibody‐mediatedimmunity;a. Classes:T‐helpercells,SuppressorT‐cells,andcytotoxic(killer)cells.b. PtswithperiodontaldiseasehaveT‐lymphocytessensitizedtoplaquebacterialantigens.

InflammationofGingivitis:1)Initial(2‐4dys)–neutrophils. 2)Gingivitis(4‐7dys)–lymphocytes,macrophages,IgG,andmastcells. 3)Chronic(wks–yrs)–increaseinplasmacells(IgG)andBlymphocytes. Whengingivitisturnstoperiodontitis–gainelymphocytes,plasmacells,andmacrophages

(representtransitionb/wacuteandchronicinflammation). 3phasesofAcuteInflammation–

1) Vascular–vasocontriction,vasodilation,andincreasedvascularpermeability;basophils,mastcells,andplatelets.

2) Cellular–firstdefensecellsareleukocytes/neutrophils(viachemotaxis–chemotaticfactorsC5aandLeukotrieneB4{LTB4});PMNsengulfmatterbyphagocytosis‐phagosome&phagolysosome.

3) Repair–eitherbyregenerationorreplacement. 4signsofAcuteInflammation‐ 1)redness–dilationofcapillaries(fromhistamine)

2)heat–increasedbloodflow3)swelling–increasedcapillarypermeability(fromhistamine)4)pain–lysisofbloodcellsthattriggerbradykininandprostaglandins.

Mastcellsincreaseinnumberwithincreasedinflammation;releasesheparin/histamineinresponsetoinjury/inflammation;mastcellsparticipateinearlyphaseofinflammation.

o Majorstoragesightsforhistaminearemastcells,plateletsandbasophils.o Anaphylacticresponseischaracterizedbydegranulationofmastcells.

Eosinophilsarenotinvascularphasebutarepredominantinallergicrxnsandparasiticinfections.TRAUMA&INFECTIONS: Radiographicsignsofreversibleocclusaltrauma: 1)wideningofPDL

2)thickeninglaminadura3)angularboneloss4)rootresorption5)hypercementosis

Othersignsofocclusaltrauma:1)alternatingrepairandresorptionofbone2)fibrosisofalveolarbonemarrowspaces3)cementalresorptionleadingtodentinalresorption4)cementaltears

5)ankylosis 6)pulpalnecrosis/calcification Primaryocclusaltrauma–whenocclusaltraumaisprincipaletiologyinchangesinperiodontium.

• EarlyeffectishemorrhageandthrombosisofbloodvesselsinPDL. Secondaryocclusaltrauma–whenperidontiumisalreadycompromisedbyinflammationandbone

losssocantwithstandocclusalforceswell;• Earlyeffectismobility

Rosininperiodontalswellingusedasfillerforstrength; Typesofperiodontaldressings:

a. Eugenoldressing(hardpack)=powder+liquid(eugenol);ie–PPC,Wards.b. Non‐Eugenol(softpack)=base+accelerator;ie–Coe‐Pak&PerioCare;todayperiodontal

dressingsdon’tcontaineugenolb/citcausesitsowntissueinjuryandnecrosis.c. Light‐Cure=syringe;ie–Barricaid

Periodontaldressingshavenowell‐definedeffectonprocessofwoundhealingorsurgicaloutcomes;Mustberemovedin7‐10days.

Afteracuteperiodontalabscessesexude,theybecomechronic. Bruxism:primarycauses–occlusalprematurities,muscletension,andemotionalfactors.

• S&S:PDLwideningandthickeningoflaminadura,soremuscles,andjawpain,difficultyopeningmouth,increasedmobility,andocclusalwearfacets.

IfperiodontalabscessislocalizedthenperformIND;ifnotthenRxantibiotics;themostprevalentsymptomisacutepainandcancauserapidalveolarboneloss.

SplintingTeeth:primaryreasonforsplintingistoIMMOBILIZEexcessivelymobileteethforpatientcomfort;providesevendistributionforocclusalforces;oftenonteethwithreducedperiodontalsupport;• teethtendtoloosenB/LnotM/D.TypesofSplints:1. External–ligatures,toothbonding,etc.;unesthesticandunhygienic;lackdurabilityandfitbutno

toothstructureisremoved.a. NightGuards–primarypurposeistomodify/controlbruxismortoREDIRECTFORCESinot

anon‐traumaticpattern;useCRocclusalsplints.2. Intracoronal–amalgam/acrylicw/embeddedwireandacrylicforprovisionalsplints;tooth

structureremoved;moreserviceablethanexternalsplintsbuttendtobreakandplaquebuild‐up. Stepsinadjustingocclusion:eliminateprematuritiesinCR,inprotrusivemvmt,andlateral

excursivemvmt.PERIOSURGERY: Autogenousfreegingivalgraft–totallydependentonthebedofrecipientbloodvessels!Thistxis

goodforincreasedwidthofattachedgingivaforwideningrecessionofgingivaandprophylacticallytopreventrecessioninthingingiva;

Allograft–grafttakenfrom1humanandplacedinanotherhuman;afreeze‐drieddecalcifiedbonegraftakenfromahumandonor&placedinaperiodontaldefectinanotherhumanisalsoanallograft.

Hemopoieticmarrowisthebonedonorgraftwiththegreatestosteogenicpotential. FreeGingivalGraft–autogenousgraftplacedonviableconnectivetissuebedonB/Lmucosa;donor

siteisoftenedentulousareaorpalatalarea;successdependsongraftbeingimmobilizedatrecipientsite.• Graftepitheliumfirstdegenerates,thensloughs,andreconstructedinaweek;at2wks,thetissue

reformedbutmaturationtakes10‐16wks.• Toplayerofgraftisrevascularizedlast;re‐epithelizationoccursbyproliferationofepithelialcells

fromadjacenttissueandsurvivingbasalcellsofthegrafttissue.• Healingtimeisproportionaltograftthicknessandthegreatestamtofthicknessoccursin1st6mo.

• Freegingivalgraftisnotassuccessfulw/deepwiderecessionsouselaterallyrepositionflap/pediclegraftwhichhasagreaterpredictability.

• Oftenusedinconjunctionwithfrenectomy.• RarelyusedonF/Lofmand.3rdmolars.

Hemisection–verticalsectioningthrubothcrownandroot;ofterMand.Molars;½oftoothextractedandtxlikepremolar.

RootAmputation‐separatingrootfromcrown;mostlymax.1st&2ndmolars; BothhemisectionandrootamputationresultinirreversiblepulpaldamagerequiringRCTafter

resection. OsseousRecontouring–usedtoeliminatepockets!Alsoothertreatmentforeliminatingpockets:

a. Maintenanceb. Bonegraftsc. Reattachment–filledproceduresd. Hemisection/rootamputation

Palatalflapscantbedisplaced!! Flapsaremostcommonperiosurgeriesandfullthinknessflapsaremostcommon! Full‐thicknessflapsareusedwhereattachedgingivaisthin(<2mmwide). Partialthicknessflapincludesonlymucosaandbonenotexposed;usedwhena

dehiscence/fenestrationispresent;usedwhenattachedgingivaisthick(baseofflapis2mm/more). InternalBevelIncision–theincisionfromwhichtheflapisreflectedtoexposethebone/root;the

incision… 1)removespocketlining2)conservesrelativeuninvolvedoutergingiva3)sharpthinflapmarginforadaptingtooth‐bonejunction

DistalWedge–simplestdistalflapforretromolarreduction;performedafterTEof3rdsb/cbonefillispoorleavingperiodontaldefect;baseofwedgeisperiosteumandapexisgingivalsurface;performedif:• Sufficientspacedistaltolastmolar• Maxtuberosity• Mandretromolartriangle• Distaltolasttoothinarch.

Gingivectomy–pocketdeptheliminatedbyresectingthetissuecoronaltopocketbase;alsobevel/contourthecoronalmargin;musthaveadequateattachedgingivaandnoinfrabonydefects.• Factorsaffectingsurgery–pocketdepth,accesstobone,amtofattachedgingiva.• Whendetermininggingivectomyvs.periodontalflap–ifbaseofpocketislocatedatthe

mucogingivaljunctionorapicaltothealveolarcrestDONOTperformagingivectomy. Gingivoplasty–reshapesgingivaandpapillaforcorrectingdeformities;objectiveismore

physiologicaltissuecontournotreducedpockets;commontxforANUG. Primaryobjectivetosurgicalflapproceduresistoprovideaccesstorootsurfacesfor

debridement. ModifiedWidmanFlap–modificationofreplacedflap;full‐thicknessflap;foropenflap

debridementandregenerativeperiodontalprocedures;objectives:o Gainaccesso Reducepocketdepthso Preserveadequateattachedgingivao Provideenv’tforhealingbyprimaryclosure

• Indications: 1)pocketswithbaseslocatedcoronaltomucogingivaljunction 2)little/nothickeningofmarginalbone 3)shallowtomoderatepocketdepthscanbereduced. 4)whereestheticsareimportant. RepositionFlaps:1)Replacedflaps,2)MWF,3)Excisionalnewattachementprocedures.

• Healbyrepair&theyarepocketreductionproceduresthatgainclinicalattachmentmediatedbyrepair.

PositionedFlaps:whencoronalmarginsofflapareliftedfromanareaadjacenttorecipientsitebutflapisntfree’dup.• 1)laterallyrepositionedflaps,2)coronallypositionedflaps,&3)apicallypositionedflaps;• vascularsupplymaintainedsononecroticsloughing;healbyrepair.

ApicallyPositionedFlap:fullthickness,mucoperiostealflap;highdegreeofpredictabilityand“work‐horse”ofperiotherapy;indications:

o Moderatetodeeppocketso Furcationinvolvedteetho Crownlengthening

• Flapissuturedmoreapically,soexposingalveolarmargintoformbroaderzoneofgingiva• Objectiveistosurgicallyeliminatedeeppocketsbypositioningtheflapapicallywhileretaining

theattachedgingiva.• Maxmolarspalatalsurface–trimflapmargintoproperlength;• Contraindications:ptriskforrootcariesandunestheticiftoothexposed.

CoronallyPositionedFlap–full‐thicknessflapexclusivelyusedtorestoregingivalheightandzoneofattachedgingivaoverisolatedareasofrecession.

PedicleGraft(lateralpositionedflap)–firstperiosurgeryforrootcoverage;defectcoveredbystretchingflaplaterallyuntilfreeendcomesoverit;superiorestheticsbutlessversatile;• baseofgraftremainsattachedtodonorsiteforuninterruptedbloodsupplysopositionand

repositionedflapscanbepediclegrafts;oftenfull‐thicknessflaps.• Indications: 1)widenzoneofattachedgingiva

2)repairisolatedrecession• Advantages: 1)predictablecorrection/preventionofrecession

2)minorpost‐opdiscomfort3)goodesthetics.

• Contraindications: 1)lacksattachedgingiva2)donorsitehasfenestration/dehiscenceofsupportingbone.

GuidedTissueRegeneration–blocksrepopulationofrootsurfacetoallowcellsfromPDLandbonetorepopulatebonedefect;useeither:• Non‐resorbablebarriers–expandedpolytetrafluoroethylene(teflon)• Resorbablebarriers–type1collagen,calciumsulfate(plasterofparis),orpolyacticacid.

Mostcommonreasonforfreegingivalgraftfailures=disruptionofbloodsupplyb/fengraftmentand2ndreasonisinfection.

DoublePapillaFlap=variationoflaterallypositionedflap;gingivab/wteethoneithersidearemovedoverexposedroot;indications:

o Traumafrombrushingo Coveringexposedrootsurfaces

DentalalveolarprocesslesssusceptibletopermanentdamageaftersurgicalexposurethanB/Lplatesofbone;

Fourrulesofflapdesign: 1)baseofflapwiderthanfreemargin 2)linesofincisionnotplacedoveranydefect3)incisionsthattraversebonyeminence(canine)shouldbeavoided.4)allcornersofflapshouldberounded.

FreeMucosalAutografts–whentransplantofconnectivetissuew/oepithelialcovering(differfromfreegingivalgrafts);formationofkeratinizedtissueevenifnotkeratinizedrecipient;oftencanineswherelittlekeratinizedgingiva.

Osteoplasty–reshaping/recontouringbonethatisnon‐supportivebone(notattachedtoPDL);indications: 1)deepproximalpocketsofbuccalbone.

2)pocketsonB/L/Psurfaceswhereresorpioncausesledges

3)tilted2ndmolaradjacenttono1stmolar Ostectomy–removalofosseousdefectsorinfrabonypockets(belowthecrestofbone)byeliminating

bonypocketwalls;boneissupportiveinnature;indications: 1)interproximalcraters

2)deepinterproximalpocketswhereneighborareasareintact. 3)shallowinfrabonydefect(proximal)wherereattachment failed.

o Contraindications: 1)ifweakenssupportforadjacenttooth. Insomesurgialprocedures,itisnecessarytoleaveinterradicularboneexposedwhichmayresultin

boneloss. Withoutdirectvisualizationprovidedbyaflap,itisrarethatacliniciancaneffectivelyrootplane

beyond5mmofprobingdepthorintorootfurcationsoflesservalue. Mostcriticalfactorindeterminingtoothprognosisisamt.ofattachmentloss! Defectsthat“willholdwater”offerexcellentopportunitiesforbonegraftcontainmentand

periodontalregenerationprocedures. Bonegraftsuccessdependson#ofbonywallsofdefect;3‐walleddefectisbestandworstisthru‐thru

furcationofmax.molar. Bestindicatorofsuccessofperiodontalflapprocedureispostoperativemaintenanceandplaque

controlbythepatient. Rootresorptionmostlikelysideeffectofautogenousbonegraft.

PHARMACOLOGYSYMPATHOMIMETICS: AutonomicNervousSystem:

1. SYMPATHETIC(“fightorflight”)a. Preganglionic→CHOLINERGIC→Acetylcholine.b. Postganglionic→ADRENERGIC→NOREPI,EPI,&Dopamine(exception–innervationto

sweatglandsischolinergicandsecreteAch)2. PARASYMPATHETIC(“rest&digest”)

a. Preganglionic→CHOLINERGIC→Acetylcholineb. Postganglionic→CHOLINERGIC→Acetylcholine(MuscarinicResponse)

Drugsthatproducetissueresponsesresemblingthoseproducedbythesympathesticnervoussystem;adrenergicagonists;ie–dopamine,epi,norepi,isoproterenol,andphenylephrine.• α1–causescontraction&vasoconstrictionofbloodvesselssodecreaseshypotension;

→ Controlshemorrhage(EPI/adrenalin),allergicshock(EPI/adrenalin),nasalcongestion(phenylephrine–Neo­synephrine);

→ Contractssphinctermusclesinintestines,urinarybladder&uterus;whileβrelaxesthosemuscles;alsoinfatcells&platelets.

• α2–nerveendings;foundinpresynapticnerveendingstoinhibitsNEreleaseandpostsynapticnerveendingstodecreasesympathetictone.

• β1receptor–increasescardiacoutput&conractionviacardiacmuscle;leastcommonreceptor.o Cardiacstimulation(isoproterenol–forasthma);

• β2receptor–↑dilationofbronchiandrelaxationofarterioles;ONLYEPI!;also↑bloodglucose;bronchodilation(albuterol);Betareceptorsmostlyvasodilation&relaxation.

• alphaspredominantlyexcitatorywhilebetasareexcitatoryinhearbutinhibitoryelsewhere. PostJunctionα1–smoothmuscleofiris,arterioles,veins,andGItract(relaxesit!). PreJunctionα2–inhibitsnorepirelease;foundonpost‐synapticendingsinCNSto↓sympathetictone. PostJunctionβ1–inheart(mainlyb1receptors),intestinesmoothmuscle,andadiposetissue. PostJunctionβ2–bronchodilatorandvascularsmoothmuscle. Cranialnervesw/parasympatheticactivity–3,7,9,&10. Catecholamines–sympathomimeticcompoundscomposedofcatecholmolecule&aliphaticportionof

amine;ie–epi,norepi,&isoproterenol:alldirectactingcatecholamines;also,Ach,Dopa,dobutamine,seratonin,GABA,opoids,&glutamate&aspartate;theypassbloodbrainbarrierverypoorly.

Epinephrine–catecholamine;physicalpropertiesunknown;rapidonsetandprolongsdurationofLA;stimulatesα&βadrenergicreceptorsw/insympatheticdivisionofANS.• Epiistheprototypicaladrenergicagonist;• Duringanaphylaxis,extremereductioninBP&bronchospasms,EPIstimulatesα1

(vasocontriction),stimulatesβ2(dilatesbronchioles),stimulatesβ1(increasecardiacoutput).• itproducesphysiologicactionsthatareoppositetheeffectsofHISTAMINE.• Italsodecreasebloodvolumeinnasaltissuesandrelievesnasal,sinus,&throatcongestion.• Restorescardiacactivityincardiacarrest;txforglaucomabyreducinginternaleyepressure.• CanbeadministeredthruIV,sublingually,subcutaneously,orintramuscularly;• Contraindication–ptsw/ANGINA;sideeffects–headache,anxiety,tachycardia;cautioninptsw/

highBPandhyperthyroidism. Norepinephrine–catecholaminethatworksonalpha1&2,andbeta1receptors.

o Forvasoconstricitoninhypotension. Isoproterenol–isb1&b2agonistandtheMOSTPOTENTbronchodilator;causecardiacstimulation. Dopamine–immediateprecursortoNE;catecholaminew/2subtypes:D1–activatesadenylcyclase&

D2–inhibitsadenylcyclase.o Dopamine&Dobutaminebothusedforshock&heartfailure.

Seratonin–5‐Hydroxytryptamineworkthru14subreceptor“trytominergic”typeneurons. Glutamate&Aspartate–aminoacidsthathavepowerfulEXCITATORYeffectoneveryregioninCNS; Sympatheticactivationofeye–mydriasis(dilation),heart–tachycardia(↑HR),salivarygland–thick,

ropeysaliva(↓saliva);activationofparasympatheticdivisionofANScausesoppositeoftheserxns! Ephedrine–non‐catecholamineforurinaryinconstinence&vasoconstrictioninhypotension. Phenylephrine–non‐catecholamineformydriasis,vasoconstriction,&decongestion. Oxymetazoline&Xylometazoline–causesnasaldecongestion. Adrenergicagonistsaredirectactingorindirectingacting(storeandreleaseNOREPI). Amphetamines–sympathomimeticaminesstimulatebothCNS&PNS;passreadilythruCNSand

releaseNE;potentCNSstimulants;increasesystolic&diastolicBPsandweakbronchodilators;Usedfortreatmentsin…

1. ADHD–dexedrine,adderall(dextroamphentamine)insteadofritalin(methyphenidate).2. Narcolepsy–dexedrine(preventsdaytimesleep)3. WeightLoss–lonamine(phentermine)

ADHDTreatment: 1)Methylphenidate(Ritalin)–mildCNSstimulant.2)Focalin–nerformofritalincalledDexmethylphenidate.3)Concerta–long‐actingformofmethylphenidate.4)Adderall–mixedamphetaminesalts(mixofdextroamphetamine&amphetamine).5)Strattera–nameforatemoxetine(1stnon‐stimulant)6)MetadateCR–controlleddeliveryofmethylphenidate.7)Dexedrine–Dextroamphetamine.

SelectiveDirect‐ActingAdrenergicAgonists:1. Phenylephrine(Neo‐synephrine)–a1selectiveagonist;nasaldecongestantandtxorthostatic

hypotensionandpreventsLAdiffusionawayfrominjectionsite;100xlesspotentthanepi.2. Clonidine(Catapres)–a2selectiveagonist;anti‐hypertensiveagent.3. Dobutamine–b1selectiveagonists.4. Terbutaline–b2selectiveagonist;administeredorally,subcutaneously,orinhalationtotreat

longtermobstructivediseaseandERtxofbronchospasm.5. Albuterol–b2selectiveagonist;

α1AdrenergicBlockers(‐ZOSIN)–causetachycardia,vasodilation,↓BP,andorthostatichypotension.o Ie–Doxazosin(longDOA)&Prazosin‐↑BP;Terazosin–txforbenignprostatehyperplasia.

Anti‐Hypertensives–4forms:1. β‐adrenergicblockers(‐OLOL):commonsideeffectisdrowsiness&weakness;

a. Propranolol,Timolol,Nadolol–Blockbothβ1&β2receptors;↓BPby↓CO;contraindicatedinptsw/asthmaorCOPDb/ccausefatalbronchospasm;alsocontraindicatedininsulin‐dependentdiabetesptsb/blockhypoglycemiarecovery.

i. Propranolol–majoranti‐anginaleffectbyblockingβ‐adrenergicheartreceptors;drugofchoiceforadrenergicallyinducedarrythmias.

b. Metaprolol(Lopressor)&Atenolol(Tenormin)–cardioselectivelyblockβ1receptors.i. Metaprolol–B1blockerfortxforangina&↑BP;causesdrowsiness.ii. Atenolol–B1blockerw/longDOA;txforchronicangina&↑BP;lowlipidsolubility

andrenallyeliminated;longdurationofaction.iii. BothMetaprolol&Atenoloarelonger‐acting&morepredictablethanPropranolol

andsafertouseinptsw/asthmaorbronchitis.c. Acebutolol(Sectral)–cardioselectiveB1blocker&partialB2blocker;txfor↑BP&

ventriculararrythmias;↓solubility&mildintrinsicsympathomimetic(similartoPindolol);2. α‐adrenergicblockers:causetachycardia,lowerBP,vasodilation,&orthostatichypotension.

a. Non­Selectiveblockers:don’ttreatcardiacconditionsb/ccancausetachycardia&palpitations.

i. PhentolamineHydrochloride&PhenoxybenzamineHydrochloride–blockbothα1&α2fortxofpresurgicalmanagementofpheochromocytoma(tumorofadrenalglandsthatreleasesexcessiveEPI&NE).

b. SelectiveBlockers:blocksa1totreathypertension&benignprostatichyperplasia(BPH).i. Doxazosin–blocksα1totxhypertensionw/longDOA.ii. Prazosin–blocksα1butrarelyusedtotxhypertension.iii. Terazosin–blocksα1tomanagemildtomoderatehypertensionandBPH.iv. Tolazoline–blocksα2fortxofpulmonaryhypertensioninnewborn;causesdirect

peripheralvasodilation.c. Majoradverseaffectishypotension;d. α‐adrenergicblockerscancauseEPIREVERSAL;theanti‐adrenergicsreversepressoraction

ofadrenalin/EPI;theyblockbothEPI&NEbutthenEPIcauseslowBPb/cstimulatesβ2receptorstooandtheyarenotblockedbyalphablockers.

3. CentralActingAgents:a2selectiveAGONISTSthatinhibitadrenergicnervetransmissionthruactionsw/inCNS;

a. Clonidine,Guanfacine,Gaunabenz,Methyldopa.i. Clonidine–a2selectiveagonistii. Methyldopa–hypertensivetxforrenaldamage(goodw/diuretic);producesfalse

transmitterthatreplacesNE;sideeffects–CV,CNS,GI,hepatitis,andcirrhosis.iii. Guanfacine&Guanabenz–stimulatedcentrallyα2and↓SNSflow&reducevascular

resistance;Tx–antihypertensive;usedeitheraloneorw/diuretic.4. NeuronalDepletingAgents:depletecatecholamine(NE)&seratoninfromadrenergicterminals

andinthebrain;a. Reserpine(blocksNE,EPI&seratonin)&Guanethidine(blocksNE).

αblockersblockepi(adrenaline)andthedepressorresponsemediatedbyβ2receptors(↓BP). α&βblockingagentsactasCOMPETITIVEINHIBITIONonpost‐junctionalreceptors. DrugsforAsthma–β2agonists(bronchodilate)–Epi,Albuterol,Salmeterol,andMetaproterenol.

o Aminophylline–theophyllinecompound–bronchodilator&relaxessmoothmuscleofbronchi.CHOLINERGICS: Cholinergicdrugsstimulateacetylcholinecholinergicreceptors;theycause↑salivation,sweating,GI

motility,miosis(constriction),↑flushing&bradycardia;↑secretions&muscleweakness!• Direct‐Acting(Esters&Alkaloids):Methocholine,Carbochol,Bethanecol,Pilocarpine.• Indirect‐Acting(CholinesteraseInhibitors):Neostigmine,Physostigmine,Edrophonium,&

Pyridostigmine;• 2CholinergicAGONISTSdrugsinDentistry:

1) Pilocarpine(Salagen)–txforxerostomiafromsalivaryglandhypofunctionincancerpts.2) Cevimeline(Evoxac)–specificforM3receptorinsalivaryglands;txofxerostomiainSjrogen’s

Syndrome. 3classesofCholinergicAgonists:stimulatemuscarinicsite&mimicAch;ifanyofthesecholinergic

agentsareadministeredb/fACh,theactionofAchisenhanced&prolonged.1. CholineEsters:↓BPw/generalizedvasodilation;↓HR,↑GItone,miosisthru↓intraocularpressure;

a. AcetylcholineChloride–txtoproducemiosis;methacholine(notusedasmuch).b. Bethanecol–post‐opabdominaldistension&urinaryretention.c. Carbachol–txtoproducemiosis.d. Methacholine–notusedmuchanymore.

2. CholinergicAlkaloids:Muscarine,Pilocarpine,Nicotine,Lobeline;a. Pilocarpine‐mostusefulalkaloidformiotic&txofglaucoma&xerostomia.b. BothCholineesters&Cholinergicalkaloidsstimulatesmoothmuscleactivityandbothare

direct‐actingcholinomimeticagents.

