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fORAL PATHOLOGY Hyperthyroidism: caused by excessive production of thyroid hormone (thyroxin)In excess leads to high basal metabolism, fatigue, weight loss, excitability, elevated temperature (heat intolerance, sweating), generalized osteoporosis, fine hair, diarrhea, tremor (shakiness), tachycardiaTwo types:Graves Disease- most common, affecting women ages 20-40 years oldGoiter (bulging neck) and exophthalmos are typical signs Plummer’s Disease- caused by presence of many toxic thyroid nodules within thyroid glandIncreases with ageHypothyroidism: weight gain, cold intolerance, lowered pitch of voice, mental and physical slowness, constipation, dry skin, coarse hair, and puffiness of face, eyelids, and hands Myxedema- very severe in adults; more common in womenCharacterized by puffiness of face and eyelids, swelling of tongue and larynx, lower basal-metabolic rate, low body temperature, poor muscle tone, low strength, tires easily, mentally sluggishHashimoto’s Disease- immune system attacks the thyroid gland causing primary hypothyroidism Most common cause of hypothyroidism in US Caused by genetics, hormones, excessive iodine or radiation exposureSymptoms= fatigue, weight gain, pale/puffy face, feeling cold, joint or muscle pain, constipation, thin or brittle hair, depression, slow heart rateCretinism- severe hypothyroidism in a child due to lack of thyroid hormone causing retardation of growth and abnormal bone developmentSevere mental retardation is caused by improper CNS development Dental findings= large tongue, under-developed mandible, over-developed maxilla, delayed eruption, and longer retained deciduous teeth Hyperparathyroidism: main cause is an adenoma (benign tumor of the gallbladder epithelium)Common complication is kidney stones form due to an increase in urinary excretion of calcium and phosphate Lab findings= hypercalcemia, decreased serum phosphorus, increased serum alkaline phosphatase and serum PTHClinical characteristics= cystic bone lesions, nephrocalcinosis, kidney stones, and peptic duodenal ulcers Osteoporosis, giant cell granulomas, and metastatic calcifications are manifestationsExcess loss of calcium in urine stimulates parathyroid glands to undergo hyperplasia Hypoparathyroidism: most commonly caused by accidental surgery excision during thyroidectomy Associated with congenital thymic hypoplasia (DiGeorge’s syndrome)Acromegaly- occurs when pituitary gland produces excess GH due to a benign tumor after adolescence Most commonly affects middle-aged adults GH overproduction is caused by a benign tumor of the pituitary gland Clinical Signs= soft tissue swelling of hands and feet, enlarged tongue, mandibular prognathism, teeth tipped buccally or lingually due to enlarged tongue, and roots larger than normalGigantism- begin tumor before adolescenceDwarfism- characterized by arrested growth caused by undersecretion of growth hormoneOral manifestations= delayed eruption rate and shedding of teeth, clinical crowns and roots appear smaller, dental arch is smaller causing malocclusion and an underdeveloped mandible Most common type is AchondroplasiaOsteogenesis Imperfecta: “brittle bones” genetic defect/disorder that affects collagen productionEither less collagen than normal, or poorer quality of collagen than normal causing weak bones that fracture/break easily from little or no cause Main clinical characteristic= extreme fragility and porous bonesAdditional clinical features= blue sclera, deafness due to osteosclerosis, loose joints, low muscle tone, triangular face, and tendency toward spinal curvatureTeeth have bulbous crowns with a cervical constriction, partially/completely obliterated pulps, and narrower and shorter roots May be linked to Dentinogenesis ImperfectaHypophosphatasia: bone disease that results from low levels of alkaline phosphataseCharacteristics= loosening, hypocalcification, and premature loss of deciduous teeth; large pulp chambers and alveolar bone lossPaget’s Disease of Bone (Osteitis Deformans): non-metabolic bone disorder characterized by an increase in serum alkaline phosphatase levels Bones become enlarged and deformed, dense, but fragile due to excessive breakdown and formation of boneRadiographic Features= “cotton-wool” appearance on pano, hypercementosis of roots and loss of lamina dura around rootsPatients are predisposed to developing osteosarcomasClinical Features= increase in hat size or need for new dentures due to bony changes, bones warm to touch due to increased vascularity, highly increased serum alkaline phosphatase, urinary calcium and hydroxyproline; with normal levels of serum phosphate and calciumTreatment= anti-metabolites or calcitonin to decrease bone resorptionOsteomalacia (Adult Rickets): softening of bones in adults because osteoid tissue in bones failed to calcify due to lack of vitamin DSteatorhhea- most common cause due to fat malabsorption where the body cannot absorb fats Affects ALL bones, specifically at their epiphyseal growth plates Rickets (Child Osteomalacia)- causes skeletal deformities- bowlegs, pigeon breast, and protruding stomachTeeth affected by delayed eruption, malocclusion, developmental abnormalities of dentin and enamel, with higher caries rate Cerebral Palsy: disorders affecting body movement and muscle coordination due to an insult or anomaly of brain’s motor control centers- damage interferes with messages from brain to rest of bodyMainly characterized by spastic paralysis or impairment of control or coordination over voluntary muscles Higher incidence of periodontal disease, caries, bruxism, and malocclusion; prone to gingival hyperplasia if Dilantin is used to control seizures; more susceptible to trauma Down Syndrome: congenital defect caused by a chromosomal abnormality (Trisomy 21) Has various degrees of mental retardation, Clinical Features= short, flattened skull, slanting eyes, thickened tongue/fissured, broad hands and feetOral manifestations= mandibular prognathism, increased periodontal disease, thickened or fissured tongue, delayed teeth eruption, higher incidence of congenitally missing teeth, malocclusion, and enamel dysplasia Muscular Dystrophy: genetic disease marked by progressive weakness and degeneration of skeletal or voluntary muscles that control movement Oral manifestations= increase in dental disease if oral hygiene is neglected, weakness in muscles of mastication causing decreased maxillary biting force, higher incidence of mouth breathing, and open biteEctodermal Dysplasia: characterized by abnormal development of skin and associated structures Involves all structures derived from ectodermManifests orally as reduced/missing teethClinical signs= hypothrichosis (decrease in hair), anhidrosis (no sweat or sebaceous glands), anodontia, oligodontia, no tooth buds of primary/permanent dentition, depressed nose bridge, lack of salivary glands, and child looks olderAffects tooth bud development causing congenitally missing teeth and/or peg-shaped or pointed teethCleidocranial Dysplasia (Dysostosis): genetic disorder of bone development characterized by absent or incomplete formed collar bones, heaving protruding jaw, wide nasal bridge, malaligned teeth, multiple supernumerary teeth, and unerupted teethPierre-Robin Syndrome: inherited disorderMicrognathia- smallness of jawsGlossoptosis- downward displacement or retracted tongue Breathing problems and cleft palateLateral Clefting of Lip: results from failure of the maxillary and frontal nasal processes to merge; occurs during the 5th-6th week of embryonic life ; involves the left side more commonlyCleft Palate: occurs in the 6th-8th week of embryonic life Isolated cleft palates are more common in females Impairs normal speech and swallowing *speech problems associated with cleft lip and palate are due to inability of soft palate to close airflow into nasal area Cherubism: genetic autosomal dominant disease of the maxilla and mandible, usually by age 5Usually occurs in the mandible Bilateral expansion of jaws gives child a very round faceTumors stop growing shortly after pubertyLesions resemble Central Giant Cell Granulomas histologicallyLesions appear as multiple, well-defined, multi-locular radiolucencies of the jaw Often delayed eruption of permanent teethCystic Fibrosis: disorder causing exocrine glands to produce abnormal secretions mainly affecting GI and respiratory systems Mucous producing glands produce abnormal secretions that clog the airways allowing bacteria to multiply Most common genetic disease causing death among white people in the USIs characterized by COPD, exocrine pancreatic insufficiency, and abnormally high sweat electrolytes Oral Manifestations= staining of teeth due to tetracycline during childhood, dark-colored teeth, reduced caries rate Signs and Symptoms= poor growth, malabsorption, foul, bulky stools, COPD, recurrent pneumonia with respiratory infections, clubbing of fingers/toes, and barrel-chested appearance Osteomyelitis: inflammation or infection of bone marrow and adjacent bone, usually caused by bacteria due to trauma or surgery by direct extension from nearby infectionSigns and Symptoms= pain, redness, swelling in infected area, fever, general malaise, poorly circumscribed radiolucency with a central sclerotic nidusCondensing Osteitis (Chronic Focal Sclerosing Osteomyelitis): unusual bone reaction to an infection (usually long-standing PA infection) Mandibular 1st molar most commonly involved Radiographic findings= well-circumscribed radiopaque mass of sclerotic bone surrounding and extending below apex of one or both roots; entire root outline is visible Can be treated with RCT or extracted Periapical Abscess: usually arises from pulpal infection of a tooth due to carious involvement of tooth Well defined ovoid shaped radiolucency at root apexCellular debris and/or infection that caused the tooth to become necrotic, slowly filters out of root tip, producing an inflammatory reaction around root tip Acute Periapical Abscess- tooth is extremely painful to percussion and is mobile; radiographically, only slight thickening of PDLChronic Periapical Abscess- presents as granuloma or cyst, usually asymptomaticTreatment= establish drainage by doing RCT or extracting tooth Osteonecrosis: bone death or necrosis; rare complication of cancer patients, patients with tumors or infectious embolic events, or with osteoporosis taking IV or oral bisphosphonates May be caused by a defect in bone remodeling or wound healing Bisphosphonate-Osteonecrosis (BON): may lead to surgical complications due to impaired wound healing after extractions, periodontal surgery, or RCTCaution with patients taking IV bisphosphonates and Aredia for osteoporosis Occurs more commonly in patients taking IV bisphosphonates Osteoporosis: reduction of total skeletal mass due to increased bone resorptionBones become less dense and brittle Most common in thin, elderly white womenTreatment= estrogen therapy, calcium and vitamin D supplements, bisphosphonates Osteopetrosis (Albers-Schonberg Disease or Marble Bone Disease): manifests in infancy characterized by an overgrowth and denseness of bones due to a defect in osteoclasts Long bones become dense and hard to extent that bone marrow is obliteratedBones become hard, but brittle and dense Clinical Signs= abnormal bone and dental development, fragile bones, stunted growth anemia, liver enlargement, blindness, and progressive deafnessVon Recklinghausen’s Disease (Neurofibromatosis): Neurofibromatosis- multiple tumors of nerve tissue origin Common autosomal dominant trait characterized by multiple neurofibromas, cutaneous café-au-lait macules, bone abnormalities, and CNS changes Clinical Signs= 6 or more café-au-lait macules > 1.5 cm in diameter Lesions run high risk of becoming malignantSingle neurofibroma presents at any age as a non-inflamed, asymptomatic nodule on tongue, buccal mucosa, and vestibuleScleroderma: rare autoimmune disease affecting blood vessels and connective tissue characterized by hardness and rigidity of skin and subcutaneous tissue Continuous deposition of collagen in major organs can cause dysfunction and potential organ failure Clinical features= appears during middle age, mainly in females; skin is usually affected first and becomes indurated Oral radiographs= abnormal widening of PDL around rootsSpace is created by thickening of periodontal membrane due to increase in size and # of collagen fibers Bilateral resorption of angle of mandible’s ramus, or complete resorption of mandibular condyles and/or coronoid processOral Traumatic Neuroma: soft tissue tumor due to trauma to a peripheral nerve Usually appears like a very small nodule/swelling (<0.5cm in diameter) of mucosa near/over mental foramen on alveolar ridge in edentulous areas, lips, and tongueMost common site= over mental foramen in edentulous patients Also, extraction sites in anterior maxilla and posterior mandible Multiple neuromas on lips, tongue, or palate may indicate the patient might have MEN III (Multiple Endocrine Neoplasia Syndrome)Neurilemoma (Schwannoma): benign soft tissue tumor of Schwann cells around nerve that presents as an asymptomatic lump most common on tongue Derived from a proliferation of Schwann cells on neurolemma that surround peripheral nerves Covered by normal mucosa, sessile, and does not metastasize Neurofibroma: derived from either Schwann cell or Perineural FibroblastsOccurs in 2 forms:Solitary neurofibroma- asymptomatic nodule on tongue, buccal mucosa, or vestibule treated by surgical excisionMultiple lesions as part of Neurofibromatosis syndrome- removing lesions is impractical, but monitor due to high risk/rate of malignant transformationFibroma: most common intra-oral BENIGN neoplasm of connective tissue occurring at all ages MOST common tumor in oral cavityMost common on buccal mucosa, lateral border of tongue, lower lipClinical features= usually pink, smooth, sessile, soft-to-firm noduleBundles of collagen interlaced with fibroblasts and small blood vesselsPeripheral Fibroma: well-demarcated focal mass of hyperplastic tissue with either a sessile or pedunculated base 3 forms:Peripheral Ossifying Fibroma- gingival mass with characteristic calcified islands of bone and an ulcerated surface Gingiva anterior to permanent molars is most often affected Vascularity is NOT prominent Usually presents as a well-demarcated focal mass of hyperplastic tissue on gingiva with a sessile or pedunculated basePeripheral Odontogenic Fibroma- gingival mass made of well-vascularized, non-encapsulated fibrous C.T. Giant Cell Fibroma- fibrous hyperplasia composed of multi-nucleated C.T. cells Giant Cell Tumor: bone tumor of multi-nucleated giant cells that resemble osteoclasts scattered in a matrix of spindle cells; can cause pain, functional disability, and sometimes pathologic bone fracture Papillary Fibroma: benign neoplasm of C.T. originLipoma: completely benign soft tissue tumor derived from adipose tissueSmooth or lobulated, sessile or pedunculated, soft, movable, painless, yellowish-white nodular massLocations= floor of mouth, buccal mucosa, and tongue Floats in formalin Microscopic features= lobules of mature fat separated by delicate C.T. septaeRhabdomyoma: rare benign tumor of skeletal muscle; tongue is most common place in head and neck Leiomyoma: benign tumor of smooth muscle Lymphangioma: benign yellowish-tan tumor composed of a mass of dilated lymph vessels Tongue is most common site Derived from endothelial cells, C.T. origin Superficial lesions are grayish-red papillary lesionsPapilloma: most common BENIGN neoplasm of epithelial tissue origin Appears as a pedunculated, or sessile whitish cauliflower-like mass on tongue, lips, gingiva, or soft palateIs a disease of epitheliumLateral border of tongue, hard and soft palate are common areas Must excise surgically and recurrence is rare Microscopic= finger-like projections of stratified squamous epithelium supported by thin cores of vascular fibrous C.T. Verruca (Warts): similar to papilloma, but NOT pedunculated, caused by a viral infectionKeratoacanthoma: non-painful crater formed lesion growing for 2-3 months in skin that looks like squamous cell or basal cell carcinoma; usually only in skinMultiple Endocrine Neoplasia Syndromes (MEN Syndrome): groups of syndromes characterized by tumors of various endocrine glands that occur with other pathologic features Most important aspect is medullary carcinoma of thyroid due to its ability to metastasize and cause death3 groups:Men 1 Syndrome- tumors or hyperplasias of pituitary, parathyroids, adrenal cortex, and pancreatic islets Men 2 Syndrome (Sipple’s Syndrome)- parathyroid hyperplasia or adenoma, but NO tumors of the pancreas Men 3 Syndrome- mucocutaneous neuromas, pheochromocytomas of the adrenal medulla, and medullary carcinoma of thyroid gland most constant feature is neuromas, commonly on lips, tongue, and buccal mucosa Epulis Granulomatosum: soft, non-painful, bleed easily, most often caused by retained foreign material due to an iatrogenic errorMost commonly in post-extraction socket, usually within 10 days of extraction Microscopic features= granulation tissue in bone, dentin, cementum, or foreign material Congenital Epulis of Newborns (Congenital Gingival Granular Cell Tumor): composed of cells identical to a granular cell myoblastomaUsually on anterior gingiva of newborns Maxillary is more involved than mandibular gingivaGranular Cell Myoblastoma (Tumor): uncommon neoplasm of unknown etiology, presenting as an uninflamed, asymptomatic massTongue is most common location *Congenital Epulis and Granular Cell Myoblastoma lesions are histologically identical, since they both contain granular cells. Congenital Epulis of newborns does not exhibit pseudo-epitheliomatous hyperplasia of overlaying epithelium Pyogenic Granuloma (Pregnancy Tumor): elevated ulcerated mass that bleeds easily and is caused by minor traumamost commonly found on gingiva and inter-dental gingiva, along with lower lip, tongue, and buccal mucosa benignPregnant patients are prone and may be caused secondarily by an altered endocrine state during pregnancy in 1st trimester Clinical Features= soft, pedunculated broad-based growths with a smooth red surface due to presence of hyperplastic granulation tissueOften ulcerated, bleed easily, and may look raspberry likeVerruca Vulgaris (Squamous Papilloma): common wart of viral etiology Incubation period of 6 weeks to 1 yearPrimary lesion of skin, may occur in oral cavityIs a sessile, soft, cauliflower like lesionMicroscopically= papillomatous lesion where epithelium is thrown into folds, shows alternating hyperkeratosis, parakeratosis, and long epithelial ridges Inflammatory Fibrous Hyperplasia (Epulis Fissuratum): found at area of denture borders, most common in maxilla (hard palate) and caused by ill-fitting dentures and poor oral hygiene Clinical Features= rolls of soft tissue in muco-labial fold, red-pink, elongated, firm, ulceration, soft lesionLymphoepithelioma: poorly differentiated squamous cell carcinoma involving lymphoid tissue in tonsils and nasopharynx regionsPrimary lesion is usually really smallMost common symptom is swelling of lymph nodes, followed by sore throat, nasal obstruction, bloody nose, and headache Composed of squamous or undifferentiated cells, with slight-to-moderate amounts of fibrous stroma that contain lymphocytes Shows metastasis at an early stage to cervical lymph nodes Poor prognosisMetastic Carcinoma: most common malignancy affecting skeletal bonesA jaw tumor may be first evidence of dissemination of a known tumor from its primary site Metastases to jaws commonly originates from primary carcinomas of breast, kidney, lung, colon, prostate, and thyroid Clinical Features= may be completely asymptomatic, usually paresthesia or anesthesia of lip or chin due to involvement of mandibular nerve; teeth in area are loose or extruded; affect mandible more than maxillaOsteosarcoma (Osteogenic Sarcoma): malignant bone tumor of anaplastic cells derived from mesenchymeMost common primary malignant tumor of bone, arising in long bones Peak incidence is before epiphyseal fusion Radiographic Features= early feature is symmetrically widened PDL space around 1 or more teeth; “sun-burst” or “sun-ray” appearance due to excessive bone production Erwing’s Sarcoma: malignant tumor developing from bone marrow, usually in long bonesUncommon, HIGHLY lethal malignant neoplasm of boneMost common sites= pelvis, thigh, and body trunkRadiographic Characteristics= moth-eaten destructive radiolucencies of medulla, with erosion of cortex with expansion; “onion-skin” reaction; intermittent pain and swelling of involved bone; cells contain glycogenPredilection for ramus of mandible with pain and rapid swelling and loosening of teeth Multiple Myeloma (Plasma Cell Myeloma): fetal malignant neoplasm/lesion of bone marrow and plasma cellsCharacterized by elevated blood levels of Bence-Jones protein and multiple radiolucent areas in mandible and skullAffects males 2x more than females Tumor consists mainly of plasma cells that destroy osseous tissues Vertebrae, ribs, and skull most often involved Pain in lumbar or thoracic regions of spine is a common early symptomMandibular molar-ramus area is most common intra-oral site Radiographic features= multiple, small, discrete “punched out” radiolucencies of involved bones Odontogenic Myxoma: RARE slow growing usually asymptomatic mandibular tumor; causes localized jaw expansionOsteochondroma: benign tumor of bone and cartilage TNM: method to clinically stage and assess prognosis and therapy of malignant neoplasms based on primary tumor’s size, presence of regional lymph node involvement, and presence of distant metastasesT= size of primary tumorN= presence of regional lymph node involvement M= presence of distant metastasisMelanoma: has either a “radial” (horizontal) or “vertical” growth phase in skinRadial Growth Phase- INITIAL growth phase of melanoma just above and below dermo-epidermal junction in horizontal plane; clinically macular or only slightly elevatedVertical Growth Phase- begins when neoplastic cells populate underlying dermis. Characterized by an increase in size, change in color, nodularity, and ulceration. Metastasis is possible when melanoma reaches this phaseMalignant Melanoma: MOST SEVERE and potentially serious type of SKIN CANCER mainly due to excessive exposure to UV sun radiation causing melanocytes in skin to undergo uncontrolled growthOften develops from or near a MOLE (NEVUS)Skin cancer is most common malignancy in U.S.Linked to excessive sun exposure and painful sunburns during childhoodMalignant melanoma is an uncommon neoplasm of oral mucosa, but has a definite predilection for hard palate and maxillary alveolar ridges Most common intra-oral site for melanoma is hard palate 4 Types of Melanoma:Superficial Spreading MelanomaMOST COMMON form of malignant melanomaLesion is tan, brown, black, or admixed on sun-exposed skinInitially grows in a horizontal planeVertical growth phase is characterized by an increase in size, change in color, nodularity, and ulceration Nodular MelanomaNO “radial” growth phase Presents as a sharply defined nodule with degrees of pigmentation or blackOccurs more often on back, head, and neck of men Lentigo Maligna MelanomaMost common in ELDERLY populationMay grow for years in “radial” growth phase before developing into more aggressive “vertical” growth phase Acrolentiginous Melanoma Occurs on hands and feet Nevus (Moles): all moles are normalAtypical nevi-unusual moles are usually larger than normal moles, are flat or have a flat part, with irregular borders with variable shades of color Acquired Nevi (Moles): small, usually dark, skin growths that develop from melanocytes in skinCommon on skin and intra-orally hard palate 5 subtypes microscopically:Intramucosal Nevus- MOST common nevus in oral cavityNevus cells are located in C.T. or lamina propria of oral mucosaAppear solid and slightly raised Blue Nevus- SECOND most common nevus in oral cavityCongenital, painless, color based on deep cutaneous/subcutaneous/submucosal deposits of melaninCompound Nevus- rare in oral cavityNevus cells located at epithelium-lamina propria interface deep in dermisRaised and solidJunctional Nevus- nevus cells are located at interface between epithelium and lamina propriaFlat and not detected by palpationIntradermal Nevus (common mole)- MOST COMMON LESION OF SKIN. Nevus cells exclusively in dermis*treatment of choice for oral pigmentations with unknown etiologies is conservative, excisional biopsy to rule out melanomaBasal Cell Carcinoma: MALIGNANT epithelial cell tumor that begins as papule that enlarges peripherally, forming a central crater that erodes, crusts, and bleedsOnly found on skin due to excessive sun exposure Tx= eradicate lesion of electrodessication or cryotherapyRarely produces metastasis NEVER found in mouthMOST COMMON SKIN CANCER Squamous Cell Carcinoma (Epidermoid Carcinoma): MOST COMMON MALIGNANCY IN ORAL CAVITYOccurs more often in oral cavity than any other type of cancer More common on lower lip than intra-orallyMost common intra-oral site is posterior lateral border and ventral surface of tongueFloor of mouth is second most common intra-oral site, with WORST prognosis Risk Factors= smoking, smokeless tobacco, alcohol, painful and ill-fitting dentures, and chronic inflammationINVASION is most reliable criteria for diagnosingTx= surgery and radiation to remove lymph nodes in neckCan be RED, irregular, non-painful lesion, or WHITE lesion caused by sun exposure. Lasts > 1 monthHistology= hyperchromatism, pleomorphism, atypical mitosis, dyskeratosis, alteration of nuclei-cytoplasm ration, acanthosisMetastasis occurs via CERVICAL LYMPHATICSMost easily managed when found on LOWER LIP9-10x more common in males Highest incidence is after age 40 yrs Occurs in these head and neck locations:Nasopharynx- caused by tobacco and alcohol roof or lateral wall is most common sitePalate- caused by tobacco, alcohol, and denture irritationOropharynx- caused by tobacco and alcohol Maxillary sinus- unknown etiologySigns= chronic sinusitis, bulging palate, teeth loosening, paresthesia in cheekTongue- most common site is posterior LATERAL BORDERTongue cancer causes more deaths than any other malignant lesion in other regions of head and neck because it is a highly mobile organ with rich lymphatics and blood vessels that facilitate metastasis Etiology= tobacco, alcohol, syphilis, Plummer-Vinson SyndromePresents as a painless ulcer with leukoplakia and erythroplakia Lips- MOST COMMON SITE FOR SCC95% of SCC are found on lower lipPainless ulcer and keratotic plaque Floor of Mouth- 2nd most common intra-oral site for cancer, mainly in anterior segment on either side of midline near salivary gland orifices Caused by tobacco and alcoholVERY POOR PROGNOSIS Buccal Mucosa- generally occurs along plane of occlusion, midway anteroposteriorlyCaused by tobacco, alcohol, and denture irritationGingiva and Alveolar Mucosa- more common in posterior mandible than maxillaCaused by tobacco and alcoholCommon on mandibular mucosa as a painless ulcer and plaque like or exophytic mass Types of Squamous Cell Carcinoma:Verrucous Carcinoma- RARE form of malignant SCC that does NOT metastasize Occurs in oral cavity soft tissues, or laryngeal cavity due to tobacco chewing, smoking, or snuff dippingHas a characteristic whitish-cauliflowers or coral like papillary appearance Slow growth pattern and well-developed hyperkeratotic epithelial boundaries Non-aggressive Carcinoma in SituLocated inside epithelium, atypical mitosis, hyperchromatism, all epithelial layers affectedDoes NOT invade C.T.Is malignant, but CANNOT metastasize due to lack of blood