ENDODONTICS (31 QUESTIONS) Endodontics: science of diagnosing and treating pulpal and apical disease

1.1 Pulpal Disease

Hard tissue surrounding the pulp limits the available room for expansion and restricts pulp from experiencing edema

Pulp has odontoblasts and mesenchymal cells that differentiate into osteoblasts to form more dentin

A-Delta Fibers: large, myelinated fibers, that course coronally through pulp- Quick, sharp, momentary pain- Pulpodentinal complex: association of A-delta fibers with odontoblastic cell layer and dentin - Easily provoked

C Fibers: dull, throbbing pain - Small, unmyelinated fibers, that course centrally in the pulp stroma - Not easily provoked - If C fiber pain predominates irreversible local tissue damage - Pain can be elicited by hot foods and liquids - Pain is distant and can be referred to a distant site or other teeth

Normal Pulp Asymptomatic Produces a mild to moderate response to thermal and electrical stimuli that goes away fast when

stimulus is removed Tooth NOT painful when percussed or palpated

Reversible Pulpitis Thermal stimuli causes a quick, sharp, hypersensitive response that stops immediately when removed

Any irritant that can affect the pulp can cause reversible pulpitis NOT a disease, is a SYMPTOM

Symptomatic irreversible pulpitis

Pulp has been damaged beyond repair, will NOT heal Microabscesses of pulp begin as tiny zones of necrosis within dense acute inflammatory cells Characterized by spontaneous, unprovoked, intermittent or continuous pain Pain lingers after thermal stimulus removed

Asymptomatic irreversible pulpitis

Microabscesses of pulp begin as tiny zones of necrosis within dense acute inflammatory cells No clinical symptoms

Pulp Necrosis Death of pulp from:- Untreated irreversible pulpitis, traumatic injury, any event causing long-term interruption of

blood supply to pulp In anterior teeth, there could be crown discoloration Region of liquefaction necrosis Not enough drainage of inflammatory fluids

Only endo therapy can stop process of internal resorption

1.2 Apical Diseases

Sign most indicative of an apical inflammatory lesion is radiographic bone resorption

Symptomatic apical periodontitis

Painful inflammation around apex- localized inflammation of PDL in apical region, results from:

- Extension of pulpal disease into apical tissue- Canal over-instrumentation or overfill- Occlusal trauma

Tooth might be painful during percussion Asymptomatic apical periodontitis

Long-standing, asymptomatic or mildly symptomatic lesion Usually radiographic apical bone resorption Presence of an apical radiolucency Pulpal necrosis

Acute apical abscess Painful, with purulent exudate around apex Result of exacerbation of symptomatic apical periodontitis from a necrotic pulp Relatively normal or slightly thickened lamina dura Liquefaction necrosis containing disintegrating neutrophils and other debris;

surrounded by macrophages and sometimes lymphocytes and plasma cells Rapid onset of swelling, moderate to severe pain, pain with percussion and palpation,

increase in tooth mobility Chronic apical abscess Associated with either a continuous or intermittently draining sinus tract

Necrotic pulp Bone loss at apical area Resolves spontaneously with endo tx

Condensing osteitis Excessive bone mineralization around apex of asymptomatic vital tooth Radiopacity Asymptomatic and benign

1.3 Endodontic Diagnosis

Characteristics of nonodontogenic involvement 1. Episodic pain with pain-free remissions2. Trigger points3. Pain travels and crosses midline of face4. Pain that surfaces with increasing mental stress5. Pain that is seasonal or cyclic6. Paresthesia

Only contraindications to endo therapy are uncontrolled diabetes or heart attack in last 6 months

When inflammatory process extends beyond apex, it’s easier for patient to identify source of pain Maxillary molars usually refer pain to zygomatic, parietal, and occipital regions of headMandibular molars refer pain to ear, angle of jaw, or posterior regions of neck

1.4 Endodontic Examination and Testing

Facial asymmetry may indicate swelling of odontogenic origin Sensitivity of proprioceptive fibers reveals inflammation of apical PDLSensory fibers of pulp ONLY transmit pain, whether pulp has been cooled or heated Use of EPT is contraindicated if patient has a cardiac pacemaker Radiolucency doesn’t begin until demineralization extends into cortical plate of bone

Sudden change in appearance of canal from dark to light indicates the canal is bifurcated or trifurcated

SLOB Rule: same lingual, opposite buccal the object closest to buccal surface appears to move in direction opposite the movement of the tube head or cone objects closest to the lingual surface appear to move in the same direction of the cone

Traumatic Bone Cyst- usually reveals a smoothly outlined radiolucent area of variable size

Ameloblastoma- occurs in 4th and 5th decade Aggressive lesions occur as multilocular radiolucencies Frequently causes resorption of roots in area

Cemental dysplasia- commonly associated with vital mandibular anterior teeth

Cementoblastoma- a well-circumscribed dense radiopaque mass surrounded by a thin, uniform radiolucent outline

Odontogenic lesions= dental papilla, dentigerous cyst, odontogenic keratocyst, residual cyst, odontoma (early stage)

Nonodontogenic lesions= fibro-osseous lesions, osteoblastoma, cementifying fibroma, ossifying fibroma, malignant tumor, multiple myeloma

1.5 Cracked Tooth Syndrome- cracked teeth can be diagnosed using transillumination, a tooth sloth

1.6 Vertical Root Fracture

Vertical root fractures start apically and progress coronally Usually in B-L plane of root Diagnosis is confirmed by visualizing fracture with an exploratory surgical flap

1.7 Endodontic-Periodontal Relationships

Endo pathosis can cause periodontal disease, but perio disease does NOT cause endo problems Primary periodontal lesions with secondary endodontic involvement- deep pocketing with hx of extensive perio disease

2.1 Nonsurgical Endodontics

Instruments for shaping and cleaning1. Gates-Gliddon- long thin shaft with parallel walls and short cutting head; used to pre-enlarge coronal canal areas2. K-files- twisted square or triangular metal blanks along their long axis; can be used with watch winding or

balanced forces technique 3. Hedstrom Files- spiraling flutes cut into shaft of round, tapered, stainless steel wire; cut only in ONE direction4. Barbed broaches- sharp, coronally angulated barbs in metal wire blanks; used to remove vital pulp from root

canals 5. Nickel-titanium rotary instruments-superelasticity and high resistance to cyclic fatigue

a. Have reduced incidence of blocks, ledges, transportation, and perforation

Crown down cleaning: inserting a large instrument into canal up to a depth that allows easy progress and then continuing on with smaller instruments until the apex is reached

Step back cleaning: working lengths decrease in stepwise manner with increasing instrument size

Irrigation and Medicaments1. Sodium Hypochlorite- disinfects root canals, dissolves organic matter, does NOT remove smear layer2. Ethylenediamine tetraacetic acid (EDTA)- 17% EDTA; removes inorganic material and removes smear layer 3. Chlorhexidine4. Calcium Hydroxide- BEST intracanal medicament; high pH causes antibacterial effect; inactivates

lipopolysaccharides; has tissue-dissolving capacity

Gutta Percha Characteristics:- Plasticity- Easy to manage- Not toxic- Easy to remove

- Self-sterilizing - Does not adhere to dentin- Shrinks after cooling

2.2 Surgical Endodontics

Best treatment for swelling from acute apical abscess is to establish drainage and clean and shape canal

Trephination: surgical perforation of alveolar cortical bone to release accumulated tissue exudates

Indications for root resection: Class 3 or 4 periodontal furcation defect Infrabony defect of one root of a multirooted tooth that cannot be successfully treated periodontally Existing fixed prosthesis Vertical root fracture confined to root to be resected

2.4 Sterilization and Asepsis1. Glutaraldehyde

a. Cold and heat labile instruments b. 24 hours required to achieve sterilization c. Least desirable

2. Pressure Sterilization

a. Instruments should be wrapped and autoclaved for 20 minutes at 121C and 15 psib. All bacteria, spores, and viruses are killed

3. Dry heat sterilizationa. Superior for sterilizing sharp-edged instruments

2.5 Radiographic Techniques

Paralleling technique- most accurate radiographs are taken this way

Bisecting angle technique is least accurate Optimal setting for maximal contrast between radiopaque and radiolucent structures is 70 kV

2.6 Microbiology of Endodontics

Primary Endodontic Infection:1. Strict anaerobes predominate2. Gram negative anaerobic black pigmented

bacteroides 3. Gram positive anaerobic Actinomyces

Unsuccessful RCT1. Enterococcus faecalis 2. High incidence of facultative anaerobes

Lipopolysaccharides are found on the surface of gram negative bacteria

Penicillin V or amoxicillin are 1st choice of antibiotics used in endodontics Effective against: Prevotella, porphyromonas, Peptostreptococcus, Fusobacterium, and Actinomyces Clindamycin is effective against many gram negative and positive organismsMetronidazole is effective against strict anaerobes

NaOCl is a good irrigant for disinfection and removal of debris, but need an additional lubricant

A vertical root fracture can only be identified with visualization, and surgery is often needed to confirm the fracture

Pulp vitality testing immediately after the injury frequently yields a false-negative response test results may be unreliable for 6 to 12 months repeat tests at 3 weeks, 3 months, 6 months, and 12 months and then yearly

Pulp testing detects only responsiveness and NOT vitality of pulp

Uncomplicated fractures (without pulp involvement)

Infraction Incomplete crack of enamel without loss of tooth structureEnamel fracture Only involves enamelCrown fracture without pulp involvement (Ellis Class 2)

Involves enamel and dentin only restore with resin

Complicated fractures Crown fracture with pulp involvement (Ellis Class 3)

Fracture involving enamel, dentin, and exposure of pulp

Root Fracture Horizontal Root Fracture Fracture involving roots only (cementum, dentin, and pulp)Coronal root fracture If fracture occurs at level of or coronal to crest of alveolar

bone, POOR prognosis-stabilize coronal fragment with rigid splint for 6 to 12 weeks

Midroot fracture Needs to be stabilized for 3 weeks Apical root fracture Horizontal fractures in apical 1/3 have the best prognosis

Ideal healing of a root fracture is calcific. A calcific callus is formed at the fracture site on the root surface and inside the canal wall Displacement Injuries

Luxation Dislocation of a tooth from its alveolus from acute trauma(Ellis class 5)

Concussion No displacement, normal mobility, sensitive to percussion, usually responds to pulp testingNo immediate treatment needed, let tooth rest

Subluxation Tooth is loosened but not displaced Splint for 1-2 weeks if mobile

Extrusive or lateral luxation

Tooth is partially extruded from its socket Usually displaced palatally and root displaced labially

Intrusive luxation Apical displacement of tooth96% rate of pulpal necrosis

Avulsion (Ellis Class 6) Complete separation of tooth from its alveolus

Replacement resorption (ankylosis) Caused by damage to PDL Continuous replacement of lost root with bone

Cervical resorption Caused by a sulcular infection from physical and chemical injuries Mimics appearance of cervical caries Ragged, asymmetric, and irregular “moth-eaten” appearance Usually begins at CEJ

Inflammatory resorption Caused by pulp necrosis Bowl shaped resorption involving cementum and dentin Usually at apical 1/3 of root

Frequency of pulpal necrosis: intrusion > lateral luxation> extrusion > subluxation > concussion

INTERNAL ROOT RESORPTION EXTERNAL ROOT RESORPTION Destructive process within root canal system Inflammation occurs from: caries, cracked

teeth, trauma, idiopathic Occurs anywhere along root canal Rare in permanent teeth Usually seen in radiographs Sharp, smooth, and clearly defined margins Usually symmetrical Does NOT move with angled radiographs Endo therapy stops process

Destructive process initiated in periodontium Margins less defined, ragged, and irregular “moth-eaten” appearance Usually asymmetrical

Within pulp there are odontoblasts, fibroblasts, nerves, blood vessels, and lymphatics

Bacteria from dental caries are main cause of more serious pulpal injury and main cause of pulpitis

Vital Pulp Therapy MaterialsCalcium Hydroxide Used as pulp capping material

High pH of 12.5 that cauterizes tissue and causes superficial necrosis Encourages pulp to induce hard tissue repair with secondary odontoblasts

MTA Consists of calcium phosphate and calcium oxide Sets in presence of moisture Long setting time Non-resorbable great sealing agent