3. CholinesteraseInhibitors:inhibitacetylcholinesteraseatbothmuscarinic&nicotinicsites(indirectactingcholinomimeticagents);cholinesteraseinhiibitorsalso↑secretionsb/cthey↓AChmetabolism;theyincreaseeffectsofAchw/inautonomicnervoussystem&atNMJ.a. Physostigmine,Neostigmine,Endrophonium,Pyridostigmine,Malathion,Parathion.b. Endrophium–drugofchoiceindiagnosingmyastheniagravisb/crapidonsetand

reversibility;distinguishesmyastheniagravisfromcholinergiccrisisb/cimprovesMGbutworsenscholinergiccrisis.

c. Neostigmine&Pyridostigmine–txformyastheniagravis.d. Malathion&Parathion–insecticides.

Organophosphates(CHOLINERGIC)–estersofphosphoricacid&alcoholthatinhibitcholinesterase;• Isofluorophate(glaucoma),Malathion(insecticide),Parathion(insectiside),

Echothiophate(glauoma),Tabun(toxicnervegas),Metrifonate(destroysintestinalworms). Pralidoxime(Protopam)–anti‐cholinergic→cholinesterasereactivatorwhichreversesmuscle

paralysisfromorganophosphateanti‐cholinesterasepesticidepoisoning;o Reversedeffectsofoverdoseofanti‐cholagentsusedintxofmyastheniagravis.o S&Sofpoisoning‐↑salivation,bronchoconstriction,diarrhea,&twitching.

StimulationofskeletalmusclebyexcessAcheventuallyresultsinmuscleparalysis. Anti‐Cholinergics–blockpost‐ganglioniccholinergicfibers;causeXEROSTOMIA,MYDRIASIS,

TACHYCARDIA&↑bodytemp,↓SPASMSofsmoothmuscleofbladder,bronchi,&intestines;• Anti‐chols‐nointrinsicactivity,butcausexerostomiabyblockingpostganglioniccholinergic

fibersandpreventAchfromoccupyingsamereceptor!• Contraindications‐glaucoma,CVproblems,asthma,GIobstruction;• Ie‐Beladonaderivatives,PropanthelineBromide.• Glycopyrrolate(Robinul)–treatstraveler’sdiarrhea&anti‐secretory.• BenztropineMesylate&TrihexyphenidylHCl–treatParkinson’s(anti‐parkinsonism).• Atropinesulphate–producesmydriasis&cycloplegia(paralysisoftheciliarymuscleoftheeye).• Scopolamine(pre‐opmed)–prevents/reducesmotionsickness.• Mecampylamine(Inversine)–nicotinicganglion‐blockingagent.

Anti‐Sialogogues–drugsthatcontrolsalivarysecretions;anti‐cholinergics;alsoreducespasmsofsmoothmuscleandaccelerateimpulseconductionthruthemyocardiumbyblockingvagalimpulses.

Acetylcholine–chemicalmediatorofallAUTONOMICganglia&parasympatheticpost‐ganglionicsynapses;AChalterscellmembranepermeability&issecretedbycholinergicfibers;affectsCNSbyactingonthese2receptors:1. MuscarinicReceptors:primarilyinautonomiceffectorcells(heart,vascularendothelium,smooth

muscle,presynapticnervesterminals&exocrineglands)inCNS(alsorespondstoMuscarine).2. NicotinicReceptors:locatedinganglia,skeletalmuscleendplates&inCNS(alsorespondsto

nicotine);drugslikeAchmirroreffectsofpara‐post‐ganglionicactivity;2receptors:i. Receptors@NeuromuscularJctsofsomaticnervoussystem;Neuromuscularblockersacthere.

ii. Receptors@AutonomicGangliaofbothPSNS&SNS;Ganglionicblockersacthere. LAprevents/reducesliberationofAchatneuro‐muscularjctofskeletalmuscle; 2typesofNicotinicReceptors:

1. NeuromuscularBlockers–atneuromuscularjctofsomaticsystem.2. GanglionicBlockers–atautonomicganglia(bothsymp&parasymp);rarelyusedbecausecause

pronouncedxerostomia,constipation,blurredvision,andposturalhypotension.• Mecamylamine&Trimethaphanareusedfor↑BP,ER↑inBP,&bloodlessfieldsurgery.

NeuromuscularBlockingAgents:producecompleteskeletalmusclerelaxation&facilitateendotrachealintubation;interactw/nicotinicreceptorsatNMJ;twotypes:1. Nondepolarizing–competitivelycompetew/Achatnicotinicreceptors&preventAchfrom

stimulatingmotornerves&canresultinparalysis;

a. prototypeofNon‐depolarizingNMJblocker=Tubocurareb. Mivacurium,Vecurium,Doxacurium,Pancuronium,Atracurium,Cisatracurium,&

Rocuronium;Neostigmine&Pyridostigminecanreversethese!2. Depolarizing–noncompetitive;

c. Succinylcholine(Anectine)–nicotinicagonist&depolarizestheneuromuscularendplate;prototypeforDepolarizingNMJblockingagent.

Usedw/cautioninptsw/↓levelsofpseudocholinesterase,whichbreaksdownsuccinycholine–resp.failuremayresult;maycausemuscarinicresponselikebradycardia&increasedglandularsecretions;usediflaryngospasmoccursduringGA.

SpasmolyticDrugs(skeletalmusclerelaxants)–relievemusclespasmsw/oparalysis;actonCNS&skelatalmusclecells;usedinMS,cerebralpalsy,cerbrovascularaccidents/strokes).

TreatmentforChronicMuscleSpasms:1. Baclofen–derivativeofGABA(siteofactioninreducingmusclespasms)thattxchronicmuscle

spasms;txofMS&otherspinalcorddiseases;2. Carisoprodal(Soma)–txofmusclespasms&acuteTMJpain.

TreatmentofAcuteMuscleSpasms:1. Cyclobenzaprine–relievesmusclespasmthrucentralaction.2. Methocarbamol–centrallyactingmusclerelaxanttorelieveacutepain&tetanus.

Quinidine–txfornocturnallegcrapms;ANESTHESIA: IVagentsforGA:

1. Barbituates–Thiopental,Methohexital,Ketamine,Etomidate,Propofol.2. Benzodiazepines–Diazepam,Midazolam,Lorazepam.3. NeurolepticOpoids–neuroleptanalgesics&fentanyl,anddroperidol.

Nitrous(BLUE)–rapidonsetw/recoveryin5min;lesssolubleinbloodthanalveolarair;consideredsedativebutnotGAunless>80%whichcancausehypoxia;gasatroomtemp&pressure.o Sweetsmelling,colorless&inertgas;coupledw/nolessthan20%O2.(failsafemethod).o UsedtoproduceSEDATION&MILDANALGESIAbutmustbecoupledw/LA.o Excretedunchangedbylungs;storedasliquidunderpressure;onsetofsedation=5min.o Ptgivenoxygenfor5‐10minaftertakenoffNitroustopreventdiffusionhypoxia.o DoseresponseforNO: 10‐20%‐extremitytingling

20‐40%(usually30‐50%)–sleepiness&relaxation>50%‐toomuch,nausea&sweating.

o Contraindications–ptsw/URI,pregnancy(1sttrimester),bronchitis,emphysema,andspeechproblemsandptsw/contagiousdiseases.

o MostcommoncomplaintfromptsonNOismildNAUSEA. ChloralHydrate–onlynon‐barbituatesedativehypnoticagent&inducessleep;

o DOESN’TRELIEVEPAIN.o Orallyforpreopmanagementofanxiouskids;kidsexcitedandthensedated;o Rapidonset(15‐30min)&DOA=4hrs;kids–50mg/kgw/max1gmin500mg/5mLsolution.o unpleasantordor&taste;prodrug&metabolizedtotrichloroethanol(displaceswarfarin).

ToxicityofLA–causesbradycardiaanddecreasecardiacoutput;affectsCNS&CVsystem;maycauserestlessness,stimulation,tremors,seizures,CNSdepression,slowedrespiration,&coma.

AllergytoLA–maypresentasnasolabialswelling,itching,andoralmucosalswelling; LAreversiblyblockssodiumfromgoingfromoutsidetoinsideofaxon;soLAdecreasessodium

UPTAKEthrutheaxon’ssodiumchannels;noeffectonpotassium;decreasespainbyblockingpropogationofnerveimpulses;o Small,unmyelinatednerves(pain)affected1stbecausegreatersurfacevolume.;o Nonionizedfree‐baseformpenetratetissue;fatsoluble/lipophilicdrugs;convertedtohydrophilic

salts(watersoluble)toprepareasinjectablesolution;pH=7.8.

o ↓pKa=↑pH=morefree‐baseavailableforinjection.o AtphysiologicalpHof7.4,5‐20%ofLAinfree‐baseformsoenoughtoanesthetized.o ActionofallLA’sdependsonanestheticsaltabilitytoliberatefree‐baseo Maxdose=300mg;4.4mg/kgforkids;Maxcarps→Lido–8.3carps,Mepivacaine(3%)–5.6,

Prilocaine(4%)–5.6,Bupivacaine(.05%)–10carps.o 1kg=2.3lbs;MAXDOSEofLIDO=300mgor4.4mg/kgforkids.o AmideLAsaremetabolizedinliver,sotoxicityismorelikelyifamidesgiventoptsw/liver

dysfunction. ***POINT–potentialactionofallLAdependsonabilityofanestheticSALTtoLIBERATEFREE‐BASE. Articaine(4%HCl)–amideLA;hasestergroupsocouldbeinactivatedbyplasmacholinesterase;

onlyamidemetabolizedinbloodstream;onset=1‐6min&DOA=1hr;→ volume=1.7mL&Maxdose=7mg/kgor490kg.→ contraindicatedinptsw/bisulfiteorLAamideallergy.

Prilocaine(Citanest)–intermediateDOA,longeractingthanLidobutlesspotent&lessvasodilationthanLido;metabolizedasorthotoluidine‐causesmethemoglobinemia–notforhypoxicpts;o MAXDOSE=400mg

Bupivacaine(Marcaine)–haslongestDOAofanyLA;Radiotoxicinsomepts&usedw/causinginCVdisease,elderly,&peds;MAXDOSE=90mg

Lidocaine–anti‐arrythmicagentoftheventricle;actsonfibrillatingventriclestodecreasecardiacexcitability&sparestheatria;

***Lidocaine&Mepivacainemostlikelytoshowcross‐allergy. Mepivacaine(Carbocaine)–equaltolidoinefficacybutineffectiveastopicalagent;shortDOAand

toxictoNEONATES;MAXDOSE=300mg. EsterLA–mainlyusedastopical(BENZOCAINE)duetoallergies;procaine/novocainemetabolized&

formsparaminobenzoicacid(PABA)whichptscanbeallergicto;nolongerusedindentistry;rapidonset&shortDOAexcepttetracainewhichhaslongerDOA.

Cocaine–1stLAever;esterofbenzoicacid;definitevasoconstriction;ONLYLAthatincreasespressoractivityofEPI&NEbyinhibitingcatecholamineuptakebyadrenergicnerveterminals.

Bisulfites(preservativeforepi)cancauseallergyinLA;onlyinLAw/episo3%mepivacaine(carbocaine)doesn’thaveepisonobisulfites;mostptsw/allergytoLAhavehistoryofasthmaandairwayhyperactivitytosulfites.

ANTIBIOTICS:

• Thefollowingprocedureswereidentifiedashavingahigherincidenceofbacteremia:dental

extractions;periodontalprocedures,includingsurgery,subgingivalplacementofantiobioticfibers/strips,scalingandrootplaning,probing,recallmaintenance;dentalimplantplacementandreplantationofavulsedteeth;endodontic(rootcanal)instrumentationorsurgeryonlybeyondtheapex;initialplacementoforthodonticbandsbutnotbrackets;intraligamentary&intraosseouslocalanestheticinjections;prophylacticcleaningofteethorimplantswherebleedingisanticipated.

OtherConditionsforYESforProphylaxis:

1. TetrologyofFallot2. TotalJointReplacementONLYifsurgeryw/inthepast2years!

OtherConditionsforNOforProphylaxis:1. RheumaticHeartDisease2. MVPw/orw/oRegurgitation3. SeptalDefectsorPatentDuctusArteriosus4. HypertrophicCardiomyopathy5. BypassGraftSurgery6. HeartMurmurs&KawasakiDisease7. CardiacPacemakers&ImplantedDefibrillators

Ifapatientisalreadyreceivingantibiotictherapywithamedicationthatisalsorecommendedforinfectiveendocarditis(IE)prophylaxis,theguidelinesstatethatitisprudenttoselectanantibioticfromanotherclassratherthantoincreasethedoseofthecurrentlyadministeredantibiotic.Forexample,ifapatientisalreadytakingamoxicillin,thedentistshouldselectclindamycin,azithromycin,orclarithromycinforIEprophylaxis.Ifyoudon’twanttotakeantibioticfromdifferentclassthendelayprocedure9‐14daysafterptcompletesantibiotic.

Ifunanticipatedbleedingoccurs,administerprophylaxisw/in2hoursafterprocedure.

#ofCapulsesforAntibioticsofProphylaxis:→ Amoxicillin–4capsules(500mg/capsule)→ Clindamycin–2capsules(300mg/capsule)→ Cephalexin–4capsules(500mg/capsule)→ Cefadroxil–4capsules(500mg/capsule)

Probenecid–usedw/antibiotictodelayrenalclearanceofantibiotic;interferesw/organicacidsatnephron&diminishesthePCNtubularsecretion;

→ affectsPCNs&cephalosporinsotherβ‐lactamantibioticslikeAztreonam&Imipenem.→ DrugofchoicefortxofGOUT.

AntibioticsAFFECTINGCELLWALL:→ PCN,Cephalosporins,Vancomycen,Imipenem,Cycloserine,Bacitracin,Aztreonam;

Penicillin–derivativeof6‐aminopenicilllanicacid&containsβ‐lactamringjoinedbythiazolidinering;β‐lactam(3C&1N)ringisresponsibleforantibioticactivity;

→ synthesizedfromL‐cysteine&L‐valine.→ PCNisgoodforANUGpts;10%ofpopulationallergictoPCN.→ β‐lactamantibiotics–PCN,Cephalosporins,Carbepenems,&Monobactams.→ ExcretedDIRECTLYintourineviarenaltubularcellsecretion.

PenVK–antibioticw/narrowspectrum&bacteriocidal;goodforminimizingresistance;usedtotreatORALinfectionsb/cmoreacidstable;highestincidenceofdrugallergy;

→ drugofchoiceforgram+staphylococcalinfection; PCNG–PCNprototypeduetobasice6‐aminopenicillanicacidmolecule;addsidechainstomakeit

semi‐syntheticPCN–morestableandbroaderspectrum&morepenicillinaseresistant.→ PCNGProcaine(Crysticillin)–IMroute→ PCNGBenzathine–IMroute;txforsyphilis&preventrheumaticfever;longerDOA.

Ampicillin(IV/oral)&Amoxicillin(oral)–bothAMINOPENICILLINS(alsoBecampicillin)b/ccharacterizedbyaminosubstitutionofPCNG;neitherpenicillinaseresistant;extendedspectrumPCN.

→ AminoPCNsworkagainstmanygram(‐)morereadillythannaturalPCNslikeHaemophilusinfluenzae,Escherichiacoli,Proteusmirabilis.

→ BotharepreferredtxforUTIcausedbyenterococci;alsotxforURI,otitismedia,bronchitis,sinusitis,&bacterialcystitis.

→ AmpicillinisgoodforptswhocantakeoraldrugsandareNOTallergictoPCN;→ Amoxicillinsignificantlyinteractsw/Methotrexate;Amoxinhibitsrenaltubularsecretionof

methotrexate;methotrexatecancauseulcerationoforaltissues.→ Amoxicillin‐↑oralabsorption,↑serumlevels,↑half‐life,↓GIeffectsthanampicillin;forgram+

cocci&gram(‐)bacilli. Methicillin–partofthePCNfamily;notoftenusedduetonephritisbutgiveIVinseverPCN‐

producingSTAPHinfections;• MRSA(methicillin‐resistantStaphAureus)–resistanttoallantibioticsincludingvacomycin.• Methicillin,PCNG,&Carbenicillinaredegradedbystomachacid.

Carbenicillin,Piperacillin,&Ticaillin–WIDESTbroadspectrumofPCNs(Carbenicillin);allagainstgram(+)rods&cocci,likePseudomonas,Proteus,Klebsiella,&Bacteroides;

→ txforUTIcausedbyPseudomonas&Proteus;givenparenterally(IV). Bacampicillin–txforURI&LRI,UTI,&skininfections;hydrolyzedtoamoxicillinwhenabsorbedby

GI;betterabsorptionthanampicillinandlessGIeffects. Bacitracin–gram(+)bacteria;fortopicaluseb/cnephrotoxic. PolymyxinB–cationicdetergentsthatscrubbacteriacellmembranes;topicaluseb/cnephrotoxity

potential;againstgram(‐)rods=Pseudomonas;tripleantibioticointmentforsuperficiallacerations; Beta‐Lactamase–enzymeofgram(+)&(‐)bacteriathatworksagainsPCNs&cephalosporins;adding

clavulanicacidw/PCNcaninhibitthebacterialenzyme;MOAofenzymeissplittingopentheβ‐lactamringstructuretorendertheantibioticineffective.

→ Augmentin–Amoxicillin&ClavulanicAcid.→ Unasyn–Amoxicillin&Sulbactum;IVorIM.

Penicillinaseisaspecifictypeofβ‐lactamase,showingspecificityforpenicillins,byhydrolysingthebeta‐lactamring.

Penicillinase‐ResistantPCNs–Methicillin(IV),Nafcillin(IV),Oxacillin(IV),Cloxacillin(Oral),Dicloxacillin(Oral);theyhaveprotectedβ‐lactamringwhichpreventpenicillinaseeffects;• thesePCNsareeffectiveagainspenicillinase‐producingStaphAureus.• Ampicillin(unasyn)&Amoxicillin(augmentin)–blockpenicillinasefromreachingbeta‐lactam

ringb/ccontainclavulanatepotassium&sulbactum.• Dicloxacillin–similarspectrumasPenVKbutactiveagainstpenicillinaseproducingStaph.

IVPCNs–Methicillin,Carbenicillin,PCNG. AcidStablePCNs(Oral)–PCNVK,Amox.,Amp.,Nafcillin,Oxacillin,Cloxacillin,&Dicloxacillin. ExtendedSpectrumPCNs–Aminopenicillins(Amp&Amox). BroadSpectrumPCNs–Carbenicillin,Piperacillin,Ticarcillin–WIDESTspectrumofPCNs. Cephalosporins:PCN‐likeb/caffectcellwall;bacteriocidal;broadspectrumantibiotics(bothgram(‐)

&⊕;Increaseingram(‐)butdecreaseingram(+)asyouincreasegenerations;4generations: 1. 1stGen.–Cephalexin,Cephradin,Cefadroxil,Cefazolin–usedtoasantibiotic

prophylacticinptsw/non‐immediateallergicrxntoPCN;Cephalexin&Cephradineare1stchoiceforprophylacticinptsnotallergictoPCNw/TotalJointReplacementw/in2yrs.

2. 2ndGen.–Cefaclar,Cefuroxime,Cefoxitin–txfororo‐dentalinfectionscausedbygram(+)&(‐)bacteriaandagainstanaerobicbacteriacausingperiapicalabcesses.

3. 3rdGen.–Cefixime,Cefoperzone4. 4thGen.–Cefepime.

→ UsedinPCN‐allergicptsw/Staphinfections. Imipenem–β‐lactamantibioticfromthienamycin&1stdrugclassifiedascarbapenemantibiotic;

→ txforEnterobacterinfections;combinedw/Cilastinfortxofsevere/resistantinfections,espnosocomialinfections..

Aztreonam–synthesticβ‐lactamantibiotic;againstgram(‐)rods,likeKlebsiella,Pseudomonas,&Serratia;synergisticw/aminoglycosides.

10%ofptsallergictoPCNareallergictocephalosporins. 3typesofPCNallergicrxns:

1. AnaphylacticShock–30min;IgEmediated;characterizedbyurticaria,angioedema,bronchoconstriction,GIdisturbances,&shock(hypotension);Tximmediatelyw/EPI.

2. Accelerated–30‐48hoursafter;uticaria(hives),pruritis,wheezing,edema.3. Delayed–2‐3daysafter;skinrashes;80­90%ofPCNallergies.

RashismostcommonsignofallergytoPCN. AntibioticsINTERFERINGW/PROTEINSYNTHESIS:

→ Clindamycin(50S),Tetracycline(30S),Erythromycin(50S),Azithromycin,Aminoglycosides(30S),Linomycin,Clarithromycin,Chloramphenicol.

Clindamycin–bacteriostaticagainsgram(+)likeStaph&Strep&anaerobicgram(‐)likeBacteroidfagilis;causesdiarrheaandpseudomembranouscolitiscausedbyovergrowthofclostridiumdifficile.

→ Nocrossallergenicityb/wPCNs&Clindamycin. Tetracycline:limitedoraltreatment;cancausecandidiasisandphotosensitivity;absorptionintoGI

tractinhibitedbycations(Ca,Mg,Fe,&Al)sodon’ttakew/milk,vitamins,orminerals;3types:1. Tetracycline–usedforLocalAggressive(Juvenile)periodontitis,becausegoodw/AA

bacteria,ANUG(ifPCNisnotused),a. acne,gonorrhea,syphilis,mycoplasmapneumonia,chlamydia,rickettsia,bronchitis.

2. Minocycline–acne,anthrax,andmeningococcalprophy;Ie–Arestin:usedtotxperiodontalpocketscausingpockettoshrink.

3. Doxycline–Syphilis,Rickettisa,Chlamydia,andmycoplasmainfection.

→ Contraindicatedw/child<8yrs&pregnantwomenwhileDoxycline&Minocycline–bothcontraindicatedinpregnantwomen.

→ BROAD‐SPECTRUMantibiotic,forGram(+)andGram(–)bacteria;Tetracyclinesarrestrapidbonelossviatissueregeneration&enhancedrepairduetotheircollagenaseinhibitingeffect.

→ AbsorptionoftetracyclinefromGItractinhibitedbythesecations–Ca,Mg,Fe,&Al;thesecationsformCHELATIONPRODUCTSw/tetracyclinetopreventtheirabsorption;sonotgivenw/milk,mineralsupplements,orantacids.

→ AdverseEffects–photosensitivity,nausea,diarrhea,fungalsuperinfections(Candidiasis),teethdiscoloration,&enamelhypoplasiainkids.

MACROLIDEFAMILYOFANTIBIOTICS–erythromycin‐typeantibiotiticsthatareeffectiveagainstGram(+)butNOTgram(‐);GIupset;includesazithromycin,clarithromycin,&dirithromycin

Erythromycin–causes21%GIproblems&tinnitus(deafness);metabolizedinliver&excretedbybile;entericcoated–preventsreleaseandabsorptiontilreachintestines;poororalbioavailability.

a. 2types:ErythromycinStearate&ErythromycinEstolate;cancauselivertoxicity.b. 2ndchoiceofantibiotictoPCNtotxOro‐dentalinfectionscausedbygram(+)bacteria.c. PreviouslyusedasalternatetoPCN‐allergicptsbutnolongerusedduetoGIupset,the

mostcommonsideeffect,sotakewithfood; Azithromycin(Zithromax‐1x/day)&Clarithromycin(Z‐Pak‐2x/day)–Azithromycin–5%GI

effects,Clarithromycin–10%GIeffects;prolongedeliminationhalf‐life.• bothhavesimilarbacterialspectrumsaserythromycinbutbetteragainstH.influenza;• concentrationonmacrophagessogoodagainstMycobacteriumaviumintracellulare.

Aminoglycosides(IV/IM)–maycausemuscleweaknesssomayaggravateptsw/myastheniagravis,infantbotulism,orParkinsons;rapidlyexcretedbykidneys;

→ causesototoxicity&nephrotoxicitysomustbeusedforseriousinfections.→ bacteriocidal&broadspectrum–aerobicgram(‐)infections.→ Streptomycin–1staminoglycosideforTBtx;rarelyused.→ Gentamicin,Amikacin,Tobramycin,Netilmicin,Spectinomycin(txforGonorrhea).→ Neomycin(topicallyusedb/chightoxicitypotential)&Kanamycin(rarelyusedb/cof

ototoxicity); Chloramphenicol–broadspectrumgram(+)&(‐)&bacteriostatic;usedas2ndor3rdlineofdrugsfor

seriousinfectionsb/ccauses3toxicities: 1)aplasticanemia2)bonemarrowsuppression3)Gray’ssyndrome(circulatorycollapse)

AntibioticsINTERFERINGW/BIOSYNTHETICPATHWAYS:→ Sulfonamides,Fluoroquinolones,Trimethoprim.

Sulfonamides(sulfadrugs)–similarstructuretoPara‐aminobenzoicacid(PABA),whichisusedtosynthesizefolicacidinbacteria,whichisusedtohelpbacterialcellgrowth;BACTERIOSTATIC.

→ competesw/PABA&inhibitsfolicacidsynthesis,soinhibitingcellgrowth.→ TxforUTI;Bactrim=Trimethoprim(antimicrobial)+Sulfamethoxazole(sulfonamide);

BactrimisdrugofchoiceforUTI.→ NOTfordentalinfections;

Tuberculosis–causedbyMycobacteriumTuberculosis(needscombinationofdrugssincemycobacteriumtendstodevelopresistantstoanysingleanti‐tubulardrug)).1. Isoniazid–4drugregiminw/rifampin,pyrazinamide,&ethambutol;alsousedfor

prophylactic;maycauseperipheralneuritis(paresthesia)causedbypyridoxine(vitB6)deficiency.2. Streptomycin–combow/isoniazid;aminoglycoside.3. Rifampin–preventstranscription;mostpotentanti‐leprosyagent.4. Ethambutol–incombo;maycauseopticneuritis,hyperuricemia,&colorvisiondisturbances.5. Pyrazinamid–incombo;entersCSFtotreattuberculosismeningitis.6. Rifabutin–activeagainstMAIcomplex.