or lymph vessels in epitheliumLocal ONLY in epitheliumCarcinoma Invasive- red area in floor of mouth, asymptomatic, flat, increasing in size Characteristics of Malignant Lesions:Erythroplasia- lesion is totally red or speckled red and whiteNon-ulcerated area on a mucous membrane Usually no symptoms Early carcinoma often appears as an area of erythroplasiaRapid growth, ulcerated fixed lesion that bleeds on gentle manipulationPainless induration of soft tissue suggests an invasive malignant lesion Intrinsic Staining: can be caused by all of the following except DIABETES MELLITUSDentinogenesis Imperfecta- causes a translucent or opalescent hue, usually gray to bluish-brownErythroblastosis fetalis- causes intrinsic stain that is bluish-black, greenish-blue, tan, or brownPorphyria- causes an intrinsic stain that is red or brownishFluorosis- causes white opacities, or light brown to brownish-blackPulpal injury- intrinsic stain starts pink, then becomes orange-brown to bluish-blackInternal resorption- causes a PINKISH intrinsic stainTetracyclines- stain varies from light-gray, yellow, or tan to darker shades of grayGermination (Twinning): division of a single tooth germ by invagination causing incomplete formation of two teethFusion: joining of two normally separated tooth buds to form a single, large, wide crown (results in 1 less tooth in arch)Dilaceration: a sharp bend or curve in a root due to trauma during tooth development Taurodontism (“Bull-like”): usually found in molarsTooth body and pulp chamber are enlarged vertically at root’s expense causing an apical shift of the pulpal floor and tooth furcation down the tooth root Caused by failure or late invagination of Hertwig’s epithelial root sheath*Hypercementosis is seen in ARCOMEGALY and PAGET’S DISEASE Enamel Hypoplasia: enamel developmental defect due to incomplete formation of enamel matrixEnamel is hard, but thin and deficient in amount Usually caused by illness or injury during tooth formation Seen as white and brown defects on tooth surface Clinical features= lack of contact between teeth, rapid breakdown of occlusal surfaces, yellowish-brown stain that appears due to exposed dentin Enamel Hypocalcification: hereditary dental defect where enamel is soft and undercalcified, yet normal in quantity due to defective maturation of ameloblasts Teeth are chalky, surfaces wear down fast, and yellowish-brown stain appears due to underlying exposed dentinAmelogenesis Imperfecta: inherited hereditary ectodermal defect transmitted as a dominant defect that affects both primary and permanent dentitionCauses enamel to be soft, thin, and yellow due to EXPOSED DENTIN through thin enamel layer Teeth easily damaged and susceptible to decayOpen contacts between teeth and occlusal surfaces/incisal edges are severely abradedDentin, pulp, and cementum are NOT affected 3 types of Amelogenesis Imperfecta:Hypoplastic (Type 1)- enamel has not formed to full normal thickness, or may be completely absent on newly erupted developing teeth due to defective formation of enamel matrix Hypomaturation (Type 2)- enamel can be pierced by an explorer tip under firm pressure and chipped away from normal appearing dentin; immature crystallites Hypocalcified (Type 3)- quantity of enamel is normal, but so soft it can be removed during a prophy due to defective mineralization of enamel matrix Dentinogenesis Imperfecta (Hereditary Opalescent Dentin): inherited/hereditary mesodermal defect of dentinTeeth has opalescent hue Clinical Features= teeth have amber, gray, or purple opalescence/translucence or discoloration, pulp chambers may be completely obliterated due to deposition of dentin, crowns are short and bulbous, with narrow roots Enamel is structurally and chemically normalTeeth have a translucent or opalescent appearance, and an abnormal constriction at CEJ 3 types of Dentinogenesis Imperfecta:Type 1- dentin abnormality occurs in patients with osteogenesis imperfecta, characterized by blue sclera or history of bone fractures Type 2- most common; only dentin abnormality exists, no bone involvement Type 3 (Brandywine Type)- only dentin abnormality exists; clinical and radiographic variations that include multiple pulp exposures Dentin Dysplasia (Rootless Teeth): hereditary disease transmitted as an autosomal dominant traitClinical Features= normal enamel, atypical dentin, pulpal obliteration, defective root formation, tendency toward multiple periapical radiolucencies and early exfoliation of teeth 2 types of Dentin Dysplasia:Type 1 (Radicular)- normal morphology and color, mobile teeth, premature exfoliation, short roots, obliterated pulp chambers, crescent shaped pulpal remnant, periapical radiolucencies, root dentin is disoriented; “chevron” shaped pulp chambers Type 2 (Coronal)- deciduous teeth exhibit bluish-gray opalescent appearance, obliterated pulp chambers, amorphous and atubular dentin in radicular portion of teethAnodontia= total absence of teethOligodontia= congenital absence of MANY teethHypodontia= absence of a FEW teeth Oral Candidiasis (“Thrush” or “Moniliasis”): fungal infection of oral cavity or vagina caused by a Candida species causing an inflammatory, pruritic infection with a thick, white dischargeAppears diffuse, curly or velvety white mucosal plaques on cheeks, palate, and tongue that can be wiped off Most common symptoms are discomfort and burning of mouth and throat, and altered taste Growth is stimulated by extended use of antibiotics, steroids, diabetes, pregnancy, or vitamin deficiencyCommon in patients on long-term antibiotics or chemotherapy, and immunosuppressed patients Tx= topical lozenges (Trouches) and Nystatin (mouth rinses)Acute Pseudomembranous Candidiasis: most common oral candidiasis, usually found on buccal mucosa, tongue, and soft palateBudding organism with branching pseudohyphaeAngular Cheilitis (Perleche): chronic inflammatory lesion that occurs at labial commissure due to unknown cause Associated with loss of vertical dimension in elderly patients Predisposing Factors= Candida albicans infection, loss of VDO, trauma to labial commissure due to prolonged dental treatment, and vitamin deficiencies Tx= Nystatin Actinic Cheilitis (Solar Cheilitis/Farmer’s Lip): pre-malignant condition caused by chronic and excessive exposure to UV sunlight radiationCan develop into squamous cell carcinomaThick, whitish discoloration of lip at border of lip and skin Leukoedema: appears to be white patch, a variant of normal mucosaVaries from a filmy opalescence of mucosa in early stages, to a more definite grayish-white cast with a coarsely wrinkled surface in later stages Usually occurs bilaterally along occlusal line in bicuspid and molar regionCan stretch tissue and white disappears White Sponge Nevus (Familial White Folder Dysplasia): benign buccal mucosal abnormalityCharacterized by white, corrugated thick soft folding of buccal mucosa Can occur on labial mucosa, alveolar ridge, and floor of mouthLeukoplakia: premalignant lesion white patch on oral mucosa that does NOT rub offPossible etiologic factors= tobacco, alcohol, oral sepsis, and chronic irritationMost often due to tobacco and chronic irritation Pipe-smoking is most important predisposing etiology Does NOT DISAPPEAR when stretched Regions at greatest risk= floor of mouth, tongue, and lower lip Speckled Leukoplakia- has mixed red and white areas Is a slow developing change in a mucous membrane characterized by thickened, white, firmly attached patches, that are slightly raised and sharply circumscribed Lesions on floor of mouth and base of tongue are most aggressiveTx= must biopsy all lesionsHairy Leukoplakia: BENIGN form of leukoplakia seen in people with HIV/AIDS or immunocompromised caused by Epstein-Barr VirusFuzzy, hairy white patches mainly on tongueTx= systemic anti-viral therapy or topical therapy Hairy Tongue- Hypertrophy of Filiform Papillae: benign condition of tongue dorsum with elongated filiform papillaeDiscoloration of dorsum tongue surface, elongation and hyperkeratosis of filiform papillae on dorsum surfaceHairy tongue can be white, green, brown, or black Etiology= overgrowth of fungal microorganisms due to smoking or poor oral hygieneBenign Migratory Glossitis (Geographic Tongue): harmless, usually painless condition due to desquamation of filiform papillaeOne or more irregular-shaped patches on tongue existsPatches do NOT respond to treatment, but disappear spontaneously Fissured Tongue (“Scrotal Tongue”): deep, usually asymptomatic median fissure with laterally radiating grooves, usually symmetrically arranged across dorsum of tongueFound in Melkersson-Rosenthal SyndromeStomatitis Nicotina (“Pipe-Smoker’s Palate” or Nicotinic Stomatitis): initial response is generalized palatal erythroplakia then becomes a white hyperkeratotic area w/small red dotsRelated to pipe smoking, occurs ONLY ON PALATE, and mainly affects males Only lesion produced by tobacco that is not cancerous White areas with multiple red dotsLichen Planus: oral lesion appearing as a white or grayish-white striae arranged in a lace-like patternUsually affects skin, mouth, or bothMAINLY on buccal mucosa Microscopic Features= hyperparakeratosis with thickening of granular cell layer, development of a “saw-tooth” appearance of rete pegs, degeneration of basal cell layer, and infiltration of inflammatory cells into sub-epithelial layer of C.T. Tx= intra-oral lesions respond to topical steroids Bullous Lichen Planus- fluid filled vesicles project from buccal mucosa surfaceErosive Lichen Planus- intensely red or raw-appearing lesions that resemble desquamative gingivitis when they involve gingiva Fordyce’s Granules (Ectopic Sebaceous Glands): found in oral mucosa; usually appear as yellow or yellow-white submucosal clusters Usually found bilaterally on buccal mucosa, upper lip vermillion, mandibular retromolar pad, and tonsillar areaPurpura: hemorrhages in skin and mucous membranes that cause appearance of purplish spots or patches tooth extractions are contraindicated due to potential excessive bleeding Thrombocytopenic Purpura (Werlhof’s Disease): bleeding disorder characterized by a deficiency in # of platelets, resulting in multiple bruises, petechiae, and hemorrhage into tissuesOral Manifestations= severe/profuse gingival hemorrhage and palatal petechiaeThrombocytopenia: dominated clinically by petechiae cutaneous bleeding, intra-cranial bleeding, and oozing from mucosal surfaces; characterized by decreased platelet count causing prolonged bleeding time MOST COMMON CAUSE OF BLEEDING DISORDERS Idiopathic Thrombocytopenic Purpura: bleeding disorder due to a deficiency in # of platelets causing multiple bruises, petechiae, and hemorrhage into tissues Common complication of leukemia, aplastic anemia, and aggressive cancer chemotherapyBleeding time is abnormally prolonged Thrombotic Thrombocytopenic Purpura: severe and frequently fatal form characterized by thrombocytopenia, hemolytic anemia, renal insufficiency, fever, and neurologic abnormalitiesLow platelet count in bloodPurpura- condition characterized by hemorrhages in skin and mucous membranes resulting in appearance of purplish spots or patches Petechiae- small pinpoint hemorrhages flush with skin surfaceEcchymosis- discoloration of an area of skin due to extravasation of blood into subcutaneous tissues due to trauma or hemorrhage Prolonged Bleeding Time (Thrombocytopenia) Conditions: Patient taking Dicumarol- inhibits formation of prothrombin in liver Patient taking Heparin- acts as antithrombin by preventing platelet aggregation Idiopathic Thrombocytopenic Purpura- often associated with leukemia decrease in # of plateletsVon Willebrand’s Disease- deficiency of vWF; results in impaired platelet adhesionLong-term treatment with aspirin; aspirin is a COX inhibitor; results in impaired production of thromboxanesAgranulocytosis: abnormal blood condition due to a severe reduction in # of granulocytes caused by ingesting a drugCharacterized by pronounced leukopenia with a severe reduction in # of PMNsToxic effect of certain anti-thyroid drugs WBC count is < 2000 with almost complete absence of PMN neutrophils Begins with a high fever, chills, and sore throat; patient suffers from malaise, weakness, and prostrationPresence of infection in oral cavity Oral lesions appear as necrotizing ulcerations of oral mucosa of gingiva and hard palate- covered by a gray membrane Sickle-Cell Anemia: chronic, usually fatal inherited form of anemia marked by crescent-shaped RBCsCharacterized by fever, leg ulcers, jaundice, and episodic pain in joints due to production of abnormal hemoglobinN2O is contraindicated Mainly affects black peopleSigns= weak, short of breath, easily fatigued, and muscle and joint pain Dental radiographs show enlarged bone marrow spaces because of loss of many bony trabeculae Leukemias: cancers of mainly WBCsInvolves uncontrolled proliferation of leukocytes causing a diffuse and almost total replacement of red bone marrow with leukemic cellsAgents closely associated with leukemia development:Ionizing radiation- increased incidence of leukemia among atomic bomb survivors and radiologistsViruses- shown to cause leukemia in fowl and rodents Genetic mutations- Philadelphia chromosome Other- chronic exposure to benzol. Aniline dyes, and related chemicalsAll leukemias occur in ACUTE or CHRONIC formAcute leukemia is most common malignancy of pediatric age groupOral Manifestations= gingivitis, gingival hyperplasia, petechiae, and hemorrhage; spontaneous gingival bleeding in acute leukemia is due to thrombocytopenia Classes of Leukemia:Myelogenous Leukemia- involves granulocytes and megakaryocytesPhiladelphia chromosome and low levels of leukocyte alkaline phosphatase are commonMassive splenomegalyCML is characterized by uncontrolled proliferation of immature granulocytes CML Clinical Signs= spongy bleeding gums, fatigue, fever, weight loss, moderate splenomegaly, joint/bone pain, and repeated infectionsLymphocytic Leukemia- involves lymphocytesCLL has a variable courseLymph node enlargement is main findingAcute lymphocytic (lymphoblastic)- most common leukemia in childrenMonocytic Leukemia- involves monocytesOral lesions are commonGingivitis, gingival hemorrhage, generalized gingival hyperplasia, petechiae, ecchymosis, and ulcerationsChronic Monocytic Leukemia is VERY RARE Chronic Leukemia Clinical Features= slow onset with weakness and weight lossAcute Leukemia: has an abrupt onset with fever, weakness, malaise, severe anemia and generalized lymphadenopathy Untreated patient dies within 6 months Remissions last up to 5 yearsClinical Features= severe anemia, hemorrhages, and slight enlargement of lymph nodes or spleen; petechiae and ecchymosis in skin and mucous membranes Lab Findings= leukocytosis 30,000-100,000/mm3 with immature forms predominating; anemia and thrombocytopenia, prolonged bleeding and coagulation times Acute Myeloid/Myelogenous Leukemia (AML): malignant BONE MARROW diseasePresence of > 30% myeloblasts in blood and/or bone marrow that contain AUER RODS in their cytoplasmMOST MALIGNANT LEUKEMIAPolycythemia Vera (Primary Erythemia): a chronic myeloproliferative condition of too many erythrocytes produced in circulation due to tumorous abnormalities, making blood TOO THICKLeads to clot formation and blockage of vessels causing a strokeClinical Features= headache, weakness, weight loss, pruritus, hemorrhage, and thrombosis Oral Manifestations= oral mucous membranes appear deep purplish-red, gingiva is swollen and bleeds easily, and submucosal petechiae, ecchymosis, and hematomas common Secondary Polycythemia- increase in total # of erythrocytes due to another condition or secretion of erythropoietins by certain tumors Plummer-Vinson Syndrome: rare disorder associated with severe and chronic iron-deficiency anemiaDue to predisposition to develop carcinoma of oral mucous membranes Systemic symptoms= weakness, pallor, difficulty swallowing due to esophageal stricture or web, and dyspneaOral Symptoms= angular stomatitis, smooth, red, painful tongue with papillae atrophyAplastic Anemia: anemia where bone marrow’s capacity to produce RBCs is defective MOST SERIOUS AND LIFE THREATENING blood dyscrasia associated with drug toxicity Primary Anemia- unknown cause, affects young adultsSymptoms= pallor, weakness, malaise, dyspnea, headache, and vertigoOral Symptoms= spontaneous bleeding, bruising, and gingival infectionsSecondary Anemia- caused by exposure to toxic agents; same symptoms as primary anemia and good prognosis Pernicious Anemia: disease caused by an inability to absorb adequate amounts of vitamin B12 from digestive tractCaused by lack of secretion of intrinsic factor in normal gastric juiceLeads to low RBC production Diagnosed by Schilling TestTriad of Symptoms= weakness, sore painful tongue, and tingling of extremities Thalassemia Major and Minor: hemolytic anemias caused by a genetic defect, characterized by a low level of erythrocytes and abnormal hemoglobinOral manifestations= oral mucosa may exhibit anemic pallor, flaring of maxillary anterior teeth with malocclusionErythroblastosis Fetalis (Hemolytic Disease of Newborn): severe hemolytic disease of fetus caused by production of maternal antibodies for fetal RBCInvolves Rh factor incompatibility between mother and fetusCharacterized by excessive destruction of erythrocytes due to an antigen-antibody reaction in infant’s bloodstreamHemolytic reaction only occurs when mother is Rh (-) and infant is Rh (+)Oral Manifestations= teeth have a green, blue, or brown hue due to deposition of blood pigment in enamel and dentin; enamel hypoplasia may occur Erythrocyte Sedimentation Rate: rate at which RBC settle out in a tube of un-clotted blood, expressed in mm/hourSpeed that RBC fall to bottom of tube reflects degree of inflammationnon-specific test that monitors progression of diseaseESR rises during inflammation, tissue degeneration, suppuration, and necrosisWiskott-Aldrich Syndrome: affects only boys and causes eczema, low platelet count, and a combined deficiency of B and T lymphocytes that leads to repeated infectionsEmbolus: mass, air bubble, or foreign body that moves within a blood vessel to a site distant from place of originMost common source of a pulmonary embolism is thrombophlebitisFemoral vein is common source of origin of thrombus which then occludes a blood vessel in lungGingival Hyperplasia: diffuse soft tissue overgrowth affecting both jaws with a pink-to-red color and firm consistency from mucogingival junction to free gingival marginLocal Factors= can be caused by poor oral hygiene, malocclusion, tooth malformations, caries, faulty restorations, allergens, chronic mouth breathingSystemic Factors= diabetes, hormone changes, immunoincompetence, gingival fibromatosis, Wegener Granulomatosis, aplastic anemia, leukemia, scurvy, and drugs Histologic Exam= epithelial hyperplasia with acanthosis, parakeratosis, and elongated, slender epithelial RETE PEGS and dense C.T. with foci of chronic inflammation Trigeminal Neuralgia (Tic Douloureux): excruciating, painful illness where person feels sudden stab-like pains in face that usually only last moment, but severe painsPain is provoked by touching a “trigger zone” near nose or mouth, caused by degeneration of trigeminal nerve or applying pressure to nerve Paroxysmal episodes of pain may last hours Drug Treatment= Carbamazepine relieves pain within 48 hours Multiple Sclerosis: chronic disease that randomly attacks CNS due to an autoimmune responseWomen affected 2x more than menSymptoms= tingling, numbness, paralysis, and blindness; facial and jaw weakness, Bell’s Palsy, Trigeminal Neuralgia Glossopharyngeal Neuralgia: pain that arises from glossopharyngeal nerveSharp, sudden, shooting, unilateral pain in ear, pharynx, nasopharynx, tonsils, or posterior tonguePostherpetic Neuralgia: persistent burning, aching, itching, and hyperesthesia along distribution of cutaneous nerve after an attack of herpes zoster; involves facial nerve and geniculate ganglion that produces Ramsey Hunt SyndromeMyasthenia Gravis: chronic condition of extreme muscle weakness due to an autoimmune disorder where body creates antibodies against its own nicotinic acetylcholine receptors in neuromuscular junctionsMuscles are quickly fatigued with repetitive useTypical for patients to have a flattened smile and droopy eyes Xerostomia and rampant caries may be present Difficulty speaking and swallowing, and weakness of arms and legs are common Drugs for Tx= Pyridostigmine or neostigmine increase level of acetylcholine Eaton-Lambert Syndrome: an autoimmune disease causing weakness, due to inadequate release of acetylcholine Frey’s Syndrome (Auriculotemporal Syndrome): due to damage to auriculotemporal nerve and subsequent reinnervation of sweat glands by parasympathetic salivary fibers Can occur after surgery removal of parotid tumor, ramus of mandible, or infection of parotid that has damaged auriculotemporal nerve Chief complaint= gustatory sweatingBell’s Palsy: facial paralysis from damage to facial nerve More commonly attacks pregnant women, diabetics, and people with influenza, cold, or other upper respiratory infectionsClinical Signs= unilateral paralysis of all facial musclesDrooping mouth on 1 side with a watering eye, loss of taste on anterior portion of tongue may occurSudden onset, but paralysis begins to subside in 2-3 weeksCongenital CystsBranchiogenic Cyst: arises from persistence of second branchial arch cleft; located along anterior border of sternocleidomastoid muscle at any level in neck; lined with ciliated and striated squamous epitheliumDermoid Cyst: uncommon cyst, containing hair, sebaceous and sweat glands, and tooth structures; most common on FLOOR OF MOUTHThyroglossal Duct Cyst: may arise from any part of thyroglossal duct, found in midline position and usually dark colored, may be vascular resembling a hemangiomaHemorrhage into mouth is a common and important symptom caused by rupturing of overlying veinsDevelopmental Cysts (Non-Odonotogenic Fissural Cysts):Nasopalatine Duct Cyst (Incisive Canal Cyst): oval or “heart shaped” radiolucency in midline of hard palateMost common non-odontogenic/developmental/fissural cystRadiographic Features= a round well-demarcated oval or heart-shaped radiolucency between and above maxillary central incisors Cysts that arise from epithelial remnants in incisive canal are most common type of maxillary development cysts Nasolabial Cyst (Nasoalveolar Cyst): soft tissue cyst of upper lip in soft tissue of upper lip that develops from epithelial remnants from inferior and anterior portion of nasolacrimal ductClinical Features= swelling below or inside nostril, cannot see on radiographMedial Palatal Cyst: rare, may occur anywhere along median palatal raphe, usually in hard palate midline, posterior to pre-maxillaPresents as firm, painless swellingEpithelial remnants in line of fusion of palatine processesWell-demarcated radiolucency in midline of hard palate5196177276860Globulomaxillary Cyst: an inverted “pear-shaped” radiolucency in bone between roots of maxillary lateral and canine often causes roots of involved teeth to divergeClinical Features= usually asymptomatic, occurs within boneConsists of epithelial remnants where globular and maxillary processes are fusedMedian Alveolar Cyst: rare, occurs in bony alveolus between central incisors; teeth are vitalOdontogenic CystsLateral Periodontal Cyst: painless unilocular well-defined tear-drop shape radiolucency along lateral surfaces of vital mandibular canine and premolar roots; has a thin lining of non-keratinized epithelium Radicular Cyst (Apical Periodontal Cyst): MOST COMMON odontogenic cyst, found at root apexDevelops with pre-existing dental granulomaTooth is asymptomatic and necrotic, can be sensitive to percussionExhibits a lumen invariably lined by stratified squamous epithelium, cyst wall is condensed C.T. with plasma cells, lymphocytes, and PMN leukocytes Residual Cyst: occurs when a tooth with a radicular cyst is extracted but the radicular is left undisturbed and persists within jaw now as residual cystTo prevent residual cyst, you must curette radicular cyst out of tooth socket after extraction Found in edentulous areas Has stratified squamous epithelium lining lumen Dental Granuloma: MOST COMMON sequelae of pulpitis at root apexOnly distinguished from radicular cyst histologicallyAsymptomatic, necrotic toothCircumscribed radiolucency at tooth apexLined by stratified squamous epithelium; cyst wall is fibrous C.T. with macrophages, lymphocytes, cells, and capillaries Dentigerous Cyst (Follicular Cyst): always associated with crown of an unerupted or developing tooth or dental anomalyMost commonly found with a developing 3rd molarCan cause marked displacement of teeth due to presence of accumulated fluid that usually displaces tooth apicallyFound in mandibular 3rd molar and maxillary canine area 2nd most common odontogenic cystWell-defined, unilocular radiolucencyLined by non-keratinized, stratified squamous epithelium with NO rete-pegsAn ameloblastoma is likely to develop in wall of a dentigerous cyst Eruption Cyst: soft-tissue variant of dentigerous cyst, associated with erupting teethUsually a smooth-surface lesion that is reddish-pink or bluish-pink-black, fluctuant, localized swelling of alveolar ridge over crown of an erupting primary or permanent molar Primordial Cyst (Follicular Cyst): well-defined, oval radiolucent lesion that contains no calcified structuresLocated in mandibular 3rd molar spaceFound in place of a tooth, rather than directly associated with tooth Lined by stratified squamous epithelium; no rete pegs Odontogenic Keratocyst: follicular and dentigerous cysts that contain keratinizing materialMay resemble periodontal, primordial, or follicular cysts, and CANNOT usually be distinguished radiographicallyGreat tendency to reoccur 50% are found in mandibular 3rd molar area Increase in size by process of epithelial cell multiplicationWell-circumscribed radiolucency with smooth margins, and thin radiopaque border Thin layer of corrugated parakeratin; uniform thin stratified squamous liningTraumatic Bone Cyst: most commonly found in young people, in mandible between canine and ramus Large radiolucent area on mandible apical to roots of premolars and molars on pano producing a scalloped appearanceGingival Cyst: rare, circumscribed swelling of gingiva usually found in canine and premolar areas on mandibleFibrous Dysplasia: genetic condition characterized by fibrous replacement of osseous tissues in affected bones Demonstrates “ground glass” appearance of bone Symptomatic alteration of bone Radiographically, you never see lesion’s borders blends with boneCharacterized by normal bone replaced by fibrous tissue3 types depending on bone involvement:Monostotic Fibrous Dysplasia- most common form involving 1 bone (ribs and femur are common)Pano reveals a radiopaque mass/lesion with irregular borders Often causes expansion and deformity of jawbone and tooth displacement Polyostotic- involves multiple bones; affects long bones, face, clavicles, and pelvic bonesAlbright’s Syndrome (McCune-Albright Syndrome)- disease of unknown cause affecting bones, skin pigmentation, and causing premature sexual development Hallmark Sign= female premature pubertyAlbright’s= MOST SEVERE form of polyostotic fibrous dysplasia Triad of Symptoms= polostotic fibrous dysplasia, café-au-lait brown skin spots, endocrine abnormalities, and pathologic bone fractures Gardener’s Syndrome: polyposis syndrome Most serious complication is multiple polyps that affect large intestine, duodenum, colon, and stomach Polyps eventually become malignant causing colon cancer Oral Findings= multiple odontomas, multiple impacted and supernumerary teeth, and multiple