Indirect Pulp Cap Material is placed on thin amount of remaining carious dentin, that if removed could expose pulp Wait for 6 to 8 weeks to allow deposition of reparative dentin and then remove remaining caries

and permanently restore tooth

Direct Pulp Cap Dental material placed directly on vital pulp exposure Indicated when pulp has been exposed for less than 24 hours

Partial Pulpotomy (Cvek pulpotomy)

Surgical removal of a small portion of coronal pulp tissue to preserve remaining coronal and radicular pulp tissues

Indicated if inflammation is greater than 2mm into pulp chamber but hasn’t reached root orifices, exposures longer than 24 hours

Pulpotomy Surgical removal of coronal portion of a vital pulp to preserve vitality of remaining radicular pulp Indicated for a vital pulp in immature teeth with exposures after 72 hours

Pulpectomy Removal of coronal and radicular pulp tissues Temporary pain relief on teeth with irreversible pulpitis until endo can be performed

Apexogenesis Maintenance of pulp vitality to allow for continued development of entire root Indicated for an immature tooth with incomplete root formation and with a damaged coronal pulp

and healthy radicular pulp Contraindicated for avulsed teeth, un-restorable teeth, teeth with severe horizontal fracture

Apexification Method to stimulate formation of calcified tissue at open apex of pulpless teeth Indicated for infected teeth with open apices Tooth pulp is removed

Calcific metamorphosis gives tooth a yellow colorFluorosis gives teeth a mottled white-to-gray appearance Walking bleach= sodium perborate Intracoronal bleaching has the complication of external cervical resorption because irritation diffuses through the dentinal tubules to cementum and PDL

A longer tooth ferrule increases resistance to fracture

Primary purpose of a post is to retain a core in a tooth with extensive loss of coronal structure posts further weaken the tooth by removal of additional dentin and creating stress that predisposes to root fracture 5-7mm of remaining gutta percha is recommended

Coronal seal of RCT is more important than apical seal Debridement= KEY TO SUCCESS

OPERATIVE DENTISTRY

Dental Caries: a multifactorial, transmissible infectious oral disease caused by the complex interaction of cariogenic oral flora with fermentable dietary carbohydrates on tooth surface over time

Streptococcus mutans primary causative agent of initial caries Adheres to enamel Its glucosyltransferase enzyme causes formation of an extracellular polysaccharide, allowing it to stick to smooth

tooth surfaces S. mutans produces and tolerates acid metabolizes sucrose to an end product of lactic acid Once cavitation has occurred, Lactobacillus becomes the primary agent for further dentin destruction

Caries is most prevalent in the pits and fissures of the occlusal surfaces where developmental lobes of posterior teeth failed to coalesce

3 parts of hand instruments= handle, shank, and blade for non-cutting instruments, the blade is the NIB

o Blade/nib- working end of instrument, connected to handle by shank

Cutting Instrument Formula10-8.5-8-141st #= width of blade or primary cutting edge in tenths of a mm2nd #= primary cutting edge angle3rd #= blade length in mm4th #= blade angle, relative to long axis of handle in clockwise centigrade

Chisels are used mainly for cutting enamel

Excavators1. Ordinary hatchets- has cutting edge of blade directed in same plane as long axis of handle and is bibeveled

a. Used mainly on anterior teeth for preparing retentive areas2. Hoes- primary cutting edge is perpendicular to axis of handle and used for planing tooth prep walls and forming

line angles 3. Angle formers- used mainly for sharpening line angles and creating retentive features in dentin 4. Spoons- used to remove caries

Tooth Preparation Connect two preps if they are within 0.5mm of one another Restrict depth into dentin to 0.2 to 0.75mm Primary Resistance Form: prevention of tooth or restoration fracture from occlusal forces along long axis of

tooth Primary Retention Form: prevention of dislodgement of material Convenience Form: alterations to improve access and visibility for preparing and restoring cavity Secondary Resistance and Retention Forms: may be performed after placement of bases and liners Outline Form: initial extension of tooth prep should be visualized preoperatively by estimating extent of defect,

prep form requirements of amalgam, and need for adequate access to place amalgam into tooth

Amalgam Composite Create 90 degree amalgam margin No bevels Primary retention form= convergence occlusally Secondary retention form= grooves, slots, locks, pins, bonding Resistance form= flat floors, rounded angles, box-shaped floors

Greater than or equal to 90 degree cavosurface margin Primary retention form= none Secondary retention form= bonding Resistance form= no special form for small/moderate

prepsFor composite restorations, a bevel is usually 0.5mm wide and at 45 degrees

Increased surface area increased retention

Sealers are effective disinfectants, provide cross-linking of any exposed dentin matrix and occlude dentinal tubules by cross-linking tubular proteins

Liners are used to provide a barrier to protect dentin from residual reactants diffusing out of a restoration and/or from oral fluids covers a direct or near pulpal exposure and line very deep areas of a tooth prep in vital teeth

Bases are used to provide thermal protection for the pulp and to supplement mechanical support for the restoration by distributing local stresses from restoration across underlying dentin surface

Spherical amalgam has great leakage and post-op sensitivity Spherical amalgam is more easily condensed than admixed amalgam When carving amalgam, a discoid-cleoid instrument is used to carve occlusal surface- position discoid on unprepared enamel next to amalgam margin and pull parallel to margin

C-factor is determined by the ratio of prepared vs unprepared walls with a tooth prep higher C-factor may indicate increased chance for post-op sensitivity

ORAL AND MAXILLOFACIAL SURGERY AND PAIN CONTROL

Contraindications of the extraction of teeth: Severe uncontrolled metabolic diseases End-stage renal disease Advanced cardiac conditions Leukemia and lymphoma Head and neck radiation patients commonly treated with hyperbaric oxygen therapy before dentoalveolar

surgery IV bisphosphonate treatment Pericoronitis – must clear infection before extracting involved tooth

Most commonly impacted teeth are mandibular 3rd molars, maxillary 3rd molars, and maxillary canines

Inadequate arch length is the primary reason teeth fail to erupt

Classifications of impacted teeth1. Angulation:

a. Mesioangular (least difficult)b. Horizontalc. Vertical d. Distoangular (most difficult)

2. Pell and Gregory classification- relationship to anterior border of ramusa. Class 1- normal position anterior to ramusb. Class 2- one half of crown is within ramusc. Class 3- entire crown is embedded within ramus

3. Relationship to occlusal plane:a. Class A- tooth at same plane as other molarsb. Class B- occlusal plane of 3rd molar is between occlusal plane and cervical line of 2nd molarc. Class C- 3rd molar is below cervical line of 2nd molar

When removing bone for a surgical extraction, a trough of bone on the buccal aspect of the tooth down to the cervical line should be removed initially

Maxillary sinus communications should be managed with a figure-of-eight suture over the pocket

Tooth Displacement 1. Maxillary 1st and 2nd molar roots displace into maxillary sinus2. Maxillary 3rd molar roots displace into infratemporal fossa 3. Mandibular molar roots displace into the submandibular space through the buccal cortical bone

Excessive bleeding causes: injury to inferior alveolar artery during extraction of a mandibular tooth; muscular arteriolar bleed from elevation of a mucoperiosteal flap for 3rd molar removal; bleeding related to patient’s hemostasis

Denser cortical bone has a higher implant success rate than loose cancellous bone and thin cortical bone

Most common graft sites for autogenous bone are= anterior cortex of symphysis, lateral cortex of ramus and external oblique ridge, iliac crest, and rib

Bone morphogenetic protein (BMP): can induce bone formation and enhance graft healing

Distraction osteogenesis (DO): biologic process of new bone deposition and formation between osteotomized bone surfaces that are separated by gradual traction

Anatomic Limitations to Implant Placement Buccal plate, lingual plate, maxillary sinus, nasal cavity 1mm Incisive canal avoid midline maxilla Interimplant distance 3mm between outer edge of implants Inferior alveolar canal 2mm from superior aspect of bony canal Mental nerve 5mm from anterior or bony foramen Inferior border 1mm Adjacent natural tooth 1.5mm

Mandible fractures can almost ALWAYS be identified on a panoramic radiograph suspected fractures should always be visualized in at least 2 radiographs

Most common sites for mandibular fracture= condyle, angle, and symphysis Contemporary treatment for mandibular fractures that are displaced and mobile is with open reduction and internal fixation using titanium bone plates and screws

Lateral cephalograms are the main images used in treatment planning for orthognathic surgery

Apertognathic= anterior open bite

Maxillary surgery- aka Le Fort 1 osteotomies; maxilla can be moved forward and down more easily than up or back Mandibular surgery- done using either bilateral sagittal split osteotomy or vertical ramus osteotomy

Trigeminal neuralgia is treated with anticonvulsant drugs- carbamazepine, oxcarbazepine, gabapentin

Ramsay Hunt Syndrome is a herpes zoster infection of the sensory and motor branches of cranial nerves 7 and 8 resulting in facial paralysis, vertigo, deafness, and cutaneous eruption of external auditory canal

Myofascial pain disorder (MPD): characterized by diffuse, poorly localized pain in preauricular region

Trauma is the most common cause of TMJ ankylosis

Autorepositioning splints are used for muscle and joint pain when no specific anatomically based pathologic entity can be identified reduces intraarticular pressure Anterior repositioning splint protrudes the mandible into a forward position

The most common organisms of Odontogenic Infections are aerobic gram-positive cocci, anaerobic gram-positive cocci, and anaerobic gram-negative rods

- Aerobic Streptococcus species initiate infectious process after inoculation into deep tissues - Penicillin V is often the preferred drug for treatment

Indications for Culture and Antibiotic Sensitivity Testing Infection spreading beyond the alveolar process Rapidly progressive infection Previous therapy with multiple antibiotics Nonresponsive infection (after >48 hours) Recurrent infection Compromised host defenses

Narrow spectrum antibiotics are preferable over broad-spectrum antibiotics because they are less likely to alter the normal flora with associated symptoms and impact on development of resistant strainsBactericidal agents are preferred to bacteriostatic

Osteomyelitis: inflammation of the medullary portion of bone Progresses by infection, inflammation, and ischemia until surgical and medical interventions bring the process

under control Most commonly caused by odontogenic infections and trauma Infection begins in medullary space involving the cancellous bone More commonly in mandible

Bisphosphonate medications inhibit osteoclast activities decreased bone resorption

Risk of BRONJ is increased as duration of bisphosphonate therapy exceeds 3 yearsA 3 month drug holiday is recommended for patients taking oral bisphosphonates for longer than 3 years surgeries and dental implant placement should be avoided, and endo treatment should be considered before extractions

Biopsies Block anesthesia is preferred because injection into the lesion directly can distort the architecture Proper specimen care requires that the tissue be placed in 10% formalin in a volume 20x that of the specimen Wound placement requires either a primary closure or placement of periodontal dressings 1. Cytology- used to detect cancerous and precancerous lesions 2. Aspiration- used for relatively low morbidity and high diagnostic accuracy for most lesions3. Incisional- used when a lesion is large (>1cm), polymorphic, suspicious for malignancy, or in an anatomic area

with high morbidity 4. Excisional- used on smaller lesions (<1cm) that appear benign and on small vascular and pigmented lesions

a. Entails removal of entire lesion and a perimeter of surrounding uninvolved tissue

All radiolucent lesions that require biopsy should be aspirated first Mucoperiosteal flaps are always used for intraosseous lesions and should be full thickness

Odontogenic keratocysts tend to act more aggressively and have higher rates of recurrence than fissural cysts and cysts of odontogenic inflammatory origin Cysts of the jaw are treated by enucleation, marsupialization, or a combo of both

Most common malignant tumors are epidermoid carcinomas (squamous cell)

Local anesthetics block sodium channels Complete anesthesia occurs when 3 consecutive nodes of Ranvier are blocked

If an inferior alveolar nerve block fails, do another one via Gow-Gates technique because this would lead to an increase in the length of inferior alveolar nerve bathed in local anesthetic

Sensations disappear in a specific order= pain temperature touch pressure

Increased blood flow= shorter duration of action Increased protein binding= increased lipid solubility Lower pKa of drug= faster onset of action