ANTIPROTOZOALS:1. Nitrazoxanide–txofGiardia(diarrhea)whichiscommonprotozoaninfection;

a. txofinfectionsfromGiardiaLamblia&CryptosporidiumParvum.b. MOA–interfersw/electrontransferrxnw/inprotozoathatisessentialtoitsmetabolism.

2. Atovaquone–txofPneumocystitisCariniiPenumonia(PCP),inptsintoleranttoCo‐trimazole(combinationofTrimethoprime+Sulfamethoxazole–whichisdrugofchoiceforPCPbyinhibitingfolicacidsynthesis.

3. Eflornithine–orphandrugstatusformeningoencephaliticstageofTrypanosomaBruceiGambienseInfection(SleepingSickness).

4. Furazolidone–txofdiarrheafromGiardiaLambliaorVibrioCholerae.5. Metronidazole–antibacteria&antiprotozoalforTrichomonasVaginalis;affectscellwalls!

a. nottrueantibioticb/cSYNTHETIC&labfabricated;b. mosteffectiveRxagainstanaerobicbacterialinfections;c. causesdizziness,headaches,andnausea.

ANTI­MALARIAAGENTS:

1. Mefloquine‐againstPlasmodiumfalciparum,P.vivasmaraliae,P.ovale;activealoneagainsmulti‐drugresistantPlasmodiumflaciparum.

2. Cloroquine–eradicatesRBCformsbyinhibitingplasmodialhemepolymerase;txforerythrocyticformsofPlasmodiumfalciparum&vivax;systemicamebicliverabscess&extraintestinalamebias.

3. Quinine–backupagentforchloroquineusedincombinationw/Fansidarchloroquine‐resistantmalarialstrains;adverseeffects–Cinchonism‐nausea,vomiting,vertigo,tinnitus.

4. Atovaquone+Proguanil(Malarone)5. Sulfadoxine+Pyrimethamine(Fansidar)6. Halofantrine7. Pyrimethamine­folateantagonist:activeagainstP.falciparum,P.malariae,&Toxoplasmagondii.

ANTIVIRALS: Viruseslackcellmembrane,wall,&metabolicmachinery,thusareObligateIntracellularParasites. Oseltamivir(tamiflu)&Zanamivir(relenza):antiviralneuraminidaseinhibitors;txforinfluenzaA&B. Acyclovir(zovirax)–antiviralthatinhibitsDNAsynthesis. HerpesSimplexType1Treatment:

1. Penciclovir(Denavir)–CREAM;txofrecurrentherpeslabialis(coldsores)foradults;inhibitsherpesviralDNAsynthesiswhichinhibitsviralreplication.

2. Acyclovir–inhibitsviralDNApolyermase/viralDNAsynthesis;TABLET/CREAMtotxHSV‐1,HSV‐2,&varicellazoster(chickenpox/shingles);

a. DrugofchoiceforHSVEncephalitis,genitalherpes,herpeslabialis,&varicella‐zostervirus;b. EntersCSF&accumulatesduringrenalfailure.

3. Docuosanol(Abreva)&Lysine–anti‐viralsthattxHerpesLabialis.4. Valacyclovir(valtrax)–PRODRUGofacyclovirgivenorallythatiscovertedby1stpass

metabolismintoAcyclovir;txforHSV‐1/2,genitalherpes,coldsores&herpeszoster.5. Ganciclovir–inhibitsviralDNApolyermase/viralDNAsynthesis;txCytomegalicretinitis&CMV

prophylaxisintransplantpts;crossBBB; HIV–depletionofT‐cells(CD4);retrovirusw/RNAasnucleicacid&usesreversetranscriptaseto

copygenomeintoDNAofhost’schromosomes;DNAsegmentispermenentlyincorporatedintohost.→ Tx–Didanosine(Videx),Zidovudine(Retrovir,AZT),Ritonavir(Norvir),Indinavir(Crixivan).

NucleosideReverseTranscriptaseInhibitors–stopsHIVRNAfrombecomingDNA;drugsconvertedintoAZT‐triphosphateanalogsincellstoinhibitviralDNAsynthesis&replicationbyinhibitingreversetranscriptase;maycausemyelosuppressionofbonemarrow.→ Ie–Didanosine,Zalcitabine,Zidovudine,Stavudine,Lamivudine.

ProteaseInhibitors–suppressesproteasefromcleavingviralprecursorsintopeptides;contraindicatedw/ptstakingRifampin.→ Ie–Indinavir,Nelfinavir,Ritonavir,&Saquinivir

Non‐NucleosideReverseTranscriptaseInhibitors–non‐competitiveinhibitingrxnofreversetranscriptasethatisindependentofnucleotidebinding;→ Ie–Delavirdine,Adefovir,Efacirenz&Nevirapine.

Interferon–naturalglycoproteinssynthesizedbyrecombinantDNAtechnologytoactivatehostenzymestoblockviralRNAtranslationandinterverew/virusinfectingcells.→ TxforchronicHepB&C,Genitalpapilloma,Kaposi’ssarcomainHIVpts.

Amantadine&Rimantadine–anti‐viralthatinhibit/blockviralmembranematrixproteinM2ionchannel;forprophyortxofInfluenzaAvirus;alsoentersCNStotxParkinson’s.

Ribavirin–inhibitsviralmRNAsynthesis;txforseriousRespiratorySynctialVirusinfectionforkids,influenzaA&B,HepC,&Sars;ORAL,IV,andAerosol.

ANTIFUNGALS: Mycoses–chronicfungalinfections;oftensuperficialandsubcutaneous. CandidaAlbicans–inflammatorypruriticinfectioncharacterizedbywhite,thickdischarge(also

causesangularcheilitis);normalinhabitantoforalcavity&vaginaltract;Drugofchoicefortx=Nystatin.

ListofAntifungalsthataltercellmembranebybindingtosterolincellmembrane:1. Clotrimazole–MycelexTroche/Lozenge–forOropharyngealCandida;altersfungalcellmembrane.2. Nystatin–OralSuspension(swish&swallow)/Ointment–forOralCandidiasisorCutaneous;

similarstructuretoAmphotericinB;altersfungalcellmembrane.3. Amphotericin­B–Cream/IVinj.–Cutaneous/SystemicCandidiasis;altersfungalcellmembraneby

bindingtoergosterolinfungalmembrane;anti‐fungaldrugofchoiceforsystemicfungalinfections;→ maycauseKidneyToxicity;doesnotenterCSF.

4. Ketoconozol–Cream/Tablet–Cutaneous/OralCandidiasis;inhibitsErgosterolsynthesistodisruptfungalmembrane;caninhibit/antagonizeAmphotericinBantifungaleffect;→ GivenorallytotreatHistoplasmosis,Nonmeningealcoccidiodomycosis,Blastomycosis,

Dermatomycosis;toxicitymaycauseENDOCRINEEFFECTS.5. Fluconozole–Tablet/Oral‐EsophagealCandida;inhibitserogosterolsynthesis;crossesBBBand

entersCSF;drugofchoiceforMucosalCandida;→ txforBlastomycosis,Histoplasmosis,&CyptococcalmeningitisinAIDSpts;

6. Itraconazole–inhibitsergosterolsynthesis;Broad‐Spectrumanti‐fungalgiveORALLY;DrugofchoicefoBlastomycosis&Paracoccidioidomycosis;

7. Flucytosine–aPRODRUGthatinhibitsfungalDNA&RNAsynthesis&celldivision;giveORALLYtotxsystemicmycosisofChromoblastomycosis,Candidiasis,&Cryptococcus;entersCSF;

Nystatin&Clotrimazolealterfungalcellmembranebybindingtosterolsinthefungalcellmembrane,increasingpermeability&permittingtheleakageofintracellularcomponents.

SEDATION: Tranquilizers;Anti‐convulsants;SmoothMusclerelaxant;Pre­opsedative;inductionagent&

supplementformaintaininganesthesia; Tranquilizerspromotecalmness&soothingbutw/osedationordepressanteffects;

o MajorTranquilizers–anti‐psychoticagents.o MinorTranquilizers–anti‐anxietyagents(benzos)

Alleviateanxiety&inducesleep&IVcausesCONSCIOUSsedation; Benzodiazepines,Barbituates,Narcoticsallproducesedation&haveabilitytoproducedependence; Benzosdepresseslimbicsystem&reticularformationthrustrengtheningGABA(gamma‐

aminobutyricacid,inhibitoryneurotransmitter);NOTusedduringpregnancy.

Benzosusedforanti‐anxiety,sedative,anti‐convulsant,&skeletalmusclerelaxant;usedforIVCONSCIOUSsedationduringoutpatientsurgery.

Benzosaresaferthanbarbituates;butcausesfatigue,slurredspeech,drymouth,nausea,hypotension. Mosteffectiveoralsedativedrugusedindentistry;BenzodiazepinesdonotprovideAnesthesia! OralBenzodiazepines: 1)Chloridiazepoxide(librium)–pre­opsedative

2)Diazepam(valium)–pre­opsedative;anti‐anxiety3)Alprazolam(Xanax)–anti‐axiety,goodfortxofAgoraphobia.4)Lorazepam(Ativan)–anti‐anxiety.5)Clonazepam(Rivotril)6)Temazepam(Restoril)

BenzodiazepinesforInsomnia: 1)Flurazepam(Dalmane)&2)Triazolam(Halcion)• Triazolamusedaspre‐opsedativeindentistryandmetabolizedinliverbyP‐450isoformCYP3A4

enzyme;antifungalagentscanincreaselevelsoftriazolamb/ctheyinhibitCYP3A4isoformforhepaticmetabolismoftriazolam.

Diazepam–preferredoverbarbituateasantianxiety;TxforreversingstatusepilepticuscausedbyLAoverdose;IVinj.intolargevein;contra–glaucoma&psychosis;maycausewithdrawalsymptoms.

o PropyleneGlycolintheIVmixofvaliumismaincauseofthrombophlebitis(veinclot).o Alsousedformusclespasticityinptsw/cerebralpalsy.

Midazolam–liquidbenzousedforpre‐opsedationinkids&asinjectableforIVconscioussedation;veryshorthalflife;preferredoverdiazepam.

Flumazenil(Mazicon)–BENZOANTAGONIST;reversesbenzoineventofoverdose. Buspirone–oralanxiolytic;partialagonistonserotonicreceptors(5‐hydroxytryptamine)&

diminishesserotonergicaction;fewersideeffects&lesssedationthanbenzos.• structurally&physicallydifferfrombenzos&barbsb/cnotanti‐convulsantanddoesn’tcause

sedationandnotphysicallydependentandnothypnotic;• slowonset‐upto2weeks;maycauseTARDIVEDYSKINESIA(involuntarymvmts);

EthylAlcohol–cuasesdiuresisbyinhibitingproductionofADH/Vasopressin;ethanoldilatesbloodvesselsinskin,depressesCNSandmaycausecoma/death;• Itisasedative,ahypnoticdrug;alcoholeuphoriafromremovalofinhibitoryactivityofthecortex;• Synergisticw/Diazepam,Meperidine,Pentobarbital,&Chlorpromazine.

Disulfiram(Antabuse)–managesethanolabuse;inhibitsaldehydedehydrogenase(mitochondrialliverenzyme)sointerferesw/hepaticoxidationofacetaldehydemetabolismfromalcohol.

Metronidazolealsoinhibitsaldehydedehydrogenase. ANTICONVULSANTS:

1. Phenytoin(Dilantin)(IV)–txoftonicclonic(grandmal)seizures;maycausephenytoin‐inducedgingivalhyperplasia;producesNa+channelblockade;mostextensivelyused;

2. Gabapentin–adjuncttotreatmentofpartialseizures.3. Carbamazepine(Tegretol)–prophyforpartialseizures(psychomotor)&temporallobeseizures

&txfortonicclonicseizures&trigeminalneuralgia;producesNachannelblockadeinordertotreattrigeminalneuralgia;rarebutmaycauseaplasticanemia.a. Adverseeffects–diploma,ataxia,enzymeinduction,blooddyscrasias.

4. Diazepam(Valium)–txforstaticusepilepticus&emergencytreatmentforseizures.a. Adverseeffects–drowsiness,dizziness,&ataxia.

5. ValproicAcid(Depakene)–causesneuronalmembranehyperpolarization;preferedtxforcomplexparticalseizures,absenceseizures,&multipleseizuretypes;a. Adverseeffects‐hepatotoxicity&dyscrasias,GIdistress,lethargy,headache.

6. Ethosuximide(Zarontin)–txforabsenceseizuresb/ccausesminimalsedationbyblockingCa+channels;adverseeffects–GIdistress,lethargy,&headache.

• MostcommonanticonvulsantsareCNSdepressants;maycauserespiratorydepression. BARBITUATES:depressneuronalactivityinthemidbrainreticularformationby↑membraneion

conductance(Cl‐)&↓glutamate‐induceddepolarization&↑inhibitoryeffectsofGABA;

→ maydevelopseriousdrugdependency;anti‐convulsantbutNOTANALGESIC!→ Barbituatesarewell‐absorbedorally;CNSdepressant;metabolizedinliver;→ causeofdeath–resp.failureduebutreversedw/O2underpositivepressue;somostimportant

therapeuticmeasuretakenineventofbarbpoisoningistoassureADEQUATERESPIRATION.→ Barbsexhibitsteeperdose‐responserelationshipsthanbenzos;→ ↓½lifeofdrugmetabolizedinliverb/cinduceformationoflivermicrosomalenzymesthat

metabolizeindrugs;4typesclassedbyDOA:1. Ultra­ShortActing–IVforGAinduction&StageIIIsurgicalanesthesia.

i. 5‐20min;thiopental(MOSTCOMMON,foranesthesia),methohexital,thiamylal;contra‐PROPHYRIA,liverdysfunction,emphysema,drugaddiction.

2. ShortActing–oralforcalmingeffectforpre‐opappts&insomnia;i. 1‐3hrs;secobarbital&pentobarbital;goodforkids.

3. IntermediateActing–relievedentalanxietyw/daytimesedation&txforinsomnia.i. 3‐6hrs;amobarbital&butabarbital.

4. LongActing–txofdaytimesedation&epilepsy.i. 6‐10hrs;phenobarbital(anti‐convulsant),mephobarbital,primadone.

→ AsdecreaseinDOA,increaseinlipidsolubilitysoUltra‐shortactinghashighestlipidsolubilityandrapidlyleavesbrainforothertissuesduetoincreasedsolubility(reasonforshortDOA);

MaintargetofINHALATIONANESTHETICisbrain;Lipophilicmolecules;administrationofanestheticprecededbyIV/IMbarbituatew/endotrachealintubation;5volatileliquidsthatrequirevaporization&mayirritaterespiratorytract&causemalignanthyperthermiaI;theycause↓inarterialpressure.1. Enflurane–lesspotentbutrapidonsetwithrisksofseizures;CNSirritanteffect.2. Halothane–powerfulbuttoxininadultliver;sensitizeshearttocatecholamines.3. Isoflurane–combowithIVanesthetics;cancauseheartirregularities.4. Sevoflurane–goodforkids,lessirritatingwithrapidawakening.5. Desflurane–heatingcomponent;irritatingsousedw/IVagentsbutawakenfasterthanany

otherinhalant;haslowblood:gaspartitioncoefficient,butnotusedtoinduceanesthesia.NARCOTICS: Opoidsareanalgesics,antitussives,antidiarrheals,&preanestheticmeds;DEAscheduleII&III;opoid

alkaloids=morphine&codeine;opoidsraisepainthreshold&tolerance;→ Opiodsaremostpowerfuldrugsforpainrelief;reducesamtofGArequiredforsurgical

anesthesia;strongestopioids–Morphine,Meperidine,Fentanyl,&Methadone.→ Sideeffects–sedation,drowsiness,dizziness,nausea(MOSTCOMMONSIDEEFFECT).→ RespiratoryDepressionismajordisadv.Ofopioids&mostsignificantadverserxn.→ OpoidReceptors:

1. Mu–formorphine;thesupraspinalanalgesicactivityofmorphineismediatedprimarilythruitsinfluenceontheMuopioidreceptor.

2. Delta–forenkephalins3. Kappa–fordynorphinso Opoidsbindtothesereceptorsinbraintoincreasepainthreshold.

3typesofEndogenous(producenaturallyinbody)Chemicals(producemorphine‐likeeffectstoreducepain):1. β‐endorphines–bindtoopoidreceptorsandhavepotentanalgesicactivity.2. Enkephalins–bindtoOPIOIDDELTAreceptors&moredistributedthanendorphines;roleinpain,

mvmt,&moodpreception.3. Dynorphins‐mostPOWERFULopioidfoundthroughoutCNS&PNSthatbindtoKappareceptors;

regulatespainatspinalcordlevel,influencesbehavioratthehypothalamiclevel,&regulateCVsystem.

Morphine(Opiates)­istheprimaryactiveagentinopium,anopiumalkaloid;causesanalgesia,drowsiness,euphoria,mentalclouding,miosis,constipation,nausea,vomiting,&resp.depression.→ IVorIM(2‐3hrs),oral(3‐4hrs),sustainedreleaseis8‐12hurs;→ NOTusedindentistryduetoitsaddictiveliability.

Narcoticanalgesics=effectivelyreducepain(not‐inflammation)byworkinginbraintoblockascendingpainimpulsesthattravelfromperphery(PNS)intobrain(CNS);opoids–commonindentistryisHYDROCODONE(simlarpotencyasmorphine);okw/coumadin/warfarin.→ Hydrocodone+Acetaminophen=Vicodin,Lorcet,Lortab,Maxidone,Zydone.→ Hydrocodone+Ibuprofen=Vicoprofen;goodformod.toseverepain,goodanti‐inflammatory.→ Oxycodone+Acetominophen=Roxicent,Percocet,Tylox.→ Oxycodone+Aspirin=Combunox,Percodan**strongestpainmedforoutpatientbasis.→ Oxycodone(similarpotencyasmorphine)=Oxycontin→ Meperidine+Promethazine=Meperganfortis;→ Codeine+Acetaminophen=Tylenol#3;betterthanEmpirinbutpooranti‐inflammatory.→ Codeine+Aspirin=Empirin;avoidinasthmaticsb/ccodeineprecipitatesacuteasthmaattacks.

Mostcommonsideeffectofopoids=nausea;alsoconstipation,resp.depression,drowsiness,sedation,miosis,&euphoria.

Narcoticsworkinthebrain(CNS)whileibuprofen&NSAIDSworkinperipheraltissues(PNS);canbegivenincombinationb/c2differentmechanismcompletmenteachotherforeffectivepainreduction;

Hydrocodone–Syntheticcodeinederivativebutmoreefficaciousthancodeine;pooranti‐inflammatory&avoidinasthmatics.

Oxycodone–Syntheticcodeinederivativebutmoreefficaciousthancodeine;avoidinasthmatics;Highestdependencyliability;

Codeine–lessefficascousopiumalkaloidanalgesic;alsoantituissivethatisweakerthanmorphine,lessaddictive,andlessconstipating;givenORALLY(3‐4hrs).

Meperidine(Demerol)–syntheticopioidbutlesspotentthanmorphine&shortDOA&doesn’tcausemiosis&coughsuppressant;mostabuseddrugbydoctors;IV(forconscioussedation)ororal(3hrs);demeroltxformod.toseveredentalpainandmaybeusedaspre‐oppain/anxietyreliever.→ Cancauseseizures,tremors,&musclespasms.

Fentanyl–transmucosalprep/lollipoplozenge(Actiq),patch(Duragesic),IV(Sublimaze);100xmorepotentthanmorphine;IVforconscious/generalanesthesia;

Pentazocine(Talwin)–chemicallyrelatedtomorphinebutlesspotent;asstrongascodeine;givenORALLYandlasts4hrs;blockspainkillingactionofotheropioids;

Propoxyphene–propoxyphenenapsylate+acetaminophen;oralsyntehticopioidanalgesicstructurallysimilartoMethadone;

Darvocet­N100=acetaminophen+propoxyphene;forpaincontrolafterdentalsurgery. Darvoncompound­65=aspirin+caffeine+propoxyphene. Naloxone/Narcan,Nalmefine&Naltrexone(alsoforalcoholdependency)–allnarcoticantagonist

fornarcoticoverdose. Methadone–alsotxHeroinwithdrawal.ANTIDEPRESSANTS&ANTIPSYCHOTICS: TricyclicAntidepressants–txforunipolardisease(depression);inhibitsneuronalre‐uptakeofNE&

serotoninsoincreasepotentiationofneuotransmitteraction;o Ie–bestdrugisAmitriptyline(Elavil)‐greatestanticholinergic;Desiparmine

(Norpramin)hasleastanti‐choleffects;alsoDoxepin&Imipramine.o Sideeffects–drowsiness,xerostomia,constipation,blurredvision&tachycardia.o HighestincidenceofDRYMOUTHw/75%ofpts,duetosecondaryanti‐choleffect.

SelectiveSerotoninReuptakeInhibitors(SSRI)=txfordepression;veryhighspecificityforblockingre‐uptakeofserotoninintopre‐synapticcellsoincreasingtimeforattachementtopost‐synapticcell.

o Ie–Fluoxetine(Prozac)–SSRIprototype&longest½life.

o Ie–Paroxetine,Sertraline,Fluvoxamine–alltxforpanicattacks,depression,&OCD.o Ie–Citalopram(Celexa)&Escitalopram(Lexapro)–txfordepression&anxiety.o Sideeffects–nausea,headaches,anxiety,agitation&SD.

LA&Tricyclicantidepressants&SSRIallincreaseNEintissuessonotgoodwithLA&EPIdueto↑BP. TricyclicAntidepressants&SSRIareNEreuptakeinhibitorssocausexerostomiain75%ofpts

(secondaryanticholinergiceffects). Lithium–txforbipolardisorder(cyclicalchangesb/wmanic&depressivephasesofbehavior);

supressesMANICphase;s‐timesadministeredw/anti‐depressantsb/ccanthandledepressivestatealone;notusedforacutemanicepisodes.

MonoamineOxidaseInhibitors–txfordepression&parkinson’s;antagonizesmonoamineoxidasewhichdegradesnaturallyoccuringmonoamines(likeEPI,NE,DOPAMINE,SEROTONIN);• Contraindicatedw/LA.• Interactsw/Meperidine(demerol),EPI,EPHEDRINE(foodw/largeamtsofTYRAMINE).• Ie–Isocarboxazid(Morplan),Phenelzine(Nardil),Tranylcypromine(Parnate),

Selegiline(Eldepryl). ANTI‐PSYCHOTICS–txofpsychosisw/schizophenia,paranoia,&manic‐depressiveillness;

1. Phenothiazines–blockdopaminergicsitesinbrain;mosteffectiveantiemeticb/cdepresschemoreceptortriggerzonetoreducenausea&vomiting;notforptsw/CNSdepression&epilepsy;maycauselivertoxicity,hypotension,drymouth;NOTanti‐convulsant!→ TARDIVEDYSKINESIA–involuntarymotionoffacialmuscles,limbs,&trunck;effectsbasal

ganglia;irreversibleeffectofphenothiazine;effects20%ofptsondrug>1yr;→ ExtrapyramidalSyndrome–musclespasmsoforal‐facialregion;resultsfromblockadeof

dopaminereceptorsinbrain;stopdrugimmediately.→ Chloropromazine&Thioridazinearephenothiazineprototypesthatcausesedation,

antiemetic(preventsnausea),α‐adrenergicblocker&potentiationofnarcotics.→ Contra–severeCNSdepression/epilepsy;cautioninptsw/liverdisease.→ Adverseeffects–hypotension,livertoxicity,xerostomia,tardivedyskinesia.→ Thesedrugswillpotentiateactionofsedativedrugssousecautionw/sedation.

2. Butyrophenones–Haloperidol(potentdopamineantagonist)&Droperidol;txforschizo&Tourette’s.

3. Thioxanthenes–lesspotent;Cloroprothixene&Thiothixene;txforschizo.4. DiverseHeterocyclicAntipsychotics–antagonizedopamine&seratonin;moreeffectiveandless

toxicthanolderRx;effectivelytxSchizophreniabutmoreexpensive!→ ie‐Molindone,Clozapine,Loxapine,Olanzapine,Risperidone,Quetiapine.

NeurolepticAgents(anti‐psychotic)–txofACUTEmanicepisodesofbipolardisorder. Ie–Chlorpormazine(phenothiazine)&Haloperidol–effectinextremepsychoticbehavior.

Neuroleptanalgesics–neuroleptic‐opoidcombinationsthatcombineFentanyl&Droperidol;Opoidsprovideanalgesia&anesthesia;• Fentanyl–highlypotentopoidusedaspremed/adjuncttoinhalationagents;usedw/Droperidal

&Nitroustoprovidebalancedanesthesia;Fentanylcomeintransmucosalprep,transdermalpatch,orasIVprep.

• Innovar=Fentanyl+Droperidol;producesneurolepanalgesiaw/tranquilizingfromDroperidoleandanalgesiafromFentanyl.

Propofol(Diprivan)–IVanestheticw/rapidonset/recovery(morerapidthanbarbs)&bettertolerated;respiratorydepressantbutdoesn’tproducevomiting/nauseaanddoesn’tincreaseintracranialpressure;saferforpregnantwomenbutcontraforkids!

Etimodate(Amidate)–advantageoverotherIVdrugsisminimalresp/CVdepressanteffects;rapidinduction/recovery;oftenusedw/opoids;maintainsCVstabilitybuthighincidenceofvomiting.