jaw osteomas giving “cotton-wool” appearance to jaws Central Giant Cell Granuloma: benign tumor almost exclusively in jawbones after traumaMost common in anterior mandible (symphysis)Slight to moderate bulging of jaw occurs due to expansion of cortical plates in involved area Radiographically has unilocular or multi-locular radiolucencies of bone with well-defined margins Loose fibrillar C.T. multi-nucleated giant cells are prominent throughout C.T. Mandibular Tori: bony exophytic growths that occur along lingual surface of mandible, superior to mylohyoid ridge, usually in premolar region Exostosis: slow-growing, benign bony knots on hard palate or lingual aspect of mandible; most common exophytic lesionsCondylar Hyperplasia: rare, unilateral enlargement of condyle, that may be due to mild, chronic inflammation that stimulates growth of condyle or adjacent tissues Unilateral, slowly progressive elongation of face with deviation of chin away from affected side Central Ossifying Fibroma: slow-growing, painless, benign, asymptomatic, neoplasm that occurs in maxilla or mandibleMost commonly involves only one boneMore common in young adults Lesion is always well-circumscribed and demarcated from surrounding boneTeeth displacement is common Histiocytosis X: disorder where abnormal scavenger immune system cells histiocytes and eosinophils proliferate in bone and lungs, causing scars to form; occur due to metabolic defects in reticuloendothelial systemEosinophilic Granuloma: most benign form of Histiocytosis XMay be totally asymptomatic, but there may be local pain or swelling, especially if bone fracture occursIn mouth, mandible is most likely affected with teeth being loose and gingivitisPneumothorax is a common complicationRadiographic Features= lesion appears as irregular radiolucent areas involving superficial alveolar boneLetterer-Siwe Disease (Acute Disseminated Form): usually fatal without treatmentHistiocytes damage lungs, skin, lymph glands, bone, liver, and spleen Hand-Schuller-Christian Disease (Chronic Disseminated Form):Triad of Symptoms= exophthalmos, diabetes insipidus, and bone destructionOral signs= halitosis, sore mouth, mobile teeth All 3 disorders may be treated with corticosteroids and cytotoxic drugsUse radiation therapy if there is bone involvement Verruciform Xanthoma (“Histiocytosis Y”): benign soft tissue tumor presenting as a normal or white colored verrucous lesion In adults, alveolar and palatal mucosa are common sites Histologic Features= verrucous, hyperparakeratotic surface with parakeratotic plugging; large “foam” cells in C.T. papillae between elongated rete ridges Ameloblastoma: tumors of odontogenic epithelial origin and most common epithelial (ectodermal) odontogenic tumorEnlargement of tumor may expand buccal and lingual cortical plates of bone, or palatal bone plates Unerupted, mandibular 3rd molar is commonly associated with radiolucent defect Often associated with unerupted teeth mainly in posterior body and angle of mandible Looks like “soap-bubble” on panoSlow-growing, locally invasive tumors that are usually benignAsymptomatic, painless swelling or expansion of jaw occurs usuallyMay arise from rests of dental lamina, epithelial lining of dentigerous cyst, basal cells of oral epithelium, developing enamel organ, and remnants of Hertwig’s sheathRadiographic Features= multi-locular or uni-locular radiolucency on vital teeth with “soap bubble” appearance Has irregular-scalloped marginsMicroscopic Features= follicular and plexiform, cystic, acanthomatous, granular cell, desmoplastic, and basal cell. All are non-encapsulated Adenomatoid Odontogenic Tumor (Adenoameloblastoma): benign tumor of ectodermal originLimited to teenagers and childrenOccurs mainly in anterior maxilla and affects females 2x more Clinical Features= small ( < 3cm diameter); looks like a gingival fibrous lesion, asymptomatic, circumscribed, unilocaular radiolucency associated with crown of an unerupted toothRadiolucency sometimes extends apically along root past CEJOften contains snowflake calcificationsHistology= well-defined lesion surrounded by a thick, fibrous capsuleEnamel organ, lining of dentigerous cyst, reduced enamel epithelium, Rests of MalessezDerived from ectoderm enamel organ and remnants of dental laminaCalcifying Epithelial Odontogenic Tumor (“Pindborg Tumor”): a rare lesion derived purely from ectoderm2/3 of cases occur in mandible (molar-premolar region)Painless, slow-growing swelling is most common clinical signRadiolucent-radiopaque areas associated with an unerupted tooth and amyloid productionRadiographic Features= unilocular or more often multi-locular radiolucent defect; scalloped marginAssociated with an impacted mandibular 3rd molar Squamous Odontogenic Tumor: rare benign odontogenic tumor derived from ectodermRandomly distributed throughout alveolar processes of maxilla and mandible Painless or mild painful gingival swelling associated with tooth mobilityRadiographic Features= triangular/circumscribed radiolucency lateral to roots of an unerupted or erupted toothHistogenesis= rests of Malassez Cementoma (Periapical Cemental Dysplasia): benign odontogenic tumor that occurs most frequently in anterior mandible and affects multiple vital teethAn unusual response of periapical bone to some local factorLesions arise within bone Clinical Features= occurs at apex of vital anterior teeth, women over 30 years old, esp. black women, asymptomatic, usually multiple, small periapical radiolucent areas in mandibular incisor area 3 Cementoma Stages:Stage 1 lesion is a periapical radiolucencyStage 2 lesion begins to calcify and become more radiopaqueStage 3 well-defined radiopacity bordered by a thin radiolucent lineRadiographic Features= small sharply circumscribed radiopacity attached to, or adjacent to apices of teeth Opacities are boneBenign Cementoblastoma (True Cementoma): in mandibular premolar or molar area; usually solitary and may cause expansion of cortical platesRadiographic Features= well-demarcated, mottled or densely radiopaque mass with radiolucent periphery attached to root, causing root resorptionMicroscopic Features= cementum-like tissue with conspicuous reversal lines, variable amounts of fibrous C.T. with sheets of uncalcified “cementoid”Tx= extract involved tooth Gigantiform Cementoma (Familial Multiple Cementomas): large, dense lobulated radiopaque masses; large sheets of tissue that resemble secondary cementumOdontogenic Myxoma: an aggressive tumor derived from papilla, dental sac, or PDL Occurs as a painless swelling in mandible May be associated with unerupted or displaced teeth Odontogenic Fibroma: derived from dental papilla, dental sac, or PDLOccurs as a painless swelling in mandible of children and young adults A multiocular or unilocular radiolucency that may be associated with unerupted or displaced teeth Cementifying Fibroma: well-defined radiolucency with scattered radiopaque fociOccurs in mandible of adults as a painless swellingOdontoma (Hamartoma): odontogenic tumor often associated with an unerupted tooth; average age found is 14 yrs oldComplex Odontoma: amorphous radiopaque mass with a thin, radiolucent rim at junction of surrounding boneMost common in posterior mandible, premolar-molar area Derived from ectodermal and mesenchymal components of tooth germ Asymptomatic, but may delay eruption of permanent teeth Radiographic Features= well-defined, radiopaque mass surround by a narrow radiolucent zoneHistologic Features= conglomerate mass of dental tissues; characterized by formation of calcified enamel and dentin in an abnormal arrangement due to lack of morpho-differentiation Compound Odontoma: tumor of enamel and dentin common in anterior maxilla derived from ectodermal and mesenchymal components of tooth germArranged in form of anomalous miniature teethAppears in mandible canine-premolar area, and can cause delayed eruption or prevent eruption of permanent teeth Common between maxillary premolar and central incisor on panoMultiple, small malformed teeth of dentin, enamel, and cementum Peutz-Jeugher Syndrome (Hereditary Intestinal Polyposis Syndrome): autosomal dominant inherited disorder, characterized by multiple intestinal polyps through entire intestines and intra-oral melanin pigmentation of lips and oral mucosa at birth or early age Pigmentation most common on buccal mucosa, gingiva, and hard palateMucosal surface of lower lip is almost always involvedOral pigmentations are harmless, but their presence is important to determine if multiple polyposis exists in intestines and colon which may be harmful Pigmentations of Peutz-Jeghers Syndrome may occur without polyps and multiple polyps may be present without any pigmentationsAddison’s Disease: rare endocrine disorder characterized by adrenal cortex hypofunction of cortisolHyposecretion is either due to an adrenal gland disorder or inadequate secretion of ACTH by pituitary gland Causes bronzing of entire skin Cortisol’s most important function is to help the body respond to stressMain dental concern= adrenal cortex has no capacity to produce extra cortisol in response to stress, which can result in Addison’s CrisisClinical Signs= weight loss, loss of appetite, muscle weakness, low BP, darkening of skin Oral Signs= diffuse pigmentation of gingiva, tongue, hard palate, and buccal mucosa Low blood concentrations of Na+ and glucose, increased serum K+, and decreased urinary output of steroids Albright’s Syndrome (McCune-Albright Syndrome): severe form of polyostotic fibrous dysplasia that causes lesions of nearly all skeletal bones, brown patches of cutaneous pigmentation, and endocrine dysfunction Amalgam Tattoo: most common on gingiva, buccal mucosa, and alveolar mucosa Aspirin Burn: when patient places an aspirin tablet against aching tooth, allowing cheek/lip to hold it in position while it dissolvesSurface becomes blanched or white, with sloughing of necrotic epithelium Most pigmented skin tumors are composed of nevus cells due to a developmental anomaly of melanocytes, and are rare in oral cavity Intra-orally, pigmented skin tumors are most often on hard palate, but may appear on gingiva and lips Congenital Nevi (Birthmark): can change from a flat, pale tan macules into elevated, verrucous, hairy lesionsHave higher incidence of malignant transformation than acquired neviMost common intra-oral location= hard palate Focal Melanosis: presents as a single or multiple small, flat brown asymptomatic lesion mainly on lower lip Labial Melanotic Macule- lesion on lip, mainly lower lip, usually 5mm or less in diameter Oral Melanotic Macule- lesion found on gingiva, buccal mucosa, and palate, under 1.0cm in diameter Median Rhomboid Glossitis: affects middle-aged adults and is believed to be the permanent end result of a chronic candida albicans infectionsDiabetics, immunosuppressed patients, and patients on long-term antibiotics are most susceptible Clinical Features= smooth, denuded, beefy-red lesion devoid of filiform papillae; mainly on midline of tongue dorsum, anterior to circumvallate papillae Erythroplakia: velvety-red patch condition Histologically diagnosed as severe epithelial dysplasia, carcinoma in-situ, or invasive squamous cell carcinoma Most likely found in mandibular mucobuccal fold, oropharynx, and floor of mouth Burning Tongue Syndrome: symptoms of intense pain and burning Usually no clear-cut cause and no uniformly successful treatment Possible Etiologic Factors= anemias, diabetes mellitus, gastric disturbances, psychogenic factors, xerostomia, local irritation, and vitamin deficiency Peripheral Giant Cell Granuloma: pedunculated broad-based growths with a smooth surfaceAlways on gingiva (between 1st permanent molar and incisors) or alveolar process Mandibular gingiva is affected more than maxillary gingiva Represents a usual hyperplastic C.T. response to injury of gingival tissues May resemble a fibroma or pyogenic granuloma Consists of a non-encapsulated tissue mass composed of a delicate reticular and fibrillar C.T. stroma with multi-nucleated giant cells Hemangioma: benign tumor consisting of a mass of blood vessels In some locations, can interfere with proper organ development and function Clinical Features= common benign tumor of a proliferation of blood vessels; commonly affects tongue, buccal mucosa, lips, and palate Microscopic Features= capillary, cavernous, and a hemangioendothelioma of stratified squamous epithelium covering of loose, fibrous C.T. that contains many thin-walled engorged vascular spacesTraumatic Bone Cysts (Pseudocysts): non-cysts found in mandible (between canine and ramus) of mainly teenagers due to traumaPainless, well-defined scalloped radiolucency between teeth Aka simple bone cyst, hemorrhagic bone cyst, unicameral bone cyst, extravasation bone cyst, idiopathic bone cyst, and solitary bone cystAneurysmal Bone Cyst: benign bone lesion regarded as a “reactive process”Rare expansile, osteolytic bone lesion consisting of proliferation of vascular tissue that forms a lining around blood-filled cystic lesionsInvolves proximal humerus, femur, tibia, and pelvisLesions usually tender or painful on motion of affected boneTissue often resembles “blood-soaked” sponge Histology= fibrous C.T. stroma with many cavernous or sinusoidal blood-filled spaces; fibroblasts and macrophages line sinusoids Bone appears cystic with a “honeycomb or soap-bubble appearanceBenign Salivary Gland Tumors: normal mucosa, painless, nodular, localized, movable, firm, slow-growing, well-differentiated, and encapsulated/well-circumscribed Cortex remains in tact in benign lesion, but may be thinned and part involved may be expanded Pleomorphic Adenoma (Mixed Tumor): most COMMON BENIGN salivary gland tumorMost common site of intra-oral MINOR salivary gland neoplasms/tumors is PALATEMost common site of intra-oral MAJOR salivary gland neoplasms is PAROTID GLAND Necrotizing Sialometaplasia: benign lesion of minor salivary glands, characterized by necrosis of glandular parenchyma with associated squamous metaplasia and hyperplasia of ductal epitheliumMay be related to vascular insufficiency and infarction of glands Hard palate is most common site Clinically presents as a tender deep ulcer with sharply demarcated marginsHealing usually occurs within 6-12 weeks Mumps: most common VIRAL DISEASE of salivary glands caused by RNA-ParamyxovirusMajor site= sudden salivary gland swelling without purulent discharge from duct Parotid gland is involved 90% of the time and bilaterally involved in 2/3 of cases Patients present with mild fever, malaise, and anorexiaComplications= orchitis and epididymitis, CNS disturbances Serum amylase may be elevated during acute phase Measles (Rubeola): RNA Paramyxovirus spread by nasopharyngeal secretions Characterized by Koplik’s spots opposite the 1st and 2nd molars near Stenson’s duct Measles can cross the placenta Mucoceles (Mucous Retention Cyst): fluid-filled sac under the mucosa usually on lower lip usually due to traumaInvolves the MINOR salivary glands and their ducts Superficial mucocele= raised, circumscribed vesicle, several mm to 1cm in diameter with a bluish-translucent castDeeper mucocele= tissue is normal in colorRanula (“True Retention Cyst”): fluctuant and painless cyst that presents as a translucent, bluish, well-rounded, smooth surfaced bulge that protrudes from one side of mouth floorOccurs unilaterally in floor of mouthCaused by an obstruction of either the submandibular or sublingual glands Mikulicz’s Disease (“Benign Lymphoepithelial Lesion”): rare lesion, closely related to Sjogren’s Syndrome Asymptomatic enlargement of parotid and submandibular glands Begins unilaterally, but becomes bilateralHistology: replacement of gland parenchyma by lymphocytic infiltrate that contains scattered epimyoepithelial islands within Clinical Features of Malignant Salivary Gland TumorsPainful, ulcerated mucosa, nodular, firm, fixed, rapid growth, invasion, immovableMetastasis is most important characteristic that distinguishes a malignant tumor from a benign tumorParesthesia suggest metastatic disease Histologic features= anaplasia, abnormal mitosis, pleomorphism, hyperchromatism, increased number-cytoplasmic ratio Host response to malignancy is best reflected by lymphocytic infiltration at edge of a tumorGrade 1= well-differentiatedGrade 2= moderately, well-differentiated Grade 3= poorly undifferentiated Grade 4= undifferentiated Adenocarcinoma: affects major and minor salivary glands; usually presents as an asymptomatic mass Adenoid Cystic Carcinoma: malignant salivary gland tumor that usually affects minor salivary glands of palate, parotid gland, and submandibular gland Patient presents with pain and/or nerve dysfunctionFacial weakness or paralysis is common Acinic Cell Carcinoma: malignant salivary gland tumor most likely associated with parotid gland Patient presents with swelling, pain, or tenderness, and may have facial weakness or paralysis Mucoepidermoid Carcinoma: usually occurs in parotid glandPatient usually has asymptomatic swelling, with a peak incidence in 3rd decade of life Patient may have a facial weakness or paralysis Conditions Associated with PAROTID GLAND Enlargement:Sjorgen’s syndrome and SarcoidosisWarthin’s TumorInfections- mumps, actinomycosis, tuberculosisBenign Lymphoepithelial LesionAcute Epidemic ParotitisMalnutritionSjogren’s Syndrome: salivary gland disorder of unknown cause, but is autoimmuneMarked mainly by chronic inflammation of salivary and lacrimal glands 50% of cases have bilateral enlargement of parotid and submandibular glands Symptoms= rheumatoid arthritis, xerostomia, keratoconjunctiva siccaDecrease in salivation may cause rampant caries Xerostomia (Dry Mouth): caused by sialadenitis (insidious inflammatory disease of major salivary glands), Sjorgen’s syndrome, medications, cancer therapy, nerve damage, Alzheimer’s stroke, bone marrow transplants, endocrine disorders, stress, anxiety, depression, and nutritional deficiencies Often caused by failure of salivary glands to function normallyExtreme cases can cause rampant tooth decay and periodontal diseaseSialoliths: in Wharton’s duct Common symptoms of duct obstruction are an increase and decrease in swelling of gland Most common in submandibular gland and duct Oncocytomas (“Oxyphilic/Acidophilic Adenoma”): small, benign RARE glandular tumor composed of large cells with a granular and eosinophilic cytoplasm due to presence of many mitochondria Development may be related to aging process Most common in parotid glands of patients over 50 Sialoscintigraphy: simple, non-invasive procedure that separates benign and malignant tumors of salivary glands Warthin’s Tumor (“Papillary Cystadenoma Lymphomatosum”): benign parotid tumor, arising from heterotopic ductal epithelium within lymph nodes or near parotid glandStrong association with cigarette smoking Tumor often arises in tail of parotid gland as a painless, non-tender, slow growing, firm-to-fluctuant nodule over angle or ramus of mandible Tumor is encapsulated and composed of cystic spaces surrounded by two uniform rows of cells with centrally placed pyknotic nucleiPleomorphic Adenoma (“Benign Mixed Tumor”): most common tumor of major and minor salivary glands Of both ectodermal and mesenchymal originMostly arise in parotid gland Present as firm, painless lumps below and anterior to earStevens-Johnson Syndrome: severe bullous form of erythema multiforme Characterized by acute onset of fever, and eruptive, ulcerative lesion on skin, oral mucosa, and eyes Clinical Features= “Bull’s eye shaped” lesions with classical triad of eye lesions, genital lesions, and stomatitis Erythema Multiforme: allergic hypersensitivity reaction in response to medications, infections, or illness Exact cause is believed to involve damaged skin blood vessels with subsequent damage to skin tissues Classic target or “Bull’s eye shaped” lesion that appears as a central lesion surrounded by concentric rings of pallor and redness over dorsal of hands and forearms Low-grade fever, general malaise, and headache precede lesionsOral lesions appear as red macules, papules, or vesicles that may become eroded and painful, covered by a yellowish-white membrane after rupturing Recurrent Aphthous Ulcers: may be associated with stress, a bacterial infection, trauma, endocrine conditions, allergic factors, immunologic abnormalities, iron, vitamin B or folic acid deficiencies Recurrent Aphthous Minor- most common form (“canker sore”)Starts as a single or multiple superficial erosions covered by a gray membrane Very painful, heals with little or no scarringOccurs on cheeks, lips, tongue, roof of mouth Recurrent Aphthous Major- large, usually >10mm, very painful ulcersCan last up to 6 weeks and leave a scar upon healingOccurs on non-keratinizing tissue (lips, tongue, cheek)Recurrent Herpetiform Ulcerations- most severe aphthous ulcer, characterized by crops of multiple, small, shallow ulcersLesions are present almost continuously for 1-3 years Heal within a month and DO NOT leave scarringActinomycosis: subacute-to-chronic bacteria infection with Actinomyces Characterized by contiguous spread, suppurative and granulomatous inflammatory reaction, and formation of multiple abscesses and sinus tracts that discharge sulfur granules Most likely to cause chronic suppurative lesion about jaws Most common clinical forms are cervicofacial actinomycosis (LUMPY JAW), thoracic, and abdominal actinomycosisCervicofacial Actinomycosis (“Lumpy Jaw”): most common manifestation of ActinomycosisInfection usually occurs in patients with poor dental hygiene or after surgery Histoplasmosis: caused by Histoplasma CapsulatumPrimarily affects the lungsUsually asymptomatic, but may produce a benign, mild pulmonary illness Oral Manifestations: nodular, ulcerative, or vegetative lesions on buccal mucosa, gingiva, tongue, palate, or lips usually covered by a non-specific indurated gray membrane Syphilis: STD caused by a spirochete Treponema Pallidum; usually treated with a penicillin injection Primary Syphilis- first symptom is a non-painful ulcer that appears 2-6 weeks after exposure/infectionFound on body part exposed to partner’s ulcerChancre disappears within a few weeks even without treatment Secondary Syphilis- highly infectious stage that occurs 6 weeks after non-treatment of primary syphilisOften marked by skin rash characterized by brown “penny-sized” sores Maculopapular cutaneous rash Tertiary Syphilis- occurs in infected people many years after non-treatment of secondary syphilisGUMMA most commonly occurs on palate and tongue Can cause serious heart abnormalities, mental disorders, blindness, neurologic problems, and deathCongenital Syphilis- caused by an infection by Treponema Pallidum during fetal periodExpectant mothers can transmit the disease through the placenta to unborn infant Nearly 50% of all infants infected during gestation die shortly before or after birth Newborn Symptoms= saddle nose, frontal bossing, short and high maxillaInfant/Child Symptoms= bone pain, joint swelling, abnormal teeth- peg laterals, and notched at end with a centrally placed crescent-shaped deformity Herpes Simplex Virus: a vesicle that breaks and crust forms due to dried fibrinHerpes Simplex Virus 1: oral herpes transmitted by direct contactIncludes herpetic gingivostomatitisLabial and intra-oral herpes that are groups of small ulcerations in hard palate, outside of lips, gingiva, or hands and fingers Primary Herpetic Gingivostomatitis: primary herpes infection that mainly affects young children and young adultsUsually occurs in a child who has not had any contact with HSV-1May only have flu-like symptoms with 1-2 mild sores in mouth Dehydration is the most serious potential problemPatients develop fever, irritability, regional lymphadenopathy, and headacheVery painful ulcers covered with a gray membrane and surrounded by a red halo After recovery, virus lies dormant in sensory nervous system trigeminal ganglion Emotional stress, trauma, and excessive sun exposure may cause recurrent herpetic lip lesionsSecondary (Recurrent) Herpetic Stomatitis: usually occurs in adults, triggered by trauma, fatigue, respiratory tract infection, stress, allergy, or UV exposure that causes the release/reactivation of latent HSV-1 virus Reactivation causes a recurrent infection on the lips, hard palate, attached gingiva, and alveolar ridge Recurrent Herpes Simplex Virus cold sores on lips are most common manifestation of infection Remains localized on lower lip or inside mouthHerpes Labialis (Fever Blisters/Cold Sores): extremely common HSV-1 diseaseCharacterized by an eruption of small, painful blisters on skin of lips, mouth, gingiva, or skin around mouthHerpes Simplex Virus Type 2 (“Herpes Genitalis” or “Genital Herpes”): transmitted via sexual contact and affects mucosa of genitalia and anal regionsCan be transmitted to infant during vaginal deliveryHerpes Simplex Virus Type 3: caused by herpes varicella-zoster virusProduces recurrent herpes and chickenpoxOccurs after activation of varicella virus, and affected skin has very painful ulcerated redicule vesicles Varicella Virus: causes chickenpox and shingles Highly contagious and spread by direct contact or droplets Chickenpox- disease of children; characterized by appearance on skin and mucous membranes of successive crops of typical pruritic vesicular lesions that break easily and scabVery contagious 1 day before rashes’ onset and until all vesicles have crusted Shingles (Herpes Zoster)- caused by reactivation of a latent varicella-zoster virus that may have remained in the body from a childhood chickenpoxCharacterized by painful vesicles on skin or mucosal surfaces along distribution of sensory nerveHerpes Simplex Virus Type 4: caused by Epstein-Barr VirusHairy Leukoplakia- white furry lesions on lateral tongue borders caused by EBVSurface lesion is irregular, bluish areas on gingiva99% occur in HIV+ patients Infectious Mononucleosis- secondary lesions occur and neck swellingsBurkitt’s Lymphoma (HSV-4): cancer caused by EBVNon-Hodgkin’s Lymphoma with a viral etiology Manifests most often as a large osteolytic jaw lesion Mobility of involved teeth“Moth-eaten” appearance with poorly marginated bone destruction First human cancer with strong evidence of viral etiology *Epstein-Barr is associated with infectious mononucleosis and oral hairy leukoplakia Herpes Simplex Virus Type 5: cytomegalovirus that affects salivary glands Herpes Simplex Virus Type 8: associated with Kaposi’s sarcoma-AIDS/HIV Superficial cancer on skin, multiple, made of blood vessels, and is negative to pressure testVery common on palate red lesionsKaposi’s Sarcoma: oral manifestation most commonly associated with AIDSMalignant neoplasm originating in skin, characterized by abnormal vascular proliferation Initial lesions are small, red papules, that enlarge and fuse to form purple-to-brown spongy nodulesSpreads to lymph nodes and internal organs Hard palate is most common intra-oral site Tests to Diagnose Herpetic LesionsTzanck Smear- cytologic exam of fluid harvested from an unopened vesicle stained with giemsa Look for Lipshultz Bodies Fluorescent Staining- cells show (+) fluorescence when stained with fluorescent labeled HSV immune serum and globulin Used to distinguish between herpes zoster and herpes simplex Isolation in tissue cultureAntibody Titers (Anti-HSV Ab Titers)- test for complement fixing or neutralizing antibody in acute and convalescent sera Biopsy- shows intra-epithelial cleft covered by an exudates of fibrin and PMN leukocyteEpithelium exhibits degenerative cellsHerpangina: acute infectious disease affecting young children caused by a Group A coxsackie virusOral ulcerations/vesicles usually occur in back of throat around tonsils and