Esters have a high incidence of allergic response, amides have a low incidence

Methemoglobinemia- unique to Prilocaine A drug in 1mg/mL is more potent that a drug in 2mg/mL

Bupivacaine is the MOST potent local anestheticPrilocaine and articaine are the LEAST potent

Vasoconstrictors increase duration of effect

Positive aspiration is directly correlated to needle gauge

ORAL PATHOLOGY

Cleft lip- defect between medial nasal (frontonasal) process and maxillary processCleft palate- lack of fusion between palatal shelvesLip pits- invaginations at commissures or near midlineFordyce granules- ectopic sebaceous glands commonly in buccal mucosa or lip Lingual thyroid- caused by incomplete descent of thyroid anlageThyroglossal tract cyst- midline neck swelling secondary to cystic change of thyroid tissue remnants Fissured tongue- component of Melkersson-Rosenthal syndrome Hemangioma- focal proliferation of capillaries Dermoid cyst- mass in midline floor of mouth if above mylohyoid muscle; mass in upper neck if below mylohyoid muscle

Herpes causes mucosal ulceration (preceded by vesicles), HPV typically induces a verruciform lesion, and EBV causes a white lesion (hairy leukoplakia)Most bacterial and fungal infections manifest as chronic ulcersCandida albicans can cause either white or red lesions

Herpes zoster= reactivation of latent VZVMeasles- caused by measles virus; fever, malaise, skin rash; punctate buccal mucosa ulcers (Koplik’s spots)Almost all hairy leukoplakia is associated with HIVMalignancies associated with Hairy Leukoplakia= Burkitt’s lymphoma, nasopharyngeal carcinoma

Syphilis- caused by Treponema pallidum Primary lesion- chancre Second lesion- oral mucous patches, condyloma latum, maculopapular rash Tertiary lesion- gumma, CNS involvement, cardiovascular involvement

Tuberculosis- caused by inhalation of Mycobacterium tuberculosis Oral nonhealing chronic ulcers follow lunch infection Caseating granulomas with multinucleated giant cells (Langerhans’ giant cells) Multi-drug therapy= isoniazid, rifampin, ethambutol

Gonorrhea- caused by Neisseria gonorrhoeae

Actinomycosis- caused by Actinomyces israelii found in the oral flora of many patients Chronic jaw infection may follow dental surgery Head and neck infections are called cervicofacial actinomycosis Treated with long-term, high dose penicillin

Scarlet Fever- caused by some strains of group A streptococci Children develop a skin rash caused by erythrogenic toxin Strawberry tongue Treated with penicillin

Deep fungal infection of the lung may lead to oral chronic granulomatous ulcers secondary to oral implantation of microorganisms

Candidiasis- caused by C. albicans Acute lesions are white Chronic lesions are erythematous Topical treatment= nystatin, clotrimazole Systemic treatment= fluconazole, itraconazole, capsofungin

Aphthous ulcers- recurrent painful ulcers, NOT PRECEDED by vesicles Appear on nonkeratinized oral mucosa

Behcet’s Syndrome- multisystem disease to represent immune dysfunction in which vasculitis is a prominent feature Manifestations= oral and genital aphthous-type ulcers, conjunctivitis, uveitis, arthritis, headache Treated with corticosteroids and other immunosuppressive drugs

Erythema Multiforme MINOR= associated with secondary herpes simplex hypersensitivity MAJOR= Stevens-Johnson syndrome

Wegener’s Granulomatosis- destructive granulomatous lesions with necrotizing vasculitis of unknown cause Affects upper respiratory tract, lungs, and kidneys Treatment with cyclophosphamide and corticosteroids or rituximab

Lichen Planus T lymphocytes target and destroy basal keratinocytes Hyperkeratosis Lymphocyte infiltrate at epithelial-CT interface Basal zone vacuolation secondary to basal keratinocyte destruction Epithelium may have a “saw tooth” pattern

Scleroderma- autoimmune, multiorgan disease of adults Fibrosis of tissues eventually leads to organ dysfunction Cutaneous changes include induration and rigidity, atrophy, and tenangiectasias

Pemphigus Vulgaris- antibodies are directed against desmosomal protein Clinical Features= multiple painful ulcers preceded by bullae that form within epithelium

o Positive Nikolsky’s sign may be present o Oral lesions usually precede skin lesions

Treated with systemic corticosteroids

Mucous Membrane Pemphigoid- antibodies directed against basement membrane antigens Manifests as multiple, painful ulcers preceded by bullae that form below epithelium at basement membrane Positive Nikolsky’s sign Managed with corticosteroids

Idiopathic Leukoplakia- white/opaque oral mucosa lesions that DO NOT rub off; unknown cause HIGH RISK for malignant transformation= floor of mouth and tongue

Proliferative Verrucous Leukoplakia- unknown cause; lesions may start with a flat profile and then progress to broad-based, wartlike lesions HIGH RISK of malignant transformation to verrucous carcinoma or squamous cell carcinoma

Erythroplakia- high risk red patch of mucosa, most represent dysplasia or malignancy High risk sites= floor of mouth, tongue, retromolar area

Oral submucous fibrosis- irreversible mucosal change due to hypersensitivity to dietary substances Mucosa comes opaque secondary to submucosal scarring

Melanomas manifest as abnormally pigmented surface lesions that start at the junction of epithelium and submucosa

Verrucous Carcinoma: well-differentiated, slow growing; treated via surgical excision

Squamous Cell Carcinoma: caused by mutation, amplification, or inactivation of oncogenes and tumor suppressor genes May manifest as chronic, nonhealing ulcer, red or white patch, or mass

Most commonly seen in posterior-lateral tongue and floor of mouth Treat with excision or radiation

Basal Cell Carcinoma: low-grade skin cancer usually in sun-damaged skin Usually manifests as nonhealing, indurated chronic ulcer Good prognosis

Oral melanoma: malignancy of melanocytes- High risk sites are palate and gingiva

Nodular Fasciitis: rare submucosal proliferation of fibroblasts Reactive lesion that exhibits rapid growth

Fibromatosis: locally aggressive and infiltrative; difficult to eradicate and often reoccurs

Granular Cell tumor: benign, nonrecurring submucosal neoplasm of Schwann’s cells Tumors have granular or grainy cytoplasm Overlying epithelium may exhibit pseudoepitheliomatous hyperplasia Most commonly on tongue Occurs on gingiva as pedunculated mass

Schwannoma: benign neoplasm of Schwann’s cells; tongue is favored

Neurofibroma: benign neoplasm of Schwann’s cells and perineural fibroblasts; favored on tongue and buccal mucosa

Leiomyoma- benign neoplasm of smooth muscle origin

Rhabdomyoma- benign neoplasm of skeletal muscle origin

Kaposi’s Sarcoma: malignant proliferation of endothelial cells commonly seen as a complication of AIDS

Mucous extravasation phenomenon: recurring submucosal nodule of saliva from the escape from duct of salivary gland Caused by traumatic severance of salivary excretory duct Common in lower lip and buccal mucosa

Mucous retention cyst: submucosal nodule resulting from blockage of salivary duct by a salivary stone (siololith) Common in floor of mouth, palate, buccal mucosa, and upper lip When on floor of mouth= RANULA

Necrotizing Sialometaplasia: chronic ulcer of palate secondary to ischemic necrosis of palatal salivary glands (mimics carcinoma)

Maxillary Sinus Retention Cyst or Pseudocyst: may represent blockage of sinus salivary gland or focal fluid accumulation of sinus mucosa

Infectious Sialadenitis: infections of salivary glands Acute viral infection= MUMPS Chronic infection= CYTOMEGALOVIRUS

Sarcoidosis: chronic granulomatous disease of unknown cause Predominantly a pulmonary disease

Granulomas cause organ nodularity and loss of parenchyma

Sjogren’s Syndrome: chronic lymphocyte-mediated autoimmune disease Primary= keratoconjunctivitis sicca and xerostomia Secondary= dry eyes and mouth plus another autoimmune disease, usually rheumatoid arthritis Patients are at risk for development of lymphoma

Pleomorphic Adenoma: MOST COMMON benign salivary gland tumor Palate is most common site for minor gland lesions

Warthin’s Tumor: an oncocytic tumor containing lymphoid tissue

Mucoepidermoid carcinoma: most common salivary malignancy in both minor and major glands Palate is most common intraoral site Composed of mucous and epithelial cells

Polymorphous low-grade adenocarcinoma: 2nd most common minor salivary gland malignancy Palate is most common site Low grade malignancy

Adenoid cystic carcinoma: high-grade salivary malignancy Palate is most common site Cribriform or “Swiss cheese” microscopic pattern Spreads through perineural spaces

Non-Hodgkin’s Lymphoma: malignancy of one of cells making up lymphoid tissue

Multiple Myeloma: plasma cell myeloma; Bence-Jones proteins Multiple “punched-out” bone lucencies Abnormal immunoglobulin protein peak (M protein) on serum electrophoresis Anemia, bleeding, infection, and fracture associated with extensive marrow involvement

Amyloidosis: due to formation of complex proteins in which immunoglobulin light chains are precursors

Leukemias: neoplasms of bone marrow Malignant cells occupy and replace normal marrow cells Clinical Features= bleeding, fatigue, and infection Infiltration of gingival tissues by leukemic cells is common in CML

Odontogenic cysts are derived from cells associated with tooth formation

Periapical Cyst (Radicular cyst): MOST COMMON odontogenic cyst Always associated with non-vital tooth Necrotic pulp causes periapical inflammation If acute periapical abscess forms If chronic dental granuloma forms

Dentigerous Cyst: manifests as lucency around crown of impacted tooth 3rd molar and canines most often affected Eruption cyst= if occurs over tooth that has erupted into submucosa Epithelial lining from REE has potential to transform into ameloblastoma

Lateral Periodontal Cyst: unilocular or multiocular lucency in lateral periodontal membrane of adults Usually found in mandibular premolar region

Tooth is vital

Bohn’s Nodules: gingival cysts of newborns resulting from cystification of rests of dental lamina

Odontogenic Keratocyst: lesions may be aggressive, recurrent, or associated with nevoid basal cell carcinoma Mutation of patched tumor suppressor gene is evident Lining epithelium is thin and parakeratinized

Calcifying Odontogenic Cyst: rare odontogenic cyst Potential to reoccur “Ghost cell” keratinization characterizes this cyst Cutaneous counterpart= Malherbe calcifying epithelioma or pilomatricoma

Odontogenic tumors are bone tumors unique to the jaw, derived from epithelial or mesenchymal cells involved in the formation of teeth; lesions are almost always benign

Ameloblastoma: benign, aggressive odontogenic tumor Peripheral or gingival ameloblastoma exhibits banal behavior

Calcifying epithelial odontogenic tumor (Pindborg tumor): rare odontogenic tumor with unusual microscopy- sheets of large epithelioid cells with areas of amyloid

Adenomatoid Odontogenic Tumor: odontogenic hamartoma containing epithelial duct-like spaces and calcified enameloid material

2/3 in maxilla, 2/3 in females, 2/3 in anterior jaws, and 2/3 over crowns of impacted teeth

Odontogenic Myxoma (Fibromyxoma): tumor of myxomatous CT Radiolucency with small loculations (honey-comb pattern)

Central Odontogenic Fibroma: tumor of dense collagen with strands of epithelium; well-defined radiolucency

Cementifying Fibroma: well-circumscribed lucency, usually in mandible

Cementoblastoma: well-circumscribed radiopaque mass of cementum and cementoblasts replacing root of a tooth

Periapical Cemento-Osseous Dysplasia: unknown cause; commonly seen at apices of one or more mandibular anterior teeth

Teeth are vital Most frequently in middle-aged BLACK women Florid osseous dysplasia= form involving the entire jaw

Ameloblastic Fibroma and Ameloblastic Fibro-odontoma: typically in mandibular molar region Appear as a radiolucency or a radiolucency with an opacity Microscopally an encapsulated myxomatous CT lesion containing strands of epithelium

Odontoma: opaque lesions composed of dental hard tissues Compound= miniature teeth Complex= conglomerate mass

Fibro-osseous lesions are benign tumors composed of fibrous tissue in which new bony islands develop

Ossifying Fibroma: appears as a well-circumscribed lucency or a lucency with opaque foci Usually in the body of the mandible