Ketamine–drugofchoiceforDISSOCIATIVEANESTHESIA;causescatatoniaamnesia&analgesiaw/olossofconsciousnessbyblockingNMDAreceptor&blockingexcitatoryeffects;ONLYanestheticthatactsasCVstimulant;increasecrebralbloodflow&intracranialpressure;nobronchospasms;

ANTIHISTAMINES: TwotypesofHistamines:

1. H1receptors–allergicrxns.2. H2receptors–gastricacidsecretions;histaminestimulatesparietalcellstoproduceHCL.

Antihistaminescompeteforreceptorsitesw/naturalhistomine(foundinalltissues);histamineisstoredinpreformedmastcells&basophils;• HistamineisreleasedafterresponsetoIgEallergicrxns–roleinhayfever,uticaria,angioneurotic

edema;alsocontrolsacidsecretion(HCl)instomach.• H1Blockers–bothstimulate&depressCNS:twogenerations

1. 1stGen.–Diphenyhydramine(benedryl),Chloropheniramine,Tripelennamine(PBZ);broadaction=antihistamine,anticholinergic,antiserotonergic,antibradykinin&sedative.

2. 2ndGen.–Cetirizine(Zyrtec),Fexofenadine(allegra),Loratadine(claritin),Desloratidine(Clarinex);theyhavepoorCNSpenetrationsolessdrowsiness.

• AllH1receptorantagonistblockvasodilation,bronchicontriction,&capillarypermeability.• H2Blockers–competew/H2receptorssoonlycompetew/histamineinGItract;interferesw/

acidsecretioninGI;allreversibleCOMPETITVEantagonistsofH2receptorsw/DOA=12‐24hrs.→ Blockstomachacidsecretions&treatduodenalulcersbyinhibitinghistamineatparietalcells.→ Ie:Cimetidine(Tagamet‐mayinteractw/hepaticmetabolizeddrugs,maycause

gynecomastia),Ranitidine(Zantac–forGERD),Famotidine(Pepcid),Nizatidine(Axid).→ Txforacid‐pepticdiseases,ulcers,Zollinger‐EllisonSyndrome(Hypersecretorydisease)&

GERD(butOmeprazole(Prilosec)ismoreeffectivewhichisa“proton‐pump”inhibitor). HCl–producedbyparietalcellsofstomachthrupumpw/ineachcellwhichpumpsprotonsinto

stomach;usedforfooddigestion;H+ispumpedintostomachcontentstomakeHClfordigestion.→ H+/K+ATPasepumpwhichisinhibitedbyOmeprazole(Prilosec),Lansoprazole(Prevacid);

sotheyreducestomachacidformationbyinhibitingproton‐pumpofstomach’sparietalcells;→ Alsoreducedbyinhibitinghistamineisstomachathistaminetype2receptors;ie‐Ranitidine,

Cimetidine,&Fomatidine.NSAIDS:

→ Cyclooxygenase(COX)–enzymeproducesprostaglandins;Prostaglandinsderivedfromunsaturatedfattyacidsincellmembranes;2formsofCOXenzymes:

1. COX­1:enzymeproducesprostaglandinsinGItractandprotectsagainstulcers;a. Ie–NSAIDSinhibitCOX1&2sonon‐selectiveCOXinhibitors.

2. COX­2:enzymesproducesprostaglandinsatsitesofsurgery,infection,inflammation;noGIulcers.a. Doesn’taffectclotting/plateletaggregation.b. Rofecoxib(Vioxx),Celecoxib(celebrex),Valdecoxib(Bextra)–COX‐2inhibitor(notsalicylates,

notopiates,notNSAIDS);txofrheumatorid&osteoarthritis&painfromdysmenorrhea.c. Piroxicam–NSAIDfortxofrheumatoid&osteoarthritis;

Acetaminophen(TYLENOL)–weakCOXinhibitorbutalsoinhibitsprostaglandinsynthesisinCNSbutreducespain&doesn’teffectcoagulation;Analgesic&Anti‐Pyretic,NOTANTI‐INFLAMMATORY;categorizedw/NSAIDSbutnotnecessarilyone;goodforptsw/GI,bleedingdisorders,asthma,youngchildren,andpregnancy;lessdruginteractionsbutcancausehepaticnecrosis.→ Drugofchoicetorelievemildtomod.paininptstakinganti‐coagulantb/cnoplateletproblems!→ OnlyOTCnon‐inflammatoryanalgesicintheUS.

Analgesicefficacyofcombiningacetaminophen&ibuprofenisgreaterthaneitheracetaminophenoribuprofenalone.

NSAIDS(COXInhibitor)–inactivateenzymeprostaglandinendoperoxidesynthase(cyclooxygenase)sodecreasesprostaglandinsythesis;ANALGESIC,ANTI‐PYRETIC,ANTI‐INFLAMMATORY;3types:1. ProprionicAcidDerivatives:Ibuprofen(motrin‐400mgofIbuprofen,advil,rufen),Fenoprofen,

Ketoprofen,Naproxen,NaproxenSodium;allNON‐SELECTIVECOXinhibotors.

→ Ibuprofenmayinteractw/Warfarin(Coumadin)tocauseunnecessarybleeding.→ Naproxen–anti‐inflammatory&analgesicandlongeractingthanibuprofenbutinhibits

plateletaggregation;betterw/TypeIIdiabetespts.2. AceticAcidDerivatives:Indomethacin,Sulindac,Tolmetin;3. FenamicAcidDerivatives:Meclofenamate,MefenamicAcid.4. Ketorolac(Toradol)–moreeffectiveanalgesicthanaspirin;usedformodtoseverepainafter

dentalsurgerybutsuggestedforno>5days;→ SideeffectsofNSAIDS:GIulcers,↑bleedingtime,impairedrenalfct,contra‐pregnancyin3rdtrim.→ NSAIDSreversiblyreduceplateletadhesives;worksbestformildtomoderatepain;“ceilingeffect”

Salicylate/SalicylicAcid(Aspirin)–non‐selectiveCOXinhibitor;interferesw/clottingirreversiblyreducingplateletadhesivesbutdoesn’taffectcoagulationpathway;• discontinue5‐7daysfornormalclottingtimetoreappear.• ifgivenw/ibuprofen,analgesicefficacy<aspirin/ibuprofenalone.• Antipyreticactionexplayedbycutaneousvasodilationleadingtoincreasedheatloss.• Salicylism–overdoesofaspirin;notforkidsw/viralinfection(REYE’SSYNDROME);headache,

confusion,vertigo,tinnitus,nausea,sweating,vomiting;alsocontraforpregnancyin3rdtrimester.• Lowdosesofaspirinhascardioprotetiveeffectsb/creducethromboxaneproductioninplatelets

causinginhibitionofplateletaggregationandcan’tformthrombi(clots).CORTICOSTEROIDS: Corticosteroids:(don’tcurediseases)–producedbyADRENALCORTEXbutdon’tCUREanydisease.

1. Glucocorticoids–affectcarbs,lipids,&proteinmetabolism;usedasanti­inflammatories.2. Mineralcorticoids–regulateNa+(atcollectingduct)&K+metabolismintheCOLLECTING

TUBULES;txforasthma,arthritis,allergies,stomatitis,erythematosis,&TMJdisorders. Contraindication–anyinfections(bacterial,viral,fungal),CHF,orulcers; Adverserxns–Cushing’ssyndrome,HyperglycemicaOsteoporosis,ulcers&increaseriskofinfection;

theyrepresentreplacementinAddison’sDisease(deficiencyinsteroids). Addison’sDisease–hyposecretionofaldosterone&cortisol;txw/2mlofcortisol;corticosteroids

onlyREPLACEMENTtherapyforaddison’s,nottreatment; InhaledCorticosteroids(forasthma)–↓airwayinflammationinasthmaenhancingbonchodilating

effectsofβ2adrenergicagonists;↓bloodlevelsbutcancausecandidiasisofmouth&pharynx;o Ie‐Triamcinolone,Beclomethasone,Fluticasone,&Budesonide.

Glucocorticoids–actonarachidonicacidmetabolismwhichinducessynthesisofproteinthatinhibitsphospholipaseA2,thus↓prostaglandin&leukotrieneproduction;maycauseULCERS!• createsanti‐inflammatory&immunosuppressiveactions.• ↑gluconeogenesis,↓useofglucose,↑proteinsythesis,↑proteincatabolism,impairwoundhealing,

and↑chanceofinfections.• Ie–Prednisone,Prednisolone,Dexamethasone,&Triamcinolone.• Ie–Beclomethasone,Budesonide,&Flunisolide–specialglucocorticoids(INHALERS)usedto

txchronicasthma&bronchialdisease.• Fluticasone(Flonase/Flovent)–corticosteroidadministeredbyinhalationtotreatasthmaby

decreasinginflammationintheairwayofasthmatics.• Inhaledcorticosteroidsoftencausefungalinfections(candidiasis).• Nasalspraycortico.usedforseasonalallergies:Triamcinolone,Fluticasone,Budesonide.• Toxiceffects–growthinhibition,hyperglycemia,osteoporosis,psychosis,&saltretention.

Prednisone–corticosteroidw/anti‐inflammatoryactions;txforrheumatoid&osteoarthritis;sideeffects–insomnia,ingestion,arthalgia,edema,pepticulscers,osteoporosis,muscleweakness.

Cortisol–majornaturalcorticosteroidproducedbyadrenalcortex;mainlyglucocorticoid. Mineralcorticoids‐↑Naretention,↑Potassiumdepletion(cancauseedema&↑BPifexcessive).

o Ie–Aldosterone(natural),Deoxycorticosterone,Fludrocortisone;

Aldsterone–secretedbycellsinZoneGlomerulosaofadrenalcortex;regulatedbyACTH&renin‐angiotensinsystem(regulatesbloodvolume&pressure);

o promotesreabsorptionofNaintobloodfromglomerularfiltrate;o so↑aldosterone=↑Na&↓Kinblood;so↓Nainbloodcauses↑BP/bloodvolume.o ↓Na=juxtaglomerularcellssecretereninwhichconvertsangeiotensinogentoangiotensin1

whichisconvertedtoangiotensin2whichstimulatesadrenalcortextoreleasealdosterone. ADH(Vasopressin)‐↓urineby↑reabsorptionofwaterbytubules;↑ADHcausesarteriolestoconstrict

=↑BP;↓ADH=↓water;alcoholinhibitsADHproductionsoextremelossofwater.CVDRUGS: ANTIARRHYTHMICAGENTS(classifiedviaVaughan‐WilliamsClassificationSystem)

1. GroupI–Nachannelblockers;furtherclassifiedbasedonactionpotentialduration.1. IA–Prolongactionpotential:a. Procainamide–anti‐Aagent;txofcardiacarrhythmias;derivativeofesterLAprocaine;

↓myocardialconductionvelocity,excitability,&contractibilitybyinhibitinginfluxofNathrumyocardialcellmembranesoincreaserecoveryperiodafterrepolarization.

b. SimilartoQuinidine(atrialfibrillation,txforsupraventriculartachyarrhythmia,PROTOTYPEforanti­A)&Disopyramide–convertsatrialarrhythmiastonormalsinusrhythm.

2. IB–Shortenactionpotential–Lidocaine(usedforemergencyventriculararrythmias&decreasecardiacexcitability,IV),Mexiletine,&Tocainide.

3. IC–Noactionpotential–Flecainide,Moricizine,&Propafenone(txforventriculararrhythmias&supraventriculartachycardias).

2. GroupII–Betablockers–forcontrollingventricularrateduringatrialtachyarrhythmias.1. Propranolol&Esmoloareprototypes!Sideeffects–bradycardia&hypotension.

3. GroupIII–PotassiumBlockers‐Amiodarone(Cordarone)–mostpotent&broadspectrumanti‐Acompound;blocksNa,K,Cachannels&βreceptor;txforsuppressingsupraventricular&ventriculararrhythmias.

4. GroupIV–CaChannelBlockers‐Verampamil–anti‐AagentthatinhibitsintracellularentryofCa;***drugofchoiceforsuppressionofsupraventriculartachycardiasstemmingfromAVnode.

→ Cachannelblockersaregoodantianginalagent,esp.chronicangina;→ Causeperipheralarteriolestodilate&totalperipheralresistancedecrease.→ Alsocauseincreaseinoxygendeliverytomyocardium;nitratesrelieveacuteangina.→ Ie–Verampamil(prototype),Ditiazem,Nifedipine

OtherAnti‐arrythemics–Adenosine&Digitalis(cardiacglycoside). CardiacGlycosides:calleddigitalisb/cfromdigitalisplant;

helpsheartbeatstrongly,slowly,&efficiently;txofsupraventriculararrythmias,shock,&CHF. InhibitsNa­K­ATPasemembranepumpbyinhbitingadenosinetriphosphateenzymes

(ATPase/Na‐K‐ATPase);inhibitingNa‐K‐ATPaseleadstoincreaseCALCIUMioninfluxwhichcausesionotropiceffectofglycosides.

Digoxin(Lanoxin)–anti‐Athatdirectlyincreasesmyocardialcontractionforce;mostcommon&versatile;createspositiveionotropiceffect(helpheartbeatstronger);maycauseappetiteloss&diarrhea;contra–ventricularfibrillation&ventriculartachycardia.

Mostdrugsofcardiacarrhythmiasactprimarilyby↑refractoryperiodofcardiacmuscle. ANTICOAGULANTS: ProthrombinTime–detectsplasmacoagulationdefects(factorsV,VII,X);thrombin–prothrombinin

presenceofCa,thromboplastin,orotherfactors. InternationalNormalizedRatio–prothrombintimeexpressedinINRvalues;fibrin=bloodclot.

• INR=PTT/standardPTtimeXconstant(INR=1,thennormalPTtimeof12sec).• INR>1=anticoagulanteffect;incr.INR=inc.inanticoagulanteffect.• Nooralsurgeryif>5;veryeffectiveis<4.

Wafarin/Coumadin&Dicumarol–anticoagulant;antagonizedvitKtoprolongclottingtimesodecreasingliversynthesisoffactorsII,VII,IX,Xsocantforfibrin;→ usedafterMItopreventcoronaryocclusion,pulmonaryembolism,andvenousthrombosis.

GlycoproteinIIB/IIAInhibitors–reversibleanti‐plateletagentsusedtopreventacutecardiacischemiccomplications;theblockplateletglycoproteinIIB/IIAreceptor(bindingsiteforfibrinogen,vonWillebrandfactor,andotherligands);→ Abciximab(Reopro),Eptifibatide(Integrilin),Tirofiban(Aggrastat).

Enoxaparin,Dalteparin,Tinzaparin–lowmolecularweightheparintypeanticoagulantsthatpreventdeepveinthrombosis;HeparininhibitsrateofclottingproteasesbyantithrombinIIIimparingnormalhemostasis&inhibitingfactorXa.

HeparincreatespotentiationofantithrombinIIIinactivatingthrombin/prothrombin(factorII)&preventsfibrinogenconversiontofibrin;containedinmastcells&basophils;→ highMWheterpolysaccharidefoundintheLUNGS;→ neutralizestissuethromboplastinandblocksthromboplastingenerationsoaffectscoagulation

pathwayandpreventsfibrinformation.→ SmalleffectonPTTbutstronglyinhibitfactorXa.→ Usedforprophy/txforthromboembolicdisorders;administeredsubcutaneously.

VitaminK–groupoffatsolublevitaminsforsynthesisoffactorsII,VII,IX,&X&prothrombininliver. Clopidogrel(Plavix)–inhibitsbloodclottingbyinhibitingplateletaggregation;noulcersideeffect

likeaspirinsoantiplateletdrugofchoiceforptsw/historyofulcers. Abciximab,Eptifibatide,Tirofiban–glycoproteinIIb/IIainhibitortypeofantiplateletagent;

reversibleanti‐plateletagentstopreventcardiacischemiccomplications; Lepirudin,Argatroban,Danaparoid–thrombin‐inhibitortypeanticoagulants;inhibitsfibrin

formation;txforpost‐opdeepveinthrombosis. ConditionsManagedbyAnticoagulants:

1. CoronaryArteryDisease2. AnginaPectoris–preventthrombusfromforming.3. MI4. Stroke–preventsthrombusfromforming.

ANTICHOLESTEROLS: HMG‐CoAReductase=hydroxymethyglutarylcoenzymeAreductase,whichiskeystepinsynthesizing

cholesterol;inhibitedby“statin”drugs–Atorvastatin(lipitor),Simvastatin(zocor),Fluvastatin(lescol),Lovastatin(mevacor),Pravastatin(pravachol),Rosuvastatin(Restor);→ Whenstatindrugsinhibitthisenzyme,cholesterolisntproducedinliver,sodecreasesblood

cholesterollevels.Txforcoronaryarterydisease;→ **donotprescribestatindrugsw/ERTHROMYCINdrugs,maycauserenalfailure.

CoronaryArteryDisease–narrowingofbloodvesselsofheartrestrictingO2flowtoheartmuscles. MechanismofActionofANTIHYPERTENSIVES:

1. Diuretics:3typesa. Thiazides–inhibitNareabsorptioninDISTAL

OFRENALTUBULEcausingincreasedexcretionofsodium&water;i. Hydrochlorothiazide(HCTZ)–most

widelyuseddiureticforhypertensionbutmayrequireK+supplementation;

ii. Dyazide=Triamterine+HCTZ;iii. Metolazone–oralquinazoline&

sulfonamidediuretictomanageedema&hypertension;

iv. Indapamide‐firstnewclassofantihypertensives/diuretics;usedin

advancedrenalfailure;v. Thiazidestx=hypertension,edemaofCHF,renaledema,Hypercalciuria,Nephrotic

diabetesinsipidus;adverseeffects:Hypokalemia(canpredisposepttodigitalistoventriculararrhythmias),Hyperuricemia,Hypercalcemia.

b. LoopDiuretics–inhibitreabsorptionofCl‐&NainASCENDINGLOOPOFHENLEcausing↑secretionofNa,water,&Cl;i. ie–Furosemide(Lasix)–prototype,Bemtanide,Torsemide,EthacrynicAcid.ii. MOA–↑Cacontentofurinewhichcuases↓renalvascularresistance&↑renalbloodflow.iii. DrugofchoicewithAcutePulmonaryEdemaofCHF;adverseeffects–earproblems.

c. Potassium­SparingDiuretics–actinCOLLECTINGTUBULE&conserveK+;mosttoxiceffect=hyperkalemia;ie:i. Spironolactone(Aldactone)–competesw/aldosteronereceptorsitescausingincreased

secretionofNa,Cl,&water;txforaldosteronism&CHF.ii. Triamterine(Dyrenium)–promotesNa&waterexcretionbutretainsK+;blocksNa

channels;Dyazide=HCTZ+Triamterine.iii. Amiloride(Midamore)blocksNachannelsinlatedistaltubule&collectingductwhich

decreasesK+excretion;• OsmoticDiuretics–highlyfilteredbyglomerulus;reduceedemafromneurosurgeryortrauma

totheCNS;ie–Manitol,Glycerin,Isosorbide,&Urea;givenviainjection.2. β‐adrenergicblockers–decreaseperipheralpressurebyincreasecardiacoutput.

a. Cardioselectiveβblockers‐blockβ1receptor;Atenolol(tenormin)&Metoprolol(lopressor).b. Nonselectiveβblockers–Nadolol(Corgard)&Propanolol(Inderal).c. BothAtenolol&Propanolgoodforanginatoo.

3. Angiotensin‐convertingEnzymeInhibitors–inhibitconversionofangiotensin1to2byinhibitingangiotensinconvertingenzyme,causingvasodilation&increasedurinaryvolumeexcretionbecauseAngiotensinIIstimulatesreleaseofAldosteronewhichpromotesNa&H20retention;a. Ie–Lisinopril,Ramipril,Enalapril,Captopril,Benazepril,Ramipril,Fosinopril,Quinapril,

&Perindopril;usedtotreathypertension&CHF.b. AngiotensinII(stimulatereleaseofADH–sodium&waterretention)receptorblockers–

Losartan,Valsartan,Candestartan,&Irbesartan.c. ACEinhibitors&AngiotensinIIreceptorblockersindirectlyinhibitfluidvolumeincreases.d. Renin–proteolyticenzymeofkidney&storedinjuxtaglomerularapparatusandconverts

angiotensinogentoangiotensin1.e. AngiotensinII–vasopressor;↑peripheralresistance&ADHreleasecausing↑cardiacouput.

4. Ca‐channelBlockers–Nifedipine&Ditiazem–bothforangina;**maycausegingivalhyperplasia. Othervasodilators(DIRECTVASODILATORS)–Minoxidil(severe↑BP),Nitroprusside(ERBP),

Diazoxide(ERBP),Hydralazine(Apresoline);directvasodilatoractiononsmoothmuscleofarterioles.

Angina–chestpainfromocclusionofcoronaryarteries;Treatment:1. Nitroglycerin(Nitrates)–coronaryarteryvasodilator;administeredSUBLINGUALLYw/onset2‐

4min;sideeffects–hypotension&headache;singlemosteffectiveanti‐anginalagentforacuteanginaepisodes.

2. Non‐nitratevasodilator=Dipyridamol(persantine)3. βblocker–Propanol,Nadolol,Atenolol.4. Cachannelblockers–Verapamil,Nifedipine,Diltiazem;theyareINDIRECTvasodilators.5. AmylNitrite–inhalationagent;oxidizeshemoglobintomethemoglobinwhichbindscyanide

tightlykeepingitincirculation&awayfromtissues;usedforemergencytxforcyanidepoisoning;o vasodilator&highlyvolatile&extremelypotentsorarelyprescribedandnotdrugofchoicefor

angina;sideeffects–orthostatichypotension&o Mostrapidantianginaldrug(10sec)w/DOA=3‐5min;

o Abusedtoproduceeuphoriaandassexualstimulant;ANTIDIABETICS: Insulin:secretedbypancreaticβcellsofisletsofLangerhans&essentialforglucosemetabolism;

subcutaneousinjection;a. ↑proteinsynthesis,↓gluconeogenesis,↑glycogensynthesis,↑triglyceridestorage.

Antidibetic/OralHypoglycemicagentsforType2diabetes;1. Glyburide&Chloropropamide–stimulateinsulinreleasefrompancreas&reducingglucoseout

fromliver.2. Metformin&Pioglitazone–increaseinsulinsensitivityatperipheraltagetsites;3. Tolbutaminde–sulfonylurea;stimulatessynthesis&releaseofinsulinfrompancreasand

increasessensitivityofinsulinreceptors&utilizationofinsulin. Humulin70/30–brandnameforhumanformofinsulin;aninsulinmixtureofinsulin(30%,fast

onset)&isophaneinsulinsuspensioncomponent(70%,longduration). InsulinZincSuspension(lenteinsulin):DOA=18‐24hrs&anintermediateactinginsulin. Insulinprepsmimicendogenousinsulinfortype1&2diabetes:

1. Ultra‐rapidactinginsulin–Onset‐.25‐.5hrs;DOA=3‐4hrs;InsulinLispro2. Short‐actinginsulins:onset=.5‐3hrs;DOA=8‐12hrs;

a. RegularInsulinorPromptInsulinSuspension.3. Intermediate‐actinginsulin=onset=8‐12hrs;DOA=18‐24hrs;

a. Lenteinsulin&Isophaneinsulin.4. Long‐actinginsulins=DOA>36hrs,Protaminezincinsulin&Ultralenteinsulin.

Insulinsdifferintheironset&DOA. Hypoglycemiaismostseriousandmostcommoncomplicationofinsulintherapy;DRUGS: Onsetofaction(RateofAbsorption)fordifferentdrugadministration:

1. Oral–30min(safest&easiestroutebutunpredictable&leasteffective;manydifferentdosageforms);oralroutemostknownforitssignificanthepatic“firstpass”metabolism;

a. generallyabsorbedbestfromduodenum;disadvan‐1stabsorbedinintestines&bloodfromintestinesthenfilteredinliver(hepaticfilter);emotionalstressdecreasesrateofabsorptionofadrugwhengivenorally.

2. IM–5min;notbicepts;forchild=ant.thigh&¼”ofneedle;adult=butt/deltoid&1”ofneedle;nevergodeeperthan2/3rdofneedlelength.

3. Subcutaneous–15min;injectionundertheskinsoabsorptionlessrapid.4. Inhalation–5min;MOSTutilizedrouteofadministrationw/NOtosedatepedspatients.5. Patch–12‐24hrs;systemiceffect.6. Intra‐arterialInjection–injectedintospecificartery;maycauseburning.7. IntravenousInjection–mostrapidonset;allowsfortitrationofindividualdosagesofdrugbut

difficulttoreverse;disadv–suchrapidonsetthatoverdoseisdifficulttoreverse.o ParenteralAdministration(notGI)–IV,IA,IM(uniformadmin)&Subcutaneous.o EnteralAdministration(GI)–buccal,sublingual,rectal,ororalo Topical–localeffect.o Transdermal–systemiceffect.

Drug’sonsetofactionprimarilydeterminedbyrateofabsorption. Majoreffectofadrugisdeterminedbyhowmuchofthedrugisfreeinplasma. AdditiveEffect–nogreatereffects!;when2drugsgiven&resultissumoftheirindividualactions

whengivenalone. Synergistic–combine2drugs&sumofaction>sumofindividualactions. CompetitiveAntagonism–whenresponseachievedbyincreasedoseofagonistinpresenceof

antagonist;cantrespondinpresenceofnoncompetitiveantagonism.

CumulativeAction–excessiveaccumulationeffectthatoccursifadrugisadministeredrepeatedandhigherconc.ofdrugisdesiredmaybeachieved.

Fourtypesofbindingtoreceptors:1. IonicBonds–electrostaticattractionb/wions;NOTcovalentbondsornitrogenbonding!2. H+Bonds–b/wpolarmolecules.3. VanderWalls–weakinteractionsoccurb/ccloseproximity.4. HydrophobicInteractions–b/wdrug,receptor&env’t.