posterior palateClinical Features= mild and of short durationBegins with a sore throat, fever, headache, and sometimes vomiting and abdominal painHand, Foot and Mouth Disease: viral infection that affects infants and childrenProduces red-erythematous lesions/macules/vesicles areas in mouth, foot, and handsOral lesions appear on buccal mucosa, tongue, gingiva, and lips Patient has fever, malaise, vomiting, fatigue Benign Mucous Membrane Pemphigoid: chronic self-limiting mucocutaneous autoimmune diseaseUsually limited to oral and ocular mucous membranes Vesiculobullous disease where auto-antibodies act against basement membrane components, between epithelium and C.T. so destruction is below epithelium Oral lesions present as a “desquamative gingivitis” in which vesicles form, rupture, and leave gingival erosionsPemphigus Vulgaris: chronic rare skin disease characterized by formation of vesicles and bullae produced by dyhesion of epideral cells due to an autoimmune mechanism Oral lesions are 1st manifestationLarge areas of ulceration and erosions are seen covered by a white or blood-tinged exudateOften fatal without treatment Histology= vesicles and bullae are formed intra-epithelially, above basal layer of cellsClumps of cells are often found floating free in vesicle space (Tzanck cells)Patient has auto-antibodies produced against epidermal cell surface glycoprotein Gingiva is red, inflamed, and most common location in mouth Desmosomes are destroyed and epithelium is broken causing gingival ulcerationsRubella Virus: causes German Measles Characteristic rash flat, pink spots on face that spread to bodyOral- swollen and congested tonsils, and red macules Hepatitis A (Vital or Infectious Hepatitis): caused by an RNA Enterovirus usually transmitted by fecal-oral routeInitial symptoms= fever, abdominal pain, nausea, then jaundice Damage to liver cells causes increased serum levels of enzymes Self limiting, and recovery within 4 months Hepatitis B (“Serum Hepatitis”): liver disease caused by a DNA virus that produces liver inflammation and necrosis Transmission is via exposure to contaminated blood or serum High rate of transmission among drug addicts MAJOR CONCERN TO dental professionPresence of surface antigen A or B in a patient’s serum indicates patient is potentially infected with Hepatitis Hepatitis D is ONLY found in patients with acute or chronic episodes of Hep BHepatitis C: liver disease that can cause liver scarring and cirrhosisSpread mainly via blood-to-blood contact associated with IV drug use, poorly sterilized medical equipment, and transfusionsBiopsy: most reliable technique to diagnose soft tissue lesions; scalpel is instrument of choice Formalin is fixative of choice Excisional Biopsy: involves total excision of a small lesion for microscopic studyIncisional Biopsy: removes only a small section of tissue for examination Periapical Abscess: well-defined ovoid shaped radiolucency at root apexRADIOLOGYRadiopaque Structures and dense materials= metals, enamel, dentin, and bone appear white on processed film Radiolucent Structures and Materials: less dense materials like soft tissue and air spaceAppear gray to black on processed filmAllow radiation to pass through by absorbing very little radiation Well-defined unilocular- border is well-defined; usually benign lesionsWell-defined multilocular- border is well-defined with several cavitiesWell-defined honeycomb or soap bubbleDiffuse- cannot follow border of radiolucencyOsteoradionecrosis: necrosis of bone produced by ionizing radiation that is more common in mandible than maxilla due to richer vascular supply to maxillaMost common precipitating factors= pre-irradiation and post-irradiation extractions, and periodontal disease; damage to blood vessels Hamular Process: bony projection that arises from sphenoid bone and extends downward and slightly posteriorly Coronoid Process: mandible anatomical landmark that appears in periapical radiographs of molar region of maxillaAppears as a tapered or triangular radiopacityComes into most view when mouth is opened to its fullest extent when radiograph is taken *Dental radiographs should be kept INDEFINITELY*Legally, dental radiographs are the property of the dentist Digital RadiographyRadiation exposure is reduced 50-80% because sensor is more sensitive to x-raysAdvantages= superior gray-scale resolution and less patient radiation and increased speed of image viewing Storage Phosphor Imaging: digital imaging system that uses a reversible imaging plate to record imageDirect Digital Imaging System- uses an intraoral sensor attached to a fiberoptic cableIndirect Digital Imaging System- scans an existing radiograph and digitizes the imageCharge-Coupled Device- most common digital image receptor Primary Radiation: radiation generated at the anode of the x-ray tube that is attenuated by the filter and object Secondary Radiation (“Scattered Radiation”): occurs from interactions of primary radiation beam with atoms in object being imaged deviates from straight line path between x-ray focus and image receptor, Is major source of image degradation in x-ray and nuclear medicine imaging techniques Scatter radiation can be reduced by a leaded, rectangular cone *Operator receives greatest hazard from secondary (scatter) radiationCollimation: control of size and shape of x-ray beam using metal plates, slots, or bars to confine direct radiation Have radiation beam be as small as practicalDiameter of a circular beam of radiation at patient’s skin cannot be larger than 2.75 inches Short wavelength (high energy) x-rays have great penetrating powerProduced at higher kV and penetrate objects more readily forms image on film Long wavelength (low energy) x-rays produced at lower kV and have low penetrating power Attenuated by soft tissuesAluminum discs are used to “filter” out useless long wave rays to increase overall quality of x-ray beam Filtration: removal of parts of x-ray spectrum using absorbing materials in x-ray beam reduces patient dose, contrast, and film density Inherent filtration- filtration of an x-ray beam by any parts of x-ray tube or tube shield that beam passes Added filtration- obtained by placing thin sheets of aluminum in cone to filter useful beam furtherTotal filtration- consists of inherent filtration + added filtrationRecommended total of 0.5mm and 2.5mm of aluminum Ekta-Speed Film: most effective way to reduce exposure time, amount of radiation reaching patient, and amount of scatter radiation to dentist Committee on Radiation Protection of National Bureau of Standards- recommends a person be exposed in 1 year to a maximum dose of 5 REM (0.1 REM per week)Sequence of Radiation injury:Latent Period- period of time between radiation exposure and onset of symptomsPeriod of Cell Injury- may cause cell death, changes in cell function, or abnormal mitosis of cellsRecovery Period- some cells recover from radiation injury, esp if radiation is “low level”Radiosensitive Cells- small lymphocytes, bone marrow, reproductive cells, and immature bone cells prostate gland is very sensitive to radiation hemopoietic tissue is most sensitive to radiationRadioresistant Cells- mature bone, muscle, and nerve muscle cells are most radio-resistant Radiation Absorbed Dose (“RAD”): measure of energy imparted by any type of ionizing radiation to a mass of matterEquivalent Dose (“Dose Equivalent”): unit of measurement used by dentist to compare biologic-risk effect/estimates of different types of radiation damage to a tissue or organ Effective Dose: used to estimate risk in humansExposure: measure of radiation quantity, capacity of radiation to ionize airRoentgen is unit of measurement only applies to x-rays and gamma rays Electromagnetic Radiation: includes microwaves, x-radiation, visible light, and gamma radiation x-rays and gamma rays are types of non-particulate radiation energyPanoramic RadiographIndications: diagnose oral pathology not seen on PA radiographs, tx planning, evaluation of anomaliesAdvantages: screening for pathology of jaws For 3rd molar pathology and to observe TMJ, sinuses, and in sialography Disadvantages: provides less image detail and definition than PA radiographs due to intensifying screens, movement of x-ray tube and film, and increased object-film distance Loss of image detail Image distortionInadequate for interproximal caries detection or periodontal breakdownProximal overlappingAdded exposure to large area of body tissue in addition to oral tissues Poor definition of interproximal caries Positioning Errors:Chin tilted too far upward- causes a reverse occlusal plan curve on a panoMandibular structures look narrower and maxillary structures look wider (“frown”)Chin tilted too far downward- occlusal plane shows an excessive upward curve (“big smile”)Severe interproximal overlapping, anterior teeth highly distortedCone Beam Volumetric Tomography: converts images into 3-D view that can be manipulated by software for implants, orthodontics, orthognathic TMJ, and diagnostic purposes Cephalometrics (“Lateral Head Radiograph”): technique for purpose of making head measurements used to study craniofacial growth, diagnosis, planning ortho tx, and evaluation of treated casesUseful to assess tooth-to-tooth, bone-to-bone, and tooth-to-bone relationshipsAnalysis includes hard and soft tissue structures *Adjust horizontal angulation to direct central ray toward center of film Submental-Vertical (Submentovertex): x-ray designed to diagnose basilar skull fractures, provides some diagnostic information about zygoma, zygomatic arches, and mandible Film taken with source below mandible and film above headUsed when you suspect a fracture of zygomatic arch Water’s View: standard radiograph of choice for showing an anterior view of paranasal sinuses and mid-face and orbits Posterior-anterior projection with patient’s face lying against film and x-ray source behind patient’s head One of best films for radiographic diagnosis of mid-facial fractures, sinus infections, and best demonstrates lesions of maxillary sinusTowne’s View: best film to visualize condyles and neck of mandible from an anterior-posterior projectionPatient lies on back with film under head; x-ray source is from front, but rotated 30 degrees from Frankfort plane and directed right at condyles Of value to assess status of condyles, condylar neck, and ramiReverse Towne’s View- used to identify fractures of condylar neck and ramus area Conventional TMJ Radiographs: show condyles position in glenoid fossa, range of condyles’ antero-posterior movement, and areas of bone destruction on condylar heads Developer Solution functions to reduce silver halide crystals to black metallic silver Contains 4 chemicals:Developing agent (hydroquinone)- chemical compound capable of changing exposed silver halide crystals to black metallic silver, which produces no effect on unexposed silver halide crystals in immulsionAntioxidant preservative (sodium sulfite)- prevents developer solution from oxidizing in presence of airAccelerator (sodium carbonate)- alkali that activates developing agents and maintains alkalinity of developer at correct valueRestrainer (potassium bromide)- added to developers to control action of developing agent so it doesn’t develop unexposed silver halide crystals to produce fog As developing solution gets weaker films get lighter Yellowish-brown film caused by insufficient fixing or rinsingFogged film from improper film storage or outdated filmsLow solution levels will appear as developer cut-off or fixer cut-off X-Ray Fixing Solution (“Fixer”) Solution: chemical solution whose function is to STOP development and remove remaining unexposed crystalsContains 4 chemicals:Clearing agent (sodium or ammonium thiosulfate)- dissolves and removes underdeveloped silver halide crystals from emulsionClears film so black silver image produced by developer is distinctly perceptibleAntioxidant preservative (sodium sulfite)- prevents decomposition of fixer chemicalAcidifier (acetic acid)- necessary for correct action of other chemicals and neutralizes any alkaline developer that may be carried over by film or hangerHardener (potassium alum)- shrinks and hardens gelatin in emulsion, shortens drying time and protects emulsion from abrasion *Film appears brown when it is not completely fixed Vertical Angulation: directing x-rays so they pass vertically through part being examinedAccomplished by positioning tubehead and direction of central ray in an up-and-down (vertical) planeForeshortening shortened image caused by excessive vertical angulationTeeth appear too short due to either too much vertical angulation or poor chair positionElongation elongated image caused by insufficient vertical angulationMost common when taking dental radiographs where teeth appear too long due to either too little vertical angulation, or film not being parallel to long axis of teeth or occlusal plane not being parallel to floorHorizontal Angulation: maintaining central ray at 0 as tube is moved around head accomplished by positioning tubehead and direction of central ray in a side-to-side (horizontal) planeCentral ray should be perpendicular to mean antero-posterior plane of teeth being x-rayed Overlapping interproximal areas are overlapped due to incorrect horizontal tube angulation Bisecting Angle Technique: image on film is equal to length of tooth when central ray is directed at 90 to imaginary bisector Advantages: decreased exposure time; central ray is positioned perpendicular to imaginary bisector Disadvantages: x-ray film image may be dimensionally distorted due to use of short coneParalleling Technique: film is placed parallel to long axis of tooth being x-rayed, and central x-ray beam is directed perpendicular or at right angles to long axis of teeth and plane of film Advantages: little or no root superimposition on a maxillary molar view, accurate diagnosis of periodontal bone height, and image formed is dimensionally accurate Disadvantages: film placement may be difficult is some areas, increased exposure time required due to use of a long cone, object-film distance must be increased to keep film parallelBuccal Object Rule (“Tube Shift Technique” or “SLOB” rule): used to determine an object’s special position within jawsSLOB (Same Lingual, Opposite Buccal): if object in question appears to move in SAME direction as x-ray tube, then it is on lingual aspect; if it appears to move in OPPOSITE direction as x-ray tube, then it is on buccal aspect Cervical Burnout: caused by relatively low x-ray absorption on mesial or distal surfaces of teeth, between edges of enamel and adjacent crest of alveolar ridge Caused by normal configuration of affected teeth that results in decreased x-ray absorption in those areas *for a given beam of radiation, intensity is inversely proportional to square of distance from radiation source Focal Spot: small area of tungsten on anode (target) which x-rays originates and receives impact of speeding electronsSize of x-ray tube focal spot influences radiographic definitionTarget (tungsten target)- tungsten wafer embedded in anode face at point of electron bombardmentTarget Film Distance (source-to-film distance)- distance from x-ray source to film Determined by length of cone 20 cm (8 inches) short cone that exposes more tissue by producing a divergent beam40 cm (16 inches) long cone that reduces amount of exposed tissue by producing less divergent beam and a sharper image Half-Value Layer: determines quality of penetrating x-ray beamThe amount of aluminum or copper thickness required to reduce the intensity of an x-ray beam by 50%Half life value of radiation beam is about 2mm of aluminumIntensifying Screens: devices used in extra-oral radiography that convert x-ray energy into visible lightUsed to decrease amount of radiation exposure to patients Cassette Holder: light-tight device used in extra-oral radiography to hold film and intensifying screens Radiograph Operator Controls 3 FactorsKilovoltage (kVp)- quality or penetrating power of x-ray beam that controls speed of electronsInfluences x-ray beam and radiograph by altering contrast quality, determining quality of x-rays produced, and determining velocity of electrons to anode Most directly affects radiographic contrast and determines penetrating ability of x-ray beamTo increase film density= mA, kVp, and time, and source-object densityIncreasing kVp causes resultant x-ray to have a longer scale of contrast Milliamperage (mA)- controls quantity of x-rays produced and temperature of tungsten filamentAn increase in mA produces a denser and darker image and increases quantity of x-ray photonsAdjusting mA on dental x-ray unit affects quantity of x-ray photonsExposure time- length of time x-rays are produced and time patient is exposed to themUsing high speed E or F film or digital x-rays reduces exposure timeDensity: an image’s overall darkness or lightness is affected by kVp kVp= density and darker image kVp = density and lighter image (helps reveal caries)Contrast: how sharply dark and light areas are distinguished on an imageImage contrast and quality are affected by mainly kVp and filtration Low kVp setting produces a high contrast image High kVp setting produces a low contrast image Rules to Create Accurate Images when taking x-raysUse smallest practical focal spotUse longest source-film distance practical in situationPlace film as close as possible to structure being radiographedDirect central ray as close to a right angle to filmKeep film parallel to structure being radiographed *image magnification is minimized by using a long cone Dental X-Ray Tube: protective high vacuum leaded glass housing surrounded by refined oil with high insulating powersFilament- coiled tungsten wire inside cathode that when heated to incandescence, emits/produces stream of electronsMolybdenum cup- houses tungsten filamentElectron stream- travels from filament in cathode to tungsten targetTungsten target- located in anode (-) to stop stream of electronsFocal Spot- portion of tungsten target struck by electron beamCopper sleeve- located in cathodeVacuum X-ray beam- produce when electron stream bounces off focal spot on tungsten targetLeaded glass housing- houses entire x-ray tube X-rays are generated when a stream of electrons travels from CATHODE ANODE and is suddenly stopped by its impact on tungsten targetA pediatric patient who is caries free and asymptomatic, child’s 1st BW radiographs should NOT be taken until spaces between posterior teeth have closed DENTAL EMERGENCY PROTOCOLAnaphylactic Reaction: allergic reaction that develops in seconds or minutes after local anesthetic, nitrous, or dental material exposure Life-threatening causing bronchospasm and drop in BPGet preloaded EPI syringe in emergency kit and inject EPI pen into patient’s deltoid, tongue, or lateral thighChest Pain (Angina Pectoris): patient has tight, heavy, or constricted chest pain and may clench their fist against chestGive patient nitroglycerinHeart Attack: after chest pain, patient says their pain is getting worse, patient has taken 3 doses of nitroglycerin at 5 min intervals and pain continues Crushing, intense, radiating pain from chest to stomach or to left side of neck, jaw, left arm, and/or pinkie fingerSkin turns ashen gray and patient may sweat profusely Cardiac Arrest (Unconscious Patient):Lay patient flat in dental chair with feet elevated Start chest compressions, check airway, and open with head lift/chin tiltGive CPRDiabetic Shock (Hypoglycemia= Low Blood Sugar): mental confusion, patient feels cold, sweaty, and shaky Syncope: can occur due to emotional stress (nervousness)Occurs when there is a temporary decrease in blood flow to brain due to sudden drop in BP, HR, or blood volume changeSigns of fainting= light-headed, nausea, heart palpitations Administer O2 and aromatic ammonia held under patient’s nose to stimulate blood flow to brain via movement Seizure (Epilepsy): caused by signals in brain that are disruptedMost common type= GRAND-MAL (lasts 2-3 minutes)Status Epilepticus= seizure lasting more than 5 minutes Signs= patient may have a visual, sound, or smell aura immediately before seizure startsDENTAL CONSIDERATIONS FOR MEDICALLY COMPROMISED PATIENTSChronic Obstructive Pulmonary Disease:Sit patient upright in dental chairNo rubber dam in severe casesNo N2O if severe emphysemaAvoid barbiturates, narcotics, anti-histaminesAvoid erythromycin, clarithromycin if patient takes theophyllineAsthma:Have patient bring bronchodilator inhalerAvoid aspirin, NSAIDs, narcotics/barbiturates Avoid erythromycin if patient takes theophylline Avoid sulfite-containing local anestheticsTuberculosis:Active TB consult with physician before treatment and only tx emergencies Prior TB (Non-active) use caution; treat as normal patient is TB-free confirmed by physicianViral Hepatitis (B, C, D, E):Active Hepatitis treat on emergency basis onlyNon-Active Hepatitis consult with physician, treat as normalDiabetes Mellitus: Uncontrolled diabetics are prone to infection and poor-wound healingInstruct patients eat normal meal before appointmentHyperthyroidism (Thyrotoxicosis): overactive thyroid produces too much T3 and/or T4 Most commonly caused by Grave’s diseaseHemodialysis: renal replacement therapy to remove creatine, urea, and free water from blood during kidney failureDelay tx until off dialysis machine for at least 4 hours Avoid drugs metabolized by kidneysAvoid BP cuff on arm containing shuntConsider antibiotic prophylaxis to minimize effects of bacteremiaEnd-Stage Renal Disease:Avoid drugs excreted by kidney or nephrotoxic drugs Extensive reconstructive crown and bridge not recommended Pregnancy and Lactation:Don’t place patient in supine position for long periods Avoid Aspirin and NSAIDsAvoid elective care in 1st trimester, 2nd and 3rd trimesters are best for elective treatment Seizure (Epileptic) Patients:Get bleeding time for patients taking Valproic AcidNo aspirin or NSAIDsNo propoxyphene and erythromycin for patients taking CarbamazepineUse metal instead of porcelain when possibleRadiation Patients:Patients may develop mucositis, xerostomia, taste loss, trismus, candidiasis, and other secondary infections, cervical caries, osteoradionecrosisBefore Radiation= extract non-restorable teeth, restore large carious lesions, start daily fluoride treatment, treat RCT or extract non-vital teeth After Radiation= don’t extract teeth, treat diseased teeth with RCT if needed Chemotherapy Patients:Eliminate oral infections and treat advanced caries Use topical fluoride for caries control and chlorhexidine for plaque/candidiasis Hypertension:Send for medical eval if BP is > 180/110 before any dental treatmentAvoid orthostatic hypotensionUse minimal EPIStroke History (CVA): poor blood flow to brain causes cell death; high BP is main risk for CVANo elective care for current transient ischemic attacks delay treatment for 6 months Short, morning appointments Pacemakers:No antibiotic prophylaxis neededAvoid ultrasonic scalers or electrosurgeryThrombocytopenia: prolonged bleeding due to decrease in thrombocytes/platelets in bloodDo not use aspirin-containing drugs or NSAIDsHemophilia (Congenital Coagulation Disorders): excessive bleedingNo dental procedures until cleared with physicianAvoid aspirin and NSAIDs; use AcetaminophenVon Willebrand’s Disease: coagulation abnormality due to protein deficiency required for platelet adhesionAvoid aspirin and NSAIDsUse Acetaminophen or COX-2 inhibitors Anti-Coagulation: patients taking Heparin, Warfarin, Coumadin for clotting problemsNo dental procedures until medical consult; need to check prothrombin timeCan do most procedures if PT ratio is 2.5 or less or INR is 3.5 or less PHARMACOLOGY Standard RegimenPenicillin Allergic PatientsAmoxicillin:Adults= 2g orally 1 hour prior to aptChildren= 50mg/kg orally 1hr before apt Clindamycin:Adults= 600mg orally 1hr prior to aptChildren= 20mg/kg orally 1 hr prior to apt[each capsule is 300mg]Cephalexin:Adults= 2g orally 1 hr prior to aptChildren= 50mg/kg orally 1 hr prior to apt[each capsule is 500mg]Cefadroxil:Adults= 2g orally 1hr prior to aptChildren= 50mg/kg orally 1hr prior to apt[each capsule is 500mg]Azithromycin:Adults= 500mg orally 1 hr prior to aptChildren= 15mg/kg orally 1hr prior to apt1kg=2.2lbs22lb child can Rx 500mg44lb child can Rx 1000mg (1g)88lb child or more can Rx adult dose Clarithromycin:Adults= 500mg orally 1 hr prior to aptChildren= 15mg/kg 1hr prior to aptBacterial Endocarditis Prophylaxis is RecommendedProsthetic/Artificial Cardiac ValvesPrevious Bacterial Endocarditis- infection of heart lining or heart valves Congenital Heart Disease; completely repaired congenital heart disease with prosthetic material or device placed surgically or via catheter during first 6 months after procedure; cardiac transplantation recipients with cardiac valvular diseaseSurgically constructed synthetic pulmonary shunts or conduitsHypertrophic cardiomyopathyDental procedures that involve manipulation of gingival tissue or periapical region of teeth or perforation of oral mucosa *No antibiotic prophylaxis is required for patient who has a non-valvular device placed, unless it has been 2-3 weeks after surgery and healing is still occurring Antibiotic prophylaxis is NOT indicated for dental patients with pins, plates, and screens Premedication is NO longer required for patients after artificial joint replacement surgery The highest risk associated with use of oral contraceptives is thromboembolic disordersAntibiotics have the potential to reduce effectiveness of oral contraceptives Central Nervous System Neurotransmitters: catecholamines pass blood-brain barrier very poorlyAcetylcholine- neurotransmitter whose CNS effects are generated by interaction with a mixture of nicotinic and muscarinic receptorsAfter threshold stimulus, liberation of acetylcholine alters cell membrane’s permeabilityEpinephrine- direct acting catecholamine and adrenergic agonistCauses vasoconstriction to prolong anesthesia Norepinephrine- direct acting catecholamine that works through 1, 2, and adrenergic receptors in CNSCauses vasoconstriction in hypotension Isoproterenol- direct acting catecholamineDopamine DobutamineSerotonin (5-hydroxytryptamine)GABA (gamma-aminobutyric acid)- major inhibitory neurotransmitter in CNS Opioid peptides: beta-endorphin, enkephalins, and dynorphin Glutamate and Aspartate- CNS amino acids that elicit powerful excitatory effects on neurons in CNS CNS Stimulants: compounds that produce various degrees of stimulationAnaleptic- CNS stimulant with ability to overcome drug-induced respiratory depression and hypnosis Xanthines- stimulants like caffeine, theophylline, and theobromine used to improve mental alertness, reduce urge to sleep, and elevate moodTheophylline is only xanthine important in asthma treatment Sympathomimetic Amines- potent CNS stimulants used to treat narcolepsy, obesity, and ADHDCaffeninism: people dependent upon caffeine Occurs if you intake > 600-750 mg of caffeine per dayCaffeine stimulates CNS unequally, with cortex being most excited, and spinal cord least excitedSymptoms of Chronic Consumption= feelings of anxiety/nervousness, sleep disruption, irritability, diuresis, stomach complaints, palpations, and arrhythmias Autonomic Nervous System: fxns independent of consciousness; controls automatic visceral functions required for life; drugs block or mimic ANS transmittersSympathetic Nervous System Function- adjusts body function in response to stress “fight or flight” HR, CO, and BP, blood flows from skin and internal organs into skeletal muscleEnergy stores are mobilized, and pupils and bronchioles dilateANS is activated to cause hypertension; mydriasis (dilation), tachycardia, thick, ropey-type salivary flowParasympathetic