Juvenile ossifying fibroma occurs in younger patients Microscopically composed of fibroblastic stroma where new bony islands or trabeculae are formed

Fibrous Dysplasia: unencapsulated fibro-osseous lesion associated with mutations of the GNAS1 gene, affecting proliferation and function of osteoblasts and fibroblasts

More common in maxilla Affects children and typically stops after puberty Involves entire half of jaw McCune-Albright syndrome consists of polyostotic fibrous dysplasia

Osteoblastoma: circumscribed opaque mass of bone and osteoblasts

Peripheral Giant Cell Granuloma: reactive red-to-purple gingival mass Found in gingiva, usually anterior to permanent molars Composted of fibroblasts and multinucleated giant cells

Central Giant Cell Granuloma: radiolucency favored in the anterior mandible composed of fibroblasts and multinucleated giant cells

Aneurysmal Bone Cyst: pseudocyst composed of blood-filled spaces lined by fibroblasts and multinucleated giant cells Multilocular lucency

Hyperparathyroidism: (von Recklinghausen’s disease of bone) multiple bone lesions resulting from excessive levels of parathyroid hormone

Multiple radiolucent foci of fibroblasts and multi-nucleated giant cells, along with loss of lamina dura around tooth roots

Cherubism: autosomal dominant condition of jaws in children Symmetric swelling of one or both jaws Stabilizes after puberty NO TREATMENT NEEDED “soap bubble” appearance radiolucencies

Langerhans’ Cell Disease: discrete “punched-out” lesions or lucencies around tooth roots (“floating teeth”)

Paget’s Disease: progressive metabolic disturbance of many bones Adults older than 50yo affected Jaw involvement symmetrical enlargement, dentures too tight, hypercementosis Osteoblasts and multinucleated osteoclasts are found in abundance

Acute Osteomyelitis: acute inflammation of bone and bone marrow of jaws Caused by extension of periapical or periodontal disease, fracture, surgery and bacteremia Most common infectious agents= Staphylococci and Streptococci

Chronic Osteomyelitis: chronic inflammation of bone and bone marrow of jaws Lucent or mottled radiographic pattern

Chronic Osteomyelitis with Proliferative Periosteitis (Garre’s Osteomyelitis): osteomyelitis involving periosteum Lucent or mottled radiographic pattern plus concentric periosteal layering

Focal Sclerosing Osteomyelitis (Condensing Osteitis): bone sclerosis from low-grade inflammation

Diffuse Sclerosing Osteomyelitis: bone sclerosis resulting from low-grade inflammation

Jaw fracture and osteomyelitis are late complications secondary to densely sclerotic bone

Bisphosphonate-related Osteonecrosis of Jaws: characterized by exposed bone in maxillofacial region for longer than 8 weeks in a patient that received bisphosphonate medication treatment= chlorhexidine rinses, antibiotic therapy, and conservative surgery

Osteosarcoma: sarcoma in which new bone is formed PDL invasion results in uniform widening Mandible more commonly affected than maxilla

Chondrosarcoma: rare sarcoma of jaws in which cartilage is produced by tumor cells

Ewing’s Sarcoma: rare “round cell” malignant radiolucency of children

White Sponge Nevus: autosomal dominant condition secondary to mutations of keratin 4 or 13 results in asymptomatic white, spongy-appearing buccal mucosa bilaterally

Epidermolysis bullosa: appearance of bullae from minor trauma

Hereditary Hemorrhagic Telangiectasia: autosomal dominant condition in which telangiectatic vessels are seen in mucosa, skin, and viscera

Red macules or papules are a source of bleeding Epistaxis is a frequent presenting sign

Cleidocranial Dysplasia: delayed tooth eruption and supernumerary teeth, hypoplastic or aplastic clavicles, cranial bossing and hypertelorism

Hereditary Ectodermal Dysplasia: X-linked recessive condition resulting in partial/complete anodontia

Gardner’s Syndrome: autosomal dominant disorder Consists of intestinal polyposis, osteomas, skin lesions, impacted permanent and supernumerary teeth, and

odontomas

Osteopetrosis (Albers-Schonberg disease, marble bone): lack of bone remodeling and resorption leads to bone sclerosis

Amelogenesis Imperfecta: all teeth of both dentitions are affected Enamel is usually yellow, reduced volume, and pitted Dentin and pulps are normal Cosmetic problem treated with full coverage crowns

Dentinogenesis Imperfecta: autosomal dominant condition with intrinsic alteration of dentin All teeth of both dentitions are affected Teeth have yellow or opalescent color Extreme occlusal wear secondary to enamel fracture Short roots, bell-shaped crowns, and obliterated pulps May be seen with osteogenesis imperfecta Treated with full coverage crowns

Dentin Dysplasia: autosomal dominant condition with intrinsic alteration of dentin

Teeth normal in color Pulps are obliterated Roots are short and surrounded by dental granulomas or cysts contributing to tooth loss

Regional Odontodysplasia: cause is unknown A quadrant of teeth exhibit short roots, open apices, and enlarged pulp chambers Radiographic appearance ghost teeth Teeth usually extracted due to poor quality of enamel and dentin

RADIOLOGY

Wavelength is inversely proportional to photon energy short wavelength= higher energy

Cathode: tungsten filament is source of electrons with an x-ray tube

Anode: tungsten target converts kinetic energy of electrons generated from filament into x-ray photons as size of focal spot decreases, sharpness of radiographic image increases

Copper stem dissipates heat and reduces risk of target melting

Quantity of radiation produced by an x-ray tube is directly proportional to tube current (mA) and exposure timeBeam quality refers to the mean energy of an x-ray beam increases with increasing kVp# of photons increases with increasing kVp

Kilovoltage: affects both quality and quantity of x-ray photons kVp increase= total # of photons increases, and mean energy and max energy of x-ray beam increases

Increase in mA increase in total # of photons

Filtration is performed by placing an aluminum filter in the beam’s path; reduces patient dose

Collimation: reduces size of x-ray beam and volume of irradiated patient tissue rectangular collimators limit size of beam to just larger than image receptor rectangular collimation reduces patient exposure by more than 50% compared to round collimation

Coherent scattering- occurs when a low energy photon passes near an outer electron, the photon ceases to exist, and excited electron returns to ground state

Photoelectric absorption- occurs when a photon collides with a bound electron

Compton scattering- occurs when a photon interacts with an outer orbital electron, which recoils from impact

Absorbed dose- unit is GrayEffective dose- used to estimate risk in humans; unit is SievertRadioactivity- decay rate of radioactive material

Osteoradionecrosis is more common in the mandible than maxilla due to richer vascular supply to the maxilla

Radon is the major contributor to background radiation exposure

Occupational exposure limit of radiation is 50mSv of whole-body radiation exposure in 1 year Primary risk from dental radiography is radiation-induced cancer

organs at risk= thyroid gland, red bone marrow, and salivary glands

Use E/F-speed films or digital imaging for periapical and BW exams Use a 16in source-patient distance to reduce patient exposure and improve image clarity

Emulsion: silver halide grains are sensitive to x-radiation and visible light; they are flat, tabular crystals in modern emulsions and attached to base with a collagenous vehicle the smaller crystals greater image resolution

Radiographic Density: overall degree of darkening of exposed film increasing mA, kVp, or exposure time increases # of photons and increases density of radiograph reducing distance between focal spot and film also increases film density

Radiographic Contrast: range and # of densities on a radiograph

Radiographic Speed: amount of radiation required to produce an image of a standard density

Foreshortening: results from excessive vertical angulation when x-ray beam is perpendicular to receptor, but not toothElongation: results when x-ray beam is oriented at right angles to object but not to receptor

Processing Solutions1. Developer solution: converts exposed silver halide crystals into metallic silver grains that are seen as dark on a

radiograph2. Rinsing:

a. Phenidone is 1st electron donor that reduces silver ions to metallic silver at latent image site b. Hydroquinone provides an electron to reduce oxidized phenidone back to its original active state

3. Fixing Solution: dilutes developer, slowing development process; removes alkali activator4. Washing: removes all thiosulfate ions and silver thiosulfate complexes that could stain film

Developmentally, the lamina dura is an extension of the lining of the bony crypt that surrounds each tooth during development

PDL= radiolucent space between tooth root and lamina dura

A lesion in proximal surfaces is most commonly found apical to the contact point

Radiographs typically show LESS severe bone destruction than is actually present

Most common route for furcation involvement of the maxillary 1st permanent molar is from the MESIAL side

ORTHODONTICS AND PEDIATRIC DENTISTRY

Nearly 15% of adolescents and adults have severely crowded incisors extraction of teeth necessary to create enough space to align them

Class 2 relationships are more common in whites Class 3 relationships are more common in Asians Class 1 normal occlusion= 30%Class 1 malocclusion= 50-55%Class 2 malocclusion= 15%

Class 3 malocclusion= 1%

Endochondral bone formation: bones of the cranial baseIntramembranous bone formation: cranial vault, maxilla, and mandible

Cranial vault- intramembranous bones that’s form without cartilaginous precursors Cranial base- ethmoid, sphenoid, and occipital bones

The maxilla migrates downward and forward away from the cranial base Surface remodeling includes resorption of bone anteriorly and apposition of bone inferiorly Increased space for eruption of posterior teeth occurs by addition of bone posteriorly at the tuberosity as the maxilla migrates downward and forward

Growth of the mandible is both endochondral and intramembranous cartilage is transformed into bone at the condyle as the mandible grows downward and forward Most growth occurs by new bone forming at the condyle and resorption of the anterior part of ramus with apposition posteriorly Space for eruption of posterior teeth occurs as the anterior portion of the ramus resorbs

Posterior face height usually increases more than anterior face height

Most tissues of the face and neck originate from ectoderm

Maxillary anterior primary teeth are about 75% the size of their permanent successors Overbite occurs as teeth eruptOverjet ranges from 0 to 4mm

If a child lacks spacing or has crowding in primary dentition permanent dentition will have crowding

Mandibular incisors erupt lingually to primary incisors

Leeway space is larger in the mandibular arch Maxillary and mandibular arches have curvature in the sagittal and frontal planes

Maxillary intercanine width increases by about 6mm between ages 3 and 13

Primary teeth begin calcification between month 3 and 4 in utero1st permanent molar shows signs of calcification during the 2nd postnatal month3rd permanent molars begin to calcify around 8 to 9 years old

Class 2 Division 1 Occlusion: maxillary incisors flared Class 2 Division 2 Occlusion: maxillary incisors upright, lateral flared, and deep overbite

SNA: anterior-posterior position of maxillaSNB: anterior-posterior position of mandible ANB: anterior-posterior difference between maxilla and mandible

- More positive= skeletal class 2- More negative= skeletal class 3

For occlusal problems, interarch relationships take priority over intra-arch relationships

For tooth movement, force doesn’t need to be continuous, force needs to be applied for a minimally acceptable period of time to elicit the biologic response necessary

Deleterious Effects of Orthodontic Forces1. Mobility of teeth subjected to orthodontic forces

a. Moderate mobility of teeth occurs during tooth movement and resolves with completion of therapy 2. Pain

a. Heavy ortho forces applied to tooth can cause pain when PDL is initially compressed b. Give patients acetaminophen for pain

3. Tissue inflammation- usually from poor oral hygiene 4. Effect on Pulp

a. Symptoms ranging from mild pulpitis to loss of vitality are rare 5. Root resorption during orthodontic tooth movement

a. Heavy continuous forces have more potential to create root resorption than light forces b. Risk factors:

i. Genetic factors heavier forces ii. Single-rooted teeth have a higher incidence

iii. Teeth subjected to trauma, bruxism, and heavy masticatory forces iv. Movement of roots into cortical plate of bone

Rapid Acceleratory Phenomenon: accelerating tooth movement by performing a surgical procedure involving tissue reflection and selective cortectomy cuts and perforations around teeth to be moved

In a healthy tooth, the center of resistance is about one half the distance from the alveolar crest to root apex

Tipping is the easiest and fastest tooth movement to accomplish, but LEAST desirable

Anchorage: resistance to movement roughly equivalent to its root surface area Stress: internal response of a wire to the application of external forces defined as force (load) per cross-sectional area Strain: deformation or deflection of archwire as a consequence of stress and defined as dimensional change divided by original dimension