FourPhysiologicalreceptorsthatdrugsbindto:1. Receptorsasenzymes:phosphorylatingproteinsincellwhichalterscellularbiochemicalactivities.2. IonChannels:bindtoionchannels&altercellpermeability.3. G­ProteinCoupledReceptors:whenbindtoreceptor,secondarymessengers(cyclicAMP)produce

toaffectcells;4. Receptorsincellnucleus:modifytranscriptionsofspecificgenes.

Drugstransferacrosscellmembranesthrough…1. Passivetransfer–simplediffusion(lipidsolubledrugs–onlyNON‐IONIZEDdrugsaresolublein

lipids)&filtration(MV<60,000)&osmosis.2. Activetrasnfer–lipidinsolubledrugs(glucose)shuttledacrossmembranesw/carriermolecules

thatprovideenergyfortransportingdrugstoregionsofhigherconcentration. Facilitateddiffusion–carrier‐basedtransfer;drivingforce=concentrationdifference;MOSTDRUGS

absorbedbyfacilitateddiffusion. Osmosis–puresolventtransfersthrusemi‐permeablemembranefromlowtohighsolute

concentration;impermeablemembranetosolutebutpermeabletosolvent. DrugsthatcauseOrthostaticHypotension:(abnormallylowBPwhenptassumesstandingposition)

1. Antihypertensives–Guanethidine(Ismelin)2. Phenothiazine–Chlorpromazine&thioridazine(anti‐psychotics)3. TricyclicAntidepressants4. Narcotics–Demerol/Morphine5. Anti‐parkinson’sdrugs–Levodopa,Carbidopa,Levidopa.6. NSAIDS.

Aftervasovagalsyncope,orthostatichypotentionis2ndmostlikelycauseoftransientunconsciousnessindentistoffice;Sny­DragerSyndrome–chronicorthostatichypotension.

PhantomPain–painw/nobasisbutfixedonsomeanatomy. Intractablepain–painresistant/refractorytoanalgesics. Referredpain–paininareaotherthansiteoforigin. Psychologenicpain–paincausedbypsychic/mentalfactors. PainThreshold–lowestlevelofpainapt.candetect. Scheduleofdrugscriteriabasedon(ControlledSubstanceActof1970):

1. Potentialforabuse,2.Medicalusefullness,3.PhysiologicalDependence,4.PhysicalDependence. ScheduleofDrugs:

I. Notconsideredlegitamateformedicine;noRx;ie–Marijuana,Crackcocaine,Heroin.II. ↑abusepotentialbutlegitamateformedicine;norefills,cantcallin;ie–Morphine,Oxycodone,

Ritalin,Cocaine,straightCodiene.III. Lessabusepotential;cancallinRx&refillsok;ie–Codiene,Vicodin,Tylenol#3,Hydrocodone.IV. Lessabusepotential;ie–Diazepam(Valium),Lorazepam(Ativan),Alprazolam(Xanax).V. Smallabuse;commonRxs,mayhavesmallamountofCodeine..

↑LD50/↓ED50=↑therapeuticindex=↑safety.(LD=lethaldose,ED=effectivedoes).o Ideal=therapeuticindexof100;ratiomeasuresdrug’sSAFETY.

Bioavailabilityofadrug–measurementofrate&amountoftherapeuticallyactivedrugthatreachessystemiccirculation=100%whenIV;affectedbydissolution(GItract)&distruction(liver).

Habituation–acquiredtolerancefromrepeatedexposuretodrug; ForalldrugsbutIV&IA,drugsabsorbedsystemicallypriortoreceptors.

***Initialdistributionofdrugintotissuesisdeterminedbyrateofbloodflowintissues. Cummulativeaction–increaseconcentrationofdrugdesiredwhenadministeredrepeated. Idiosyncrasy–responsetodrugthatisunusual/abnormal. FactorsAffectingHepaticdrugMetabolism:

1. Microsomalenzymeinhibition–drugsinhibitCYPisoformsofP‐450.2. Microsomalenzymeinduction‐↑metabolismand↓drugbloodlevels.3. Plasmaproteinbinding–drugswontenterliverifhighlyboundtoplasmaproteins.4. Geneticfactors&Pathologicalfactors.

UrinaryEliminationofDrug:1. Glomerularfiltration–alldrugsfilterthruthisb/fenterrenaltubules.2. Tubularreabsorption–reabsorbedbackintoblood(highlylipidagents).3. Activetransport.

Otherexcretorypathwaysfordrugs:GI,Lungs,Sweat. Efficacyofdrug=intrinsicability=ceilingeffect=maximal;regardlessofdose. Potency–conc.of2/moredrugsthatproducethesamedrugeffect;theeffectthatusuallyischosenis

50%ofmax.effect&dosecausingthisisEC50;determinedbyaffinityofreceptorforthedrug. MostimportantenzymesystemsforbiotransformationofdrugsisintheLIVER! Phase1Reactions:inlivermicrosomalenzymesystems(mixedfctoxidasesystemorP‐450system);3

patternsofdrugmetabolism.1. Activeparentdrugconvertedtoinactivemetabolite.2. Activeparentdrug→2ndactivecompound→inactivecompound3. Inactiveparentdrugconvertedtoactivecompound.

MostcommonrxinmetabolismisOXIDATIONRXNofwhenhydroxylgroupattachestodrugmolecule;5cytochromes(drugmetabolismfamiles);ieCYP­1A2(converttooxidizingproduct).

Phase2Reactions:parentdrugrenderedinactive&excretedinurinethruconjugationrxns–couplingdrugw/acid(glucuronicacid)&resultsinmetaboliteglucuronide;inliver,kidneys,&othertissues.

o Conjugationresultsinpolar‐watersolublecompoundssoexcretedinurine.CHEMOTHERAPY: 8classesofchemotherapy:

1. AlkylatingAgents–formcovalentbondstonucleicacidssoalkylateDNAsoitdoesn’treplicate;goodforleukemia,lymphoma,myeloma,&carcinoma;commonbondingsite=N‐7positionofGuanine.

a. Cisplatin‐sideeffects:nausea,alopecia,xerostomic,&mucositis.b. NitrogenMustards–Mechlorethamine,Cyclophosphamide,Chlorambucil,&Melphalan.c. Nitrosureas–Carmustine,Lomustine,Semustine;d. Bisulfan–txforchronicgranulocyticleukemia.

2. Anthracyclines–destroysDNA;Daunarubicin&Doxorubicin;Mucositisiscommon!3. Antibiotics–Dactinomycin4. Antimetabolites–interferesw/biochemicalrxn,sointerferesw/Sphaseofreproductioncycle;

oldest&mostimportantchemo.;Methotrexate,5­Fluorouracil(5‐FU),6‐Mercaptopurine.a. FolidAcidAnalogs–Methotrexate(maycauseoralulcers);b. PyrimidineAnalogs–5­FU,Floxuridine,CystosineArabinsoide,6­Merpatopurine.c. PurineAnalogs–Mercaptopurine,Thioguanine;

5. Antimicrotubular–inhibitscellmitosis;Paclitaxel(taxol).6. Antiestrogen–blocksestrogenictumors,likebreastcancer;Tamoxifine(nolvadex)7. VincaAlkaloids–mitoticspindlepoisons;Vinblastin&Vincristin.8. GonadotropinHormone­ReleasingAntigen–inhibitGDTH;Leuprolide.

Asparinigase–deprivestumorsofaminoacidsforproteinsynthesis;Interferons–boostimmunesystem;bothdon’tfallinchemocategorybutareusedtotxcancers!

Interferons–inhibitcellgrowth,inducegenetranscription&alterstateofcelldifferentiation;types:

o Interferonα2a–haircellleukemia.o Interferonα2b–chronichepatitisBo Interferonαn3–recurringgenitalwartso Interferonβ1a–txforMS.

Mucositis–commonrxntochemotherapyinvolvinginflammationofmucousmembranes;use5‐fluorouracil,Methotrexate,&Doxorubicin.

Alopeciaismostcommonchemosideeffect;occurs1‐2weeksaftertx;alsoincreaseininfectionslikecandidaanddegenerationoflymphatictissue;

Mostchemodrugsareteratogenicandneedtobeavoidedinpregnantwomen. ColonyStimulatingFactors:

1. DarbepoetinAlpha–induceserythropoiesis;txforanemiafromrenalfailure.2. Pegfilgrastim–stimulatesneutrophilsanddecreasesinfections.3. Sargramostin–myeloidreconstitutionafterbonemarrowtransplants.

AromatoseInhibitors–1. Exemestane–preventsconversionofandrogenstoestrogenbytyingupenzymearomatous;tx

forbreastcancer.2. Letrozole–firstlineoftreatmentforhormonereceptorpositiveormetastaticbreastcancerin

postmenopausalwomen. 5‐Hydroxytryptamintype3Receptor(5‐HT3)–seratoninreceptoractivatedduringchemocausing

emesis(vomiting);antagonistforthisreceptor:Granisetron&Ondansetron(prophyforchemo). Immunosuppressants:

1. Pimecrolimus(Elidel)–txformildtomoderatedermitis.2. Sirolimus(Rapamune)–prophyfororganrejectionpatients.3. Tacrolimus–txformoderatetoseveredermatitis.

Adalimumab(Humira)–monoclonalantibodybindstohumantumornecrosisfactoralphareceptors;txforrheumatoidarthritis.

Alefacept(Amevive)–monoclonalantibody,txofmoderatetoseverepsoriasis. Infliximab(Remicade)–monoclonalantibodybindstoTNFalpha;txforankylosingspondylitis,

Crohn’sdisease,&Rheumatoidarthritis. Trastuzumab–monoclonalantibodybindstohumanepidermalgrowthfactorreceptor2protein

(HER‐2);txformetastaticbreastcancer; Modafinil(Provigil)–CNSstimulanttoimprovewakefullnessinptsw/excessivedaytimesleepines&

ADHD;decreasesGABAmediatedneurotransmission.MISCELLANEOUS: Rx–p.c.=aftermeals;h.s.=atbedtimes,a.c.=beforemeals.

o Superscription=pt’sinfo;Inscription=drug&drugstrength;Subscription=directionstopharmacist;Transcription=directionstopt.

Glaucoma–increaseinintraocularpressure;poordrainageofaqueoushumor(fluidineye)andcancauseblindness;tx:1. Pilocarpine(Isopto‐carpine)–cholinergicagonist;eyedropscausingpapillaryconstriction.2. Latanoprost(Xalatan)–prostaglandinanalog;eyedropsreduceintraocularpressure.3. Betaxolol(Betoptic)–β‐blocker;eyedrops↓pressureby↓productionofaqueoushumor.4. Bimatoprost(Lumigan)–sameaslatanoprost.

DrugsthatproduceREVERSIBLEXerostomia:a. Amitriptyline(elavil)–tricyclicantidepressant;highestincidenceofxerostomia!b. Diphenhydramine(benadryl)–sedatingtypeanti‐histaminec. Atropine–powerfulanticholinergic,blockssalivaproduction.d. Diazepam(Valium)–benzodiazepinetranquilizer.

RheumatoidArthritis(RA)–chronicinflammationofsynoviumthatlinesjointscausingpain,swelling,&destruction;treatment:1. Prednisone–decreasesinflammatoryresponse.2. Goldinjection–decreasesprostaglandinproduction.3. Methotrexate–affectimmunefunction.4. Nabumetone(relafen)–NSAIDthatinhibitsprostaglandinsythensis.5. Piroxicam(feldene)–NSAIDthatinhibitsprostaglandinsynthesis;maycausegastricirritation,

heartburn,&nausea. AllofthesealsoworkforOSTEOARTHRITIS(exceptgoldinjections)‐theprogessivelossofarticular

cartilageduetoexcessiveloads;drugsforOAprovideanalgesic&anti‐inflammatoryaction. Anti‐RheumaticAgents:

1. Etanercept(enbrel)–decreasesS&Sofrheumatoidarthritis;recombinantDNA‐derivedproteinwhichbindstoTNF–whichplaysimportantroleinRAcausingincreasedinflammationinRA.

2. Infliximab–treatmentforCrohn’sDisease(inflammationofGItract)&RA;monoclonalantibodythatbindsTNFsodecreasesinflammation.

• Parkinson’sDisease–deficiencyofneurotransmitterdopamineinbrainduetonervecellsinbasalgangliadegeneration;slowprogressing&degenerativedisorder;distinguishingfeatures:tremorsatrest,sluggishinitiationofmvmts,&musclerigidity;Treatment‐• Levodopa–precursorfordopamine.• Carbidopaw/Levodopa(Sinemet)reducesrequireddoseoflevodopaby75%w/osideeffects;

Carbidopainhibitsperipheraldecarboxylationoflevadopa;Carbidopadoesn’tcrosstheBBB,solevodopaconvertsintodopamineinthebrain.

• Bromocriptine/Pergolide–dopamineagonists&oftengiventoenhanceLevodopa’saction.• Selegine–inhibitorofMAOTypeB:enzymecausingoxidativedeaminationofdopamineinbrain.• Amantadine–anti‐viralagentthatpotentiatesdopaminergicresponses• Anticholinergicdrugsalsotxparkinson’s–likeBenztropine&Trihexyphenidyl.

• DrugsthatcausesOSTEONECROSISoftheJaw:temp/perm.lossofbloodtobone&bonedies;non‐healingofextractionsocketorexposedjawbonearesymptoms.1. ZolendrionicAcid(Zometa),2.Palmidronate(Aredia),3.Alendronate(Fosamax)

GastricAntacids–directlyneutralizedgastricacid(HCl)fromstomach;decreaseconc.&totalloadofgastricacid;DYSPEPSIA–impairmentofthepower/functionofdigestion;antacids:1. SodiumBicarbonate(onlysystemicantacid)–Alka‐Seltzer.2. CalciumCarbonate–Amitone,Tums.3. AluminumHydroxide(mostpotentbutlessneutralizing)–Alternagel&Amphojel.4. MagnesiumHydroxide–milkofmagnesia5. BismuthSalts–Pepto‐Bismol.6. Magnesium&Aluminum–Maalox&Mylanta.

GrowthHormone–Somatotropin–secretedfromanteriorpituitarygland;↑proteinsynthesisrate,↓carbohydrateutilizationrate,&↑mobilizationoffatsforenergy;subcutaneous/IMfor3x/week.→ HumanGrowthHormone‐preparedcommerciallyaspurifiedpolypeptidehormoneof

recombinantDNAorigin;usedasreplacementtherapyforptswithHGHdeficiency. Gout–elevatedlevelsofuricacidinbloodstream;Treatment:

1. Colchicin–impairsleukocyticmigrationtoinflammationareas&disruptsuratedeposition;notIMorsubcutaneousb/ccausestissueirritation;kidney&liverdamage&bonemarrowdepressionaresideeffects;NSAIDSarealsousedlikeIndomethacinforacutegoutyarthritis.

2. Allopurinol–↓uricacidproduction;inhibitsxanthineoxidasewhichisanenzymethatcovertshypoxanthinetoxanthineandxanthinetouricacid;drugofchoiceforCHRONICGOUT.

3. Probenecid(benemid)&Sulfinpyrazone(anturane)–enhanceuricacidclearance;bothinkidnesy&inhibitreabsorptionofuricacid;slowssecretionofPCNS&cephalosporins.

Caffeinism–600‐750mgofcaffeine/day(morethan10cups/day)w/>1000mginthetoxicrange;caffeinestimulatesCNSunequallyw/cortexmostandspinalcordleast.

Mercury–prescenseinbodydeterminedbyurinetest;average½life=55days;mercuryaccumulatesinbrain,liver&kidney.• Cancauseirritability,excessivesaliva,looseteeth,gumdisorders,slurredspeech,&tremors;

thesesymptomsarechronic;higherthanavg.accumulationsoccurinbrain,liver,&kidney..• tx–gastriclavageandfluidtherapyandBritishAnti‐Lewisite(BAL)/Dimercaprol–complexw/

mercury&allowtobeexcretedasinactivecompound. Analeptic–notsafe/recommended;CNSstimulantthatovercomedrug‐inducedresp.depression&

hypnosis;ie–Pentylenetetrazol,Nikethamide,Doxapram,Picrotoxin,&Strychnine. Xanthines–formentalallertness,decreasesleep,andincreasemood;ie–Caffeine(onlyOTC),

Theophylline(forasthma),&Theobromine;• Theophylline&TheobromineweakerCNSstimulantsthancaffeine.

Loperamide(Imodium): 1)Anti‐Diarrhealwhichinhibitsperstalsis.2)Opoidfamilybutdoesn’tpenetrateCNSsoOTC.3)Nodrugabuse/dependence.

Diphenoxylate(Lomatil):antidiarrheal&inhibitsGItractmotility&propulsion;Diphenoxylate&Atropinetogetherrequireprescription;

Laxativesactinreversemannerofanti‐diarrhealsb/cincreaseGImotilitytotreatconstipation;Ie‐MagnesiumHydroxide,CasterOil,Metamucil,&Methylcellulose.

OralContraceptivesblockovulationbyinhibitinganteriorpituitaryhormonesFSH&LH;bothestrogenic&progestationalagents;increaseriskofthromboembolismandheartdiseaseinsmokers.→ Containsbothestrogenicagent&progestationalagent.→ Highestriskassociatedw/BCPisthromboembolism.

Drugstravelthrubloodstreambybindingtoalbuminprotein,whichisabundantinplasmaandenablesdrugtobecarriedtoalltissuesandorgans.

Virtuallyanydrugcancrossplacentaofpregnantwomen&enterfetalcirculationsocheckw/DR. Habituation–acquiredtoleranceformrepeatedexposuretoparticularstimulusbutw/othe

addictive,physiologicalneedtoincreasedosage. Tolerance–decreasedresponsivenesstoadrugafterchronicadministration;dosagerequiredto

produceusualeffectisincreased. Toxicityisbothdose‐depenedent&time‐dependent; Dyesthesia–uncomfortable/painfulsensation;indentistry,manifestsaspost‐opsequelatoregional

administrationtoLA.

PROSTHODONTICSFIXED: GoldCrownPreparation=.5–1.0mm; PFM:metal=.5mm,porc.=1‐1.5mm,total=1.5‐2mm;labialshoulder=1.5mm;supportingcusp

reduction=2.0mm&opposingwallsnomorethan10o. Absoluteminimumrequiredthicknessofporcelain=.7mm&metalcopingthickness=.3‐.5mmfor

highnoble&.2mmforbasemetal; Properthicknessneedtopreventdistortionduringfiringofporcelain; PFMAlloys‐

1. HighNoble–98%Au/Pl/Pt;doesn’toxidizeduringcasting;BEST!2. Noble–50‐60%Pl&30‐40%Silver;Palladium‐silveralloy;notnobelmetalsooxidizesoncasting.3. Base­Metal–70‐80%Ni&15%Chromium;Nickel‐Chromiumalloy;oxidizes&causesPFM

interfaceproblems;lessresistanttocorrosion;stronger&lowerdensitythannoblemetal;a. Alloysw/lessthan25%nobleelements;b. AnotherexampleisChromiumCobaltusedforRPDs;c. ↑resistance,modulouselasticity,meltingtemperature;comparedtotype4gold.d. ↓density,specificgravity,&yieldstrength;allcomparedtotype4gold.e. Thelowdensitymakescastingmoredifficult;

ADAClassifiesAlloysasfollows: 1)TypeI–usedforsmallinlays2)TypeII–largerinlays&onlays3)TypeIII–onlays,crowns,&short‐spanFPDs4)TypeIV–thinveneercrowns,long‐spanFPDs&RPDs

Porcelainadherestometalprimarilybychemicalbond(COVALENTBOND);sincetruechemicalbond,failure/fracturewilloccurinporcelainratherthanporcelain‐metalinterface;

RepeatedfractureofPFMisduetoINADEQUATEFRAMEWORKDESIGN; All­CeramicCrowns–havelowflexuralstrengthandtendencytofractureatminimumdeformation; PFM&AllcermaiccrownrequiretheSAMEamountofoveralltoothreduction=1.5‐2.0mm; PFMprepmusthaveallsurfacessmooth&roundedinordertopreventfractures; Outerjunctionofporcelaintometalshouldbeatrightangle=90o; ButtJoint–pooresttypeoffinishline;optimummarginisACUTEEDGE;maindisadvantageisany

inaccuraciesinthecrownfitarereproducedatthemargin,causinganincreasedthicknessofcement; Bestfinishmarginbutleastmarginalstrength=bevel/featheredge;maycausesinacurrate

extension&distortionofwaxpattern;optimummarginforcastingb/ceasilyBURNISHED; Chamferispreferredfinishlineoncastgoldrestorations;awellpreparedchamfercombinesthe

advantageofeasilydefinablemarginontheimpression&die,withminimaltoothpreparation;→ Reducesthicknessofcement;

ShoulderMarginw/aBevel–thismarginallowsaslidingfittooccuratthemargin,thusmaybeusedonproximalboxofinlaysorocclusalshoulderofmand.¾crowns;

Marginsfordifferentmaterials: ‐‐AllCeramic=Shoulder‐‐PFMw/porcelaintomarginedge=Shoulder‐‐PFMw/metalcollar=ShoulderbevelorChamfer‐‐FullGoldCrown=BevelorChamfer;

Ifmarginsextendsintobiologicwidth,constantgingivalirritantoccursandcrownfails;socrownlengtheningneedstobeperformedbeforeFIRSTcrownpreparation;

AdvantagesofPartialVeneerRestorations(¾or7/8crowns):→ Greatdealofmarginisaccessibletodentist&patient→ Lessofrestorationmarginisincloseproximitytogingivalcrevice(lessperioirritation);→ Moreeasilyseatedduringcemetation→ Portionisaccessibleifpulpvitalityeverneedstobetested;

Reverse¾crown–commononmandibularmolarstoperserveLINGUALarea.

Standard¾crown–preservesbuccalarea;MOSTCOMMONtypeofpartialveneercrown; 7/8thcrown(allmetal)isa¾thcrown(allmetal)whoseverticaldistalbuccalmarginisposition

slightlymesialtomiddleofbuccalsurface;advantages:→ esthetics,DBfinishlineeasytoaccess,providesmorecoverage,excellentabutmentforbridge;

Thepathofinsertionofanterior¾crownshouldparalleltheincisal½‐2/3oflabialtoothnottooth’slongaxis;ifparalleltolongaxis,willcausemoregoldtobedisplayed;

Apinmodified¾crowncanpreservethefacialsurface&1proimalsurface;preferredincaseswhichrequirerepairingofseverlingualabrasiononincisors&canines;

GoldCrownOcclusion–checkw/silverplasticshimshock; ALUM–aluminumpotassiumsulfate;forcordsforpatientsw/↑BP;ZnCldelayshealingsodon’t

use;↑BPw/epicordswhenappliedtoseverlylaceratedgingivalsulcusbutminimualchangeswhenplaceinanintactgingivalsulcus;

MechanicalPropertiesofRESINSinfluencedby‐ 1)MWofpolymer2)Degreeofcross‐linking3)Compositionofmonomersusedtopreparepolymer4)AcrylicresinsEXPANDwhenimmersedinwater&becomeDISTORTEDwhendriedout;

MethylMethacrylate(MMA)=liquidmonomer;hydroquinoneinhibitor,cross‐linkingagents,&chemicalactivator(dimethyl­p­toluidine)whichisonlypresentinself‐curedresins;EXOTHERMIC;

→ Othermonomers–ethylmethacrylate,vinylethylmethacrylate,&epimineresins;alllessirritatingtothepulp;MMAismostfrequentlyused!

→ Excessiveshrinkagemayoccuriftoomuchmonomerisaddedtothepolymer; PolymethylMethacrylate(PMMA)=powderpolymer;benzyolperoxideisinitiator;Cross‐linking

agentscontributegreatlytoSTRENGTHofpolymer; HeatCuredResin–stronger&superiorcolorstabilitybecausetheycontainlessresidualmonomer&

higherMWthanself‐curedresins;→ heat(accelerator)decomposesbenzoylperoxide(initiator)intofreeradicalswhichinitiate

polymerizationofMMAtoPMMA; SelfCuredResin–dimethy–p–toluidine(activator–tertiaryamine)addedtoMMAcausing

decompositionofbenzoylperoxideintofreeradicalswhichinitatepolymerizationofMMAtoPMMA;→ Generallyusedforrepairs;

PolymerizationRange=tempof60oC–77oC(140oF–170oF); PorcelainVeneerContraindications: 1)severeimbrication(overlapping)ofteeth

2)traumaticocclusalcontacts3)unfavorablemorphology4)insufficienttoothstructure&enamel5)highcariesindex6)shortclinicalcrown7)minimalhorizontaloverlap;

Sometechniquestorememberw/veneers–shouldbetriedinWET;fitsurfaceistreatedw/silane&protectedw/lightcuredunfilledresin;enamelsurfacecleanedw/pumis&water;

Mostcommoncausesofcrownfailures–lackofattentiontotoothshape,position,&contacts; Greatestpotentialforwearexistsb/wporcelain&toothb/cporcelaincausesacceleratedwearof

opposingdentition–40xmorewearthangold;sogoldpreferredforbruxismpts; ThebestmeasureofthepotentialclinicalperformanceofacastingalloyisitsADACERTIFICATION;PONTICS&FPDs: Portionofponticapproximatingridgeshouldbeasconvexaspossible! 6Types:

1. Sanitary–nonestheticzone(convexeverywhere);mostcommonlyusedwhereestheticsisnotimportant;

2. Saddle–don’tuseduetohygiene,looksmostlikeatooth;3. ModifiedRidgeLap–illusionoftoothbutallconvex;BESTforesthetics;4. Conical–rounded;formandibularthinridges;5. Ovate–sanitaryversionofsaddle;sitsinconcavityofridge.