Nervous System Function- essential to maintain digestion and excretionDominates during “rest and digest”Associated with cranial nerves 3, 7, 9, 10Miosis (pupillary constriction), bradycardia, and increased salivation 4 Types of Drug-Receptor Binding: Ionic Bonds- result from electrostatic attraction between ions of opposite chargeHydrogen Bonds- interaction between polar (water) moleculesVan der Waals forces- weak interactions that develop when two atoms are in close proximity Hydrophobic Interactions- occur between drug and its receptor, and aqueous environment that can play role in stabilizing drug-receptor binding Covalent Bonds: from sharing of electrons by a pair of atoms, and required for structural integrity of moleculesgenerally NOT involved in drug-receptor interactionsDrugs can bind to 4 major families of receptors to produce effects:Receptors as Enzymes (cell surface protein kinases)- kinases exert their regulatory effects by phosphorylating proteins within cell, altering cell’s biochemical activitiesIon Channels- drugs can bind to ion channels to cause channel opening or closingG-protein Coupled Receptors- when drugs bind to G-protein receptors, second messengers are produced to cause an effect within the cell, resulting in a drug effect Receptors in Cell Nucleus- receptors for steroid hormones are soluble DNA-transcription factors within nucleus that regulate transcription of specific genes Alpha () Receptors: mainly excitatory in nature located on vascular smooth muscle, pre-synaptic nerve terminals, blood platelets, fat cells, and CNS neuronsPost-junctional 1 adrenergic receptors- in radial smooth muscle of iris, arteries, arterioles, veins, and GI tractCauses contraction and vasoconstrictionPre-junctional 2 adrenergic receptors- inhibits release of norepinephrineFound on presynaptic nerve endings to inhibit norepinephrine releaseFound on post-synaptic endings in CNS to decrease sympathetic toneBeta () Receptors: mainly responsible for inhibitory effects- vasodilation and relaxation of respiratory smooth muscle Post-junctional 1 adrenergic receptors- found in HEART myocardium cells, intestinal tract smooth muscle, and adipose tissue HR, CO, BP, and force of contractionPost-junctional 2 adrenergic receptors- most common beta receptor found in bronchiolar and vascular smooth muscle In arteries and arterioles in skeletal muscle to cause vasodilation and uterine smooth muscle to cause relaxation Pharmacologic Agonist: drug that binds to physiologic receptors to result in specific cellular effects producing predictable pharmacological responsePartial Agonist- drug that acts on physiologic receptor, but has an effect only partly as effective as agonist drugPharmacological Antagonist: drug that binds to physiologic receptor, but does NOT trigger an effectWhen antagonist drug is present, agonist drug cannot reach receptor site to produce an effect Competitive Antagonism- when a response can be achieved by increasing agonist dose in presence of antagonistNon-Competitive Antagonism- when a response cannot be achieved with increasing doses of agonist in presence of antagonist Sympathomimetic Agents (Adrenergic Agonists): mimic effects of stimulation of organs and structures of sympathetic nervous systemAdrenergic agonists therapeutic uses:Control Superficial Hemorrhage- 1 adrenergic agonist causes vasoconstriction with EPIAllergic shock (anaphylaxis)- 1 adrenergic agonist causes vasoconstriction with EPI and 2 adrenergic agonists causes relaxation of bronchial smooth muscleEPI is prototypical adrenergic agonist Anaphylaxis is characterized by rapid, extreme reduction in BP and bronchospasms Nasal decongestant- 1 adrenergic agonist causes vasoconstrictor with Phenylephrine Bronchial relaxation/dilation and airway dilation- 2 adrenergic agonist Asthma- respiratory disorder characterized by recurring episodes of paroxysmal dyspnea, wheezing on expiration, coughing, and viscous mucoid bronchial secretionsBronchodilators- 2 adrenergic agonists that treat an acute asthma attack stimulate beta receptors in airway to cause bronchodilationAminophylline- theophylline compound administered orally as bronchodilators in reversible airway obstruction due to asthma or COPDRelax bronchial smooth muscle to improve airway functionCardiac stimulation- 1 adrenergic agonist like IsoproterenolTypes of Adrenergic Agonists (Sympathomimetic Agents)Direct-Acting Agonist- drugs that interact with or receptorsPhenylephrine (Neo-Synephrine) 1 selective agonistnasal decongestant, and mydriatic in ophthalmic preparations to treat chronic orthostatic hypotensionClonidine 2 selective agonist; used primarily as an anti-hypertensive agent Dobutamine 1 selective agonistTerbutaline 2 selective agonist administered orally, subcutaneously, or by inhalationUsed in long-term treatment of obstructive airway disease or emergency treatment of bronchospasmAlbuterol 2 selective agonist; used in long treatment of obstructive airway diseases, emergency treatment of bronchospasm, or to delay premature delivery Epinephrine vasoconstrictor and 1,2 and 1,2 direct acting agonistPhysiologic actions produced by EPI:Constricts arteriolar blood vesselsRelaxes bronchial smooth muscle by binding to 2 receptors Decreases blood volume in nasal tissues Causes hypertensive responseTherapeutic Indications:Alleviates symptoms of an acute asthma attackTreats bronchospasm associated with hypotensionAgent of choice to treat/reverse anaphylactic reactionsTreats hypersensitivity reactionsAdded to local anesthetics to prolong activity/duration of local anesthetic by decreasing rate of diffusion and absorption from injection site Reduces rate of vascular absorption into systemic circulation and provides hemostasis Treats glaucoma by reducing internal eye pressureControls superficial hemorrhage/bleedingHas rapid onset of action if administered via IV, sublingually, subcutaneously, or intramuscularly If norepinephrine or epi combine with eye -receptors causes pupil dilationContraindications= patients with angina conditionsSide effects= headaches, agitation, and tachycardia Norepinephrine 1,2 and 1 agonistIsoproterenol 1,2 agonist and most potent bronchodilator Indirect-Acting Agonists (Sympathomimetic): cause release of stored norepinephrine at post-ganglionic nerve endings to produce their effects; bring about tissue responses resembling those produced by stimulation of sympathetic nervous systemUsed as pressor agents to maintain BP in vascular shockUsed as bronchodilators for asthma attacks and for allergic states like anaphylactic shockAmphetamines amines that stimulate CNS and PNS, increase systolic and diastolic blood pressures, and act as weak bronchodilators and respiratory stimulantsHave a high abuse potential Pass readily into CNS and cause a rapid release of NE into brain Therapeutic Uses:ADHD:Methylphenidate (Ritalin) increases attention span, reduces hyperactivity, and improves behaviorFocalin (Dexmethylphenidate)ConcertaAdderall mixture of Dextroamphetamine and AmphetamineNacrolepsy- Dextroamphetamine is used to prevent daytime sleepinessWeight lossSympatholytic Agents (Anti-Adrenergics): drugs that act in a way opposite to sympathetic nervous system Beta-Adrenergic Receptor Blockers ( Blockers): selectivity for 1 is lost at high doses; as dose is increased, also blocks 2 receptors most common adverse side effects are weakness and drowsiness treat hypertension, angina, cardiac arrhythmias, MI, glaucoma, and prophylaxis of migraine Propranolol (Inderal), Timolol, Nadolol- lipid souble drugs that blocks both 1 and 2 receptors Used to treat hypertensionContraindicated in patients with asthma or other chronic obstructive airway disease as they cause fatal bronchospasm Contraindicated in patients with insulin-dependent diabetes as they block hypoglycemia recovery Propranolol exerts its major anti-anginal effect by blocking beta-adrenergic heart receptors Propranolol is the drug of choice for adrenergically induced arrhythmias Acebutolol (Sectral)- 1 cardioselective antagonist that treats hypertension and controls ventricular arrhythmias Metoprolol (Lopressor)- competitive 1 cardioselective antagonist that blocks 1 receptors to treat hypertension, acute angina pectorisAtenolol (Tenormin)- competitive 1 cardioselective antagonist that blocks 1 receptors to treat hypertension, chronic angina pectoris, or after heart attackHas a long plasma ? life Excreted by kidneys due to low lipid solubility*Metoprolol and Atenolol are longer acting and more predictable than Propranolol Alpha-Adrenergic Receptor Blockers- can cause tachycardia, lower BP, vasodilation, and orthostatic hypotension Any antagonist can cause EPI reversalMajor pharmacological effect of -antagonists is to decrease BP, eliciting reflex tachycardia Act by competitively inhibiting catecholamine actions at alpha receptor site to cause blood vessels to relax (dilate)*After vasovagal syncope, orthostatic hypotension is 2nd most likely cause of transient unconsciousness in dental office Drugs that can cause orthostatic hypotension:AntihypertensivesPhenothiazinesTricyclic antidepressants NarcoticsAntiparkinson drugs Types of Alpha BlockersSelective Alpha Antagonists- block 1 receptors to treat hypertension and benign prostatic hyperplasia Doxazosin (Cardura)- selective to block 1 receptors to treat hypertension preferred agent for hypertension due to longer duration of actionPrazosin (Minipress)- selectively blocks 1 receptorsTerazosin (Hytrin)- selective to block 1 receptors to manage mild-to-moderate hypertension and treat benign prostate hyperplasia Non-Selective Alpha Antagonists- blocks 1 and 2 receptors and DO NOT TREAT CARDIAC CONDITIONS used in pre-surgical management of pheochromocytoma and Raynaud’s Phenomenon Tolazoline (Priscoline)- selectively blocks 2 receptorsActions are caused by a direct peripheral vasodilationTreats persistent pulmonary hypertension of newborns Phentolamine hydrochloride (Regitine) & Phrnoxybenzamine hydrochloride (Dibenzyline)- non selective blocker of 1 and 2 receptorsMajor used in pre-surgical management of PheochromocytomaEpinephrine Reversal- predictable result of using EPI with a patient who has received an -blockerHas ability to reverse “pressor” action of adrenaline“Pressor” Response- produces an increase in BP and is mediated by -receptors “depressor” response produces a decrease in BP, and is mediated by 2 receptors Central-Acting Anti-hypertensive Agents: 2 selective agonists that inhibit adrenergic nerve transmission through actions within CNS; reduce BP by reducing cardiac output, vascular resistance Clonidine (Catapres)- 2 selective agonists used in combination with thiazide diuretic and hydralazine Reduces HR, CO, and total peripheral resistance Guanfacine (Tenex) & Guanabenz (Wystensin)- stimulates 2 adrenergic receptors to inhibit sympathetic nervous system outflow, reducing peripheral vascular resistance Methyldopa (Aldomet)- most beneficial for treating hypertension in patients with renal damageAdverse effects= orthostatic hypotension, bradycardia, sedation, fever, colitis, and hepatitis and cirrhosis Neuronal Depleting Agents: deplete catecholamine stores from adrenergic terminals in brain *Alpha and beta adrenergic blocking agents act by competitive inhibition of post-junctional adrenergic receptors INCLUDEPICTURE "/var/folders/14/kfphkf717_q461gqnnf3ht700000gq/T/com.microsoft.Word/WebArchiveCopyPasteTempFiles/page341image21097232" \* MERGEFORMATINET INCLUDEPICTURE "/var/folders/14/kfphkf717_q461gqnnf3ht700000gq/T/com.microsoft.Word/WebArchiveCopyPasteTempFiles/page341image21087456" \* MERGEFORMATINET Cholinergic Fibers release/secrete AcetylcholinePreganglionic sympathetic and preganglionic parasympathetic fibersPostganglionic parasympathetic fibers Adrenergic Fibers secrete norepinephrine, EPI, or DopaminePostganglionic sympathetic fibers are ADRENERGIC fibers Acetylcholine Receptors cholinergic receptors Muscarinic receptors- located mainly in autonomic effector cells in CNS heart, vascular endothelium, smooth muscle, presynaptic nerve terminals, and exocrine glands in CNSRespond to muscarine and Ach action of Ach at postganglionic parasympathetic sites is “muscarinic response”Nicotinic receptors- located in ganglia, skeletal muscle end plates, and CNSRespond to nicotine and AchAction of Ach on ganglia and its actions at NMJ of skeletal muscle 2 major nicotinic receptors:Nicotinic receptors at NMJs of somatic nervous systemNicotinic receptors at autonomic ganglia in both sympathetic and parasympathetic systems Drugs that resemble Ach bind to muscarinic and nicotinic receptors and imitate effects of parasympathetic postganglionic activity Acetylcholine is chemical mediator at all autonomic ganglia and parasympathetic postganglionic synapses, and transmitter substance at NMJ in skeletal muscle and sweat glands Ach causes an alteration in cell membrane permeability to produce actions:Cholinergic Drug Actions= slowing of heart, pupil constriction, stimulation of smooth muscles of bronchi, GI tract, gallbladder, bile duct, bladder, and uretersCholinergic drugs are useful to induce salivation and stimulate Ach cholinergic receptors to cause salivation, miosis, excessive sweating, flushing, increased GI motility, and bradycardia Overdose of a cholinergic drug causes sweating, urination, bradycardia, copious serious saliva3 classes of Cholinergic Agonists= choline esters, cholinergic alkaloids, and cholinesterase inhibitors *if cholinergic agents are administered before Ach, action of Ach is enhanced and prolonged Indirect-Acting Cholinergic Agonists (Cholinesterase Inhibitors): action increases effects of Acetylcholine within ANS and at NMJActions of cholinesterase inhibitors causes a cholinergic effectStimulation of skeletal muscle by excess acetylcholine eventually causes muscle paralysisEdrophonium- indirect acting cholinergic agonistdrug of choice to “diagnose” myasthenia gravis due to rapid onset of action and reversibility Does not treat myasthenia gravis due to short duration of actionNeostigimine and Pyridostigmine- treats myasthenia gravis and can reverse blockade caused by non-depolarizing neuromuscular blocking drugs during anesthesia Malathion and Parathion- insecticidesPhysostigmine- reversible cholinesterase inhibitorTreats glaucoma, Alzheimer’s, delayed gastric emptying, and orthostatic hypotensionPralidozime (Protopam): cholinesterase reactivator used as an antidote to reverse muscle paralysis due to organophosphate anticholinesterase pesticide poisoningReverses effects of an overdose of anti-cholinesterase agents used to treat myasthenia gravisTreats poisoning with an organophosphate cholinesterase inhibitorDirect-Acting Cholinergic Drugs: produce a cholinergic effect via direct stimulation of cholinergic receptors Esters and alkaloids are used to stimulate smooth muscle activity Choline Esters- cause decreased BP due to generalized vasodilation, flushing of skin, slowing of HR, and increased tone and activity of GI and urinary tracts Cholinergic Alkaloids- Pilocarpine- most useful alkaloid used as a miotic and to treat open-angle glaucoma and xerostomiaMuscarine, nicotine, and lobelineCholinergic Drugs to treat Xerostomia:Pilocarpine (Salagen)- cholinergic agonist and alkaloid to treat xerostomia caused by salivary gland hypofunction Cevimeline (Evoxac)- cholinergic agonist indicated to treat xerostomia in patients with Sjogren’s syndrome Typical cholinergic effects caused by stimulation of acetylcholine receptors are salivation, miosis, excessive sweating, flushing, increased GI motility, and bradycardia Anti-Cholinergic (Anti-Muscarinic) Drugs: produce dry mouth, papillary dilation, anti-spasmodic actions, decreased GI motility, reduction in gastric and salivary secretions, tachycardia, and dry skinCONTRAINDICATED IN GLAUCOMA PATIENTS Actions of Anti-Cholinergics:Inhibit secretions of all nasal glands, mouth, pharynx, and respiratory tract Inhibitory effect on GI motilityIncreases HR and body temperature, and dilates pupilsCause xerostomia by blocking postganglionic cholinergic fibers Prevent acetylcholine from occupying same receptor Nicotinic Receptor Antagonist (Nicotinic Blockers):Ganglionic Blockers- seldom used due to disabling parasympathetic blockade which causes pronounced xerostomia, constipation, blurred vision, and postural hypotensionMecamylamine and Trimethaphan- treat severe or malignant hypertension, and during an emergency hypertensive crisis Cause a rapid and reversible fall in BPNeuromuscular Blockers- produce complete skeletal muscle relaxation and facilitate endotracheal intubation Interact with nicotinic receptors at skeletal NMJMajor danger= can lead to excessive paralysis 2 classes:Non-depolarizing (Competitive) NMJ Blockers: competitively bind and compete with ACh at cholinergic nicotinic receptors to prevent acetylcholine from stimulating motor nerves, to cause muscle paralysisDepolarizing NMJ Blockers (Non-Competitive)Skeletal Muscle Spasmolytic Drugs (Skeletal Muscle Relaxants): agents that relieve muscle spasms without paralysis by acting in CNS or in skeletal muscle Used in multiple sclerosis, cerebral palsy, and cerebrovascular accidents/strokes associated with painful muscle spasms Baclofen- derivative of GABA to treat chronic muscle spasm; site of action is in spinal cord Carisoprodol- used to treat chronic muscle spasms and pain associated with acute TMJ pain Cyclobenzaprine- used to treat acute muscle spasm through a central action; used to relieve acute, painful musculoskeletal conditionsMethocarbamol- centrally acting muscle relaxant used to relieve acute, painful musculoskeletal conditions and to manage tetanusQuinine- used to effectively relieve nocturnal leg crams Bioavailability- measures rate and amount of therapeutically active drug that reaches systemic circulation is affected by dissolution of a drug in GI tract and destruction of a drug by liver Drug’s onset of action is PRIMARILY determined by RATE of ABSORPTION Major effect of a drug is determined by how much of the drug is FREE IN PLASMA ENTERAL ROUTE OF ADMINISTRATIONOral Route: takes about 30 min for onset of a drug’s effect after swallowed Most common route where the drug is swallowed Most convenient for safe drug admin, but also most unpredictable and least effective route Known for its significant hepatic “FIRST PASS” metabolism After admin, best absorbed from duodenumNot good in an emergency situation takes too long to be metabolized Emotional stress decreases rate of absorption of a drug when given orally Rectal Route: administered as creams, enemas, or suppositories in patient if vomiting or unconsciousDrugs are poorly and irregularly absorbed rectallyPoor patient acceptance Buccal or Sublingual Route: tablet is placed under tongue or in cheek Parenteral Administration (not via intestines or GI tract)Intramuscular Injection (IM): onset of action of drugs injected into muscle occurs rapidly because of high blood flow through muscles Usually an injection into a large skeletal muscle Absorption is usually faster and yields a higher bioavailability than oral admin Results in uniform absorption and can be used for solutions too irritating for subcutaneous injection Absorption is rapid from aqueous solutions and slow from oily solutionsSites= buttocks, deltoid muscle, and anterior thighProper needle depth in muscle is 1 inch into big adult muscle and ? inch in childrenNever go deeper than 2/3 of needle length Subcutaenous Injection: onset of drugs injected under skin takes about 15 minutes Intra-arterial Injection: injected into a specific artery. BURNS. Intravenous Injection: produces the most rapid onset by injecting directly into bloodstreamWhen drug is given by IV, there is complete 100% bioavailabilityAllows for titration of drugInhalation: MOST frequently utilized route of administration to sedate pediatric patientsGases are rapidly absorbed through lungs and gain access to general circulation within 5 minutes Topical Administration: ointments and creams applied to skin and mucous membranes to produce a LOCAL DRUG EFFECTPatch Delivery: skin patches release drug into bloodstream over 12-24 hours Produces a SYSTEMIC EFFECT *Initial distribution of a drug into tissues is mainly determined by RATE OF BLOOD FLOW TO TISSUE Gastric emptying time and degree of plasma protein binding also effect drug distribution *Most drugs travel through the bloodstream by binding to ALBUMIN protein which enables drug to be carried to all tissues and organs Physiochemical properties of drugs that influence their passage across biologic membranes are lipid solubility, degree of ionization, molecular size, and molecular shapeMechanism of drug transfer:Passive Transfer- essential to processes of metabolismSimple diffusion: lipid-soluble substances move across lipoprotein membraneMost drugs penetrate biomembranes by simple diffusion through membrane phospholipids Filtration: water-soluble molecules small enough to pass through membrane channels may be carried through pores by bulk flow of water Osmosis: movement of a pure solvent through a semi-permeable membrane from a solution that has a lower solution concentration, to a solution with a higher concentration Specialized TransportActive transport: involves lipid-insoluble substances that are “shuttled” across plasma membranes by forming complexes with specified membrane constituents to provide energy for transporting drugs to regions of high concentration Facilitated Diffusion: carrier-based transfer when driving force is concentration difference of drug across membrane ***Most drugs are absorbed by facilitated diffusion Factors Influencing Hepatic Drug Metabolism:Microsomal enzyme inhibitionMicrosomal enzyme inductionPlasma protein binding drugs highly bound to plasma proteins will not enter the liver to be metabolized Genetic factorsPathologyFactors that Control Urinary Elimination of Drugs:Glomerular Filtration- all drugs are filtered through the glomerulus to enter the renal tubulesTubular Reabsorption- reabsorption favors highly lipid soluble agentsActive Transport *The most important enzyme systems for the biotransformation of drug molecules are found in the LIVERPhase 1 Reactions: occur in liver microsomal enzyme systemDrug metabolism occurs in 3 basic patterns Active parent drug can be converted into inactive metabolitesActive parent drug may be converted into a second active compound that is converted into an inactive compoundPhase 2 Reactions: conjugation reactions involve coupling drug with an acid present in cellsConjugations occurs in liver, kidney, and in other tissues Conjugation of drugs results in polar, water-soluble compounds that are rapidly excreted in urine DEA DRUG SCHEDULESchedule 1= not legitmate for medical use These CANNOT be prescribedSchedule 2= considered to have a strong potential for ABUSE or ADDICTION, but have legitimate medical useAmphetamines, Morphine, Cocaine, Pentobarbital, Oxycodone, Methadone, and straight CodeineMust have a written prescription Prescriptions cannot be refilled, new prescription must be writtenSchedule 3= have less potential for abuse or addiction than Schedule 1 or 2Include various analgesic combinations with less than 90mg of Codeine per dose unitRefills can be authorized without writing a new prescriptionSchedule 4= include Diazepam, Lorazepam, Triazolam, Alprazolam, and chloral hydrateSchedule 5= have a small potential for abuse and addictionANESTHETICSAdverse side effects of local anesthetics either cause toxicity or allergyToxicity- caused by too much anesthetic in bloodstream, affecting CNS and cardiovascular systemAllergies- hypersensitivities and allergic reactions to local anesthetics, asthmatic wheezing syndromes, allergic reactions are more prevalent with ester local anesthetics, not amide local anesthetics Bisulfites- component of a local anesthetic solution that causes an allergy Preparations without EPI do not contain bisulfites Local anesthetics REVERSIBLY BLOCK nerve impulse conduction and produce the reversible loss of sensation at their administration site incorporated within nerve membrane or bind specific Na+ ion channels, restricting sodium permeabilityMOA: local anesthetics DECREASE Na+ UPTAKE through axon’s sodium channelsWhen local anesthetic is injected near nerve, solution interferes with uptake of sodium from outside inside nerve by blocking specific sodium channels, blocking Na+ uptake Local Anesthetic Mechanism: decrease pain sensation by blocking propagation of nerve impulses and block voltage-gated Na+ channels to inhibit generation and conduction of action potentials Local anesthetics help reduce saliva flow during operative procedures by reducing sensitivity and anxiety during tooth preparation Local anesthetics DEPRESS small, unmyelinated nerve fibers that conduct pain and temperature sensations further, and depress large, myelinated fibers last Order of loss of function caused by local anesthetics:Pain (1st) temperature touch proprioception skeletal muscle tone (last)Factors Influencing Absorption and Effects:Site of injection- pH in area, extent of tissue vascularity & perfusion, effects of local inflammation, or tissue damageInflammation- lowers pH of surrounding tissue, making it more difficult for local anesthetic to permeate membraneIts more difficult to achieve nerve block and satisfactory anesthesia in inflamed injured tissueWhen tissue conditions are normal (pH= 7.4), about 10-20% portion of an infiltrated local anesthetic is in the free base form, which is enough to penetrate the nerve to cause anesthesia. Non-ionized (free base form) is the form that readily penetrates tissue membranes Local anesthesia is obtained only if sufficient free base form is availableThe lower the drug’s pKa, and higher the pH of the solution or injected tissues, the MORE free base available. ESTER LOCAL ANESTHETICS- metabolized in plasmaMainly available as TOPICAL anesthetics (Benzocaine, Tetracaine, and Dibucaine)Have a rapid onset and short duration of activity Metabolized by plasma enzyme “plasma cholinesterase” or “pseudocholinesterase” Procaine: one of original ester-type local anesthetics Hydrolysis of procaine occurs mainly in plasmaCocaine: only local anesthetic that increases pressor activity of EPI and NE1st local anesthetic used in dentistry and medicine Causes DEFINITE VASOCONSTRICTION Applied to mucous membranes of oral, laryngeal, and nasal cavities for use as a topical anesthetic Inhibits catecholamine uptake by adrenergic nerve terminals Increases risk of developing cardiac arrhythmias and hypertension AMIDE LOCAL ANESTHETICS- metabolized in LIVER, and metabolites are then renally excreted Only local anesthetics presently available as dental injectablesLidocaine (Xylocaine)Prilocaine Bupivacaine (Marcaine)Mepivacaine (Carbocaine)Etidocaine Articaine Amides are metabolized by hepatic microsomal enzyme system, and products are excreted from body by KIDNEYLonger duration of actionMetabolized by P450 enzymes Articaine: only amide-type local anesthetic metabolized in BLOODSTREAMIndicated for local, infiltrative, or conductive anesthesia in dental procedureOnset after admin is 1-6 min after injectionComplete anesthesia lasts 1 hourContraindicated in patients with hypersensitivity to local anesthetics of amide type or to sodium bisulfite 7 mg/kg is max recommended dose of Articaine in children and adultsFluid carpule volume is 1.7 mL for Articaine Prilocaine (Citanest): used for nerve block, epidurals, and regional anesthesia Intermediate duration of actionProduces less vasodilation than equal amounts of Lidocaine50% as toxic as LidocaineNot used for patients with hypoxic conditions or with liver diseaseCan produce MethemoglobinemiaBupivacaine (Marcaine): has longest