Ideal Orthodontic Wire Characteristics= high strength, low stiffness, high working range, and high formability

For large orthodontic movements, wires with a low load/deflection rate are desirable able to provide constant low forces as tooth moves and appliance is deactivated

Stainless steel has highest modulus of elasticity Nickel-titanium: very low modulus of elasticity and a wide working range Beta titanium: intermediate modulus of elasticity, excellent resilience, high coefficient of friction, high formability

Stainless Steel: good mechanical properties, excellent corrosion resistance, low cost, high elastic modulus, low springback

Mandible has more potential for growth than maxilla during adolescence

Headgear: used to modify growth of maxilla, to distalize or protract maxillary teeth, or to reinforce anchorage puts a restraining force on maxillary growth and allows mandible to grow normally to catch up

High-pull headgear: used in treatment of preadolescent patients with class 3 malocclusions and increased vertical dimension, minimal overbite, and increased gingival exposure on smile

o Headgear tubes inserted to maxillary 1st permanent molar attachmentso Objectives= restriction of anterior and downward mandibular growth and molar distal movement,

intrusion, and control of maxillary molar eruption Cervical-pull headgear: correct class 2 malocclusions with deep bite

o Objectives= to restrict anterior growth of maxilla and to distalize and erupt maxillary molars Protraction headgear: used in patients with class 3 malocclusions where there is a maxillary deficiency

Functional Appliances Herbst appliance: appliance cemented/bonded to maxillary and mandibular dental arches tendency to

procline mandibular incisors due to forces that are indirectly delivered to these teeth Activator: activates mandibular growth to correct class 2 malocclusion Bionator: consists of lingual, horseshoe-shaped acrylic with a wire in the palatal area to guide maxillary and

mandibular posterior teeth and hold the mandible in Forsus Fatigue Resistant Device: efficient in treating class 2 malocclusions with minimal compliance and

breakage problemso Delivers forward, downward force to anterior mandibular arch and backward, upward force to posterior

maxillary arch

Appliances to correct posterior crossbites- maxillary or palatal expansion appliances are used to correct transverse discrepancies by skeletal expansion of the maxilla or by dental expansion

Hyrax appliance: most commonly used type of rapid palatal expansion/rapid maxillary expansion appliance Bands are cemented on maxillary 1st premolars and molars that are connected to expansion screw by rigid wires

Haas appliance: for skeletal expansionHawley-type removable appliance with a jackscrew: for skeletal or dental expansion, may be used to correct mild posterior crossbites in children and young adolescents

Quad-helix and W-arch: used for dental expansion, may be used for symmetrical or asymmetrical expansion of maxillary dental arch and for correcting rotated molars suggested for use in cases where only a small amount of expansion is needed Transpalatal arch: for dental movement, used for expansion or constriction of intermolar width, for producing root movement of 1st molars, for de-rotation of these teeth, and for anchorage reinforcement

Appliances used in Mixed Dentition1. Nance appliance- space maintainer or for anchorage purposes 2. Lower lingual arch- used for anchorage reinforcement, as a holding arch for space maintenance, for expansion,

and for increasing dental arch length 3. Lip bumper- used to control or increase mandibular dental arch length, to upright mesially or lingually tipped

mandibular molars, and to prevent interposition of lower lip between maxillary and mandibular incisors a. Allows lateral and anterior dentoalveolar development b. Causes distal movement and tipping of mandibular 1st molars

Appliances to control vertical incisor position1. Intrusion Arch- used for deep bite correction in which extrusion at molars and intrusion at incisors takes place 2. Extrusion Arch- used for open bite correction in which intrusion at molars and extrusion at incisors takes place

Crossbite elastics: worn from palatal of one or more maxillary teeth to buccal of one or more teeth in mandible to help correct crossbites

Serial extraction sequence= primary incisors primary canines primary 1st molars permanent 1st premolars

Large diastema indicates- supernumerary tooth or mesiodens or missing lateral incisors

An ankylosed primary tooth should be removed if the successor is missing to decrease chances of a vertical alveolar defect

Unilateral crossbites are usually due to a mandibular shift

Achieving overbite correction is necessary before molar correction and space closure because a deep overbite would prevent retraction of incisors to a normal overjet

Detailing and Finishing Intraarch: final tooth positioning by rebracketing misbracketed teeth or by small bends in wire to eliminate small

discrepancies in all 3 dimensions= rotations, vertical relationships, and torque Interarch: settling of occlusion into a solid relationship can be accomplished using light wires or vertical elastics

or having patient where a positioner

Cutting supracrestal fibers has been shown to reduce tendency for teeth to move after treatment

Steel ligatures retain less plaque than elastomeric ligatures

Proper Sequence for Interdisciplinary treatment= disease control (caries, periodontal disease); orthodontic tooth movement; definitive treatment (periodontal bone recontouring, final restorations- crowns, bridges, implant restorations)

Bilateral sagittal split osteotomy of the ramus is the most preferred procedure for advancement of the mandible to correct a class 2

Class 3 corrections are usually done by advancing the maxilla

Development of ToothA. Initiation (BUD stage)

a. All primary teeth and permanent molars arise from dental lamina b. Permanent incisors, canines, and premolars arise from primary predecessor c. Failure of initiation= congenitally missing teethd. Excessive budding= supernumerary teeth

B. Proliferation (CAP stage)a. Peripheral cells of cap form inner and outer enamel epitheliumb. Failure in proliferation= congenitally missing teeth c. Excessive proliferation results in a cyst, odontoma, or supernumerary tooth

C. Histodifferentiation and morphodifferentiation (BELL stage)a. Cells of dental papilla differentiate into odontoblastsb. Cells of inner enamel epithelium differentiate into ameloblasts

c. Failure in histodifferentiation= structural abnormalities of enamel and dentini. Amelogenesis imperfecta, dentinogenesis imperfecta

d. Failure in morphodifferentiation= size and shape abnormalitiesi. Peg lateral incisors and macrodontia

D. Appositiona. Ameloblasts and odontoblasts develop layerlike matrixb. Disturbances in apposition= incomplete tissue formation

E. Calcification a. Begins at cusp tips and incisal edges and proceeds cervically

Teeth erupt through bone with 2/3 of root formation Teeth typically erupt through gingiva with ¾ root formation

Most common congenitally missing tooth is mandibular 2nd premolar, followed by lateral incisor, followed by maxillary 2nd premolar

Microdontia is seen in ectodermal dysplasia, chondroectodermal dysplasia, hemifacial microsomia, and Down SyndromeMacrodontia is seen in facial hemihypertrophy and otodental syndrome

Fusion: union of 2 teeth- have 2 pulp chambers and 2 pulp canalsGemination: division of a single tooth bud, resulting in a bifid crown; has a single pulp chamber Dens evaginatus: extra cuspDens invaginatus: (dens in dente) caused by invagination of inner enamel epitheliumTaurodontism: characterized by vertically long pulp chambers and short roots Dilaceration: dilacerated, bent or twisted tooth, usually occurs as result of an intrusive or displacement injury to primary incisor

Enamel hypoplasia: quantity deficiencies of enamelEnamel hypocalcification: quality deficiencies of enamelAmelogenesis Imperfecta: dependent on developmental stage of enamelDentinogenesis Imperfecta: occurs during histodifferentiation stage treat with full coverage crowns

Averse conditioning should always be followed by positive reinforcement or praise for improved behaviors

Common medications for ADHD patient= Methylphenidate, Atomoxetine, Amphetamine/dextroamphetamine

Minimum alveolar concentration of nitrous oxide= 105%

Plateaus of Stage 1 Anesthesia:1. Paresthesia- tingling of hands, feet2. Vasomotor- warm sensations3. Drift- euphoria, pupils centrally fixed, sensation of floating4. Dream- eyes closed, but open in response to questions, difficulty speaking, jaw sags open

Total flow rate of nitrous is 4 to 6 L/min for most children

Pulp Treatment for Primary Teeth1. Indirect Pulp Cap

a. Indications= symptom free, no radiographic evidence of pathosis, minimal caries- but if caries were removed would result in pulp exposure

b. Procedure= caries removal, CaOH layer or base cement, restore tooth, wait 6 to 8 weeks, reenter and remove remainder of caries

2. Direct pulp Capa. Indications= very small, pinpoint exposure, symptom freeb. Procedure= CaOH layer and then restore tooth

3. Pulpotomy- coronal removal of vital pulp tissuea. Indications= vital primary tooth with carious/accidental exposure; clinically normal pulp; tooth must be

restorableb. Procedure= remove superficial and lateral decay, remove roof of chamber, extirpate coronal pulp,

Formocresol application for 5 minutes, ZOE buildup, stainless steel crown coverage 4. Pulpectomy- complete removal of all remaining pulp tissue

a. Indications= necrotic or chronically inflamed tooth with accessible canals b. Procedure= remove coronal pulp as for pulpotomy, irrigate chamber with NaOCl or sterile saline,

remove radicular pulp tissue with small file or barbed broach, enlarge canal, fill with ZOE via either a pressure syringe or condensation method

Formocresol- most commonly used medicament for pulpotomies on primary teeth Ferric sulfate- less toxic than formocresolMineral trioxide aggregate (MTA)- pulpotomies usually have higher success rates than those done with formocresol

If a tooth has internal or external resorption, it should be extracted

Space Management in Primary Dentition1. Primary Dentition

A. 1st primary molars= band-loop space maintainer unilateral and bilateral loss B. 2nd primary molars= distal shoe or acrylic partialC. Incisors= use fixed or removable appliance

2. Mixed DentitionA. Primary mandibular canines= lower lingual holding arch B. 1st primary molars= BLS unilateral or palatal holding arch bilateralC. 2nd primary molars= palatal holding arch unilateral and bilateral

Unilateral loss of a 2nd primary molar in the mixed dentition usually requires a bilateral holding arch

Bilateral tooth loss appliances= Lingual holding arch, Palatal holding arch, Nance holding arch, removable appliance

Puberty Gingivitis- characterized by enlarged, bulbous interproximal gingival tissue on labial aspects on anterior teeth

Herpes Simplex Infection: caused by herpes simplex virus 1 and usually affects children younger than 6 years old

Acute Herpetic Gingivostomatitis: characterized by liquid filled yellow/white vesicles intra-orally and periorally that rupture, typically found on mucous membrane, tonsils, hard and soft palates, buccal mucosa, tongue, palate, and gingiva

Recurrent herpes simplex: recurrence is associated with emotional stress or local physical trauma

Recurrent aphthous ulcer: unknown etiology; painful oval ulceration on attached mucous membrane

Acute Necrotizing Ulcerative Gingivitis: characterized by painful, bleeding gingival tissues, blunting of interproximal papillae, pseudomembrane on marginal gingiva, fetid breath, and high fever caused by fusiform bacilli (spirochetes)

Internal Resorption- caused by osteoclastic action; “pink spot” perforation may occur

Peripheral Root Resorption- caused by damage of periodontal structures - Surface- normal PDL, small areas- Replacement- ankylosis- Inflammatory- granulation tissue, radiolucency

Concussion- injury to tooth without displacement or mobility; PDL is inflamed and tender to percussion Subluxation- injury to tooth without displacement, but there is mobility

If a primary incisor is extruded more than 3mm, the tooth should be extracted

PATIENT MANAGEMENT

Dental Public Heath: the science and art of preventing and controlling dental diseases and promoting dental health through organized community efforts

Epidemiology: study of distribution and determinants of disease

DMFT/DMFS: method of defining dental caries in a population to measure either # of teeth or # of tooth surfaces that are decayed, missing, or filled as a result of caries

Gingival Index: uses 6 indicator teeth or all erupted teeth, and grades 4 sites on each tooth Scoring from 0 to 3

o 0= normal

o 3= ulcerated tissue with a tendency towards spontaneous bleeding

Simplified Oral Hygiene Index (OHI-S): method of quantifying the amount of plaque and calculus in its two components, debris index and calculus index

More than 28% of pre-school age children have experienced tooth decayMore than 90% of US adults older than 20 years of age have at least 1 decayed or filled tooth Whites have higher coronal caries than non-whites Root surface caries is 3x higher among adults 60 years and older compared with adults younger than 40 Chronic periodontitis is the most common form of periodontitis Incidence of oral and pharyngeal cancers increases with age and alcohol or tobacco use and is uncommon before age 40