FaciallingualdimensionofponticdeterminedbyopposingFLcontacts; Ponticsshouldn’tbeincontactduringnon‐workingmovement;maybeinCOcontact&may/maynot

beinworking‐sidecontact; Ponticsmusthavepassivepinpointcontactw/gingiva;excessivetissuecontactisoneofthemajor

causesoffailureoffixedbridges; Ponticsmustnotbeconcavein2directions;theyshouldbeconvexMD&concaveFL; Ponticdesignismoreimportantthanponticmaterial; MultipleadjacentponticsonanteriorFPDhavereducedFACIALEMBRASUREStoenhanceesthetics; Solderjoints–connectorsofCHOICEwhenabutmentteethareinnormalalignment&goodbone

support;strengthofsolderconnectoris↑with↑heightw/circularformpreferred;→ soldermusthavemuchlowerfusiontemp.themetalitisjoining;→ CLEANLINESSismostimportantprerequisiteofsolderingsincethesolderingprocessdependson

WETTINGthesurfacestoachievebonding;→ Flux(oftenBORAX)displacesgases&removescorrosionproductsbycombiningw/themor

reducingthem; FailedbridgeismoredetrimentaltodentalhealththanfailedRPDbutfixedrestorationsareALWAYS

thetxofchoice,unlesscontraindicated;Success/FailureofRPDdependsmostlyonPONTICDESIGN; FactorsthatDetermineaFPDDesign:

1. RootConfiguration–rootsthatarebroaderlabiolinguallythanmesiodistallyarepreferredtoroothsthathaveroundcross‐section;

2. CrowntoRootRatio–idealratiois1:2but2:3ismorerealisticand1:1isminimum!3. AxialAlignmentofteeth–parallelismofabutmentprepsisbestdeterminedbylongaxisof

preps;4. LengthofLeverArm(span)–replacing3teethisMAXIMUM,morethan2ishighrisk;

a. Edentulousspaceinvolving4adjacentteethotherthan4incirosisbesttreatedw/RPD; TheMOSTLIKELYindicationforsplintingistoothmobilityw/ptdiscomfort; DONOTsplintnaturalteeth&implantsinaFPDb/cimplantslackPDL; NonrigidConnector–mechanicalunionofretainer&ponticratherthansolderjoint(T‐shapedkey&

dovetail);restrictedtoSHORT‐SPANbridgethatisreplacing1tooth;o UsedwhenretainersCANNOTbepreparedtodrawtogetherw/oexcessivetoothreduction;o Pathofinsertionofkeyintokeywayshouldbeparalleltopathwayofretainer;

Whenstressbreakerondistalofpontic,occlusionunseatskeyfromkey;PORCELAIN: Porcelainshadeinorder–value(brightness),chroma(saturation),hue(color). Value–brightness;MOSTCRITICALcharacteristicthatismatchedFIRST;relativeamountoflightness

ordarknessinacolor;intensitiyofacolor;Impossibletoincreasevalue;stainingreducesvalue; Chroma–saturation;singlemostimportantfactorinshadematching;CANbe↑usingstains; Hue–basiccolor;drasticchangesofhueareoftenimpossiblebutORANGESTAINismostoftenused

tochangehue; SomeFactsforShadeSelection:1)quickrubbercup/prophytomakeshadeselectionmoreaccurate;

2)donotgazeformorethan5seconds3)proceedbyprocessofelimination4)half‐closedeyescanincreasesensitivityofrentinalrodsotbetterselectthecolor’sVALUE;

Porcelain‐rustsattemp>2000oF;hasgoodbiocompatibility;shouldbeunderslightcompressivestress;Porcelainsubstratealloysmeltathightemperatures;

Inallceramiccrown,highstrengthsinteredceramiciscorematerial; OpaquePorcelain–1stlayer;masksmetalcolor,createsCHEMICALbondsw/metal;

→ itwillshowthrufacialsurfaceofcrownifinadequatetoothreduction,toothickmetal,toothickporcelain,orinadequatethicknessofbodyporcelain;

BodyPorcelain–bulkofrestoration;mostofcolor&shade; IncisalPorcelain–translucentlayer; Porcelainbulkedouttocompensateforit20%shrinkage; PorcelainstainsareMetallicOxides; Smoothporcelaingivesimpressionoflargersize&changesincontourareusedtoaltertheapparent

longaxisinclinationofatooth; Metamerism–differentcolormatchunder2differentlightsources;stainingporcelaindecreases

valueandincreasesmetamericresponses;; Flourescence–materialreflectUVradiation;teethfluorescemainlyblue‐whitehues(400‐450nm);

makesadefinitecontributiontothebrightness&vitalappearanceofnaturaltooth; → Bluefatigueacceleratesyellowsensitivity:meansifyoulookatbluecolorobjectwhile

selectingtheshade,ithelpsaccentuatetheabilitytodiscriminateb/wyellowshades; Colorofapigmentisdeterminedbyselectiveabsorption&selectiveradiation/scattering; NaturalGlace(glazefiring)–whenporcelainitselfisglazedbyseparatefiring;morepermanentthan

overglazes; Glazedporcelainleastirritatingtogingivacomparedtootherrestorationsandresistsabrasion; Overglazes(appliedglazes)–ceramicpowdersthatmaybeaddedtoaporcelainrestorationafterit

hasbeenfired;erosionmayoccurinamonthcreatingrough&poroussurface; ClassesofPorcelain: ‐‐High­fusing→dentureteeth

‐‐Medium­fusing→allceramiccrowns‐‐Low­fusing→metalceramiccrowns;containsaluminumoxide(↑itsresistanceto“slumpingdown”duringfiring)+calciumoxide+oxidesofpotassium,sodium,&chromium(helpreducecross‐linkageb/woxygen&siliconetolowerporcelain’sfusingtemperature;

Porcelain=feldspar(main)+quartz(strengthener)+metaloxides(impartshadeofporcelain);amorphousstructure(notcrystalline);

→ Kaolin(clay)→bindsparticlesofporcelaintogether;moreinhouseporcelain;→ CompressivestrengthofporcelainGREATERthantensilestrength;→ PorcelainisBRITTLE&notcapableofplasticdeformation;→ ConstituentsofPorcelain: 1)SiliconeDioxide(64‐69%)

2)AluminumOxide(8‐19%)3)PotassiumOxide(8%)4)SodiumOxide(2‐5%)

Aluminousporcelainusesalumina,notquartzasstrengthener;itisconsiderablystrongerthanconventionalporcelains;

Degassing–processofheating(980oC)acastingtoburnoffimpuritiespriortoporcelainadding;necessaryforallgold‐porcelainsystems;degassingmetalattoolowtempwilleffectformationofoxidelayeranditwilldecreasethebond;

Pickling–reducessurfaceoxides;50%HCl;frequentlythesurfaceofgoldcastingisdarkduetoformationofsurfaceoxidefilm;

CausesofPorcelainFracture: 1)Poormetalframework(maincause);2)Degastoolowtemperature3)Contaminatemetalpriortoopaqueapplication4)Fusingopaqueattoolowatemportooshortatime;

Sintering–changespowderporcelaintosolid;↑dentisity;shapemaintained. Metal&CeramicmusthavecloselymatchedCOEFFICIENTSOFTHERMALEXPANSIONtoavoid

porcelainfractures; Alloysshouldhavehighproportionallimit&highmodulusofelasticitytoreducestressonporcelain; 3StagesinFiringPorcelain:1)Lowbisquefiring,2)Mediumbisquefiring,3)Highbisquefiring; Porcelainmusthave: 1)LowFusingTemperature(iffiredtoomuch,itdevitrifies/milky);

2)HighViscosity3)Resistancetodevitrivation(crystallization);

MostcommoncauseofPOROSITYinporcelainisinadequatecondensationofporcelain;REMOVABLEPARTIALDENTURES: TotalocclusalloadappliedtoRPDisenhancedby: 1)occlusalsurfacearea

2)occlusalefficiency3)numberofexistingteeth

KennedyClassification–basedonMOSTPOSTERIORedentulousareatoberestored;periodontaldamagetoabutmentteethisavoidedw/firmtissuesupport;4Classes:

1. ClassI‐bilateraldistalextension;2. ClassII–unilateraldistalextension;3. ClassIII–unilateraledentulousspaceboundbyteeth;itisatooth‐borneRPDb/citdepends

entirelyonabutmentteethforsupport;4. ClasssIV–anteriorteetharemissingandacrossthemidline;itisatooth‐borneRPDb/cit

dependsentirelyonabutmentteethforsupport;NOMODIFICATIONS!→ ClassificationsaredoneafterNOTBEFOREextractionsaredone;→ If3rdmolarispresent&nottobeusedasabutment,it’snotconsideredintheclassification;→ If2ndmolarismissing&willNOTberelplaced,it’sNOTconsideredintheclassification;

CraddockClassification–basedondenturetype;3types: 1)TypeI–mucosaborne2)TypeII–toothborne3)TypeIII–mucosa&toothborne

Major&MinorconnectorsMUSTBERIGIDforfunctionalstressesappliedtoRPDtobeevenlydistributedthroughoutthemouth;

MajorConnector–theunitofRPDthatconnectsthepartsoftheprosthesislocatedononesideofthearchtopartsontheoppositesideofthearch;

→ shouldbefreeofmovabletissues&shouldn’timpingegingivaltissues;→ mostfrequentlyencounterinterferencesfromLINGUALLYINCLINEDMAND.PREMOLARS;

MaxillaryPalatalmajorconnectorsmaybebeadedtoproduceapositivecontactw/thetissue; SinglePalatalBar–lacksrigiditysoforbilateralshortspanedentulousareas;connectedto1st

molars; PalatalHorseshoe­shapedplate–usedwhenlarge,inoperabletoruspreventusingotherdesigns; AnteroposteriorpalatalbarforRPD–MOSTRIGIDpalatalmajorconnector;usedinalmostany

maxillarypartialdenture;→ bothant.&post.connectorscrossthemidlineatRIGHTANGLESratherthandiagonal;

PalatalPlateconnector–thinkbroadconnectorthatcanbeusedforsimpleedentulousareasandfullpalatalcoverage;

LingualBarneeds7mmofheight=3mmbelowgingivalmargin+4mmofverticalheight; LingualPlateshouldcovermiddle1/3oflingualsurfaceofteeth;Indications:

1. HighlingualfrenumorwhenthereisNOSPACEinthefloorofthemouth2. Ifvestibuleis<5mm;3. Mandibulartorican’tberemoved4. Tosupport/stabilizeperiodonticallyweaknedteeth; SevereanteriorcrowdingisCONTRAINDICATEDforusinglingualplate;

LabialBar–shouldbe3mmbelowgingivalmargin;usedwithlingaullyinclinedmand.anteriorteethorw/largelingualtori;

StressBreaker–devicethatrelievestheabutmentteethtowhichanFPD/RPDisattached,ofall/partoftheforcesgeneratedbyocclusalfunction;2types:

1. Wrough­WireRetentiveClasp–simplestformofstressrelief;Wroughtmetalisstrongerw/greaterflexibilitythancastmetal;25%greaterstrength&hardness;

a. Yieldstrengthcanbedrasticallyreducedifexposedtotoomuchheatcausingrecrystallizationorgaingrowth;

b. Terminalendofretentivearmisplacedinmiddleofgingival1/3ofcrown;c. 20‐gaugewroughtwireis2xmoreflexiblethanan18‐gaugewire;d. 20‐gaugecastclaspinto.010undercutisalternativetowroughtwire;

2. Split­barMajorconnector(“hiddenlock”)–flexibleconnectionb/wdirectretainer&denturebase;stress‐breakerswithamoveablejoin;

Shorterclaspsneedfinergaugeofwire(higher#=finer)becauseneedoptimumflexibility; RoundCross‐sectionofclasps =↑FlexibilityofClasps

=↑length&taper=↓cuberatio/thickness&width;

IndirectRetainers–RESTS,MINORCONNECTORS,&PROXIMALPLATES;functiontocounteract/preventVERTICAL/UPWARDDISLODGEMENTofthedistalextensionbase;→ anti‐rotationaldevice;alsopreventsDOWNWARDmovementsoprotectssofttissue;→ Servesat3rdreferenceforseatingframework&makingalteredcastimpressions;→ Indirectretainerfordistalextensionareplacedasfarawayfromedentulousspacewhilerestsare

placedonabutmentteethnexttoedentulousareasformaxsupportfortoothbornepartials(class3&4);

→ Thegreaterdistanceb/wfulcrumline&IR,themoreeffectivetheIR; Noindirectretainerforkennedyclass3–nofulcrumline; Asdenturebasemovesupward,themostanteriorrest(directretainer)resistsdownardmovement; Directretainersmustbeeffectforanindirectretainertofunction; Directretainers–Intracoronalattachment&Clasps; IntracoronalRetainers‐MOSTESTHETICdirectretainerforRPD;builtintocontourofacrownto

producemechanical&frictionalretention;notusedwhenRPDdependsonedentulousareaforsupport(class1or2);

Clasps–extracoronalretainers;mostcommondirectretainerforRPD;2types:1. Suprabulgeclaspsoriginateabovetheheightofcontourorsurveyline,usuallyfromocclusal

rest;a. CircumferentialClasp–composedofretentivearm&bracingarm;engagesundercuton

sideOPPOSITEofsiteofrest.b. RingClasp–engagesundercutlocatedonsamesideofrest;c. EmbrasureClasp–whennoedentulousspaceexistsd. Reverse­actionClasp–hairpinclasp;enagagesundercutlocatedonsamesideasrestor

onanyposteriortooth;e. ExtendedArmClasp–circumferentialclaspthatextendstoneighboringteeth;f. ½&½Clasp–consistsof1circumfertialclaspemanatingfromrestandanotheramr

fromminorconnectoronoppositeside;2. Infrabulgeretainers–I,J,U,L,TBarclasps;approachescrownundercutfromBELOWthe

tooth’sheightofcontour;theprovideretionsbyresistanceofmetaltodeformation;a. MustNOTbeplacedintotissueundercutsnorcontactabutmentofanyplacesexcept

specifiedundercut;b. Advantages–moreefficientretention,lessdistortion,lesscaries,&greater

adjustability;

Eachclaspmustbedesignedtoencirclemorethan180o(morethan½thecircumferenceoftooth); Elongation–mostimportantmechanicalpropertyofclaspsofRPD; Faiureofpartialdenturesduetopoorclaspdesignisbestavoidedbyalteringtoothcontours;

premolars&molarsmostoftenneedtobealtered;→ GUIDINGPLANESservetoensurepredictableclaspretention;

Primarypurposeofrests–VERTICALSUPPORTforRPD&resistVERTICALFORCESofocclusion; OcclusalRest‐PositiveRest–formacuteanglesw/minorconnectorsthatconnectthemtothemajor

connectors;Rest=2.5mm&<90oangletominorconnector;reducemarginalridgeby1.5mm;→ therestoccupiesthemiddle1/3oftheocclusalsurface;

CingulumRest–verticalstoponAnteriortooth;confinedtomaxillarycanines,butsometimesmaxillarycentrals;lesstorquingstressthanincisalrest(notesthetic);

Reciprocatingarm=lingualarm;Retentivearm=buccalarm; Fuctionofreciprocalclasparm: 1)Reciprocation

2)Stabilization3)Bracing(auxillaryindirectretainer)

InRPD,stabilityinsuredbyocclusion; DesigncharacteristicsforRPD–1)Support,2)Retention,3)Bracing,4)Guidance; ForRPD,minimalfunctionalstressonabutementteeth;mostofstressonresidualridgecausing

resorption; PrecisionAttachements–Male&femalepreconstructedparts;littletolerance;

→ adv–provideretentionw/outalotofmetaldisplayed;excellentbilateralstabilization;→ disadv–difficulttorepair;nevertobeusedwithdistalextensionRPDw/ostressbreaker;→ primaryindicationarewhenteetharepresentonbothendsoftheedentulousarea;→ castcrownsmustbeprovidedonallabutments;

Semi­precisionhasmoretolerance&lessretention;itisacastintothecrown&RPD;maleportioniscastintotheRPD;

Surverying:1)PathofInsertion,2)PositionofSurveyLines,3)LocateUndercut&Nonundercutareas. DentalSurveyer–aninstrumentusedtodeterminetherelativeparallelismoforalanatomy;areas

usedforsupportCANNOTbedeterminedbysurveying; WhenselectingteethforRPD,themostimportantfactorisavailableinterarchspace;

→ MDwidth–fromdistaloflowercaninetobeginningofslopeofridge;→ BLwidth–narrowerthannaturalteethb/cdecreasesstresstransferredtodenture

supportareaduringfoodboluspenetration;alsoincreasestonguespace; ChromiumCobaltisinflexiblebutbestforRPDs;adv–corrosionresistance,highstrength,&low

specificgravity;lowdensityandhighmodulusofelasticity(stiffness);lowcost;→ Chromium–forcorrosion&tarnishresistanceduetoSURFACEOXIDELAYER;→ Cobalt‐↑rigidity,strength,&hardness;→ Nickel‐↑ductility;measuredaspercentageofelongation;metalliccomponentofRPDw/

thegreatestpotentialforallergicreactionsinthemouth; WhenrecordingCRforRPD,theocclusalrimisattachedtothecompletedpartialdenturemetal

framework,insteadofrecordbaseforcompletedenture; MostimportantfactorindeterminingthesuccesofdistalextensionRPDisproperCOVERAGEover

residualridge; Iftheindirectretainersarenotseatedasextensionbasearedepressed,thebasesneedrelining; Ifptcomplainsofsensitivitytopercussiononanabutmenttoothofdistalextension,mostlikely

causesistheocclusiononthisabutment; Defectiveocclusalcontactscanalsocauseafeelingofloosenesstothedenture; AlteredCastTechnique–purposeistorecoredtheformoftheedentuloussegmentw/otissue

displacement&toaccratelyrelatetheedentuloussegmentoftheteethviametalframework;→ Helpsobtainsofttissuesupportoaideabutmentsinresistingfunctionalstress;

→ Itisasecondaryimpressionsystemthatusesmetalframeworktoholdcustomizedimpressiontraysfortheedentulousareas;

→ ImpressionrecordsofedentulousridgetissuesintheexactformthattheywillassumethefinishedRPDisinplaceontheteeth;

ConsiderationswhenpreparinganRPDabutmenttoreceiveacrown:1. PathofDraw2. Locationofrests3. Orientationofguidingplanes4. Placementofporcelainmetalfinishlines

WhenRPDpreferredoverFPD:1)lossof4maxillaryincisors2)distalextension3)longspanedentulousarea4)periodontallyinvolvedabutmentteeth5)afterrecentextractions6)economics

COMPLETEDENTURES: Ifdenturefallsoutwhensmiling,buccalnotch&flangeoverextended;whenyawning,distobuccal

flangeoverextended; Soregums&achingmuscles=reduceVDO;generalizedsorenessafter1stappointmentofdenture

insertionismostlikelyduetoimproperocclusion;→ Toidentifyprematurities,thebestmethodinmouthistousewarmdisclosingwaxby

insertingthewaxbilaterally&haveptcloseintoCR; Tingling/numbingincornerofmouth/lip,excessivepressurefromlowerbuccalflangenearmental

foramen; MandibularDenture‐ ‐‐DistalBuccalExtension=MasseterMuscle

‐‐DistalLingualExtension=SuperiorConstrictorMuscle‐‐LingualBorder= 1)PalatoglossusMuscle 2)SuperiorPharyngealConstrictorMuscle 3)MylohyoidMuscle 4)GenioglossusMuscle

Healingofridgepost‐extraction=4‐6months(relineat5&10months); RelineCONTRAINDICATEDfordecreasingVDO;ifdecreasedVDO,thennewdenturesareindicated; Afterreliningadenture,ifaptconstantlyreturnsforadjustmentsduetosorespotsonridge,check

occlusionb/creliningmayhavechangedCRcontacts,lossofCRcontacts; RecordingCRisanessentialstartingpointindesignofdenture;forcompletedentures,MICofteethin

COisestablishedtocoincidew/pt’sCR,soCO=CR; FlabbyMax.anteriorridgewhenmax.completeopposes6mand.anteriorteeth; Settingdentureteethedgetoedge=cheekbiting;tx=reducefacialofmandibularmolars&create

properhorizontaloverlap;cheekbitingalsocausedby↓VDO; Primaryreasontouseplasticteethindentureisb/cplasticteethareretainedwellinacrylicresin;

plasticteethareretainedbetterthanporcelainteeth;porcelainteethalsocausedentureclicking; Bitingcornerofthemouth–resetcanines&PMs. WhenPthasCompleteMax.Denturebutlackingposteriorsupport,thefollowingoccurs:

1. Excessiveamtsofhyperplastictissueonanteriorportionofmaxilla;2. Poorbonestructureinanteriormaxilla3. Fibroustuberosities4. Ptcomplainsofloosenessofdentureandtheycannolongerseetheirupperteeth;

CentralIncisorsshouldbe8mmanteriortocenterofincisivepapilla;ifplacedtofarsuperior&anterior,effects“F”&“V”sounds;PrimaryroleofanteriorteethondentureisESTHETICs;

Max&Mand.anteriorteethshouldNOTcontactinCR;

MostcommonerrorthatcontributestopoorestheticsisplacingMax.anteriorteethdirectlyoveredentulousridge;MaxillaryteethshouldbeplacedFACIALtotheridge;

Max.centralsaremostimportantteethforesthetics.duh Ifburningsensationofcompletemax.denturethenpressureonINCISIVEFORAMEN; PositionofLipsforCompleteDenturescorrectedby:1)CorrectVDO

2)Thicknessofanteriorborder3)Teethposition

“S”Sound–tipoftonguew/anteriorpalate&lingualofMax.ant.teeth;soundthatbringsthemandibuleCLOSESTtothemaxilla;

“Th”Sound–tongueprotrudeb/wmax&mandanteriorteeth(2‐4mm). “F”&“V”Sound–incisaledgeofmaxillaryteeth&lowerlip; “P”&“B”Sound–formedTOTALLYbylips; Palatetoothink&incisorsaretoofarpalatalifsaying“S”butsoundslike“Th”; Ifteethsettoofarlingually,theTwillsoundlikeaD;ifsettoofarlabially,theDwillsoundlikeaT; HighpalatalvaultorconstrictedpalatecancauseWHISTLINGsound;whistlingduringspeechwith

denturescancause: 1)insufficientverticaloverlap2)excessivehorizontaloverlap3)areapalataltoincisorsareimproperlycontoured;

ApthavingdifficultyswallowingmayhaveinsufficientinterocclusalspacecausedbyexcessiveVDO; Learningtochewfoodsatisfactorywithnewdenturesrequiresatleast6­8weekstoestablishnew

memorypatters; Mosteffectivetimetotestphonetics→waxtry‐in. Longertimeptsisedentulousthengreaterdifficultyw/phoneticsthanshorttimepts; MostimportantfactorforretentionofcompletesisPERIPHERALSEAL; MucobuccalFoldismostimportantfactorforMaxillarycompleteRETENTION; MaxillaryComplete&Mand.bilatateralDistalextensionmayshow:

1. DecreasedVDO2. PrognathicFacialAppearance(associatedw/edentulousstate).

MaxillaryDenture– PrimarySupport=ResidualRidgeSecondarySupport=PalatalRugae

MandibularDenture‐ PrimarySupport=BuccalShelf&ResidualRidgeSecondarySupport=AnteriorLingualBorder

CoronoidProcessinterferesw/dentureopeningwhenMax.buccalspacefilledw/dentureflange;socoronoidprocesscanlimitthethicknessofdentureflange;

Camper’sLine–paralleltomaxillaryocclusalrim;linerunningfrominferiorborderofalanosetosuperiorborderoftragusofear;

Todeterminemaxillaocclusalrimverticallength=2mmbelowupperlip. AcrylicResinfordenturerepairs→pressure=20‐30psi;MOSTCOMMONcauseofporositiesin

dentureisduetoinsufficientpressureonflaskduringprocessing;→ Porositiesalsooccurifpacking&processingofpower&liquidresinistooplastic

(stringy/sandy); PalatalSeal– PosteriorOutline→formedby“ah”lineorvibratingline(fovealpalatini)

connectingpterygomaxillarynotches;hamularnotchisonposteriorborder; AnteriorOutline→formedby“blow”line&locatedatdistalextentofhardpalate;

→ Width=6mmonleft&right&3mmatthecenter;→ Depth=1.5mmonleft&right&.5mmatthecenter;→ Outline&depthofsealisdifferentforeverypt,determinedbypalatalformoneachpt;→ PalatalsealshouldNEVERberemoved;placementofsealALWAYSdonebydentist,notlab!→ Excessivedepthofsealusuallyresultsinunseatingofdenture;→ Functions: 1)Completesbordersealofmax.denture

2)Preventsfoodimpaction3)Improvesdenture’sphysiologicretention4)Thesealcompensatesforpolymerization&coolingshrinkageofdentureresinduringprocessing;

VibratingLine–2mminfrontoffoveapalatini;extendsfrom1hamularnotchtotheother; Hamulus–superiorattachementofpterygomandibularraphe(tendon)whichisb/wbuccinator&

superiorconstrictormuscles;extensionofMEDIALPTERYGOIDPLATEofsphenoidbone; IncreasedVDOcausesclickingofteeth,effectsphonetics,&esthetics;needtoremountornewCD/CR; CompensatingCurve–anteroposteriorcurvature&mediolateralcurvatureinthealignmentof

occludingsurfaces&incisaledgesofartificialteethusedtodevelopedbalancedocclusion;→ EntirelyinDENTIST’scontrol→ Allowsdentisttoaltertheeffectivecuspangulationw/ochangingformofmanufactured

dentureteeth; AverageInterocclusalSpaceatREST=3mm; VDO+InterocclusalSpace=VDR;VDR>VDO(always!);↓VDO=↑interocclusaldistance; CorrectVDOisevaluatedusing4methods:

1. Evaluatingtheoverallappearanceoffacialsupport;2. Visualobservationofspaceb/wocclusalrimsatrest3. Measurementofdotsonface(placedontipofnose&chin)4. Observationwhen“s”soundisenunciatedaccurately;

ExcessiveVDO=↓freewayspace;DecreasedVDO=↑freewayspace; Forcompletedentures,pathofcondyledeterminedby: 1)Shapeoffossa

2)Meniscus3)MuscularInfluence

SubmucosalVestibuloplasty–usuallyperformedonmaxillaryarchtoimproveavailabledenturebase;procedureisfavoredb/cnorawtissuesurfaceremainstogranulate&re‐epithelialize;

UnderlyingBASALBONE(undertheretromolarpad)resistsresorption;markedresorptionofridgeoccursifmandibularcompletedenturebaseterminatesshortofretromolarpad;

Forthe1stfewdaysafterptreceivesnewdentures,theywillhavesomedifficultyeating&EXCESSIVESALIVAduetoreflexPARASYMPATHETICstimulationofsalivaryglands;

BalancedOcclusionisobjectiveofcompletedentures;OVERDENTURE&IMMEDIATEDENTURES: Overdenture–denturewhosebaseisconstructedtocoverallofanexistingresidualridge&selected

roots;mostimportantispreventingridgeresorption;→ retainedrootshelpPREVENTRESORPTIONofalveolarridge,improvedenturerentention&allow

ptsomesenseof“naturalness”infunctionofthedentures;→ notalwaysnecessarytocoverrootbeneathoverdenturebutifarootisnotcovered,theexposed

surfacesarehighlysusceptibletodecay; ImmediateDentures:idealtofabricatemax&mand.denturesatsametime;Completein2steps

1. ExtractallposteriorteethEXCEPTmax.1stPM&itsopposingtoothsoleavesposteriorstoptomaintainVDO;

2. Afterhealingofposteriorarea,denturefabricationcanbegin;Anteriorteethextractedattimeofdentureinsertion;

→ Forthe1st24hours,donotremovedentures,eatsoftfoods,&returnin24hrstodentist;→ Advantage=duplicatepositionofnaturalteeth;theyareestheticallyadvantageousinthattheptis

neverw/oeithernaturalorartificialteeth;→ MajordisadvantageisAnteriorteethtry‐inforesthetics;→ Preventstongueenlargementb/cwhennaturalteetharelost&notreplaced,thetongueexpands

intotheavailablespace;

→ Relining/RebasingthedentureisREQUIREDin8‐12months!Schedulerelinesat5months&10monthspost‐extraction;

DENTUREDESIGNCHARACTERISTICS: Stability–therelationshipofthedenturebasetobonethatresistdislodgementofthedenturein

HORIZONTALdiretion;involvesresistancetohorizontal,lateral&torsionalforces(mostimportant);→ AllcomponentsofRPD,exceptretentiveclasptip,contributetostability;

Support–resistancetoVERTICALSEATINGforces;providedbyrests&denturebases;MOSTIMPORTANTdesigncharacteristicfororalhealth;forRPD,supportgivenbyrests&edentulousareas;

Retention‐qualityinrestorationthatresiststheforceofgravity,stickyfoods,&forcesassociatedw/mandibularmovement;direct&indirectretainersprovideretention;→ claspsplacedinundercutareasofabutmentteethprovideretention;

Reciprocation–themeansbywhichonepartofthemetalframeworkopposestheactionoftheretainerinfunction;reciprocatingelementmustbeplacedOPPOSITEthedirectretainer;→ MustcontacttheabutmentastheretentivetippassesOVERthetooth’sheightofcontour;→ referstofunctionofreciprocalclasparmtocounteractforcesexertedbyretentiveclasparm;

Bracing‐horizontalforcetransmissionbyplacingrigidportionsofclaspsorotherpartsoftheRPDinnon‐undercutareasofabutmentteeth;

Guidance–duringinsertion&removalobtainedbycontactofrigidpartsoftheframeworkwithareasonaxialtoothsurfacesparalleltothepathofinsertion;

IMPRESSIONMATERIALS: Rinse&Disinfectpriortopourofimpressionsorsendingtolab;spray/soakfor10minutes; BiteRegistrationMaterial→Addition­reactionsiliconeimpressionmaterial;verylowflowand

minimumresistancetothepatient’sjawclosure;→ Technique–HaveptbiteteethtightlyinCO&injectmaterialb/wmax.&mandteethONLY

intoareaswhereteethhavebeenprepared; IdealMaterialforRecordingCR(notwax!)‐ 1)Rapidsettingplaster

2)ZOEPastes3)ModelingPlaster

Bestimpressuriontechniqueforptw/loosehyperplastictissueistoregistertissueinPASSIVEposition;

Theprimaryindicatorofaccuracyofbordermoldingisthestability&lackofdisplacementofthetrayinthemouth;modelingcompundhasLOWthermalconductivity;

BorderMolding:2stages:1ststage,themoldingshouldapproximatetheborders&beslightlyOVEREXTENDED;excesstrimmed&2ndstageisrefiningremainingmoldingbyrepeatingprocess;→ MostcriticalareaonMAXdenture=MUCOGINGIVALFOLDabovemax.tuberosityarea;→ ForMAND.denture,distofacialextensiondeterminedbyMASSETERMUSCLE&distolingual

extensionlimitedbySUPERIORCONSTRICTORMUSCLE;→ Dislodgementindicatesoverextension;verycommonareaofoverextensionisthedistobuccal

cornerofmand.denturepushingagainstMassetermuscle; Ease&AccuracyofBorderMolding: 1)Accuratefitofcustomtray

2)Controlofbulk&tempofmodelingcompound3)DriedTray

Polymerization–changingelastomericmaterialsfrompastestorubber­likematerials;

→ AdditionPolymerization(noionicforms)–addingofunitsoneachsideofC‐Cdoublebond;formspolymerw/oforminganyotherchemical;

→ CondensationPolymerization–involvesionicspecies&producessmallmoleculeby‐productsofeachstepofrxn;whenotherchemicalorby‐producesareproducedthatarentthepolymer;

ReversibleHydrocolloids,likeAgar,are85%waterandcanchangephysicalstatebyaddingorremovingheat;expesiveequipment&difficulttodisinfect;

→ dimensionallyunstable(single&immediatepour);LONGESTSHELF‐LIFE; Agar–needsspecialequipement;goodforcrowns;physicalstatecanbechangedfromGELSOLby

applyingheat&reversedbackbyremovingheat;→ onlyelastomericthatdoesn’tinvolveachemicalreactiontoset;

Alginate‐↑temp=↓gelationtime;toomuch/littlewaterweakensgel;Reactor=CalciumSulfate;verylimiteddimensionalstability;want3mmb/wtray&tissue;→ SodiumAlginate–tendencytogiveupwater(synerisis­shrinksimpression)orgainwater

(imbibition–expandsimpression);CONTROLSSETTINGTIMEofalginateb/cit’stheretarder;→ ↓Water/PowderRatio=↑settingofgel;oncealltheNaPO4hasreacted,theNaAlginatereactsw/

remainingcalciumions&formscalciumalginate;→ Fastremovalofimpressionfrommouth↑compressive&tensilestrengthofimpression;→ Itisadoubledecompositionreactionb/wsodiumalginate+calciumphosphate;→ Bestmethodtocontrolgelationtimeofalginateistoalterwatertemperature;→ Ifimpressionisgrainy,maybecausedbyimpropermixing,prolongedmixing,ortolow

water:powderratio;→ ALGINATECONSTITUENTS:

1. Diatomaceous(silica)=50%(FILLER)2. PotassiumAlginate=20%(formsSOL)3. CalciumSulfate=16%(REACTOR)4. ZincOxide=7%(PLASTICIZER)5. PotassiumFluoride=6%(improvesGYPSUM)6. SodiumPhosphate=1%(RETARDER,controlssettingtime)

Polyethers–hydrophilicsounstableifmoisturebuttoleratesmoisturebetterthananyotherelastomer;rubberformedbycationicpolymerization–cationbutnofreeradicals;

→ SHORTESTWORKING&SETTINGTIMES(5‐6min);contractsslightlyduringsetting;→ Customtraysneededsinceelastomersaremoreaccurateinuniformthinlayersthatare

2‐4mmthick;→ excellentdimensionalstability;canbepouredupto1wk;2Components:

1. Base–polyether(polymer),silicafiller&plasticizer2. Accelerator–crosslinkingagentcalledaromaticsulfonicacidesterwhich

producescross‐linkingbycationicpolymerization; Hysteresis–whenmaterialhasmeltingtemperaturedifferencefromitsgellingtemperature;

Polysulfide–WATERisby‐product;exothermic&acceleratedbytemperature;strongestresistancetotearing&highflexibilitybutcausesdistortion;LongestSettingtime=12­14min.

→ requirescustomtrayforimpressiontocontrolpolymerizationshrinkage;2components:1. WhiteBASE–containslowweightpolysulfidepolymer;2. BrownACCELERATOR–containsLEADDIOXIDE&sulfur;leaddioxideaccelerator

isresponsibleforbrowncolorthatisdifficulttocleanoffclothes! Silicones–ETHYLALCOHOLisby‐product(causesshrinkage);forcompletedentures/crowns;don’t

mixinitiallybyhand;lessexpensive,easycleanup;1yearshelflife;→ lowtearstrength&poormoisturetolerance;mustbepouredimmediately;→ poordimensionalstabilitybecauseprincipalrxoccursduringsettingtimeisacondensation

reactionviaelimination/evaporationofethyl/methylalchol;2components:1. Base–liquidsiliconepolymer(dimethylsiloxane)2. Reactor–cross‐linkingagentethylortho­silicate(metalorganicester)w/

activator=tinoctoate; PolyvinylSiloxanes–NOBY‐PRODUCT;Silicone(silaneH+groups)&VinylSilicone(vinylgroups,

catalyst);↑temp=↓settingtime;canbepouredupto1week;→ Excellentdimensionalstability&verylowpermanentdeformation;→ Poortearstrength,lowesttemprises,stiff,poorwettibilitybygypsum;→ MOSTWIDELYUSED&MOSTACCURATE;

ZOEImpressionPaste–setsashard,brittlemass;↑water=↑settingtime;↓settingbyaddingoil;→ Chelate–formsintypicalacid‐basereactions;→ SettingtimeacceleratedbyADDINGadropofWATERtothemix;MESSY&notrecommened

forgaggingpt;dimensionalstabilityaffectedifcustomtrayisNOTused;→ Differenceb/wZOEpaste&modelingcompound,ZOEmustbedonein1insertionwhile

modelingcompoundisdonein2;→ canrecordsofttissueatrest,setsin5min,stable,&lessexpensivethanpolysulfides;→ Needsnoundercutsofridges;pasteneedtobeuniformincolor;5Components:

1. CalciumChloride–accelerator2. OilofCloves(70‐85%eugenol)–reducesburning3. Vegetableoil–plasticizer4. ResinousBalsam–increasesflow.5. Rosin‐↑speedofreaction&makessmootherproduct;

SULFERinlatexglovesretardsPVSsettingtimes; Elastomersaremoreaccurateinuniform→2‐4mmthickw/thinlayers; LongesttoShortestWorkingtime=Agar>Polysulfide>Silicones>Alginate=Polyether BesttoWorstDimensionalStability=Add’nSilicones>Polyether>Polysulfide>ConditionSiliconesDENTALCASTING&GYPSUM: 3typesofInvestmentMaterials:

1. Gypsum­Bonded–binderisgypson(calciumsulfateHEMIhydrate);forconvetionalgoldalloys,Type1,2,&3goldalloys;i. StrengthofinvestmentforgoldisdependentonamtofGYPSUM;

2. Phosphate­Bonded–binderismetallicoxide&phosphate;forbasemetalalloysforPFMs&Type4gold;chosenforsilver‐palladium,gold‐platinum,&nickel‐chromiumalloys;i. Anyalloww/castingtemp>2100oF/1150oC,shouldcastwithbinderOTHERthangypsum;

3. SilicaBonded–binderissilicagel;forbasemetalsforRPDframework; theexpansionofinvestmentprovideslargermoldtocompensateforsubsequentcontractionofalloy. 4MechanismCompensateforSolidificationShrinkageofAlloyduringCasting:(theyplayarolein

producingexpandingmold): 1)SettingExpansionoftheinvestment2)Hygroscopingexpansionofinvestment(presenceofwater)

3)Thermalexpansionofinvestment4)Waxpatternexpansion

QuartzorCristobalite–refractorymaterialsusedfortheseinvestmentstoprovidethermalexpansionfortheinvestment;

Potassiumfluorideaddedtofluxtodissolvepassivatingfilm(suppliedbychromium)thatmaypreventwettingofthemetalwiththesolder;Potassiumfluorideismostcommonagentinflux;

↑strengthofsolderjoint(circular)isincreasingheightofit; Antiflux–restrictsflowofsolder;softgraphitepencil. Castingalloys–Type1to4fromweakesttostrongest; GypsumProducts–differentHEMIHYDRATEparticlesineachproductsodifferentamountofwater;

mainconstituent=CalciumSulfateHemihydrate→allproductsformthisreactionproduct;4Types:1. Type1–ImpressionPlaster;β ­hemihydrate;2. Type2­Plaster(model);β ­hemihydrate;forortho–2xofwaterthanstone;

highersettingexpansionthanstone;a. Heatinggypsuminopenvesselat150‐160oC=PLASTER;

3. Type3–DentalStone;α ­hemihydrate;fordentures;a. Heatinggypsumunderpressureat120‐150oC=STONE;

4. Type4–DentalStone(diestone);α ­hemihydrate;fordie‐work;increasedstrength&expansion;

a. Boilinggypsumin30%CaCl&MgCl=DIESTONE;→ β‐hemihydraterequiresmorewaterb/ccrystalsaresponginess&irregularshaped&more

porousthanα‐hemihydrate(moredensecrystals);→ maindifferencesb/wdentalplaster&stonepowdersisPARTICLESIZE&SHAPE&POROSITY;→ morewaterused→lessexpansion&↓settingtime&↓strength;→ whenwaterremoved,itformsCalciumSulfateHEMIHYDRATE,butwhenwaterisadded,it

formsCalciumSulfateDIHYDRATE;Startinggypsumisdihydrate;→ gypsum+water=heat(exothermic);→ Allgypsumproductsareweakerintensilestrengththancompressivestrength;→ GypsumAccelerators–potassiumsulfate,sodiumchloride,&aluminum;→ GypsumRetarders–borax,sodiumcitrate;

Gypsumsetsfasterwhen→ 1)↑spatulation2)lowerwater:powderratio3)usemixofwater&groundupgypsumparticle

Topreventairentrapmentistoplacetheproperamountofwaterinthemixingbowlfirstthensiftthemodelplaster/stoneintothebowl;

MaxillarysinusappearstoENLARGEthroougoutlifeifitisnotrestrictedw/naturalteeth/dentures;asthesinusenlarges,thetuberositiesmovedownward;

Iflowtuberosityisnotremoved,accidentallyunderextendedmand.denturewillbemadecausinglimitedspaceforteeth;

WhenthecastingisCOLD‐workedtoproviderequiredarticle/appliance,itiscalledwroughtmetalincontrasttocastmetal;

Brittle–materialw/highcompressivestrengthbutlowtensilestrength; SpecificGravity–propertyofgoldalloysthatexceedsabase‐metalalloyinnumericalvalue; Sprue–smalldiameter>1.5mm(10‐12gauge)PINmadeofwax/plastic;sprueshouldbe

equal/greaterthanthickestportionofthewax/plasticpattern;→ sprueattachedtowaxpatternat45oangle;→ Spruingatathinareacanproducethesameresultasusuingaspruethatistoosmalcausing

shrinkbackporosity,causingturbulenceintheflowofthemoltenmetal;CEMENTS:

ThetypeofcementuseddoesNOTaffectorincreasecrownretention; ToothmustbeWIPEDDRY,notairdriedordriedw/alcohol,beforecementation; Alwaysapplycementtobothrestoration&tooth; CompositeResin–lutingmaterialofchoicetocementaceramiccrown&canprovideSTRONGEST

BOND; Zinc‐PhosphateCement–alsocanbeusedtocementceramiccrowns;goodcompressivestrengthbut

highpHsoneed2layersofvarnishtoprotectthepulp; ZincPolycarboxylateorZOE–biologicallycompatiblecements;usedwhenprepshaveadequate

length&retentivefeaturesorwhenprepisdeepandpulpvitalityisaconcern;o ZincPolycarboxylate&GIcementsadheretocalcifieddentaltissueandhaveSUPERIORbiologic

compatibilitythanzincphosphatecements;ANATOMY/OCCLUSION: CR=bonetobonerelation(notoothcontact)–mostunstrainedretrudedanatomic&functional

position;cannotbeforedintoCRfromrestposition,mandmustberelaxedandthenguidedintoCR;→ condyleinmostSUPEROANTERIORPOSITIONw/thearticulardiscinterposedb/wcondyle&

eminence; RestPosition→MuscleGuided(Freewayspace);tonicstretchreflex;average=2­6mm; CR→LigamentGuided(retrudedposition);bonetobone;REPEATABLEreferencepoint; CO→Toothguided(intercuspalposition);determinedbycuspsofteeth;during“emptymouth

swallowing”,themandibleisbracedinintercuspalposition;toothcontactslongerinswallowingthanchewing;

JawrelationshipmostcommonlyusedinACTUALdesignofrestorationsistheAQUIREDcentricocclusion;

Non­workingSideInterferences(BalancedSide)–facialcuspsofmandibularmolars; WorkingSideInterferences–Lingualcusps(inneraspect)ofMaxillarymolars; ProtrusiveInterference–b/wdistalinclinesoffacialcuspofmaxillaryteeth&mesialinclinesoffacial

cuspsofmandibularteeth; Protrusiverecordmadetoregistercondylarpath;whenrestoringentiremouthw/crowns/

protrusivecondylarpathinclinationinfluencesmesialinclinesofmandibularcusps; CentricInterference(forwardslide)–correctbygrindingmesialinclinesofmaxillaryteeth&distal

inclinesofmandibularteeth; MandibularMovements‐ Protrusive(anteriorly)=9‐10mm;Laterally=10mm

Inferiorly(opening)=50‐60mm;Posteriorly=1mm FrankfortHorizontalPlane–outercanthusofeyetotragusofear; ClassIIocclusionnotgoodforcanineguidanceorgroupfunction;

1‐7=AnteriorBorderMovement–MAX.OPENING; 4‐8=PosteriorBorderMovement;

MandibularCondylarMovement→ ‐‐RetrusiveMvmt=moveback&up‐‐ProtrusiveMvmt=movedown&forward‐‐Lateral&WorkingMvmt=down,forward,&laterally‐‐Lateral&Non‐workingMvmt=down,forward&medially.

MasseterMuscle–contractsduringswallowing; FunctionalCusps:UL&LB;AlsocalledSupporting,Working,Stamp,orCentricCusps;Contactcentric

stops;theyarebroader&moreroundedcuspridges;usedtoCRUSHfood; BULLRULE–forNon‐supporting,Balanced,Non‐working,&GuidingCusps;

→ innerocclusalinclineleadingtothesecuspsareGuidingInclines–b/cincontactmvmts,theyguidesupportingcuspsawayfrommidline;

→ narrower&sharpercuspridgestoSHEARfood; Inposteriorcrossbite,supportingcusps&guidingcuspsareopposite;soBULLRULEforworking

cusps; Non­Working(balancing)InterferencesoccuronINNERinclinesofFACIALcuspsofMand.molars; Workingside(non‐balancing)InterferencesoccuroninneraspectsofLINGUALcuspsofMax.molars; Duringlateralexcursions,theopposingcuspscontactonWORKINGside; Duringlaterexcurions,onthebalancing/non‐workingside,themaxillarylingualcuspscontactthe

mandibularfacialcusps; SelectiveGrinding‐ 1)NeverGrindMax.LingualCusps(Primarycentricholdingcusps);

2)GrindMand.BuccalCuspsifneeded(Secondarycentricholdingcusps);→ Onlygrindcuspsifprematurecontacts;→ Purposeofselectivegrindingistoremoveallinterferencesw/odestroyingcuspheight;so

insteadofgrindingcusps,fossaormarginalridgesopposingprematurecuspisdeepened; CentricInterferences(forwardslide)iscorrectedbygrindingMESIALinclinesofmaxillaryteeth&

DISTALinclinesofmandibularteeth; BennettMovement→akaLateralShift/ImmediateSideShift;workingsideofcondyleonly;this

mvmentinfluencesMDpositionofposteriorteethcusps; BennettAngle→sagittalplane&pathofNon‐workingcondyleduringlateralmovement; EccentricOcclusion–aprotrusive&right&leftlateralcontactsoftheteeth’sinclinedplaneswhen

themandibleisnotmoving; BilateralEccentricOcclusion–notanobjectiveinRPDconstruction,unlessopposingacomplete

denture;isanobjectiveincompletedentures; BilateralBalancedOcclusion–dictatesaMAXIMUMnumberofteeththatshouldcontactduring

mandibularlateralexcursivemovements; MutuallyProtectedOcclusion(CanineGuided/OrganicOcclusion)–mostwidelyaccepted

arrangementofocclusion;whenanteriorteethprotectposteriorteethinallmand.excursions;→ Caninesprovidepredominantguidancethrufullrangeofmvmtinlateralmand.excursions;→ Whenplacingcrownonmax.canine,ifyoucangecanineguidedocclusiontogroupfunction,

youincreasethechanceofnon‐workingsideinterferencestooccur; AnteriorGuidance‐resultofhorizontal&verticaloverlapofanteriorteeth;producesdisclusionof

posteriorteethwhenmand.protrudes&movesinlateralexcursion;→ thegreatertheoverlap,thelongercuspheight;

IncisalGuidance–measureoftheamountofmvmt&angleatwhichthelowerincisors&mand.mustmovefromoverlappingpositionofcentricocclusiontoanedgetoedgerelationshipw/max.incisors;

→ Secondend‐controllingfactorinarticulatormvmt&istosomedegree,underthedentistcontrol;otherend‐controllingfactorisRIGHT&LEFTCONDYLARmechanisms;

→ Mechanicalequivalentofhorizontal&verticaloverlap; 4Determinantsforrestoringcomplete&functionalocclusion:

1. VerticalOverlapofAnteriorteeth2. ContourofArticularEminence

3. LateralShiftofWorkingCondyle4. PositionofToothinArch

DeterminantsofOcclusion–1)TMJ,2)OcclusalSurfaceofteeth,&3)NeuromuscularSystem; GroupFunctionOcclusion(UnilateralBalancedOcclusion)–characterizedbyNOnon‐workingside

contactsinanaturaldentition;→ whenALLposteriorteethonsidecontactevenlyasjawmovestowardWORKINGside;

End‐ControllingfactorsofArticularMovement: 1)R&LCondylarMechanisms2)IncisalGuidance

Condylarguidanceistotallydictatedbypatient,notbydentistatall;inclinationofcondylarguidancedependson: 1)shape&sizeofbonycontourofTMJ

2)Muscleactionsattachedtomandible3)limitingeffectsofligaments4)methodusedforregistration;

Incompletedentures,thecondylepathduringfreemand.mvmtisgovernedmainlybyshapeoffossa&meniscus&muscularinfluence;

Inclinationofcondylarpathduringprotrusivemvmtvariesfromsteeptoshallowindifferentpts,whichisthemostimportantfactorthataffectsselectionofpost.teethw/appropriatecuspheight;

ProtrusiverecordisprobablytheLEASTreproduciblemaxillomandibularrecord; FunctionallyGeneratedPathwayTechnique(FGP)–recordsmovementsinwaxintra‐orally&

transferredtoarticulatorinformofastaticplasticcast(functionalindex); TMJ–ginglymoarthrodialjoint‐slides/glides&rotates;2compartments:

1. LowerCompartment–Condyle‐ArticularDisc;HingetypeorROTARYmovement;2. UpperCompartment–MandibularFossa‐ArticularDisc;SLIDING/TRANSLATORYmovment;

LateralpterygoidmusclecontractsocondyleslidesFORWARD; TerminalHingePosition(TransverseHorizontalAxis)–theonerelationofthecondylestothe

fossaeinwhichapurehingingmovementispossible; ClosesMandible‐ 1)Masseter

2)MedialPterygoid3)Temporalisanteriorfibers(posteriorfibersretractthemandible)

OpensMandible‐ 1)LateralPterygoid(alsoPROTRUDES&LATERALmvmt)2)AnteriorDigastric3)Omohyoid

LateralPterygoidsaremainlyresponsibleforpositioning&translatingthecondyles; CuspInclination‐anglemadebyslopesofacuspw/aperpendicularlinebisectingthecusp,

measuredMDorBL;undertheDENTIST’scontrol; FunctionallyGeneratedPathwayTechnique–prerequisiteisoptimalocclusion;allowscuspalmvmts

ofthedentitiontoberecordedinwaxintra‐orallythentransferredtoarticulatorinformofastaticplasticcast(functionalindex);uselow‐fusinghi‐fiwax;→ allmandibularmotionmustbedirectedfromaneccentriccentricposition(neverthereverse);

Whensurfacetosurfacecontactofflatcuspsoccur,itshouldbechangetoapointtosurfacecontact; Whencentricocclusionisestablished,NEVERtaketheteethoutofcentricocclusion;OCCLUSALCONTACTSFACTS: DLcuspofmand.1stmolaropposeslingualgrooveofmax.1stmolar(sameasmand.2ndmolar);its

DBcuspopposesmax1stmolarcentralfossa&itsDcuspoccludesw/distaltriangularfossaofmax1stmolar.