duration of action of any dental local anesthetic availableFor extended procedures Used with caution if cardiovascular disease, elderly, or pediatric patientExhibits strong preference for sensory fibers and is long actingLidocaine (Xylocaine): ANTI-ARRHYTHMIC AGENT effective only on ventricleOften given via IV to treat life-threatening ventricular arrhythmiasActs on fibrillating ventricles to decrease cardiac excitability and spares atria Used topically in dentistry Maximum recommended adult dose of Lidocaine is 300mg*Lidocaine and Mepivacaine are most likely to show cross-allergyMepivacaine (Carbocaine): equal to lidocaine in efficacy and used without EPI38087301624300Ineffective for topical application Less useful for procedures lasting > 25 minutes Toxic to neonates 27241529094200381010700Chloral Hydrate: only non-barbiturate sedative-hypnotic agent indicated in practice of dentistry Used orally in pre-op management of anxious pediatric dental patient Onset of action of 15-30 minDuration of action = 4 hours For kids, available as a 500mg/5mL solutionChildren often enter a period of excitement and irritability before sedationDOES NOT relieve pain Metabolized to active metabolite (Trichloroethanol) which may displace Warfarin from its protein binding sites Nitrous OxideIf administered at concentrations > 80%, it can produce general anesthesia Inhalant anesthetics like halothane and isoflurane can produce general anesthesia at concentrations of 3-5%Stored under pressure steel cylinders painted BLUEAdvantages= rapid onset of action, elevates pain threshold, produces euphoria, pleasant induction, titratable, rapid and complete recovery, no adverse effects in absence of hypoxiaUsed to produce SEDATION and MILD ANALGESIA Main therapeutic effect= relaxation/sedationUsually used in 30-50% concentrations along with pure O2Onset of sedation occurs within 5 min 1st symptom= tingling of hands Always give patient 100% oxygen after procedure to prevent diffusion hypoxia N20 is quickly absorbed from lungs and is physically dissolved in blood Contraindications= patients with upper respiratory infections, emphysema, bronchitis, 1st trimester of pregnancy, patients where communication is difficult Inhaled Ammonia: drug of choice for acting against SYNCOPEIrrigates trigeminal nerve sensory endings to cause a reflex stimulation of medullary respiratory and vasomotor centers Admin of oxygen aids in combating tissue anoxia Syncope Symptoms: beads of sweat on upper lip, weak thread pulse, cold clammy skin, pallor, and dizzy feelingTypes of Syncope= Vasovagal, Neurogenic, and Orthostatic *100% oxygen is contraindicated in patients with COPD4 Stages of General Anesthesia for INHALANTSStage 1 (Amnesia/Analgesia)Stage 2 (Excitement/Delirium) begins with unconsciousness, ending with loss of eyelid reflex, purposeless movements, hyper-reaction, dilated pupils, reflex vomiting, tachycardia, and hypertension Stage 3 (Surgical Anesthesia) patient begins stage with regular breathing, loss of reflexes, loss of pupil eyelash reflexes, complete loss of pain Stage 4 (Medullary Paralysis) loss of all spontaneous breathing and severe depression of vasomotor and respiratory centers in MedullaGENERAL ANESTHESIA AGENTS:Inhalation Agents/Anesthetics: volatile liquids that decrease arterial pressure Isoflurane- increases coronary blood flow and is safer drug to use if patient has ischemic heart diseaseHalothane & Enflurane- decreases cardiac output so NOT used for patients with history of cardiac arrhythmiasSensitizes heart to catecholamines, increasing risk of ventricular arrhythmias in susceptible patients Ether, Halothane, Enflurane, Isoflurane, Sevoflurane, Methoxyflurane, and Desflurane are inhalation agentsIntravenous Agents: primary advantage of IV sedation is ability to titrate individualized dosage Barbiturates- Thiopental/Pentothal, Methohexital/BrevitalThiopental- most commonly used ultrashort-acting barbiturate Benzodiazepines- IV preps of longer-acting Lorazepam and Diazepam provide anterograde amnesia to procedureMidazolam- short acting, and common for pre-anesthesia as part of “balanced anesthesia” program makes patient groggyDiazepam (Valium) and Lorazepam (Ativan)- anti-anxiety drugs. Contraindicated in patients with Narrow Angle GlaucomaFlumazenil- REVERSES BENZODIAZEPINE OVERDOSEAlprazolam (Xanax)- selective anxiolytic effects in patients suffering from Agoraphobia*Benzodiazepines are most effective oral sedative drugs used in dentistry Neuroroleptanalgesics: neuroleptic-opioid combinations that combine Fentanyl and DroperidolOpioids- provide analgesia and anesthesia Fentanyl- highly potent opioid used as pre-med or adjunct to inhalational agents Used with haloperidol derivative Droperidal and Nitrous to provide balanced anesthesia Others Propofol- IV anesthetic with rapid onset/recovery and better tolerated than other IV agents Metabolized in liver via conjugation with short half lifeBenefits= antiemetic agent used for induction or anesthesia maintenanceConcerns= contraindicated in children Etimodate (Amidate)- minimal respiratory and cardiovascular depressant effectsRapid induction and recovery, but no analgesic effects Does not produce hypotension or have significant HR effectsKetamine- drug of choice for “Dissociative Anesthesia”Causes catatonia, amnesia and analgesia without loss of consciousness by acting as an antagonist at NMDA receptor, blocking excitatory effects ONLY anesthetic that acts as cardiovascular stimulant ANTI-ANXIETY AGENTSBenzodiazepines, Barbiturates, and Narcotic Analgesics ALL produce SEDATION and can cause physiologic dependenceFlumazenil (Mazicon)- benzodiazepine ANTAGONIST used to reverse residual effect of benzodiazepines in event of an overdose Tranquilizer- drug promoting tranquility by calming, soothing, quieting without sedation or depressant effects Benzodiazepines (Minor Tranquilizers)- used as oral preparations to alleviate anxiety, induce sleep, anti-convulsant, and skeletal muscle relaxantUsed for IV conscious sedation during outpatient surgery Produce calming effects by depressing limbic system and reticular formation through potentiation of central neurotransmitter GABA Adverse Effects= CNS depression, GI disturbances, hypotension, ataxia, and muscle relaxation Benzodiazepines taken orally as Tranquilizers= Chlordiazepoxide, Lorazepam, Alprazolam, and DiazepamBenzodiazepines prescribed as Hyponotics for Insomnia= Flurazepam, Temazepam, and TriazolamTriazolam (Halcion)- pre-op sedative in dentistry metabolized in liver by P450 isoform CYP 3A4 enzymeAntifungal agents can significantly elevate triazolam serum levels causing toxicity with therapeutic dosesMidazolam- for pre-op sedation in children, and as an injectable for IV conscious sedation Diazepam (Valium): treats anxiety, nervous tension, muscle spasm, and seizures/convulsionsLess addiction potential, and produces less profound CNS depression Affects limbic system of brain Indications= agent of choice to reverse status epilepticus If given IV for status epilepticus, use a LARGE VEIN to decrease risk of thrombophlebitisContraindications= acute narrow-angle glaucoma and psychoses Adverse Effects= drowsiness and fatigue, produces amnesia, can be locally irritating to tissue, and can produce local thrombophlebitis*Diazepam is drug of choice to treat lidocaine-induced seizures Buspirone: minor tranquilizer orally administered anxiolytic whose mechanism works by DIMINISHING SEROTONERGIC ACTIVITYDoes not have anti-convulsant or muscle relaxant properties, does not impair psychomotor function or cause sedation or physical dependence Special Characteristics-Slow onset of actionMost likely acts as a partial agonist on certain 5-hydroxytryptamine receptors, and diminishes serotonergic action Low abuse potential Does not possess hyponotic or anti-convulsant properties Side effects= limited to restlessness, dizziness, headache, nausea, diarrhea, and paresthesiaEthyl Alcohol (Ethanol): causes a well-marked DIURESIS by inhibiting production of ADH Dilates blood vessels in skin, depresses CNSAlcohol euphoria results from removal of inhibitory activity of cortex Disulfiram (Antabuse): used to manage ETHANOL ABUSEDeters ethanol consumptionInterfere with hepatic oxidation of acetaldehyde metabolized from alcohol by inhibiting ALDEHYDE DEHYDROGENASEBarbiturates: hypontics/sedatives that depress neuronal activity by increasing membrane ion conductance, reducing glutamate-induced depolarizations, and prolonging inhibitory effects of GABAPrimary effects of barbiturates is to DEPRESS NERVOUS TISSUE depress neuronal activity in midbrain reticular formation, facilitating and prolonging inhibitory effects of GABA and GlycineMetabolized in liver, and possess serious drug dependence potential DURATION OF ACTION:Ultra-short acting Barbiturates: used IV to induce general anesthesiaBrief duration of general anesthetic action is due to rapid rate of redistribution from CNS to peripheral tissues Short-acting Barbiturates: used orally for their hypnotic, calming effect to treat insomniaGiven pre-op before a dental apt to relieve anxiety Intermediate-acting Barbiturates: may be prescribed to relieve anxiety before dental apt, used for daytime sedation and to treat insomnia by suppressing REM sleepLength of hypnotic action= 3-6 hours Long-acting Barbiturates: treats mainly daytime sedation and epilepsyLeast lipid soluble- longest duration of actionMetabolized in liverLength of hypnotic action= 6-10 hours Phenobarbital: used as a sedative-hypnoticBarbiturates may decrease half-lives of those drugs metabolized by liver by inducing formation of liver’s microsomal enzymes that metabolize drugs increased clearance of affected drugs and decrease in drug’s effectivenessCause of death from ACUTE barbiturate poisoning or overdose is respiratory failure Contraindicated in patients with respiratory disease or pregnant patients CARDIOVASCULAR AGENTS ANTI-ARRHYTHMICS AGENTS- most drugs that treat cardiac arrhythmias act primarily by increasing refractory period of cardiac muscleSodium Channel Blockers- further classified based on effects on “action potential duration”Group 1A- Quinidine, Procainamide, Amiodarone, and Disopyramide PROLONG action potential Quinidine used to treat supraventricular tachyarrhythmias Group 1B- Lidocaine, Mexiletine, and Tocainide SHORTEN action potentialGroup 1C- Flecanide, Moricizine, and Propafenone do not effect action potential duration Lidocaine (Xylocaine)- sodium channel blocker ANTI-ARRHYTHMIC AGENT effective ONLY on ventricleActs on fibrillating ventricles to decrease cardiac excitability and spares atria Quinidine- sodium channel blocker and PROTOTYPE anti-arrhythmic agent used to treat A.fibDisopyramide (Norpace)- newer anti-arrhythmic agent used to convert atrial arrhythmias into normal sinus rhythm Propafenone (Rythmol)- used to treat ventricular arrhythmias and supraventricular tachycardias Beta-Adrenergic Blockers- Propranolol and Esmolol are prototype anti-arrhythmic beta-blockersReserved for patients who only require control of ventricular rate during atrial tachyarrhythmisPotassium Channel Blockers- AmiodaroneBlocks Na+ channelsAmiodarone is the most potent and “broad-spectrum” anti-arrhythmic compound availableBlocks Na+, Ca+2, K+ channels, and beta receptors Calcium Channel Blockers- useful as anti-anginal agents to treat chronic stable angina pectoris by blocking Ca+2 entry through membranous calcium ion channels of cardiac and vascular smooth muscle, causes 2 effects:Peripheral arterioles dilate and total peripheral resistance decreases Increases oxygen delivery to myocardium Ca+2 channel blockers are associated with causing gingival hyperplasia ANTI-HYPERTENSIVE AGENTS- lower BP by reducing total peripheral resistance and cardiac outputDiuretics- inhibit Na+ reabsorption in renal tubular cells in kidney to cause excess Na+ and urinary excretion causing reduced blood volumeBeta-Adrenergic Receptor Blockers- reduce volume of cardiac output into circulation, causing reduced peripheral pressureCardioselective Beta Blockers- block beta 1 receptors in heart muscleNon-Cardioselective Beta BlockersACE Inhibitors- “inhibit” conversion of inactive Angiotesnin 1 Angiotensin 2Causes peripheral vasodilation and secondarily increases urinary volume excretion Calcium Channel Blockers- inhibit calcium from entering into vascular smooth muscle, to cause vasodilation of coronary and peripheral blood vessels, causing lower BP*Beta blocks are 1st choice for congestive heart failure before using Digoxin DIGOXIN- most versatile and widely used cardiac glycoside to treat atrial fibrillation and flutter, by causing a positive inotropic effect to directly increase force of myocardial contractionsIndications= supraventricular arrhythmias, atrial fibrillation and flutter, cardiogenic shock, and congestive heart failureAdverse Affects= appetite loss, nausea, vomiting, diarrhea, increased gag reflex and salivation Cardiac Glycosides Mechanism: inhibits Na+/K+ ATPase membrane pump in heart to increase intracellular sodium levels to reverse sodium-calcium exchanger ion reversal increases intracellular calcium causing decreased heart rate and increased heart contractility ANGINA PECTORIS- pain in heart and chest that occurs during occlusion of coronary arteries, triggered by physical exertion, increased BP, and vasoconstrictionAnti-anginal drugs prevent or provide relief of Angina PectorisNitroglycerin/Nitrostat (Nitrates): coronary artery vasodilator that relaxes blood vessels to provide increased blood flow and oxygenation to heart muscleSingle most effective anti-anginal agent available to manage acute angina episodes Fast acting and relieves acute anginal attacks Amyl Nitrite (Nitrites): vasodilator and highly volatile substance administered by INHALATIONUsed in emergency treatment of cyanide poisoning because it oxidizes hemoglobin into methemoglobinMost rapidly acting anti-anginal drug that produces effects within 10 secondsDipyridamole (Persantine): non-nitrate vasodilator that treats anginaVerampamil, Nifedipine, and Diltiazem: calcium channel blockers that prevent angina attacks by dilating coronary blood vessels to improve blood flow to heart muscle Propranolol, nadolol, and Atenolol: beta adrenergic blocker that prevent angina pectoris attacks by decreasing heart’s work load, so less oxygen is required Direct Vasodilators- exert anti-hypertensive effects by causing a direct vasodilator action on SMOOTH MUSCLE of arterioles, to produce a decrease in peripheral resistance and BPHydralazine (Apresoline)Minoxidil (Loniten)- extremely efficacious direct vasodilator for SEVERE HYPERTENSION Diazoxide (Hyperstat)- vasodilator used in hypertensive emergenciesSodium Nitroprusside- vasodilator used in hypertensive emergencies Nitroglycerin- vasodilator that treats angina pectoris and hypertension ACE Inhibitors & Angiotensin 2 Receptor Blocks- indirectly inhibit fluid volume increases when interfering with Angiotensin 2, because Angiotensin 2 stimulates release of Aldosterone, which promotes Na+ and H20 retention RENIN- proteolytic enzyme produced by and stored in juxtaglomerular apparatus in kidney that surrounds each arteriole as it enters glomerulus Released into bloodstream where it has an important role in ANGIOTENSIN FORMATION Converts Angiotensinogen Angiotensin 1 Angiotensin 2 Angiotensinogen 2- potent vasopressor that increases total peripheral resistance, and stimulates aldosterone release to cause an increase in plasma volume, venous return, stroke volume, and increase cardiac outputDIURETICS- antihypertensive agents used to treat congestive heart failure by relieving edema and symptoms of dyspnea from pulmonary congestion 4 types of widely used diureticsK+ Sparing Diuretics- cause Na+ and K+ concentrations at end of distal convoluted tubulesDiuretics act in collecting tubule to inhibit Na+ reabsorption, K+ secretion, and H+ secretion Hyperkalemia is most important toxic effect of K+ sparing diuretics Aldosterone Antagonists in Collecting TubulesSpironolactone- antagonist of aldosterone in collecting tubuleTreats primary aldosteronism and heart failure Competes with aldosterone receptor sites in renal tubules causing increased secretion of Na+, Cl, and H20Sodium Channel Blockers in Collecting Tubules Amiloride- blocks Na+2 channels in luminal membrane of principal cells in late distal tubule and collecting duct, which decreases K+ excretion Triamterene- K+ sparing diuretic that promotes Na+ and H20 excretionThiazide Diuretics- inhibit sodium reabsorption in distal portion of renal tubule within kidney causing increased excretion of Na+ and H20Most widely used diuretic drugs to treat hypertensionDyazide- combines K+ sparing diuretics with HCTZ for greater efficacy Metolazone- oral quinazoline and sulfonamide diuretic to manage edema and hypertensionProduces diuresis in patients with impaired renal function Indapamide- oral antihypertensive and diuretic Used in advanced renal failure Metabolized and excreted by GI tract and kidneys Major Actions:Inhibits NaCl resorption from luminal side of epithelial cells by inhibiting Na+/Cl co-transporter/symporter on membrane Inhibits NaCl transport in early segment of distal convoluted tubuleIncreases concentration of Na+ and Cl- in tubular fluid Thiazides Treat:HypertensionEdema of congestive heart failureRenal edema (nephrotic syndrome)Hypercalciuria Nephrogenic Diabetes InsipidusAdverse EffectsHypokalemia is most popular and can predispose patients on digitalis to ventricular arrhythmiasHyperuricemia Hypercalcemia- inhibits Ca+2 secretion causing increased Ca2+ in bloodLoop (High-Ceiling) Diuretics- inhibit Na+K+ 2Cl- symport or cotransportInhibit reabsorption of Na+ and chloride in ascending Loop of Henle to cause increased secretion of H20, Na+, and ClFurosemide is the prototype loop diureticMechanism of Action: increase Ca+2 content of urineCause decreased renal vascular resistance and increased renal blood flowTherapeutic uses: acute pulmonary edema of CHF, loop diuretics are DRUG OF CHOICE Adverse Effects: ototoxicity as tinnitus, hearing impairment, deafness, vertigo, and sense of ear fullness Hyperuricemia, acute hypovolemia, increased plasma LDL cholesterol and triglycerides, and decrease HDLSkin rashes, photosensitivity, paresthesias, K+ depletion, and bone marrow depression Osmotic Diuretics- highly filtered by glomerulus and exerts a solute-induced diuresis in proximal tubuleUsed to reduce excess edema associated with neurosurgery or trauma to CNSMannitol- treats cerebral edema, increases delivery of Na+2, and water out of loop of Henle, must be given via IVOsmotic diuretics are used to maintain urine flow after acute toxic ingestion of substances capable of producing acute renal failure; treat patients with increased intracranial pressure, or acute renal failure due to shock, drug toxicities, and trauma CORTICOSTEROIDS (STEROIDS)- steroid hormones produced by ADRENAL CORTEX that do NOT cure any disease Treat asthma, arthritis, allergic reactions, Addison’s Disease, Lupus Erythematosus, Aphthous Stomatitis, and TMJ pain Mineralocorticoids- regulate Na+ and K+ reabsorption in kidney’s collecting tubules Aldosterone- MAJOR natural mineralocorticoid secreted by cells in zona glomerulosa of adrenal cortex Secretion is regulated by ACTH and renin-angiotensin systemImportant in regulating blood volume and blood pressure, and promotes Na+ reabsorption into blood from glomerular filtrate Decreased Na+ concentration causes juxtaglomerular cells of kidneys to secrete RENIN which converts angiotensinogen angiotensin 1Addison’s Disease- caused by hyposecretion of aldosterone and cortisol Pharmacological Effects of Mineralocorticoids= increase Na+ retention and decrease K+Contraindications= latent TB, herpes, or fungal infections, AIDS; can cause peptic ulcers Adverse Reactions= Cushing’s Syndrome, hyperglycemia, osteoporosis, peptic ulcers, and increased risk of infectionGlucocorticoids- important effects on carbohydrate, lipid, and protein metabolism, catabolism, immune responses, and inflammation Induce synthesis of a protein that inhibits phospholipase A2 decreases production of prostaglandins and leukotrienes Cortisol (Hydrocortisone)- MAJOR glucocorticoid that treats Addison’s diseaseSynthetic Glucocorticoids= Prednisone and Prednisolone, Methylprednisoline, Dexamethasone and TriamcinoloneBeclomethasone, Budesonide, and Flunisolide= special glucocorticoids to treat chronic asthma and bronchial disease by penetrating airway mucosa Fluticasone (Flonase or Flovent)- corticosteroid administered by inhalation to treat asthma by decreasing inflammation in airway of asthmaticsInhaled steroids often cause fungal infections of mouth and throatPharmacological Effects of Glucocorticoids=Decrease in glucose utilization and inhibits protein synthesisIncreases protein catabolism and gluconeogenesisImpaired wound healing and decreased resistance to infectionAnti-inflammatory action, immunosuppression, and anti-allergenic action HMG-CoA Reductase Inhibitors (“Statin” Drugs)- drugs that LOWER BLOOD CHOLESTEROL levels of inhibiting hydroxyl methylglutaryl coenzyme A reductase“Statin” Drugs= Atorvastatin (Lipitor), Simvastatin (Zocor), Fluvastatin (Lescol), Lovastatin (Mevacor), and Prevastatin (Pravachol)Coronary Artery Disease: condition of narrowing of heart’s blood vessels, restricting oxygen flow to heart muscleCorrelated with levels of blood cholesterol and triglycerides Patients medicated with statins are advised to NOT take erythromycinANTI-DEPRESSANTS5 Major Categories of Antidepressant Drugs:Tricyclic AntidepressantsMonoamine Oxidase InhibitorsSelective Serotonin Reuptake InhibitorsSerotonin & Norepinephrine Reuptake InhibitorsSecond Generation Miscellaneous Amitriptyline (Elavil)- most widely used TRICYCLIC ANTI-DEPRESSANT to treat depressionTricyclics inhibit neuronal reuptake of NE and serotonin in brain results in potentiation of their neurotransmitter actions at post-synaptic receptors Most common CNS adverse reaction= drowsiness Antidepressants have HIGHEST incidence of xerostomia due to secondary anti-cholinergic nature EPI in local anesthetic must be cautiously used in patients taking antidepressants, Serotonin and NE reuptake inhibitors to avoid transient and significant increases in blood pressure Monoamine Oxidase (MAO) Inhibitors- treat depressionAnatagonize action of monoamine oxidase responsible for degrading naturally occurring monoamines (EPI, NE, dopamine, and Serotonin)Increased levels of monoamines in brain is responsible for anti-depressant effect of MAO inhibitors Local anesthetics containing EPI are contraindicated in patients taking MAO inhibitors Lithium- current drug of choice to treat MANIC PHASE of bipolar disorder Bipolar disorder is characterized by cyclical changes in affective state between manic and depressive phases of behavior Used mainly to suppress recurrences of manic phase of bipolar disorderNeuroleptic Agents (Anti-Psychotic Agents or Major Tranquilizers)- treat ACUTE manic episodes Chlorpromazine and Haloperidol are effective in quelling extreme mania and psychotic behavior Selective Serotonin Reuptake Inhibitors (SSRIs)- have very high specificity for blocking the reuptake of serotonin; increase activity of serotonergic systems in the brainFluoxetine (Prozac)- SSRI with LONGEST half-life. Treats obsessive compulsive disorder and depressionParoxetine (Paxil), Sertraline (Zoloft), and Fluvoxamine (Luvok)- have short half-lives, and given once dailyAlso effective for treating panic attacks, depression, and obsessive-compulsive disorderCitalopram (Celexa) & Escitalopram (Lexapro)- treat depression and anxietyANTI-PSYCHOTICS- indicated to treat “psychosis” associated with schizophrenia, paranoia, and manic symptoms of manic-depressive illness Phenothiazines: most widely used and most effective group of antipsychotic agents that have antipsychotic effects and neuroleptic effectsHas ability to BLOCK DOPAMINERGIC SITES in brain Most effective antiemetic agents that depress chemoreceptor trigger zone to reduce nausea and/or vomiting Pharmacologic actions are sedation, anti-emetic activity, alpha adrenergic receptor blockage, and potentiate action of narcoticsContraindications= patients with severe CNS depression or epilepsy Adverse effects= hypotension, liver toxicity, dry mouth, tardive dyskinesia Tardive Dyskinesia- serious, irreversible neurological disorder that can appear at any age; side effect of antipsychotic/neuroleptic drugsMuscle spasms of oral-facial region is an extrapyramidal syndrome caused by Phenothiazine-type antipsychotics Thioxanthenes: Chlorprothixene and Thiothixene are a less potent group of antipsychotics that treat SchizophreniaButyrophenones: Haloperidol and Droperidol are highly effective antipsychotic drugs that treat Schizophrenia and Tourette’s SyndromeDiverse Heterocyclic Antipsychotics: agents that antagonize dopamine and serotonin in the brain Effectively treat Schizophrenia and are more effective and less toxic than older drugsANTI-HISTAMINES- antagonizing agents that compete with natural histamine for H1 & H2 receptor sites Found in all tissuesStored in cytoplasmic granules of tissue mast cells and blood basophils Histamine is released in response to IgE-mediated allergic and inflammatory reactions Histamine plays an important role in hay fever, urticaria, angioneurotic edema, and in controlling stomach acid secretion H1 Receptor Antagonists: competitively block H1 receptors, blocking effects of histamine at these receptors H1 antagonists block vasodilation, block bronchi constriction, and block capillary permeability Antihistamines located at H1 receptor site:1st-Generation (Classic) H1 Blockers- Benadryl is most commonHave a broad spectrum of action that includes antihistaminic, anticholinergic, antisertonergic, antibradykinin, and sedative properties 2nd Generation H1 Blockers- Zrytec, Allegra, Claratin, ClarinexDue to poor CNS penetration, cause less sedation and drowsiness than 1st generation agents All H1 blockers do not prevent histamine release, but COMPETE with free histamine from binding at H1 receptor sites Both H1 and H2 antagonists can stimulate and depress CNS H2 Receptor Antagonists: important in HCl secretion by competitively blocking H2 receptors to block histamine’s effects at H2 receptorsBlock stomach acid secretions and treat duodenal ulcers by inhibiting histamine at parietal cellsH2 blockers reversible competitive antagonists of actions of histamine on H2 receptors Treat acid-peptic disease, Zollinger-Ellison Syndrome and GERDCimetidine (Tagamet)- antihistamine H2 receptor blocker likely to provoke interactions with hepatically metabolized drugsRanitidine (Zantac)- H2 receptor blocker that treats GERD by blocking effects of histamine at H2 receptors Famotidine (Pepcid) & Nizatidine (Axid)- H2 receptor blocker that blocks effects of histamine at H2 receptors Omeprazole (Prilosec) & Lansoprazole (Prevacid): GI drugs and proton-pump inhibitors that reduce stomach acid formation by inhibiting proton-pump of stomach’s parietal cells Proton-pump inhibitors and H2 blocks are used to treat heartburn, indigestion, sour stomach, active duodenal ulcer disease, and GERD Drugs that Reduce GI Motility to treat DIARRHEA:Loperamide (Imodium)- anti-diarrheal that acts on intestinal muscles to inhibit peristalsisOpioid that does not penetrate CNS Diphenoxylate with Atropine (Lomotil)- anti-diarrheal that inhibits excessive GI tract motility and propulsion*Laxatives act in REVERSE manner of anti-diarrheals by increasing GI tract motility to treat constipation ANTACIDS- neutralize excess stomach acid by a chemical reaction Aluminum Hydroxide- MOST POTENT ANTACID. Antacid therapy is directed at