Cancers of lip and oral cavity account for about 2/3 of all new oral and pharyngeal cancers, with tongue being most common site of incident cancers of oral cavity

Primary prevention- prevents disease before it occurs health education, disease prevention, and health protection Secondary prevention- eliminates or reduces diseases after they occur amalgam and composite restorationsTertiary prevention- limits a disability from a disease or rehabilitates an individual in later stages to restore tissues after failure of secondary prevention dentures, crowns, and bridges

Community water fluoridation- “one of the ten great public health achievements of the 20th century”; the adjustment of the concentration of fluoride of a community water supply for optimal oral health

Recommended level of fluoride ranges from 0.7 to 1.2ppm

School water fluoridation- recommended concentration is 4.5 times the concentration of fluoride recommended for community water supplies

Salt Fluoridation- controlled addition of fluoride during the manufacturing of salt for use by humans

Fluoride supplements- available only by prescription and intended for use by children at risk for dental caries who live in nonfluoridated areas

Fluoride is least effective on the occlusal or chewing tooth surfaces Flossing does not prevent tooth decay but may be helpful for gingival health

Descriptive epidemiology- used to quantify disease status in the communityA. Prevalence- indicates what proportion of a given population is affected by a condition at a given point of time

=# of people with disease/total # people at risk B. Incidence- indicates # of new cases that are expected to occur within a population over a period of time

= # new cases of disease/ total # of people at risk Analytical epidemiology- used to determine etiology of a disease

A. Cross-sectional study- health conditions of group of people are assessed at 1 time B. Case-control study- people with a condition are compared with people without it but who are similar in other

characteristics C. Cohort study- a general population is followed through time to see who develops the disease, and various

exposure factors that affected the group evaluated

Components of a Scientific Article1. Title- indicates topic and focus of study reflects/indicates central question being asked 2. Abstract- to allow the reader to quickly determine whether the study is of interest; summarizes the background

and focus of the study, population sampled or objects studied, and experimental design3. Introduction, literature review, and hypothesis- researcher attempts to educate the reader regarding the

importance and history of the problem

4. Methods- organizes research article and allows the reader to assess validity of study and reliability of measures a. Sampling strategyb. Measurement strategies and measurement instruments c. Experimental design d. Statistical analytical procedures

5. Results- describes specific findings and actual outcomes of project 6. Discussion- interprets and explains results obtained; makes “sense” of findings 7. Summary and Conclusions- summary and interpretation of study findings and attempts to draw conclusions

related to the original theory and study question8. References and Bibliography

Chi-square test: measures association between two categorical variables- used for comparison of groups when data is expressed as counts or proportions T-test: to analyze statistical difference between 2 means- provides researcher with statistical difference between treatment and control groups or groups receiving treatment A vs treatment B

Validity- extent to which it actually tests what it claims to test- how closely results correspond to the real state of affairs determined by its ability to show which individuals have the disease in question and which do not Reliability- is equal to the repeatability and reproducibility of a testSensitivity- the % of persons with disease who are correctly classified as having the diseaseSpecificity- the % of persons without disease who are correctly classified as not having the disease

HBV Etiology- produced by a highly infective virus= Dane Particle Risk of transmission= 30% after percutaneous injury from infected patient Diagnosis- based on physical exam, medical history, and blood tests Prevention- vaccine

HCV Etiology- caused by HCV Risk of transmission- 1.8% after needle-stick or sharps exposure Diagnosis- based on thorough medical history and physical exam Prevention- no vaccines, prevention is vital

HIV Etiology- caused by an RNA virus Risk of transmission= 0.3% from percutaneous exposures and 0.09% for mucous membrane exposures Diagnosis- when HIV antibodies are detected in blood ELISA test and Western Blot assay Prevention- no vaccine available

Mycobacterium Tuberculosis Etiology- caused by M. tuberculosis thrives in areas of body that are rich in blood and oxygen Risk of transmission- inhalation of infected droplet nuclei Diagnosis- based on medical history and physical exam

A new mask should be worn for each patient and masks should be changed routinely at least once every hour and more often in presence of heavy aerosol contamination

OSHA: responsible for establishing standards for safe and healthy working conditions for all employees and regulating maintenance of these standards

- Concerned with regulated waste within office

HBV vaccine must be offered to all exposed dental workers

Bacillus spores are the benchmark organisms for sterilization Sterilization- absence of all life forms

Only glass or metal objects can be sterilized by dry heat Alcohol is the most commonly used antiseptic

U.S. Environmental Protection Agency (EPA) regulates the transportation of waste from the dental office

Material Safety Data Sheets (MSDS)- comes from the material manufacturer

3 rd -party reimbursement: a system in which a provider of coverage contracts to pay for some of the patient’s dental treatment

1. Usual, customary, and reasonable (UCR)- reimbursement is based on dentist’s usual charge, unless it exceeds certain parameters

2. Table of allowances- the 3rd party payer usually determines what fees it is willing to pay for each procedure a. Balance billing- involves charging the patient any difference between what the plan agrees to pay and

the dentist’s UCR fees3. Fee schedules- a list of fees established or agreed to by a dentist for delivery of specific dental services 4. Reduced fee for service- participating dentists agree to provide care for fees usually lower than other dentists in

a particular geographic areaa. Patient is responsible for difference between dentist’s charge and amount paid by plan

5. Capitation- dentist is paid a fixed amount directly by the capitation plan a. Dentist agrees to provide specified dental services for patients who present and who are assigned to

dentist by capitation plan

Dental Managed Care: comprehensive approach to provision of quality oral health care that combines clinical preventive, restorative, and emergency dental services and administrative procedures to provide timely access to primary dental care and other medically necessary dental services in a cost-effective manner

1. Dental health maintenance organization (D-HMO)- dentists are paid on a per capita basis at a fixed rate for each individual or family; dentist is paid regardless of # or types of services provided or # of beneficiaries seen

a. If value of services exceeds payments dentist is at a loss 2. Dental preferred provider organization (D-PPO)- arrangement between a plan and a panel of providers where

providers agree to accept certain payments in anticipation of a higher volume of patients 3. Dental individual practice association (D-IPA)- delivery system that combines the risk sharing of an HMO with

fee-for-service reimbursement

Quality assessment- measures the quality of care provided in a particular setting limited to assessment of whether or not standards of quality have been met

Quality assurance- measures quality of care and implementation of any necessary changes either to maintain or to improve quality of care rendered includes additional dimension of action to take necessary corrective steps to improve the situation in the future

Behavior Change ProcessA. Precontemplation- individual is not considering a behavior changeB. Contemplation- individual begins to consider a behavior changeC. Preparation- preparing to take steps to change D. Action- individual is engaged in taking action toward behavior change E. Maintenance- individual attempts to maintain a changed behavior

The Premack principle- making a behavior that has a higher probability of being performed contingent on the performance of a less frequent behavior may increase performance of a less frequent behavior

Anxiety- a subjective experience involving cognition, emotion, behavior, and physiologic arousal

Ethical Principles1. Autonomy- (“self-governance”) dentist has a duty to respect the patient’s rights to self-determination and

confidentiality2. Nonmaleficence- (“do no harm”) dentist has a duty to refrain from harming patient3. Beneficence- (“do good”) dentist has a duty to promote patient’s welfare4. Justice- (“fairness”) dentist has duty to treat people fairly5. Veracity- (“truthfulness”) dentist has a duty to communicate truthfully

The original records are your custodial property and, by law, must be retained by you

PERIODONTICS

Microbial plaque is generally the initiating factor in periodontal disease

Erosion- usually in cervical area of facial surface of toothAbrasion- loss of tooth substance by mechanical wear; usually caused by horizontal toothbrushingAttrition- occlusal wear from functional contacts with opposing teethAbfraction- occlusal loading resulting in tooth flexure, mechanical microfractures, and tooth loss in cervical area Hypersensitivity- result of exposure of dentinal tubules in root surfaces to thermal changes following recession and removal of cementum by toothbrushing, acids, root decay, SRP

Probing pocket depth- distance from gingival margin to base of pocket Clinical attachment loss- distance from cementoenamel junction (CEJ) to base of pocket Gingival recession- exposure of root surface because of apical shift in position of gingival margin measured from CEJ to crest of gingival margin and associated with attachment loss Suppuration- measure of inflammatory response to periodontal infection due to presence of large # of neutrophils in periodontal pocket

Mobility Grade 1= slightly more than normal Grade 2= moderately more than normal Grade 3= severe mobility F-L or M-D (or both), combined with vertical displacement (tooth can be depressed)

Furcation Involvement Grade 1= incipient Grade 2= cul-de-sac with definite horizontal component Grade 3= complete bone loss in furcation Grade 4= complete bone loss in furcation and recession of gingival tissues furcation is clinically visible

o Factors predisposing tooth to furcation involvement short root trunk length, short roots, and narrow interradicular dimension

Average distance from CEJ to crest of alveolar bone in health is about 2mm

Gingivitis- gingival inflammation with NO loss of clinical attachment and alveolar bonePeriodontitis- periodontal inflammation that has extended into PDL and alveolar bone, resulting in loss of clinical attachment and alveolar bone

Necrotizing periodontal disease- gingiva may be covered by a yellowish white or grayish slough or pseudomembrane and have blunting of papillae, bleeding on provocation or spontaneous bleeding, pain, and fetid breath

Necrotizing Ulcerative Gingivitis or Periodontitis- accompanied by necrotic ulceration of marginal gingival tissues, bleeding, pain, and fetid breath Plaque-induced gingivitis- result of an interaction between plaque bacteria and tissues and inflammatory cells of host

Dental Plaque Composition Supragingival gram positive cocci and short rods Mature outer surface of plaque gram negative rods and filaments and spirochetes Subgingival gram positive rods and cocci Subgingival in sulcus or pocket gram negative rods Major organic constituents of plaque biofilm= polysaccharides, proteins, glycoproteins, and lipids Major inorganic constituents= calcium and phosphorous

Dental Plaque Formation1. Formation of pellicle occurs within seconds after tooth surface is cleaned 2. Initial adhesion and attachment of bacteria3. Colonization and plaque maturation

Phases of Specific BacteriaA. Early or Primary colonizers= Streptococcus and ActinomycesB. Late (secondary) colonizers= Prevotella intermedia, Prevotella loescheii, Capnocytophaga species,

Campylobacter species, Porphyromonas gingivalis, Treponema species, and Aggregatibacter actinomycetemcomitans

As biofilm matures, there is a shift from predominance of facultative, gram positive microorganisms to gram-negative, anaerobic microorganisms

RED COMPLEX= P. gingivalis, Tannerella forsythia, and Treponema denticola ORANGE COMPLEX= Fusobacterium species, Prevotella species, and Campylobacter species[orange complex occurs before red complex]

Nonspecific plaque hypothesis: states that periodontal disease results from the elaboration of noxious products by plaque biomass, indicating that the quantity of plaque is of most importance in the initiation of disease

Specific plaque hypothesis: states that the pathogenic potential of plaque depends on the presence of, or increasing numbers of, specific microorganisms

Ecologic plaque hypothesis: states that putative periodontal pathogens are present in both healthy and diseased sites Periodontal health- mainly gram positive facultative cocci and rods Streptococcus and Actinomyces Gingivitis- gram positive rods and cocci and gram-negative cocci Chronic periodontitis- gram negative anaerobic species P. gingivalis, T. forsythia, P. intermedia, Campylobacter rectus, Eikenella corrodens, F. nucleatum, A. actinomycetemcomitans, Peptostreptococcus micros, Treponema species, and Eubacterium species Aggressive periodontitis- A. actinomycetemcomitans Generalized aggressive periodontitis- P. gingivalis, P. intermedia, T. forsythia, and Treponema species Pregnancy gingivitis= P. intermedia

Pathology associated with gingivitis is completely reversible with removal of plaque and resolution of inflammation

MMPs are the most important proteinases involved in destruction of periodontal tissues MMPs are inhibited by tetracycline class antibiotics

IL-1: important in bone resorption Prostaglandins are produced from arachidonic acid