MB&DBcuspsofmax1stmolaropposeMB&DBgroovesofmand.1stmolar; ObliqueridgeonMax.1stmolaropposesdevelopmentalgrooveb/wDB&Dcuspsofmand.1stmolar; Lingualcuspsofmandibular1stPMsdon’toccludeanything! LingualcuspsofmaxPMsoccludethedistaltriangularfossaoftheiropposingcounterpart; Outeraspectsoflingualcuspsofmandibularmolardon’tcontactmaxillaryteeth;duh.

MLcuspsofpermanentmandibularmolarsoccludew/thelingualembrasuresb/wtheirclasscounterpart&toothmesialtoit;

Buccalcusptipsofmax.PMsopposefacialembrasureb/wtheircounterpart&toothdistaltoit; Max&Mand.caninecusptipsdoNOTcontactanyothertooth;PATHOLOGY: PalatalTori–moreFemalesthanMales;maxsizeat30’sor40’s;mayactasfulcrum&causingrocking

ofMAX.denture;post‐ophealingslowifremovedduetopoorbloodsupplyofthintissuesovertori;→ Thinmucosaisfoundoverpalatal&mandibulartori;→ PalataltoriisnotusuallyremovedbutMAND.toriisusuallyremovedpriortomakingdentures;

InflammatoryPapillaryHyperplasia–dentureirritation&foodimpaction;hardpalate;red,firm&painless;CandidaAlbicansmaycontributetoinflammation;mostptsareunawareoflesions;

Denture‐InducedFibrousHyperplasia–EpulisFissuratum;vestibularmucosa;traumafrombaddenture;painlessfoldsoffibroustissue;oftenoverextensionofdenture;→ Traumaticocclusionofnaturalteethopposinganartificialdenturemayalsocauseepulis

fissuratum; Paget’sDisease–OsteitisDeformans;bonedisorderinwhichbonebecomesenlargedbutweakened

w/heavycalcifications;oftendiscoveredindentalofficeb/cptsdenturesdon’tfitduetowideningofalveolarridge;

Diabetes–impairsWBC;delayshealing,↑progressofperiodontitis,↑calculus,&↑PAlesions;notassociatedwithmucosalbleeding/bleedingdisorders;

DentureStomatitis–localizedorgeneralizedchronicinflammationofthedenture‐bearingmucosa;presentsasredness&burning;trauma&secondaryfungalinfectionaremostlikelycauses;

Childrenwhoweardentures&acromegalyptsw/denturesoftenneedtheirdenturesrelinedorremadeoftentoallowforbonegrowth;

Osteoporosis–mostcommoncahngeassociatedw/systemicdisease;MISCELLANEOUS: ExcessivewearonoccludingsurfacesofteethisusuallycausedbydisharmonybetweenCO&CR; Soldermustmeltatleast150oFbelowfusiontemperatureofmetals;GoldsolderusedforFPD&

Silversolderusedfororthoappliances; HorizontalForces–mostdestructivetoperiodontium; Ante’sLaw–rootsurfaceareaofabutementteethsupportedbybonemustequal/surpasstheroot

surfaceareaofteethbeingreplacedw/pontics; Strain/WorkHardening–hardening/deformationatroomtemp;ultimateresultisfracture;

↑hardness,strength,&proportionallimit;↓ductility&resistance;→ ie–bendingwireback&forthrapidlybetweenthefingers;→ doneatroomtempincontrasttoforgingwhichisworkingathighertemperatures;→ undermicroscope,elongatedgrainsinmicrostructureofwroughtwireindicated

worked/strainedhardening; Quenching–metalcooledfrom↑temptoroomtemp;Toachievesoftenedconditionfortype3gold,

quenchinwater30‐40sec;advtages–maintainsthemetal’smalleability&ductilityandthecastingismoreeasilycleanedcuzinvestmentbecomessoft&granular;

Annealing–softeningametalbycontrolledcoolingofmaterialto↑ductility&strength&lessbrittle;→ 3stages–recovery,recrystallization,&graingrowth;→ goldfoilisannealedtoremovevolatilesurfaceimpuruitiespriortoplacementinprep;

Fritting–processformanufacturinglow&mediumfusingporcelains;createsfineporcelainpowder(frit)thatcanbeaddedoverbyothermetallicsubstancestoproducecolorinporcelain;

HighSagFactor(Distortion)–leadstodistortionofbridgespanswhenporcelainisfired; X‐raySignsofOcclusalTrauma: 1)Hypercementosis

2)RootResorption3)AlterationofLaminaDura4)AlterationofPeriodontalSpace

Facebow–caliperdevicerecordspts.maxilla/hingeaxisrelationship=open/closeaxis;→ Recordusedtoorientthemaxillarycasttothehingeaxisonthearticulator;→ Hinge‐axisfacebowtransferenablesthedentisttoALTERVDOonarticulator;→ Hinge‐axisfacebowisusedtorecordopening&closingofthemandible;

Thepreferredmethodtopreservetheface­bowtransferisTAKINGAPLASTICINDEX; WhenalterVDO,castsshouldbemountedonHingeaxis;

→ Facebow/hingeaxisyielderrorof2mmorlessonmostpatients; Pantograph–precisetracingofpathsfollowedbythecondyle;need2facebows&fullyadjustable

articulator; ArconArticulator–condylarelementonLOWERMEMBRANEofarticulator;FIXEDcondyleangle;like

panadent–forCROWNS&DIAGNOSTICCASTS; Non‐ArconArticulator–condylarelementonUPPERMEMBRANEofarticulator;NON‐FIXEDcondyle

angle;forDENTURES; Prolongedsensitivitytoheat,cold,&pressureaftercrowncementationisusuallyrelatedto

OCCLUSALTRAUMA;ifCRocclusionishigh,ptcomplainsofcoldsensitivity&painonbitinghard; Excursivemovementsmustalsobecheckedb/cifptcomplainsofpainwhenchewingsoftfoods,this

indicatesimproperbalancingorworkingcontacts; Initialsensitivitycanbecausedbyacidirritationaccentuatedbydehydrateddentinfromprolonged

dryingoftoothb/fcementationorincorrectliquid/powderratioofcement; Ifmarginalridgeislefthigherthanadjacentmarginalridge,aRETRUSIVEinterferencemovement

mayoccur; AdvantagesofPost&Core: 1)Marginaladaptation&fitofrestorationindependentoffitofpost;

2)Restorationcanbereplacedwithoutdisturbingpost&core;3)Canbetreatedasanindependentabutment;

Apost&coremusthaverootsw/adequatelength,bulk,andstraightness;ifrootconfigurationsnotfavorable,thenusepin‐retainedamalgmaorcompositecore;

Glazedporcelain,polishedgold,unglazedporcelain,&polishedacrylicarepreferredinthatorderoftheiracceptabilitytosofttissue;

Electrosurgery–passingsmallcurrentofelectricitythruthegingivaltissues,causingcellstodesiccateorscorch;resultsinsomedelayedhealingb/clackofproperclotformation;

→ verygoodatstoppinghemorrhage;→ toolowacurrentcanbedetectedbytissuedrag;→ objectives–coagulation,hemostasis,accesstomargins,&reduceinnerwallofsulcus;→ potentialseriousdamagetoPDL&surroundingbone,causinglossofattachment;

HumanDentitionFeaturestheEffectPDLHealth&HardTissuetoresistocclusalForce:→ Anteriorteethhaveslight/nocontactinMIP→ Occlusaltableis<60%ofoveralFLwidthoftooth→ Occlusaltableisatrightanglestotooth’slongaxis→ Mand.molarcrownsareinclined15‐20otowardthelingual

RADIOLOGYMISCELLANEOUS: Forradiopaquestructures,lessradiationpenetratesthestructure&reachesthefilmsomore

radiationabsorbedinstructure; Forradiolucentstructures,lessdensematerialsALLOWradiationtopassthrubyabsorbingverylittle

radiation; Mostbenignlesionsareunilocularandwell‐defined; 90%ofdiffuseradiolucentstructuresarecancer;iflossofcorticalplaces,the1stdiagnosisiscancer; Osteoradionecrosisisnecrosisofboneproducedbyionizingradiation;morecommoninthemandible

thanmaxilladuetorichervascularsupplyinmaxilla&b/cmandibleismoreoftenirradiated;→ Mostcommonprecipitatingfactorsarepre&postirradiation&periodontaldisease;damageto

bloodvesselspredisposesapttodevelopingthis;→ don’theatbone>116oF/47oC.

dentalradiographsshouldberetainedindefinitely;legallytheyarethepropertyoftheDENTISTbutptshaverighttoreasonableaccesstoradiographs;

ptsmayrefuseradiographsbutnodocumentcanbesignedbytheptthatreleasesthedentistfromliability;

DigitalRadiography–requiresLESSradiationgthantraditionalx‐raysb/cthesensorismoresensitivetoxrays;radiationexposuretoptisreducedby50‐80%;sensorisusedinplaceoffilm;

→ Superiorgrayscaleresolution,increasespeedofimageviewing,decreasedcostofequipment&film,imageenhancement,&superiorpteducation;

StoragePhosphorImagingSystem–typeofdigitalimagingsystemthatusesareversibleimagingplateratherthanasensortorecordimage;platesaremoreflexiblethusmorecomfortableforpt;

DirectDigitalImagingSystem–usesanintraoralsensorattachedtoafiberopticcable; IndirectDigitalImagingSystem–scansanexistingxrayanddigitizestheimage; Charge‐CoupledDevice–theMOSTCOMMONdigitalimagereceptor;solidstatedetectorw/asilicon

chipembeddedinit;usedinhomevideocameras,faxmachines,&telescopes; PrimaryRadiation–radiationgeneratedattheANODEofthexraytubethatisattenuatedbythefilter

&object; ScondaryRadiation(ScatteredRadiation)–arisesfrominteractionsoftheprimaryradiationbeam

w/atomsintheobjectbeingimaged;aLEADEDRECTANGULARconebest↓amtofscatterradiation;→ majorsourceofimagedegradationinbothxray&nucelarmedicineimagingtechniques;→ operatorrecievesgreateshazardfromsecondaryradiation;

Collimation–controlofsize&shapeofxraybeamusingmetalplates&slotstoconfine&directradiation;

Radiationbeamshouldbeassmallaspractical;diameterofcircularbeamofradiationatpt’sskincan’tbelargerthan2.75inches;

Xraybeamcomposedofraysofdifferentwavelengths&penetratingpower(polychromatic)b/cthepotentialacrossthexraytubeconstantlychangesatthekilovoltagechanges;

→ Shortwavelengthxrays=highenergy;producedathighkVp&penetratesobjectmorereadily;→ Longwavelengthxrays=lowenergy;producedatlowerkVpthus↓penetratingpower;→ Aluminumdiscsareusedtofilterouttheseuselesslongwaveraysto↑ qualityofxray;

Filtration–removalofpartsofxrayspectrumusingabsorbingmaterialsinthexraybeam;reducesptdose,contrast,&filmdensity;3typesofFiltration:

1. InherentFiltration–partsincludeglassenvelopeofthexraytube&oilsurroundsxraytubetocoolthetubetodissipateheat;correspondsto~0.51mmofaluminum;

2. AddedFiltration–obtainedbyplacingthinsheetsofaluminuminconetofiltertheusefulbeamfuther;

3. TotalFiltration–consistofinherentfiltration+addedfiltration;.5mm&2.5mmofaluminum;

Operatorshouldneverremaininroomholdingxrayinplaceforpt;ifchildneedshelp,haveparentholdfilmwithleadvestdrapedonthem;

Operatormustavoidprimarybeambypositioningthemselvesat90o‐135oangletothebeam; EKTA­SpeedFilm–providestheMOSTEFFECTIVEwaytoREDUCEexposuretime,amoutnof

radiationreachingpt&amountofscatterradiation; Otherfactorsthat↓PtRadiation: 1)LeadapronisMOSTEFFECTIVEwaytostopxrays

2)↑filtrationusingaluminumdisk3)leaddiaphragmsplacedw/inconeofxraytubehead4)collimatinganxraybeam5)↑source‐filmdistance6)intensifyingscreens(usedwithpano&ceph)

CommitteeonRadiationProtectionofNationalBureauofStandards–recommendspersonwhoworksnearradiationbeexposedin1yrtomaxdoseof5REM(.1REM/week);

→ MaximumPermissibleDose=.5REMfornon‐occupationallyexposedpersion; SequenceofRadiationInjury:1.LatentPeriod,2.PeriodofCellInjury,3.RecoveryPeriod; EffectsofradiationexposureareADDITIVE,&thedamagethatremainsnon‐repairedaccumulatesin

tissues; Thegreatertherateofpotentialformitosis&moreimmaturethecells&tissues,themoresusceptible

orsensitivethesecellsaretoradiation;→ Radiosensitivecells:immaturebloodcells(smalllymphocytes),bonemarrow,reproductive

cells,&immatureboncecells;Prostateglandisverysensitivetoradiation; Hemopoietictissuseismostsensitivetoradiation.

→ Radioresistantcells:maturebone,muscle,&nerves(pulp);Musclecellsaremostradioresistant; RadiationAbsorbedDose–measureoftheenergyimpartedbyanytypeofionizingradiationtoa

massofanytypeofmatter;unitofabsorbeddose=rad; EquivalentDose–correctunitofmeasurementusedby

dentisttocomparethebiologic‐riskeffects/estimatesofdifferenttypesofradiationdamagetotissue/organ;

EffectiveDose–usedtoestimatetheriskinhumans; Exposure–measureofradiationquantity,thecapacityoftheradiationtoionizeair;Roentgenis

tranditionalunitofradationexpsuremeasuredinair;Roetgenonlyappliestoxrays&gammarays;→ Xrayshavemoreenergythanline;~1%ofenergyreleasedinxraytubeisreleasedasxrays;

ElectromagneticRadiation–includesmicrowave,x‐radation,visiblelight,&gammaradiation;Xrays&gammaraysaretypeofnon­particulateradiationenergy;

Submandibularglandfossa–largeradiolucentspace~5mmbelowMBroothofmand.1stmolar;RADIOGRAPHICSOLUTION&ERRORS: DeveloperSolution–solutionthatconvertstheinvisibleimageonafilmintoavisibleimage

composedofminutemassesofblackmetallicsilver;→ Filmskeepgettinglighter&lighteraftereachdevelopment,tocorrectthisproblemsimply

replenishthedevelopingsolution;soasdevelopingsolutiongetsweaker,filmgetslighter;→ Functionistoreducesilverhalidecrystalstoblackmetallicsilver;4Chemicals:

1. DevelopingAgent–hydroquinone2. Antioxidantpreservative–sodiumsulfite3. Accelerator–sodiumcarbonate4. Restrainer–potassiumbromide

FixerSolution–chemicalsolutionwhosefunctionistostopdevelopment&removeremainingunexposedcrystals;fixingtimeisatleasttwiceaslongasdevelopingtime;4chemicals:

1. ClearingAgent–sodium/ammoniumthiosulfate;commonlycalledhypodissolves&removesunderdevelopedsilverhalidecrystalsfromemulsion;

2. Antioxidantpreservative–sodiumsulfite3. Acidifier–aceticacid4. Hardener–potassiumalum

Ifadriedxraywereprocesseda2ndtime,therewouldbenochangeincontrast/density; Yellowishbrownfilmiscausedbyinsufficientfixingorrinsing; Foggedfilmmayresultfromimproperfilmstorageoroutdatedfilms;orduetofaultysafelightin

darkroomwithwhitelightleaking;orb/cexposedtoradiationotherthanfromprimarybeam; Lowsolutionlevelswillappearasdevelopercut‐off(straightCLEARborder)orfixercut‐off(straight

BLACKborder); StaticMarks(multipleblacklines)‐duetofrictionwhenopeningfilmpacketscausingstatic

electricity; TornEmulsion–filmswereallowedtotouchoroverlapwhiledrying; ClearFilms–emulsionwashedawayb/cfilmleftinwaterover24hrs;orweren’texposedto

radiation; LightFilms–underexposed/imagenotdenseenough;dueto…

→ IncorrectmA(toolow)orexposure(tooshort)→ Incorrectfocal‐filmdistance→ Conetoofarfrompt’sface→ Filmplacebackwards;

DarkFilms–overexposed/imagetoodense;dueto…→ IncorrectmA(toohigh)→ Exposuretoolong→ IncorrectkVp(toohigh)

PoorContrast(verydark/verylightareas)–incorrectkVp(toohigh); Herringbone(DiamondEffect)–azigzagpatternappearsontheprocessedfilmwhenfilmisplaced

backwardsinmouth;TYPESOFRADIOGRAPHS: Panoisthescreeningxrayforpathologyofthejaws;ExcellentinSialography–techniquedusedin

radiologythatfilmsthesalivaryglandafteranopaquesubstanceisinjectedintoduct;→ Disadv.→↑object‐filmdistancecausingimagedistortion&proximaloverlapping;→ IfChintiltedtoofarUPWARD=ReverseOcclusalPlaneCurve(frown)–wheremand

structureslooknarrower&maxstructureslookwider;→ IfChintiltedtoofarDOWNWARD=occlusalplaceshowsexcessiveupwardcurve(big

smile);alsosevereinterproximaloverlapping&anteriorteethappearhighlydistored; Ceph–usefultoassesstooth‐to‐tooth,bone‐to‐bone,&tooth‐to‐bonerelationships;serialcephscan

showamount&directionofgrowth;→ Moststableareafromwhichtoevaluatecraniofacialgrowthisanteriorcranialbasedue

toitsearlycessationofgrowth; BWs–doesNOTshowrootapices;verticalBWangulation=+8o‐10o;afuzzy/indistinctimageof

crestalboneisoftenassociatedw/earlyperiodontitis;→ AdjustHORIZONTALANGULATIONtodirectthecentralraytowardcenteroffilm;→ Childw/primaryteeth,use#0film.→ Childw/mixeddention,us#1film→ Childwith2ndmolars,use2to4#2films;sometimes2long#3filmsbutnotrecommended;

Submental‐Vertical(Submentovertex)–xrayfordiagnosingBASILARSKULLFRACTURES&providessomeinfoaboutzygoma,zygomaticarches,&mandible;usewhensuspectfractureofzygomaticarch;

→ sourcebelowmandible&filmaboutthehead; Water’sView–standardxrayofchoiceforshowinganANTERIORviewoftheparanasalsinuses&

mid‐face&orbits;facelyingagainstfilm&x‐raysourcebehindthept’shead;

→ BESTfilmforradiographicdiagnosisofmid­facialfractures,sinusinfections,&itsviewbestdemonstrateslesionsofthemax.sinus;

Towne’sView–bestfilmtovisualizetheCONDYLES&neckofmandiblefromAPprojection;filmunderhead&sourceisfromthefront&rotated30ofromfrankfortplane&directedatcondyles;→ towne’svieweliminatesthesuperimpositionofthemastoid&zygomaoverthecondylarneckin

thestraightpostero‐anteriorprojectionwhichoftenmakesinterpretationdifficult;→ ReverseTowne’sView‐usedtoidentifyfracturesofthecondylarneck&ramusarea;

RADIOGRAPHICTECHNIQUES: InverseSquareLaw–theintensityofthefilmexposure

decreasesasasquaredratioasthedistanceb/wtheobject&sourceofxraysincreases;meaningintensity↑or↓exponentiallyasthesource&objectaremovedwhilethedistanceb/wobject&filmremainsthesame;

Half‐ValueLayer–amtofmaterialrequiredtoreducetheintensityofanxraybeamtohalf;normallyexpressedinaluminumorcopperthickness;HVLisindicatorofQUALITYofanxraybeam;→ Stricklydefinedfordifferentquantities–photonfluence,energyfluence,orabsorbeddose;→ Notconstant!!WhenmeasuringmutlipleHVLs,the2ndHVLisgreaterthanthe1stHVL;→ TheHVLofabeamis~2mmofaluminum(thismeans50%ofthexraysexitingthevacummetube

areabsorbedby2mmaluminum;doublingthethicknessofaluminumwillNOTabsorballthexrays,butonehalfoftheremainingxrays;

IntensifyingScreens–usedinextra‐oralxraysthatconvertxrayenergyintovisiblelightwhichthenexposesthescreenfilm;radiationaptreceivesis↓;usedforallextra‐oralxrays(pano,ceph);

Kilovoltage–qualityorpenetratingpowerofthexraybeamthatcontrolsthespeedofelectrons;→ Suitablerangesare65‐100kVp;→ Influencesthexraybeam&radiographbyalteringcontrastquality(forptsw/thickjaws,↑kVp),

determiningthequalityofxraysproduced,&determiningvelocityofelectronstoanode; Milliamperage‐thenumberofelectrons(whichdeterminesthequantityofxraysproduced)is

controlledbytheTEMPERATUREofthetungstenfilament(mAsetting);thehotterthefilament,theelectrodesareemitted&availabletoformtheelectronstream;suitablerange=7‐15mA;

→ Controlsthe#ofxraysproduced;→ theintesityofxraysproducedaparticularkVpdependsonthatnumber;→ settingthexraymachineforspecificmAmeansadjustingtheformertemptoyieldthe

currentflowindicated;→ to↑filmdensity=↑mA,kVp,&time&↓source‐objectdistance;

ExposureTime–lengthoftimexraysareproduced&thetimetheptisexposedtothem; Contrast–onlyoneexposurefactoraffectscontrast→kVp;filtrationalsoplaysarole;

→ ↑kP=moreshadesofgray=lowcontrast;so↑kVpcausestheresultantxraytohaveaLONGERSCALEofCONTRASTand↓kVPcauses↑subjectcontrastw/SHORTERSCALEOFCONTRAST;

→ highcontrast=verydark&verylightareas→ lowcontrast=manyshadesofgray;preferredindentistry;

Density–overallDARKNESSofaxraythat↑asmA,kVp,orexposuretime↑; FocalSpot–smallareaoftungstenontheanode(target)fromwhichthexraysemanates&receives

theimpactofthespeedingelectrons;itis1of3factorsthatinfluenceimagesharpness;SizeofxraytubefocalspotinfluencesradigraphicDEFINITION;→ Target(tungstentarget)–tungstenwaferembeddedinanodefaceatthepointofelectron

bombardment;→ TargetFilmdistanceisdeterminedbylengthofcone:

20cm(8inches)–shortconethatexposesmoretissuebyproducingmoredivergentbeam. 41cm(16inches)–longconethat↓amtofexposedtissuebyproducingalessdivergentbeam

&sharperimage;

Xraysaregeneratedwhenastreamofelectrons(producedbyfilament)travelsfromCathod&issuddenlystoppedbyitsimpaceattungstentarget;

Filamentlocatedinthecathodeandismadeoftungstenwire; Thesmallareaonthetargetthattheelectronsstrikeisthefocal

spot(thexraysource); DentalX‐RayTubeParts:1. Filament–coiledtungstenwireincathodthatwhenheatedto

incandescence,emits/producesstreamofelectrons;2. Molybdenumcup–housesthetungstenfilament;3. ElectronStream–travelsfromfilamentinthecathodetothe

tungstentarget;4. TungstenTarget–locatedinanodetostopstreamof

electrons;5. Focalspot–portionoftungstentargetstruckbyelectron

beam;6. CopperSleeve–locatedinthecathode;7. Vacuum8. X­rayBeam–producedwhenelectronstreambouncesofffocalspotontungstentarget;9. Leadedglasshousing–housesentirexraytube;

VerticalAngulation–foreshortening&elongationareproducedbyincorrectverticalangulation;→ Foreshortening–shortenedimagecausedbyEXCESSIVEverticalangulation;teethappearshort

duetotoomuchangulationorpoorchairposition;→ Elongation–elongatedimagecausedbytooLITTLEverticalangulation;MOSTCOMMONerror

whentakingxrayswhereteethappeartoolongduetoeithertoolittleverticalangulationorfilmnotbeingparalleltolongaxisofteethoftheocclusalplanenotbeingparalleltothefloor;

HorizontalAngulation–maintainingcentralrayat0o;centralrayshouldbeperpendiculartomeanantero‐posteriorplaneofteethbeingxrayed;

→ Overlapping‐interproximalareasareoverlappedduetoincorrecthorizontaltubeangulation; BisectingAngleTechnique–imageonthefilmisequaltolengthoftoothwhnethecentralrayis

directedat90ototheimaginarybisector;→ Tooth&radiographicimageareequalinlengthwhen2equaltrianglesareformedthatsharea

commonside(imaginarybisector);→ Decreasesexposuretime;xrayfilmmaybedistoredb/cimageisnottruereproductionofthe

object(duetouseofshortcone); ParallelingTechnique–basedonconceptofparallelismsincefilmisplacedparalleltothelongaxisof

toothbeingxrayed&centralxraybeamisdirectedperpendiculartolongaxisofteeth&planeoffilm;→ FilmholderMUSTbeused;→ Disadv–filmplacementdifficult,↑exposuretimerequiredb/cuseoflongcone,&object‐film

distanceis↑tokeepfilmparallelsoimagemagnificaiton&lossofdefinition;→ AKA–XCP(extensionconeparallelingtechnique),Right‐Angletechnique,&Long‐conetechnique;

SLOB–ifobjectinquestionappearstomoveinSAMEdirectionasxraytube,thenitisontheLINGUALaspect;ifitappearstomoveinOPPOSITEdirectionasxraytube,thenitisonBUCCALaspect;

CervicalBurnout–phenomenoncausedbyrelativelylowx‐rayabsorptiononthemesial/distalsurfacesofteeth,b/wtheedgesoftheenamel&adjacentcrestofalveolarridge;

5RulestoCreateAccurateImageonXray:1. Usesmallestfocalspotthatispractical;asfocalspot↓,imagesharpness↑;2. Uselongestsource‐filmdistancethatispractical;3. Placefilmascloseaspossibletostructurebeingradiographed4. Directcentralrayataclosetoarightangletothefilm5. Keepfilmparalleltothestructurebeingradiographed;