decreasing concentration and total load of gastric acid Aluminum Salts used as antacids- hydroxide, carbonate, phosphate, and aminoacetateDyspepsia- impairment of power or function of digestion ANTI-CONVULSANTS (ANTI-EPILEPTICS)Epilepsy: neurological disorder characterized by sudden, recurring attacks of motor, sensory, or psychic malfunction with or without loss of consciousness or convulsive seizures. Goal of anti-convulsant therapy is to reduce/eliminate seizuresCarbamazepine (Tegretol)- used as prophylaxis for partial seizures with complex symptomatology Also treats tonic-clonic seizures, and pain associated with trigeminal neuralgia by blocking Na+ channelsDiazepam (Valium)- treats STATUS EPILEPTICUS and emergency treatment of seizures Ethosuximide (Zarontin)- preferred drug for effectively treating absence seizures because it causes minimal sedation by BLOCKING CALCIUM CHANNELSGabapentin (Neurontin)- used as an adjunct to treat partial seizures Phenytoin (Dilantin)- treats grand mal seizuresProduces Na+ channel blockade Most extensively used of all anti-epilepticGingival hyperplasia is a common adverse effectValproic Acid (Depokote or Depakene)- effectively treats complex partial seizures Functions by causing neuronal membrane hyperpolarization*Most widely used anti-convulsants are CNS depressants PARKINSON’S DISEASE: slowly progressing, degenerative disorder of nervous system with distinguishing features= tremor when at rest, sluggish initiation of movements, and muscle rigidity nerve cells in BASAL GANGLIA DEGENERATE, causing decreased dopamine production Carbidopa- used to treat Parkinson’s disease, but only works when combined with LevodopaInhibits peripheral decarboxylation of levodopa to reduce peripheral side-effects and allow more levodopa to reach the brain Levodopa- in combo with carbidopa, is precursor of dopamine and MAIN TREATMENT for Parkinson’s DiseaseBromocriptine (Parlodel) & Pergolide- dopamine agonists given to enhance levodopa’s action Selegiline (Eldepryl)- selective inhibitor of MAO Type BAmantadine (Symmetrel)- anti-viral agent that enters CNS to treat Parkinson’s disease by potentiating dopaminergic responsesAnticholinergic drugs- Benztropine & TrihexyphenidylANTIBIOTICSSulfonamides (“Sulfa Drugs”): BACTERIOSTATIC agents similar to PABABacteria require PABA to synthesize folic acid needed to synthesize bacteria cellular components for bacterial cell growthSulfonamides COMPETE with PABA to inhibit PABAs actions, preventing bacterial folic acid synthesis to inhibit cellular growth Used primarily to treat UTIsBactrim- brand of combing Trimethoprim + Sulfamethoxazole; drug of choice for UTIs3 Allergic Reactions to Penicillin: RASH is most common sign/manifestation of an allergy to penicillin Acute/Immediate Onset Reactions (Anaphylactic Shock): occurs within 30 min and is IgE mediated Characterized by= urticaria, angioedema, bronchoconstriction, GI disturbances, and shock Cephalosporins are contraindicated for penicillin-allergic patients with immediate-type reactionsAccelerated Allergic Reaction: occur 30-48 hours after admin of penicillinManifestations are urticaria, pruritus, wheezing, mild laryngeal edema, and local inflammatory reactionsDelayed Allergic Reaction (Skin Rash): occur after 2-3 daysMost allergic reactions with penicillin are “delayed” and manifested by mild skin rashes Probenecid (Benemid): co-administered with antibiotics to DELAY RENAL CLEARANCE of antibiotic to elevate and prolong antibiotic’s serum concentrations when high tissue concentrations are necessary given concurrently with natural penicillins to increase their blood levels affects most cephalosporins, natural penicillins, and other beta-lactam related antibiotics like Aztreonam and ImipenemINHIBITS renal tubular cell secretion that raises penicillin blood levels by diminishing their tubular secretion DRUG OF CHOICE TO TREAT GOUTImpipenem- beta-lactam derived from ThienamycinDrug of choice for infections due to EnterobacterUsually combined with Cilastin and treats severe or resistance infections, esp nosocomial infectionsAztreonam- parenteral synthetic beta-lactam antibiotic Therapeutic Management of GOUT:Colchicine- reduces inflammation during acute attacks by impairing leukocytic migration to inflamed areas, and disrupts urate deposition and inflammatory response Most effective when given 12-36 hours after symptoms begin Adverse Effects= severe liver and kidney damageIndomethacin (NSAIDs) are important for treating acute gouty arthritis Allopurinol (Zyloprim)- decreases uric acid productionDrug of choice for managing CHRONIC GOUT by inhibiting xanthine oxidaseProbenecid (Benemid) & Sulfinpyrazone (Anturane)- uricosuric agents that enhance uric acid clearance by acting in kidney’s proximal convoluted tubules PENICILLINS: BACTERICIDAL by inhibiting cell-wall synthesis Have high incidence of allergic reactions NOT active against viruses, fungi, Rickettsiae, or other nonbacterial organisms All penicillins are DERIVATIVES of 6-aminopenicillanic acid and contain a beta-lactam ring structure connected to a thiazolidine ring Most penicillins are directly EXCRETED INTO URINE via renal tubular cell secretionPenicillin VK- associated with highest incidence of drug allergy Antibiotic of choice for treating non-penicillinase producing gram + staph infectionsNaturally occurring penicillin preferred for treating oral infections because it is more acid stableCan be used in pregnant patients Penicillin G- PROTOTYPE penicillin; needs to be given via an IM injectionCarbenicillin- WIDEST spectrum of antibacterial activity Used to treat UTIs and other infections caused by susceptible gram (-) Pseudomonas species and Proteus speciesDegraded in stomach acid, so must be given via IVAminopenicillins (Ampicillin, Amoxicillin, Becampicillin)- inhibit bacterial cell wall synthesis Characterized by amino substitution of Penicillin G, allowing for them to penetrate/work against many gram (-) bacteria more readily than natural penicillins or penicillinase-resistant penicillinsNot stable to beta-lactamases or either gram (+) or (-) bacteriaNOT penicillinase resistant Useful for treating upper respiratory infectionsAmpicillin- aminopenicillin with a broader spectrum of action than penicillin VKGiven orally or IV to treat infections like otitis media, bronchitis, sinusitis, and acute bacterial cystitis caused by susceptible organisms Preferred agent to cause UTIs caused by enterococci“Parenteral” ampicillin is drug of choice for patients unable to take oral medications and who are not allergic to penicillin for prophylaxis for bacterial endocarditis Amoxicillin- extended spectrum of action including aerobic gram (+) cocci and anaerobes, and some gram (-) bacilliHigh oral absorption, high serum levels, long half-liveDrug of 1st choice for standard general prophylaxis med in a patient NOT allergic to penicillin with TOTAL JOINT REPLACEMENT- 2gm orally 1hr prior to dental treatment Given orallyMethotrexate has a significant drug interaction with Amoxicillin may cause ulceration of oral tissues Bacampicillin- used to treat upper and lower respiratory tract infections, UTIs, and skin and skin structure infectionsBeta-Lactamases- enzymes produced and secreted by a wide range of gram (+) and gram (-) bacteria Destroy beta-lactam nucleus within antibiotics by splitting open the beta-lactam ring structure to render antibiotic ineffective Cephalosporinases- beta-lactamases that work against cephalosporins Penicillinases- enzyme secreted by bacteria that splints open beta-lactam ring to render penicillin molecule ineffective against penicillinase secreting bacteria Penicillinase Resistance Penicillins: Beta-Lactamase Inhibitors: highly effective against penicillinase-producing Staphylococcal aureus Methicillin- action only to gram (+) cocci like Staphylococcus bacteriaDegraded in stomach acid, so must be given via IVPrescribed primarily to treat severe penicillinase-producing Staph infectionMRSA- group of resistant staph bacteria that can be life-threatening and resist ALL penicillinase-resistant penicillins and cephalosporinsAugmentin- Amoxicillin + Clavulanate potassiumBlocks actions of penicillinase from reaching beta-lactam ringUansyn- Ampicillin + SulbactamBlocks actions of penicillinase from reaching beta-lactam ringDicloxacillin- active against penicillinase producing staph*Carbenicillin, Piperacillin, and Ticarcillin have the WIDEST spectrum of all penicillinsCLINDAMYCIN: BACTERIOSTATIC antibiotic effective against most STAPHYLOCOCCI, AEROBIC & ANEROBIC STREPTOCOCCI, but MOST EFFECTIVE in treating infections due to BACTERIOIDES SPECIES Binds 50S ribosomal subunit, blocking bacterial protein synthesis Adverse Side Effects: severe diarrhea & abdominal pain/GI upset due to Pseudomembranous colitisIn dentistry is an alternate antibiotic when amoxicillin cannot be used to prevent bacterial endocarditis Treats oral infections and penetrates into boneBacterial Endocarditis Prophylaxis is Recommended:High-Risk: Prosthetic cardiac valvesPrevious bacterial endocarditisComplex Cyanotic Congenital Heart DiseaseSurgically constructed synthetic pulmonary shunts or conduitsModerate-Risk:Most other congenital cardiac malformationsAcquired valvular dysfunctionHypertropic cardiomyopathyDental Procedures= extractions, perio procedures, implant placements of avulsed teeth, endo instrumentation past apex, subgingival placement of antibiotic fibers/strips, initial placement of ortho bands (not brackets), prophylactic cleaning of teeth or implants where bleeding is anticipated Bacterial Endocarditis Prophylactic is NOT required:Isolated atrial or ventricular septal defects, or patent ductus arteriosusCoronary Artery Bypass Graft SurgeryRheumatic Heart DiseaseMitral valve prolapseHeart murmurs Kawasaki disease without valvular dysfunction and bicuspid valve disease Cardiac pacemakers Calcified aortic stenosis *NO antibiotic prophylaxis for patients with non-valvular devices unless 2-3 weeks after surgery and healing is still occurring*Antibiotic prophylaxis is NOT indicated for dental patients with PINS, PLATES, and SCREWS, nor is it routinely indicated for most dental patients with total joint replacements *ALL patients during first 2 years after joint replacement require antibiotic premedication *If unanticipated bleeding occurs, administer an antimicrobial prophylaxis within 2 hours after procedure *If a series of dental procedures is required: observe an interval of 9-14 days between procedures to reduce potential for emergence of resistant organisms TETRACYCLINES: bacteriostatic antibiotics that acts by INHIBITING BACTERIAL PROTEIN SYNTHESIS in bacterial cell by binding to 30S-subunit of bacterial ribosome 1st choice to treat mycoplasma pneumonia, chlamydia infections, rickettsial infections, and vibrio infectionsGood alternatives to penicillin for patients with ANUGMinocycline- treats acne, anthrax, and meningococcal prophylaxisDoxycycline- treats syphilis, rickettsia infections, Chlamydia, and mycoplasma infectionsDemeclocyclineInfections/TreatmentsMedical infections caused by susceptive gram (+) & gram (-) bacteriaInfections caused by Mycoplasma, Chlamydia, or RickettsiaExacerbations of chronic bronchitisAcne, gonorrhea, and syphilis in patients allergic to penicillinPeriodontitis associated with ActinobacillusARREST RAPID BONE LOSS associated with juvenile periodontitis via tissue regeneration and enhanced repair due to their collagenase inhibiting effect Absorption from GI tract is inhibited by divalent and trivalent cations (Ca+2, Mg+2, Fe+2, Al+3)Don’t give with milk or dairy products, iron supplements, or antacidsCan stain teeth from 6-months in utero until 7-8 years oldAdverse Effects: photosensitivity, nausea, diarrhea, fungal infections, teeth discoloration, and enamel hypoplasia in young children; occurrence of superinfections caused by Candida albicans MACROLIDES: inhibit protein synthesis Erythromycin- 2nd choice bacteriostatic agent to penicillins to treat oro-dental infections caused by aerobic gram (+) bacteria Oral bioavailability is poor- readily inactivated by stomach acidUsually have ENTERIC coating Metabolized in liver, and excretion via bileBinds to 50S ribosomes causing inhibition of protein synthesis Clarithromycin & Azithromycin- similar to Erythromycin, but possess greater intrinsic activity against H. influenzae CEPHALOSPORINS: BROAD-SPECTRUM & BACTERICIDAL antibiotics that inhibit bacteria cell wall synthesis during cell division Act against a wide range of gram (+) & gram (-) bacteriaUsed in penicillin allergic patients with Staphylococcal infections 4 generations: progressions from 1st to 4th generation is associated with a broadening of action against more gram (-) bacteria and decreased activity against gram (+) bacteria1st generation Cephalosporins: Cephalexin (Keflex), Cephradine (Velosef), Cefadroxil (Duricef), Cefazolin (Ancef)Used to prevent bacterial endocarditis in patients with a history of non-immediate allergic reactions to penicillinCephalexin and Cephradine are drugs of 1st choice for standard prophylaxis medication in a patient NOT allergic to penicillin with a TOTAL JOINT REPLACEMENT 2nd generation Cephalosporins: Cefaclor (Ceclor), Cefuroxime (Ceftin), Cefoxitin (Mefoxin) & CefprozilTreats oro-dental infections caused by gram (+) & (-) aerobic bacteria3rd generation Cephalosporins: Cefixime (Suprax) and Cefoperazone (Cefobid)4th generation Cephalosporins: Cefepine (Maxipime)AMINOGLYCOSIDES: bactericidal antibiotics used primarily to treat AEROBIC-GRAM (-) infections Irreversible bind to 30S ribosomal subunit to inhibit protein synthesis Reserved to treat more serious bacterial infections due to 2 well-known adverse effects ototoxicity and nephrotoxicity May aggravate muscle weakness in patients with muscular disorders like myasthenia gravis, infant botulism, or parkinsonismMust be administered IM or IV to produce a systemic effect Bacitracin- inhibits bacterial cell wall synthesis, gram (+) activity; administered topicallyPolymyxin B- administered topically, only active against gram (-) rods= PSEUDOMONAS Chloramphenicol (Chloromycetin): broad-spectrum antibiotic that can cause BONE MARROW DISTURBANCES Effective against gram (+) and gram (-) bacteria and anaerobesBacteriostatic antibiotic that reversibly binds to 50S ribosome Causes 3 major toxicities:Aplastic anemiaBone marrow suppressionGray Syndrome characterized by circulatory collapse, cyanosis, acidosis, coma, and death TUBERCULOSIS: bacterial infection caused by MYCOBACTERIUM TUBERCULOSISCombination drug therapy is standard in treating tuberculosisAnti-tubercular drugs:Rifampin- prevents transcription by inhibiting bacterial DNA dependent RNA polymerase MOST POTENT ANTI-LEPROSY AGENTIsoniazid- given in a 4 drug regimen along with Rifampin, Pyrazinamide and EthambutolAdverse Effects= Periphreal neuritis caused by vitamin B6 deficiency and fatal hepatitis Pyrazinamide- enters CSF to treat tuberculosis meningitisEthambutol- given in combination with other agentsAdverse Effects= optic neuritis, hyperuricemia, and color vision disturbances Streptomycin- given in combination with IsoniazidRifabutin- active against MAI complex ANTI-MALARIA AGENTS: malaria is a disease due to infection by protozoa genus plasmodiumMefloquine- treats malaria caused by Plasmodium falciparum, P. vivax malariae, and P. ovaleActive along against multi-drug resistant Plasmodium falciparum Chloroquine- eradicates RBC forms by inhibiting plasmodial heme polymerase, and damages parasitic membranes by lysing the RBC and parasite Treats erythrocytic forms of Plasmodium falciparum and Plasmodium vivax Quinine- back up agent for chloroquine used in combination with FansidarAdverse Effect= cinchonism (nausea, vomiting, vertigo, tinnitus)Atovaquone + Proguanil (Malorine)Sulfadoxine + Pyrimethamine (Fansidar)HalofantrinePyrimethamine- folate antagonist active against P. falciparum, P. malariae, and Toxoplasma gondii ANTI-FUNGALSMycoses- chronic fungal infectionsSuperficial, or can infiltrate skin to cause subcutaneous infectionsAntifungal agents are used to treat systemic and subcutaneous fungal infectionsCandidiasis- fungal infection that causes an inflammatory, pruritic infection characterized by a thick, white discharge Common in patients with immune deficiency in T-lymphocytes, receiving chemotherapy, and immunosuppressed/AIDS patients Nystatin: drug of choice for treating oral cavity CandidiasisUsed as a “swish and swallow”Taken as an oral suspension Clotrimazole (Mycelex Troche): anti-fungal taken as a troche (lozenge); treats oropharyngeal Candidiasis by altering fungal cell membrane Nystatin and Clotrimazole work by binding to sterols in fungal cell membrane, increasing permeability and permitting leakage of intracellular components TOPICAL Anti-FungalsAmphotericin-B: given to treat severe systemic fungal infections caused by fungi; alters fungal cell’s membraneKetoconazole (Nizoral): inhibits Ergosterol synthesis to disrupt fungal membrane Given orally to treat Histoplasmosis, Nonmmeningeal coccidioidomycosis, Blastomycosis, Dermatomycosis Adverse Effects= toxicity causes endocrine effects by inhibiting cortisol and testosterone synthesis SYSTEMIC Anti-Fungal Agents:Fluconazole (Diflucan): inhibits ergosterol synthesisGiven orally or IV, crosses Blood-brain barrierDrug of choice for= mucosal candidiasis; treats blastomycosis, histoplasmosis, and Cryptococcal meningitis in AIDS patients Ketoconazole: used to treat oral, esophageal, and oral esophageal Candida infections by inhibiting ergosterol synthesis to disrupt fungal membrane Amphotericin-B: treats severe systemic fungal infections (mycoses) caused by fungi Associated with high incidence of kidney toxicity Itraconazole: inhibits ergosterol synthesis; DRUG OF CHOICE for Blastomycosis and ParacoccidioidomycosisFlucytosine: PRODRUG that inhibits fungal DNA and RNA synthesis and cell divisionTreats systemic mycosis by Chromoblastomycosis, Candidiasis, and Cryptococcus ANTI-PROTOZOALSNitazoxanide- treats DIARRHEA caused by GIARDIA LAMBLIA and protozoal infections caused by Cryptosporidium Parvum Diarrhea is known as Giardiasis Mechanism is interfering with electron transfer reaction that is essential to anaerobic metabolismAtovaquone (Mepron)- treats Pneumocystitis Carnii Pneumonia Co-trimoxazole is drug of choice for pneumocystis carinii pneumonia by inhibiting folic acid synthesis Eflornithine- treats meningoencephalitic stage of Trypanosoma Brucei Gambiense infection (sleeping sickness)Furazolidone (Furoxone)- treats diarrhea caused by Giardias Lamblia and Vibrio Chlorerae Metronidazole- synthetic antibacterial and antiprotozoal effective against Trichomonas Vaginalis that causes TrichomoniasisOne of most effective drugs available against anaerobic bacterial infectionsANTI-VIRALSViruses- double or single stranded DNA or RNA enclosed in a capsid; lack a cell membrane, wall, and metabolic machinery OBLIGATE INTRACELLULAR PARASITES Anti-Viral Medications:Penciclovir- agent active against Herpes Simplex Virus Type 1Indicated to treat recurrent herpes labialis in adults Inhibits viral action by selectively inhibiting herpes viral DNA synthesis that inhibits viral replication Acyclovir- inhibits viral DNA polymerase/viral DNA synthesis Treats HSV-1, HSV-2, and varicella zoster Drug of choice for HSV Encephalitis, genital herpes, herpes labialis, and VZVGanciclovir- inhibits viral DNA polymerase/viral DNA synthesisTreats Cytomegalic Retinitis and CMV prophylaxis in transplant patients Docosanol cream (Abreva)- anti-viral agent treating Herpes Labialis (cold sores)AIDS: major cellular defect caused by HIV infection is DEPLETION OF T-CELLSHIV is a RETROVIRUS responsible for fatal illness from AIDS HIV Drugs= Didanosine, Zidovudine, Ritonavir, IndinavirWork by inhibiting steps in HIV infection process within target cells to stop immune system destruction by HIV retrovirus HIV Protease Inhibitors= Ritonavir, Amprenavir, Indinavir, nelfinavir, SuquinavirAll inhibit aspartate proteases requires to produce structural proteins and enzymes necessary for viral replication Contraindicated with patients taking RifampinNucleoside Reverse Transcriptase Inhibitors= Zidovudine, Zalcitabine, Didanosine, Stavudine and LamivudineAll are converted into AZT-triphosphate analogs in cells to inhibit viral DNA synthesis and replication by inhibiting reverse transcriptase Non-Nucleoside Reverse Transcriptase Inhibitors= Nevirapine, Adefovir, Efacirenz, and DelaviridineNon-competitive inhibitors of HIV reverse transcriptase that inhibit the catalytic reaction of reverse transcriptase independent of nucleotide bindingInterferon- natural glycoproteins synthesized by recombinant DNA technology to activate host enzymes to block viral RNA translation, and interfere with ability of viruses to infect cells Treatment of Viral Respiratory infections:Amantadine & Rimantadine- anti-viral agents that inhibit/block viral membrane matrix protein “M2” ion channelUsed for prophylaxis or early treatment of Influenza “A” virusAmantadine enters CNS to treat Parkinson’s diseaseRibavirin- inhibits viral mRNA synthesisTreats serious RSV infections in infants/young children, influenza A&B, Acute Hepatitis C, and SARS NSAID’s (NON-STEROIDAL ANTI-INFLAMMATORY DRUGS)NSAID’s- have anti-inflammatory effects due to their ability to inactivate the enzyme “prostaglandin endoperoxide synthase” (cyclooxygenase)Enzyme inactivation inhibits the cyclooxygenase step of the arachidonic acid cascade, reducing local prostaglandin synthesis Have anti-inflammatory, analgesic, and antipyretic actionsProstaglandins are derived from the unsaturated fatty acids in cell membranes Most NSAIDs work best for mild to moderate pain NSAIDs “reversibly” reduce platelet aggregation Cyclooxygenase (COX): enzyme that produces prostaglandins COX-1 enzyme: produces prostaglandins in GI tractTraditional NSAIDs inhibit the COX-1 and COX-2 enzymes to diminish formation of protective prostaglandins reduce pain and inflammation Propionic Acid Derivations: Ibuprofen (Motrin, Advil, Nuprin, Rufen)- has anti-inflammatory properties by inhibiting prostaglandin synthesis/production in peripheral tissues at sites of pain and inflammation Inhibiting prostaglandin production decreases inflammatory response at sites of surgery, injury, or infection, resulting in reduction of perceived pain Ibuprofen may interact with Warfarin to cause unnecessary bleeding Naproxen/Anaprox/Naprosyn (Aleve)- potent anti-inflammatory and analgesicLonger acting than ibuprofen, better compliance, relieves pain longer Inhibits platelet aggregation Flurbiprofen (Ansaid)- inhibits platelet aggregationKetorolac (Toradol)- more efficacious analgesic than aspirinUsed for moderate-to-severe pain after minor dental surgery or painful dental procedure Don’t use for > 5 daysNot for long-term pain relief Acetic Acid Derivatives= Indomethacin, Sulindac, and Tolmetin can cause GI bleeding, ulcers, and possible stomach perforations Drugs that Increase Bleeding Times: aspirin, non-selective NSAIDs, anti-platelet drugs Clopidogrel- inhibits blood clotting (increases bleeding time) by irreversibly inhibiting platelet aggregation *ANTIPLATELET OF CHOICE FOR PATIENTS WITH A HISTORY OF ULCERS SALICYLATES: irreversibly reduce platelet adhesionAspirin- inhibits COX-1 and COX-2 to inhibit prostaglandin production Prevents worsening of pain, cannot reduce pain already caused by prostaglandin build-upINACTIVATES cyclooxygenase enzyme that makes prostaglandins inhibiting prostaglandin synthesis Is an irreversible platelet inhibitor and can reduce blood clotting, causing prolonged bleedingAntipyretic action of salicylates is explained by cutaneous vasodilation leading to increased heat lossAspirin is used to relieve headaches, toothaches, minor aches and pains, and to reduce fever GI tract rapidly absorbs Aspirin If aspirin is given while patient is taking ibuprofen, it will DIMINISH the analgesic effectiveness of the ibuprofen Aspirin displaces ibuprofen from plasma protein binding sites Aspirin does NOT affect the coagulation pathway CONTRAINDICATIONS:Bleeding disorders and AsthmaticsChildren with viral infections Pregnancy, esp. 3rd trimesterPeptic ulcers Salicylism- all symptoms caused from ingesting extremely large doses of aspirin COX-2 ENZYME- produces prostaglandins at sites of surgery, infection, and inflammationReduces pain and inflammations without any risk of GI ulcers Rofecoxib & Celecoxib & Valdecoxib- more efficacious analgesics than aspirin and ibuprofen with less side effects COX-2 selective inhibitors treat signs and symptoms of RHEUMATOID OSTEOARTHRITIS, acute pain, and pain from dysmenorrhea HEPARIN- found esp in lungs and inactivates other coagulation factors to prevent blood clottingContained inside mast cells and basophils found in C.T. and extracellular spaces near blood vesselsNeutralizes tissue thromboplastin and blocks thromboplastin generationInhibits blood clotting by affecting the coagulation pathway to PREVENT FIBRIN FORMATION Administration of heparin causes increased bleeding time prevents conversion of fibrinogen to fibrin Heparin is used for prophylaxis and treatment of thromboembolic disorders Low MW heparin anticoagulant agents: Enoxaprin/Lovenox, Dalteparin/Fragmin, and Tinzaparin/Innohep are used to treat acute symptomatic deep vein thrombosis and prevent deep vein thrombosis after knee or hip surgery Thrombin-Inhibitor Type Anticoagulants: administered via IV to prevent post-op deep vein thrombosis Lepirudin, Argatroban, Danaparoid WARFARIN (COUMADIN) & DICUMAROL- anticoagulants that ANTAGONIZE VITAMIN K to prolong blood clotting time, causing decreased liver synthesis of vitamin-K dependent factors Inhibits blood clotting by affecting the coagulation pathway to prevent fibrin formation Used after a myocardial infarction to prevent coronary occlusion, treat pulmonary embolism, and venous thrombosis Vitamin K- essential for synthesis of coagulation factors 2, 7, 9, 10, and prothrombin in liver; enhances blood clottingProthrombin Time (PT): used to evaluate if a patient taking anticoagulants is at a surgical risk Detects certain plasma coagulation defects owning to a deficiency of Factors 5, 7, or 10Thrombin is formed from prothrombin in the presence of adequate calcium, thromboplastin, and coagulation factors Acceptable INR for surgery is 2.5 The higher the INR, the greater the anticoagulant effect Glycoprotein 2b/3a Inhibitor Antiplatelet Agents: reversible anti-platelet agents used to prevent acute cardiac ischemic complications and patients with acute coronary syndrome Conditions Managed by Anticoagulants (Warfarin/Coumadin) & Anti-platelet Agents (Aspirin & Clopidogrel (Plavix):Coronary Artery Disease- by preventing threat of MIAngina Pectoris (Unstable Angina)- by preventing a thrombus from forming in coronary arteries Myocardial InfarctionStroke- helps prevent a thrombus from formingRheumatoid Arthritis- characterized by chronic inflammation of synovium that lines joints With disease progression, there is an accumulation of prostaglandins, leukotrienes, and other mediators Anti-Rheumatic Agents:Etanercept- used to reduce signs and symptoms of active RA It is a recombinant DNA-derived protein that binds to tumor necrosis factor Infliximab- monoclonal antibody that binds to TNF- to reduce inflammatory actionsUsed to treat Crohn’s Disease and Rheumatoid Arthritis Prednisone- corticosteroid that decreases inflammatory response due to its anti-inflammatory actionsShort term side effects= insomnia, indigestion, and arthralgiaLong-term side effects= edema, psychological disturbances, peptic ulcer, osteoporosis, and muscle weakness Piroxicam- NSAIDs drug that inhibits prostaglandin synthesisGold