Do NOT give tetracycline during pregnancy because it can lead to depressed bone growth, enamel hypoplasia, tooth discoloration, and hepatic damage

Bisphosphonates inhibit osteoclast activity and are used primarily to treat cancer and osteoporosis

Bleeding on probing is the best clinical indicator of gingival inflammation

Younger patients with evidence of periodontitis generally have a poorer prognosis than older patients with comparable levels of disease

Patients with aggressive periodontitis usually have a poorer prognosis than patients with chronic periodontitis

Scaling- removal of both supragingival and subgingival plaque and calculusRoot planing- removal of embedded calculus and areas of cementum to produce a clean, hard, smooth surface Sickle scalers- used to remove supragingival calculus

- Have 2 cutting edges and a pointed tip- Triangular shape in cross section

Curettes- instruments of choice for subgingival scaling and root planing - Universal have 2 cutting edges and can be used in any area of mouth - Face of blade is at 90 degree angle to lower shank when seen in cross section from tip

Gracey Curettes Gracey 1-2 and 3-4= anterior Gracey 5-6= anterior and premolars Gracey 7-8 and 9-10= posterior teeth, facial and lingual Gracey 11-12= posterior teeth MESIAL surfaces

Gracey 13-14= posterior teeth DISTAL surfaces

Hand instruments are held in modified pen grasp

Exploratory stroke- light feeling stroke used with probes and explorersScaling stroke- a short, strong pull stroke used with bladed instruments for the removal of calculusRoot planing- a moderate to light pull stroke used for final smoothing and planing of root surface

Magnetostrictive ultrasonic instruments- tip vibrates in an elliptic pattern, all sides of tip are activePiezoelectric ultrasonic instruments- tip vibrates in a linear (back-and-forth) pattern

Horizontal Incisions for Full-Thickness Flaps1. Internal bevel incision- made 0.5 to 1mm from free gingival margin, 1 to 2mm from free gingival margin, or

coronal to base of pocketa. Removes pocket lining, conserves outer dimension of gingiva, and produces a thin sharp flap margin that

can be adapted to bone-tooth junction 2. Crevicular incision- made from base of pocket to crest of alveolar bone3. Interdental incision- separates collar of gingiva from tooth

Vertical Incisions for Full-Thickness Flaps- should NOT be made in center of papilla or over radicular surface of a tooth, should be avoided on lingual and in palate

Modified Widman Flap- uses 3 horizontal incisions, but is not reflected beyond mucogingival line- Allows for removal of pocket lining and exposure of tooth roots and alveolar bone

In 1st post-op week, patient should rinse with 0.12% chlorhexidine 2x daily until normal hygiene can begin again

Gingivectomy- an excision of gingiva; performed to eliminate suprabony pockets, gingival enlargements, or suprabony periodontal abscesses

Bony Defects1. Osseous crater- two-walled concavity in crest of interdental bone confined within facial and lingual walls

a. Best corrected by recontouring facial and lingual walls to restore normal interdental architecture 2. Vertical or angular defects- base of bone defect is located apical to surrounding bone

Ostectomy- removal of tooth supporting boneOsteoplasty- removal of non-supporting alveolar bone Resective osseous surgery is most successful in interproximal bony craters, early furcation involvement, and cases with thick alveolar bone

Guided Tissue Regeneration (GTR): method for preventing epithelial migration along cemental side of a pocket during wound healing after periodontal flap reflection

2-walled defects are most predictable to respond with bone grafting

Titanium is the material that offers the best biologic attachment to bone and gingival tissueImplants are usually loaded after 2 to 3 months, when woven bone is still present

Technical complications are higher for implants used with overdentures than for implants supporting fixed prostheses

Tetracyclines are often used in treatment of localized aggressive periodontitis - Bacteriostatic- more effective against gram-positive than gram-negative bacteria

- concentrate in gingival crevicular fluid

Reflection of a full-thickness flap results in bone necrosis at 1 to 3 days and osteoclastic resorption that peaks at 4 to 6 days

Primary trauma from occlusion- when trauma from occlusion is the result of occlusal alterationsSecondary trauma from occlusion- trauma resulting from reduced ability of tissues to resist occlusal forces

Gingival abscesses- localized to gingival tissues; attributed to plaque, trauma, or foreign body impaction and are treated by debridement and drainage

Periodontal abscesses- characterized by mild to severe discomfort, localized swelling, presence of a periodontal pocket, mobility, extrusion of a tooth in socket, percussion or biting sensitivity, presence of exudate, elevated temperature, and lymphadenopathy; involve deeper supporting structures of teeth

Adequate plaque control is essential to reducing or eliminating root sensitivity

Gingival enlargements are usually caused by inflammation or are drug-associated enlargements associated with acute inflammation are usually treated with SRP

PHARMACOLOGY

Receptors: proteins on or in cells that mediate the effect of drugs and to which drugs bind with affinity and selectivity 5 classes of drug receptors

1. G protein-linked2. Ion channel receptors3. Transmembrane receptors with cytosolic enzyme domains4. Intracellular nuclear receptors that alter gene expression 5. Cell surfaces adhesion receptors

Intrinsic activity- maximal effect of a drugEfficacy- effect of a drug as a function of level of binding to its receptorAffinity- attractiveness of a drug to its receptor

Potency- response to a drug over a given range of concentrationsTherapeutic index= LD50/ED50

Pharmacokinetics: study of what the body does to drug involves absorption, distribution, metabolism, and excretion

Weak acids are excreted more rapidly at higher urinary pH because weak acids are concentrated in the lumen of the kidney tubule

Reactions involved in drug metabolismPhase 1- involve reactions such as oxidation, reduction, and hydrolysis Phase 2- involve conjugation most common type of conjugation reaction is glucuronide conjugation

Zero-order elimination kinetics: elimination of a constant amount of drug eliminated regardless of doseFirst-order kinetics: a constant percentage of remaining drug is eliminated

Muscarinic sites- at neuroeffector sites for all postganglionic cholinergic neuronsNicotinic sites- at the skeletal neuromuscular junction

Alpha 1 blockers= used to treat hypertension, heart failure, and benign prostate hypertrophy

Beta blocker effects= decrease blood pressure, reduce angina, reduce risk after myocardial infarction, reduce heart rate and force, have antiarrhythmic effect, cause hypoglycemia in diabetics, decrease intraocular pressure

Muscarinic effects of cholinergic agonists= salivation, miosis, bradycardia, bronchoconstriction, increase in GI motility, increased urination, and sweating

Nicotinic effects of anticholinesterases= muscle twitching and weakness, tachycardia, increase in blood pressure

Dantrolene: drug that relaxes skeletal muscle without blocking nicotinic receptors Prevents release of Ca2+ from sarcoplasmic reticulum Used for upper motor neuron disorders

Antimania Drugs MOA- lithium works inside cell to block conversion of inositol phosphate to inositol carbamazdepine blocks sodium channels

Lithium inhibits effect of ADH on kidney

Benzodiazepines- enhance effect of GABA at GABAA receptors on chloride channels increases chloride channel conductance in brain

Barbiturates- enhance effect of GABA on chloride channel but also increase chloride channel conductance independently of GABA

ANTIEPILEPTIC DRUGSSeizures are caused by inappropriate and excessive activity of motor neurons in CNS

Tonic-clonic (grand mal) Absence (petit mal) Drugs act through one or more mechanisms:

o Inhibition of sodium channelso Inhibition of T-type calcium channelso Binding to alpha-2 gamma-1 subunits o Increasing conductance at chloride channels

Phenytoino Slow absorption with useo Antacids may decrease absorptiono Highly bound to plasma protein o Metabolized in liver

Carbamazepineo Metabolized in livero Inducer of liver enzymes

Phenobarbitalo Induces liver enzymes

Primidoneo Acute systemic and CNS toxicity tend to limit useo Common side effects= sedation, vertigo, nausea, vomiting, ataxia, diplopia, nystagmus, and hepatic and

hematologic toxicity

Valproic acido Used for manic depressive illness, along with seizures

ANTI-PARKINSON DRUGSParkinson’s disease involves degeneration of dopaminergic neurons in the nigrostriatal pathway in the basal ganglia

Mechanisms of action of 3 drugs affecting DOPA1. Levodopa + carbidopa= levodopa is able to penetrate blood-brain barrier and then is converted into dopamine 2. Bromocriptine, pergolide, pramipexole, ropinirole, and apomorphine are direct dopamine receptor agonists 3. Benztropine, trihexyphenidyl, biperiden, and procyclidine are antimuscarinic drugs4. Diphenhydramine is an antihistamine that has anti-muscarinic action5. Amantadine releases dopamine and inhibits NMDA receptors6. Selegiline is an irreversible inhibitor of MAO-B, which metabolizes dopamine levels

ANESTHETICSESTERS= metabolized in PLASMA

- Procaine- Propoxycaine - Tetracaine

- Benzocaine- Cocaine

Amides= metabolized in LIVER - Lidocaine (Xylocaine)

- Mepivacaine (Carbocaine)- Prilocaine - Bupivacaine (Marcaine)- Etidocaine - Dibucaine- Articaine - Ropivacaine - Levobupivacaine

Local anesthetics become more charged as the pH is loweredThe higher the lipid solubility, the more potent and long-lasting the drug At low pH in tissues, anesthesia becomes more difficult to attain because of a higher % of charged form of drug Esters are more allergenic than amides

Mechanism of action of local anesthetics1. Block sodium channels in nerve membrane2. Prevent depolarization of nerve

Vasoconstrictors used with local anesthetics:1. To increase depth and duration of anesthesia2. To reduce systemic absorption of local

anesthetics

Sites within CNS most sensitive to effect of general anesthetics:A. Dorsal lamina of spinal cordB. Reticular activating systemC. Relay circuits between thalamus and cortexD. Hippocampus

Stages of general anesthesia:1. Analgesia- amnesia is common2. Delirium- excitement phase- begins with unconsciousness3. Surgical anesthesia- progressive loss of reflexes and muscle control4. Respiratory paralysis

Nitrous Oxide MOA: includes inhibition of nicotinic cholinergic and NMDA receptors Used in conscious sedation Rapid onset and termination, colorless, tasteless 1.5 times heavier than air Inhibits vitamin B12-dependent methionine synthase by oxidizing the cobalt in cyanocobalamin Prolonged exposure (>24 hours) causes bone marrow suppression Can cause diffusion hypoxia at end of admin if N20 is not washed out with oxygen

Propofol Agonist at GABAA receptors Rapid onset and termination

Ketamine Blocks NMDA glutamate receptors Increases blood pressure

ANALGESICS AND ANTIHISTAMINESNaloxone and naltrexone are antagonists at opioid receptors

Mechanism of action of opioids:

1. Are agonists at opioid receptors, which are in plasma membrane of neurons, both presynatpically and postsynaptically

2. Stimulation of opioid receptors leads to activation of G protein, G i, resulting in a decrease in calcium conductance, accounting for a decrease in presynaptic release of neurotransmitters

Opioid Receptors:1. Mu- largely responsible for mediating euphoria, reduced GI motility, physical dependence, and respiratory

depression 2. Delta3. Kappa

Sites of analgesic action of opioid analgesics:1. Descending pathway in CNS, including spinal cord2. Ascending pathway in CNS3. Peripheral nerve endings

Signs and symptoms of acute morphine overdose:1. Coma2. Pinpoint pupils3. Respiratory depression

Meperidine is more potent than codeine but less potent than morphineMethadone is used in maintenance for treating opioid addiction as well as pain Tramadol is a weak mu receptor agonist; also blocks reuptake of norepinephrine and serotonin analgesia

Acetaminophen is an analgesic but not an NSAID

NSAID’s Mechanism of Action:1. Inhibit COX, inhibiting production of prostaglandins and other prostanoids 2. Inhibit both forms of COX3. COX-2 selective drugs mainly affect the “right arm” and are less irritating to the GI tract 4. Acetaminophen appears to inhibit COX-1 and COX-2 in CNS and may activate the CB1 cannabinoid receptor

ASPIRIN Indications for use:

o Paino Fever

o Inflammationo Antiplatelet effect

MOA: irreversible inhibition of COX accomplished by acetylation of the enzyme o Antiplatelet effect lasts beyond presence of aspirin in body

Chronic toxicity:o Salicylismo CNS effectso Bleeding

o GI disturbanceso Kidney toxicity

Contraindications:o Disorders involving excessive bleeding, recent surgeryo Ulcerso Use of drug that interacts with aspirino Recent viral infection in children and teens

ACETAMINOPHEN’s effects: Analgesic Low effect on peripheral COX Few drug-drug interactions

Not anti-inflammatory Liver toxicity with higher doses Acetaminophen is preferred over aspirin when an analgesic or antipyretic drug is indicated and when a condition

is present:o Asthmatico Added risk of an ulcero Experiencing bleeding o Anticoagulants o Sensitive or allergic to aspirin o Taking drugs such as probenecid or methotrexate

Ziconotide inhibits N-type calcium channels and is used intrathecally for severe pain

ANTIHISTAMINES

Comparison of 1st-generation and 2nd-generation histamine receptor blockers: 2nd generation drugs do not cross the blood-brain barrier 2nd generation drugs do not cause drowsiness like 1st generation drugs 2nd generation drugs do not have the antimuscarinic activity that 1st generation drugs do

Actions of H1 antihistamines: Block pain and itch from histamine Block vasodilation from histamine Block bronchoconstriction from histamine Useful in mild allergies and cold Local anesthetic effect Reduce motion sickness Promote sleep

H2 histamine receptor blockers inhibit action of histamine on parietal cells of stomach

ANTIARRHYTHMIC DRUGS1. Class 1 block sodium channels

a. Class 1A- quinidine and procainamidei. Reduce automaticity

ii. Decrease conduction velocityiii. Increase refractory period

b. Class 1B- lidocainei. Reduces automaticity at abnormal pacemakers in His-Purkinje system and ventricular

myocardium c. Class 1C- flecainide, propafenone

i. Reduce automaticityii. Decrease conduction velocity

2. Class 2 block -adrenergic receptorsa. Propranolol, esmolol- reduce automaticity and decrease conduction in AV node

3. Class 3 block potassium channelsa. Amiodarone, dronedarone, sotalol- reduce automaticity and increase refractory period

4. Class 4 block calcium channels a. Verapamil, diltiazem- reduce automaticity and decrease conduction velocity in AV node

Adenosine stimulates adenosine receptors in the heart leads to increased potassium conductance and decreased calcium conductance

Mechanisms of Action of Drugs Used in Treating Heart Failure1. Diuretics reduce fluid load2. ACE inhibitors, angiotensin 2 receptor blockers, and -adrenergic receptor blockers reduce vasoconstrictor

response and aldosterone releasing effect of angiotensin pathway3. Aldosterone antagonists block effects of aldosterone 4. -adrenergic receptor blockers inhibit renin release, reduce downregulation of receptors and have an

antiarrhythmic effect

Epinephrine may increase risk of ventricular arrhythmias in presence of digitalis

ANTIHYPERTENSIVE DRUGSDrugs used for treating hypertension is aimed at:

1. Reducing cardiac output2. Reducing plasma volume3. Reducing peripheral resistance

Major antihypertensive drugs1. Diuretics2. ACE inhibitors3. Angiotension 2 receptor blockers 4. -Adrenoceptor blockers5. 1-Adrenoceptor blockers6. Calcium channel blockers7. Direct renin inhibitor

Diuretics cause enhanced Na+ and water excretion and reduced fluid volume inhibit Na/Cl cotransport; inhibit Na+/K+/2Cl2 cotransport

-blockers inhibit renin release

ACE Inhibitors:1. Inhibit angiotensin 2 formation2. Lower angiotensin 2 leads to less vasoconstriction3. Lower angiotensin 2 leads to less aldosterone secretion and less sodium and water retention4. Lower angiotensin leads to less cell proliferation and remodeling

-Adrenergic receptor blockers lower blood pressure

NSAIDs can inhibit antihypertensive effect of ACE inhibitors, blockers and diuretics

ANTIANGINAL DRUGS- work by reducing cardiac rate and force, reducing peripheral vascular resistance, or dilating coronary blood vessels

1. Nitrates and nitrites- dilate most veins2. Calcium channel blockers – dilate peripheral and coronary blood vessels 3. -adrenergic receptor blockers- reduce cardiac rate and force4. Antiplatelet drugs- reduce platelet aggregation5. Ranolazine improves contractile dysfunction 6. Lipid lowering drugs

Ranolazine: inhibits late sodium current and reduces sodium overload in cardiac cells, improving ischemia-induced contractile dysfunction

DIURETIC DRUGS- act on kidney to cause excretion of sodium and water1. Thiazides- decrease Na+ and Cl- cotransport

a. Can cause hypokalemiab. Reduce Ca+2 excretionc. Can cause hyponatremiad. May increase plasma uric acid

2. Loop diuretics- decrease Na+/K+/2Cl- cotransporta. Can cause hyperuricemiab. Can increase excretion of Ca+2

c. Can cause tinnitus and hearing lossd. Can cause hyponatremia and excessive fluid loss

3. Amiloride, triamterene- decrease Na+ reabsorption by blocking Na+ channelsa. K+ sparing diuretics

4. Spironolactone- blocks aldosterone receptor

ANTICOAGULANTS1. Warfarin- inhibits vitamin K-dependent synthesis of factors 2, 7, 9, and 10

a. Effect is measured by INR 2. Herparin- blocks actions of factors 10a and 2a by stimulating antithrombin 3

Plasminogen activators- used to break down clots by promoting fibrinolysis Epinephrine is used to treat anaphylactic shock

INSULIN AND ORAL HYPOGLYCEMICSInsulin

Mechanism of Action:o Reduces blood glucose by increasing its uptake and increasing conversion to glycogen and lipido Reduces lipolysiso Increases protein synthesis and cell growth

Effects: corrects hyperglycemia of diabetes and reduces long-term adverse effects of diabetes

Metformin- inhibitor of liver glucose production Activates AMP kinase regulates energy production Reduces gluconeogenesis and lipogenesis in liver

Glucocorticoids are used to reduce inflammation

DRUGS AFFECTING CALCIUM METABOLISM1. Vitamin D

a. Binds to intracellular receptors in target cells and activates transcription in nucleusb. Increases calcium absorption from GI tractc. Increases calcium-binding protein in gutd. Acts on intracellular receptor to increase mRNA and protein synthesis

2. PTHa. Secreted by parathyroid cells when plasma calcium decreasesb. Increases cAMP in target cellsc. Simulates osteoclast activity under most conditionsd. Stimulates production of active vitamin D in kidney e. Decreases calcium excretion in kidney f. Increases plasma calcium

3. Calcitonin a. Secreted by parafollicular C cellsb. Increases cAMP in osteoclastsc. Increases calcium excretion in kidney d. Indications- Paget’s disease, hypercalcemia, osteoporosis

4. Bisphosphonates- reduce turnover rate of hydroxyapatitea. Used in Paget’s disease, osteoporosis, hypercalcemia, and bone metastasis

5. Denosumab- monoclonal antibody that binds and inhibits receptor activator of nuclear factor kappa-B ligand a. Inhibits formation and activation of osteoclasts

Anti-tuberculosis Drugs1. Isoniazid- inhibits mycolic acid synthesis2. Rifampin- inhibits DNA-dependent RNA polymerase3. Ethambutol- inhibits synthesis of arabinogalactan4. Pyrazinamide- inhibits mycolic acid synthesis 5. Rifabutin- inhibits DNA-dependent RNA polymerase

ANTINEOPLASTIC DRUGS- used to inhibit steps in cancer cell growth

PROSTHODONTICS

Treatment should accomplish: correcting existing disease, arrest decay, prevent future disease, restore function, and improve appearance and oral hygiene

Splinting teeth is generally done to distribute occlusal forces

Diverging multirooted, curved, and broad labiolingual roots are preferred over fused, single, conical, and round circumferential roots

Natural teeth exert more force than a RPD or complete denture when opposing an FPD

Maxillomandibular Relationships1. Centric Relation- a terminal hinge position and “the maxillomandibular relationship in which condyles articulate

with the thinnest avascular portion of their respective discs with the condyle-disc complex in the anterior-superior position against shapes of articular eminences”

2. Maximal intercuspal position, maximum intercuspation, or centric occlusion- the complete intercuspation of opposing teeth independent of condylar position

Arcon Articulator: condyles are attached to lower member of articulator, and fossae are attached to upper member - Mechanical fossae are fixed relative to occlusal plane of maxillary cast

Nonarcon Articulator: upper and lower members are rigidly attached- Occlusal plane is relatively fixed to occlusal plane of mandibular cast - Provides easier control in setting teeth for complete and partial dentures

1. Arbitrary facebow record: orients cast in anterior-posterior and mediolateral position in articulator to anatomic average values

2. Kinematic facebow: allows more accuracy when mounting casts than with use of arbitrary facebowsa. Placed on hinge axis

Endosteal implants are most common implants used todayMost implants are made of titanium or titanium alloy with or without hydroxyapatite coating

Adequate healing time for implants before impression making is 2 weeks in noncritical esthetic areas and 3 to 5 weeks in esthetic areas

Occlusal forces should be directed in the long axis of the implant

Papillary hyperplasia- found in palatal vault- Multiple papillary projections of epithelium caused by local irritation, poor-fitting denture, poor oral

hygiene, and leaving dentures in all day and night

Vestibuloplasty: technique that increases the relative height of the alveolar process by apically repositioning the alveolar mucosa and buccinator, mentalis, and mylohyoid muscles as they insert into the mandible

Bone grafts sources include anterior iliac crest of hip and ribHydroxyapatite biocompatible bone substitution

A protrusive record registers the anterior-inferior condyle path at one particular point in the translator movement of condyles

Christensen’s Phenomenon: distal space created between the maxillary and mandibular occlusal surfaces of occlusion rims of dentures when mandible is protruded caused by downward and forward movement of condyles

Effects of excessive vertical dimension of occlusionA. Excessive display of mandibular teethB. Complaint of fatigue of muscles of masticationC. Clicking of posterior teeth when speakingD. Strained appearance of lips

E. Patient unable to wear denturesF. DiscomfortG. Excessive trauma to supporting tissues H. Gagging

Effects of insufficient vertical dimensionA. Aging appearance of lower 1/3 of face due to thin lips, wrinkles, chin too near nose, overlapping corners of mouth B. Diminished occlusal forceC. Angular cheilitis

Balanced occlusion requires that maxillary lingual cusps of posterior teeth on non-working side contact lingual incline of facial cusps of mandibular posterior teeth in conjunction with balanced contact of teeth in working side

Action of mentalis muscle and mucolabial fold determines extension of denture flange in mandibular anterior labial area

Buccal vestibule of mandible is influenced by buccinator muscle, which extends from modiolus anteriorly to pterygomandibular raphe posteriorly and has its lower fibers attached to buccal shelf and external oblique ridge

Retromolar pad marks distal termination of edentulous ridge

Genioglossus muscle influences length of flange in the lingual frenum area

Retromylohyoid area is limited posteriorly by action of the palatoglossus muscle and inferiorly by the lingual slip of superior constrictor muscle

Denture support refers to resistance to vertical seating forces Denture stability is necessary to resist dislodgement of a denture in the horizontal direction Denture retention is ability of a denture to withstand dislodging forces exerted in the vertical plane

Beading an RPD adds strength to the major connector and maintains tissue contact to prevent food impaction

Retentive clasps should only become active when dislodging forces are applied to them

Porosity on an acrylic resin is caused by underpacking with resin at time of processing or a thick denture base heated too rapidly

Anticholinergic drugs should NOT be prescribed for patients with glaucoma

High noble alloys= noble metal content of 60% or greater and a gold content of 40% or greater

Desirable properties of alloys for metal-ceramic restorations1. High yield strength minimizes permanent deformation under occlusal force and porcelain fracture secondary

to framework deformation2. High modulus of elasticity minimizes flexure of long-span FPDs and porcelain fracture secondary to

framework deformation

Hue= shade or colorChroma= saturation or intensity of color or shade Value= relative lightness or darkness of a color

Fluorescence- physical property where an object emits visible light when exposed to UV light

A non-working condyle moves down, forward, and medially

Lateral pterygoid is responsible for translation