Injections- decreases prostaglandin production MethotrexateNabumetone*NSAIDs reduce the production of PROSTAGLANDINS associated with pain and inflammation ACETAMINOPHEN & OPIODSDrugs Without Anti-Inflammatory PropertiesAcetaminophen (Tylenol)-WEAR inhibitor of prostaglandin synthesis in peripheral tissuesReduces pain by non-inflammatory mechanisms Better to use in GI, bleeding disorders, asthma, young children, and pregnancy NOT an NSAIDDisadvantage= no peripheral anti-inflammatory effects Accepted choice for short term use for mild-to-moderate pain in pregnant or nursing females DOES NOT AFFECT PLATELET AGGREGATION or the coagulation pathway2 Major Pharmacological Actions= analgesic and antipyretic (fever reducer)Does not affect clotting timeLarge doses of acetaminophen can cause liver toxicity Combination Analgesics- narcotic analgesics that effectively REDUCE PAIN by working in brain to block ascending pain impulses that travel from PNS into CNS Do NOT affect blood clotting, thus don’t enhance anticoagulant effects of WarfarinCodeine- LESS efficacious opioid analgesic with moderate abuse liabilityCodeine + Aspirin= analgesic/anti-inflammatory; avoid in asthmatics and patients who cannot take aspirin Codeine + Acetaminophen/Tylenol= poor anti-inflammatory agentsHydrocodone (Vicodin, Lorcet, Norcet, Lortab)- avoid in asthmatics; has poor anti-inflammatory effectOxycodone- more efficacious than codeine, avoided in asthmatics; treats moderate-to-severe painHighest DEPENDENCY LIABILITYOxycodone + Aspirin (Percodan)- analgesic with anti-inflammatory properties STRONGEST pain med you can prescribe on an outpatient basis Oxycodone + Acetaminophen (Percocet)- lacks strong anti-inflammatory effects3 Naturally Occurring Endogenous Opioid PeptidesBeta-endorphins: bind to opioid receptors in brain and have potent analgesic activity Enkephalins: bind to opioid DELTA receptors in brain; play a role in pain perception, movement, mood, and behaviorDynorphins: MOST POWERFUL opioids found throughout CNS & PNS that bind to KAPPA receptors May regulate pain at spinal cord level, influence behavior at hypothalamic level, and function with other endogenous opioids to regulate cardiovascular system OPIOID RECEPTORS:Mu- receptor for MORPHINEDelta- enkephalins are typical agonist Kappa- dynorphins are typical agonist OPIOIDS (NARCOTICS): drugs WITHOUT ANTI-INFLAMMATORY PROPERTIES used as effective analgesics to relieve moderate-to-severe pain, antitussives, antidiarrheals, pre-anesthetic medications, and as analgesic adjuncts during anesthesia Suppress cough reflex, cause constipation, and reduce amount of anesthetic required for surgical anesthesia Administered with caution to patients with HEAD INJURY or a history of drug abuse and dependency Most powerful drugs available for pain relief Most appropriate time to administer initial dose to control post-op pain is BEFORE effect of local anesthetic wears off Opioid analgesics mimic the body’s endogenous opioids at CNS opiate receptors to raise the pain threshold and increase pain tolerance Common Side Effects= sedation and drowsiness, dizziness, and nauseaRespiratory depression is most well-known adverse reaction *Opiates are contraindicated in patients with severe head injuries Morphine- standard drug to which all opiates are compared influences MU OPIOID receptor subtypePharmacological Effects= Length of Effectiveness= IV or IM (2-3 hours), oral (3-4 hours)Not used in dentistry due to its highly addictive liabilityPentazocine (Talwin): chemically related to morphineLasts up to 4 hours when given orallyCan block painkilling action of other opioids Can cause confusion and anxietyUsed to relieve moderate pain Codeine: opium alkaloid weaker and less addictive opioid than morphineOxycodone (OxyContin)- opiate analgesic with similar potency to morphineMild-to-moderate agonistHydrocodone- when combined with acetaminophen is called Vicodin, Lorcet, Lortab, Maxidone, and ZydoneDrug of choice for opiates in dentistry Mild-to-moderate agonist Meperidine (Demerol): SYNTHETIC narcotic agonist weaker than morphine, but equally addictiveOnly narcotic agent that does not cause miosis (pupillary constriction)Used as an IV supplement during conscious sedation procedures Demerol is used as an oral medication to control pain after dental surgery Treats moderate-to-severe pain and may be used as a pre-op medication to relieve pain and allay anxietyMeperidine can cause seizures, tremors, and muscle spasms Synthetic Meperidine Derivatives:Fentanyl potent analgesic used as an IV sedative during conscious sedation procedures or procedures requiring general anesthesia 80-100x more potent than morphine Alphaprodine and AlfentanilSufentanilDiphenoxylate and Loperamide Methadone (Dolophine): treats HEROIN WITHDRAWLPropoxyphene (Darvon): used form MILD pain control after dental surgery; taken orally; taken with aspirin or acetaminophen to treat mild pain Levorphanol: lasts 4 hours; oral form is strong and can be given instead of morphineOpioid (Narcotic Analgesic) Antagonists- reverse respiratory depressive effects caused by an overdose of Codeine, Morphine, Hydrocodone, Oxycodone, Meperidine, and FentanylNaloxone (Narcan)- prototype/pure opioid/narcotic competitive antagonist given in medical emergencies to reverse narcotic overdose resulting in respiratory depression and death due to respiratory shut downAntagonist of choice to treat opioid overdoseNalmefene (Revex)- reverses respiratory depressive effects of narcotic analgesics Naltrexone- reverses respiratory depressive effects of narcotic analgesics and used to treat alcohol dependence Toxicity is both dose-dependent and time-dependent A drug with a high LD50 and low ED50 has a HIGH therapeutic index, thus is SAFEThe greater a drug’s therapeutic index, the LESS likely fatalities will follow an accidental overdose LD50 :ED50 = Therapeutic Index amount of a drug that usually lies between the minimal and maximal doses of the drug Effective Dose- dose at which 50% of people will respondLethal Dose- dose that kills 50% of people who receive drugFatal Dose- drug dose that kills Drug Efficacy- ability of a drug to produce a desired therapeutic effect regardless of dosage Potency- relative concentration of two of more drugs that produce the same drug effect Synergistic Response- when the combined action of 2 drugs with similar pharmacological effects is GREATER than the sum of the individual actionsMERCURY: can cause prominent toxic effects like irritability, excessive saliva, loose teeth, gum disorders, slurred speech, and tremors Higher-than-average accumulations occur in brain, liver, and kidney Presence of mercury in body is determined by a urine test Oral Contraceptives (Birth Control): block ovulation by inhibiting anterior pituitary hormones FSH and LH highest risk associated with use of oral contraceptive is thromboembolic disorders PAINPain Threshold- LOWEST level of pain a patient will detectPhantom Pain- patient that has no organic basis and is fixed on some portion of anatomyPsychogenic Pain- pain produced or caused by psychic or mental factorsIntractable Pain- pain that is resistant or refractory to ordinary analgesic agents Referred Pain- pain felt in an area other than the site of origin Drug that cause XEROSTOMIA:Amitriptyline- tricyclic antidepressant work through an anticholinergic actionDiphenhydramine- sedating type of antihistamine Atropine- powerful anticholinergic that blocks saliva production in salivary glands Diazepam (Valium)- benzodiazepine tranquilizerDrugs that treat GLAUCOMA:Pilocarine- eye drops that cause papillary constrictionLatanoprost- prostaglandin analogBetaxolol- beta blockerBimatoprost- eye drops that reduce intraocular pressure CANCER CHEMOTHERAPHY (ANTI-NEOPLASTIC DRUGS)Alkylating Agents: most effective in treating chronic leukemias, lymphomas, myelomas, and carcinomas of breast and ovary These agents alkylate DNA so it cannot replicate Form alkyl bonds to nucleic acids N-7 position of GUANINE is a common bonding site Anthracyclines: destroy DNA so cell cannot replicateDaunorubicin and DoxorubicinCommonly associated with development of oral mucosititis Antibiotics specifically designed for cancer chemotherapyAntimetabolites: cell cycle-specific drugs that act in “S” phase of cell cycleInterfere with selected biomechanical reactions necessary for cell growth Interfere with biosynthesis of PURINE and PYRIMIDINE BASESFolic Acid Analogs- treat acute lymphoblastic leukemias in childrenPyrimidine Analogs Purine Analogs- treat leukemia in children and adults Antimicrotubulars- affect microtubular assembly with cells to inhibit cell mitosisAntiestrogens- block tumors on which estrogen has a stimulatory effectVinca Alkaloids- mitotic spindle poisons Vinblastine and VincristineGonadotropin Hormone-Releasing Antigens- inhibit gonadotropin secretionAlopecia (hair loss)= most common complication seen with chemotherapy treatment HYPOGLYCEMICS (ANTI-DIABETICS)Hypoglycemia- most serious and common complication of insulin therapy symptoms= sweating, weakness, confusion, slurred speech, and blurred visionInsulin: pancreatic hormone secreted by pancreatic beta-cells of ISLETS of LANGERHANDSEssential for glucose metabolism and for homeostasis of blood glucose Effects= gluconeogenesis and triglyceride storage, glycogen synthesis, and protein synthesis Anti-Diabetics (Oral Hypoglycemias): used as adjuncts to diet to treat non-insulin dependent diabetes that cannot be controlled by diet aloneGlyburide and Chloropropamide stimulates insulin release from pancreas, and works by reducing glucose output from liver and increasing insulin sensitivity at peripheral target sitesMetformin and Pioglitazone increases insulin sensitivity at peripheral target sitesTolbutamide sulfonylurea that stimulates synthesis and release of insulin from pancreas, increases sensitivity of insulin receptors, and improves peripheral utilization of insulin PROSTHODONTICS Kennedy class 1 and 2 must have a mesial rest on abutment next to posterior edentulous space Class 4 occlusal rests are placed on distal of 1st premolars Applegates’s Rules for Applying Kennedy Classification: Classification is done AFTER extractions are doneIf a 3rd molar is missing and will not be replaced, NOT part of classificationIf a 3rd molar is present and not used as an abutment, its NOT part of classificationIf a 2nd molar is missing and will not be replaced, its not considered in classificationMost posterior area always determines classificationEdentulous areas other then those determining classification are “modifications”Extend of modification is not considered, only # of additional edentulous areas No modification areas in Kennedy Class 4 Major and Minor connectors must be RIGID to evenly distribute functional stresses applied to RPD throughout mouthMajor Connectors= must be RIGID most frequently encounter interferences from lingually inclined mandibular premolars Minor Connectors= RIGID component connecting major connector to other components1.5mm thickMaximum gingival exposure= joins at right angleMinimum of 5 mm space between vertical component Mandibular RPD Major Connectors: basic cross section form is half-pear shapedLingual Bar- superior border must be at least 4mm below gingival margins to prevent plaque collection and margin inflammationMust be at least 7mm of space/clearance between gingival margin and mouth floorHalf-pear shaped in cross-sectionIndication= when sufficient space exists between slightly elevated alveolar lingual sulcus and lingual gingival tissuesContraindication= if there are severely tipped premolars and molars Sublingual Bar- when there is insufficient space for lingual barUse when height of mouth floor is < 6 mm from free gingival marginsBulkiest portion is to lingual and is tapered toward labialBar’s superior border must be at least 3 mm below free gingival marginRequires a functional impression Contraindication= if natural anterior teeth are severely tilted lingually Cingulum Bar (Continuous Bar)- used when a lingual plate or sublingual bar is indicated, but axial alignment of anterior teeth requires excessive block-out of interproximal undercuts Contraindications= if anterior teeth are severely lingually tilted, wide diastemas between anterior teeth LinguoplateIndications= high floor of mouth (<7mm vertical height) or high lingual frenumPreferred over a lingual bar when there is NO space in floor of mouthInoperable lingual mandibular tori that cannot be removed Used in class 1 designs where residual ridges have undergone excessive vertical resorptionUsed to stabilize periodontally weakened teeth Contraindications= if severe anterior crowding exists Labial BarIndications= when severe lingual inclinations of remaining premolars and incisors cannot be corrected orthodontically, when severe lingual tori cannot be removed and prevent using a lingual bar/plate *unless tori surgery is absolutely contraindicated, interfering tori are removed to avoid using a labial bar Double Lingual Bar (with continuous bar)- placed above cingula and below inter-proximal contactsNeed 7-8 mm above mouth floor and must have rests on superior bar on at least the canines Best indicated for periosurgery cases for wide embrasures Maxillary Major ConnectorsMust be rigid Superior border must be at least 6mm below free gingival marginsUse metal plating if <6mm exists from gingival marginsPosterior border of major connector must cross palate at right angles to palate midline and extend backward parallel to residual ridges Anterior border of major connector is perpendicular to midline and buried in valley of rugaeNever placed anterior to indirect retainers Bead Line (Beaded Borders): used ONLY on maxillary major connectors to seal interface of maxillary major connector to tissues to seal it to soft tissue and provide POSITIVE denture contact with tissue Anterior-Posterior Palatal Strap: almost always works for ALL Kennedy classesConnector of choice for inoperable tori cases where there is 6-8mm room to vibrating lineGreatest strength and rigidityPrimarily used for a large edentulous span Kennedy Class 3 mod 1 RPDsMust be at least 15mm between anterior and posterior straps Anterior and posterior straps are 6-8mm wide, and must be 6mm below free gingival margin to avoid rugae coverage and tongue interferencePosterior strap is located entirely on hard palate at right angles to midline to protect tongueDo NOT USE when an inoperable palatal torus extends onto soft palateHorseshoe (U-Shape Palatal Connector): least desirable maxillary major connector due to LEAST strength and rigidityUsed to go around inoperable palatal tori or major gaggersLacks rigidity Used in Class 3 mod 1 designs and/or if there is a palatal torus within 6-8mm of vibrating line Single Wide (Midpalatal) Strap: mainly used in Class 3 designs Width is kept within borders of rests Used for a large span class 3, when molar abutments are weakPalatal Plate (Complete Coverage): used mainly in class 1 designMain indication= when last abutment tooth on either side of a bilateral distal extension is a canine or 1st premolar Used for long-span class 1 bilateral distal extensions with poor residual ridges, and/or periodontally involved weak abutment teeth Covers at least 50% of hard palate Posterior border is at junction of hard and soft palateShould be anterior to posterior palatal sealActs more in INDIRECT RETENTIONModified Palatal Plate: used for maxillary class 1 and 2 designs Anterior border ends at rugae no less than 6mm from free gingival marginProvides maximum support as plate rests on tissueContraindicated with palatal tori Indirect RetainersPlaced as far away from distal extension base as possible to prevent vertical dislodgement of base from tissue Increases effectiveness of direct retainers and prevents RPD from rotating around fulcrum line Should be at 90 to fulcrum line and placed in rest seats to direct forces along abutment’s long axisGreater distance between fulcrum line and indirect retainer, more effective indirect retainer isFunctions: Prevents vertical dislodgement of distal extension base away from tissues Protects soft tissues impingement by major connector during downward movementDecreases antero-posterior tilting leverages Helps stabilize against horizontal denture movement Stabilizes against lingual movement of anterior teethFulcrum Line (Axis of Rotation): axis the RPD rotates around when denture base moves AWAY from residual ridgeMainly determined by placement of primary restsFulcrum passes through rigid metal above tooth’s height of contour and closest to edentulous spaceClass 1 and 2 always have a fulcrum lineClass 1 fulcrum passes through most posterior abutment next to edentulous spaceClass 2 fulcrum line is diagonal and passes through most posterior abutment on distal extension side Class 3 & 4 tooth-borne/supported RPDs that do not move toward tissue during function; rests are placed immediately next to edentulous spaceClass 3 doesn’t have a fulcrum lineClass 4 fulcrum line passes through mesial rests next to edentulous space Rests: indirect retainer united with major connector by a minor connector; must be RIGIDFunctions:To provide RPD vertical support and prevent vertical dislodgement Maintains components in positionPrevents soft tissue impingementDirects and distributes occlusal loads to abutment tooth’s long axisNeed a MINIMUM of 3 rests for any partial denture Must be a mesial rest on most posterior abutment tooth with distal extensionOcclusal rest- prepared only in enamel or restorative material that resists fracture and distortion 2mm deep in center Rounded triangle outline form with apex toward center of occlusal surfaceConcave spoon-shaped occlusal surfaceOcclusal rest is as long as it is wideRest floor is slightly inclined apicallyAngle formed by occlusal rest and vertical minor connector must be LESS THAN 90 Occlusal rest is always prepared after proximal guide plates Embrasure/interproximal rest- used to prevent interproximal wedging of framework and shunt food away from contact pointsRest seat is extended lingually for bulk strength Marginal ridge lowered 1.5mm on each abutmentCingulum rest- most satisfactory lingual rest is placed on a prepared rest seat in a cast restorationCanines preferredPreparation is a slightly rounded inverted V placed at junction of gingival and middle 1/3 of lingual surface 2 mm wide FL2.5-3 mm MD lengthMinimum 1.5mm deep Incisal rest- used mainly as an auxillary rest or indirect retainerRounded notch is placed 3-4mm from either MI or DI edgeLeast esthetic rest and most likely to cause orthodontic movementPrep is 2.5mm wide and 1.5mm deep Guide Plate FunctionsHelps establish a definitive path of insertion/dislodgement of RPDStabilizes RPD by controlling its horizontal position Provides contact with adjacent toothShould extend past DL line angle to provide 180 encirclement, bracing, and reciprocationPrepared in occlusal 1/3 on proximal surfaceGuide plane is 2-3mm in height occluso-gingivallyMust be below abutment’s height of contour with class 1 and 2 designs to prevent abutment torqueing during functional movements Ensure predictable clasp retentionFailure of partials due to poor clasp retention design can be avoided by altering tooth contours Primary Retention- provided by mechanically placing retaining elements on abutment teethSecondary Retention- provided by intimate relationship of minor connector contact with guiding planes, denture bases, and major connectors with underlying tissuesVertical Arm of Surveyor- indicates areas of retention, areas of support on abutment tooth, and tooth/tissue interferences to path of insertionDirect Retainers (Clasping): gives RPD mechanical retentionIntra-Coronal Retainer (“Precision Attachment or “Internal Attachment”): most esthetic direct retainerProvides best vertical support It is cast or attached totally within abutment’s restored natural contours Not used with extensive tissue-supported distal extensions unless a stress-breaker is used between movable RPD base and rigid attachmentExtra-Coronal Retainer (Clasps): placed on external surfaces of abutment teethHas retentive clasp arm that is flexible and placed in areas below tooth’s height of contour (gingival 1/3)Provides resistance to deformation from a vertical dislodging force generates retentive action of claspClasp Arm Flexibility:Longer and thinner arm= more flexible Most clasps are ? round in form Undercut location is most important factor when selecting clasp for distal extensions Has a bracing (stabilizing/reciprocating) clasp arm placed occlusal to tooth’s height of contour (middle 1/3 of crown)- MUST BE RIGID Horizontal force is transmitted by placing rigid portion of clasps in NON-UNDERCUT areas of abutment teeth Reciprocation: when retentive arm and bracing arm contact tooth at same time during seating and removing RPD Clasp Assembly Components: provide 180 encirclement of abutment 1-2 rests and at least 1 minor connectorRetentive clasp arm to engage and terminate in undercuts Reciprocating (bracing) clasp arm (rigid)When RPD is fully seated, clasps tips should NOT exert any pressure against abutment teeth Retentive arm is activated ONLY when vertical dislodging forces attempt to unseat RPD away from basal seat tissues Clasp AssemblyClasp should be completely passive and retentive function activated ONLY when dislodging forces are appliedEach retentive clasp must be opposed by a reciprocal clasp arm or another RPD element capable of resisting horizontal forces exerted on tooth by retentive arm Clasp must encircle more then ? of tooth circumference Rest provides VERTICAL SUPPORTExtra-Coronal Retainers: must have 1 retentive arm and 1 rigid reciprocal bracing arm Suprabulge Retainers: approach retentive undercut from ABOVE tooth’s HOCCircumferential Clasp (Aker’s Clasp):Engages > 180 of abutment’s circumference Terminal end of retentive clasp arm provides retention by engaging an undercut Originates on or occlusal to tooth’s HOC, then crosses in terminal 1/3, and engages undercut as taper decreases and flexibility increases Clasp of choice in Class 3 and 4 when most posterior abutment undercut is AWAY from edentulous space surface Undercut must be on opposite side of tooth/rest from where clasp originates DO NOT USE when undercut is adjacent to edentulous space Ring Clasp: indicated to engage an undercut of a mesially-lingual tilted molar when severe tissue undercut exists preventing an I-barUsed almost exclusively on mandibular molars that drifted mesially and lingually to engage lingual undercut Indicated in reverse on anterior abutment to “tooth-bound” edentulous space Allows undercut to be approached from tooth’s distalUsed almost exclusively on ML tilted molar abutments Used when LOW caries risk and in non-esthetic areas Used when a DB or DL undercut on a molar cannot be approached directly from occlusal rest and/or when tissue undercut prevent engagement with a bar claspReverse Action (Hairpin) Clasp: used on abutments of “tooth-borne” dentures where a proximal undercut is BELOW point of origin when a bar clasp is contraindicated due to tissue undercut, tilted tooth, shallow vestibule, or high tissue attachment Used when lingual undercuts prevent placing a supporting strut without tongue interference Embrasure Clasp: used on teeth with retentive areas or when multiple restorations needed Used when no edentulous space exists on opposite side of edentulous Class 2 or 3 with no mods Requires at least 1.5mm marginal ridge reduction to prevent fracture of clasp assemblyAlways used with double occlusal restsWrought wires are NEVER used for these clasps Half & Half Clasp: indicated for lingually inclined premolars (lingual undercuts)Has 1 circumferential retentive arm from 1 direction and reciprocating arm from minor connectorBack-Action Clasp:Use is difficult to justify since you can just use a conventional CCCan be used on a premolar abutment anterior to an edentulous spaceMultiple Clasp: 2 opposing circumferential clasps joined at terminal end of two reciprocal arms Used when additional retention and stabilization is needed Combination Clasp: used when an abutment next to a distal extension (Class 2, mod 1) where only a MB undercut exists or if large tissue undercuts prevent a bar clasp from being used Used when maximum flexibility is required Consists of bracing arm, wrought wire retentive circumferential arm, and distal restUse when undercut is on side of abutment away from edentulous space because it is more flexible than a cast clasp arm and can dissipate functional stresses Extended Arm Clasp: used for abutment tooth-borne dentures next to an edentulous space Infrabulge Retainers (Bar Clasps= Roach Clasp)Arises from framework or metal base and approaches abutment’s retentive undercut from gingival direction below HOCIndications= small undercut in cervical 3rd of abutmentContraindications= when a DEEP cervical undercut exists or when a severe tooth or tissue undercut exists Advantages= inter-proximal location for esthetics, increased retention without abutment tippingVertical portion crosses gingival margin at 90T BarModified T BarBest for DB undercuts below HOC immediately next to an edentulous spaceIndicated when abutment undercuts are immediately next to an edentulous space and no tissue undercutsVertical arm must approach and engage MESIAL to greatest MD curvature on abutment’s facial surface I bar Place tip of retentive arm MESIAL to greatest M-D curve on abutment’s facial surface for retention in undercutI-bar retentive arm with MESIAL rest and distal guide plate is BEST to be placed on terminal abutment for distal extensionsIndicated for a Class 1 or 2 RPD Superior border is located more than 3mm from free gingival marginIndicated for Class 2 mod 1 on a ML tilted molar Foot of I-bar is completely below HOC in distal extension designs Retentive arm should only function when there is an attempt to dislodge RPD “RPI” System (Rest, Proximal plate, I-bar): I-bar clasp that has MO rest, and distal guide plate with minor connector placed into ML embrasure Used only with Kennedy class 1 or 2Must be 180 degrees around tooth Distal guide plane extends from marginal ridge to jxn of middle and gingival 1/3 of abutment Mesial rests are placed on terminal abutment tooth for all distal extensionsY barRoach Clasp RPD Stress BreakersStress-Breaker: device that relieves abutment teeth to which RPD or FPD is attachedFunctional stress is directed onto residual ridge only minimal transfer of functional stress to abutment teeth occursIncreased ridge resorption occurs Wrought Wire Retentive Clasp (Stress-Breaker): simplest form of stress relief and has increased flexibilityHas higher yield strength, greater flexibility, more ductile and resilient Often used with a mesial rest in class 1 and 2 designs on most posterior abutment tooth If occlusion prevents using a mesial rest on most posterior abutment in a distal extension, a WW can be used with a distal rest because it is ok for its retentive tip to be in front of axis of rotation Tip of retentive arm should engage undercut anterior to fulcrum lineRetentive arm should be passive and apply no pressure to teethDon’t use through embrasures or with embrasure clasps Wrought wires have greater flexibility and adjustability than cast clasps, are more ductile than cast clasps, and have greater tensile strength .02= .5mm wrought wire Finish LinesExternal Finish Line- external junction of metal framework and denture base plastic Originates from lingual of guide plate of terminal abutment and ends at hamular notchInternal Finish Line- butt joint between metal and acrylic on tissue side of edentulous area Junction of major and minor connector at palatal finishing lines are 2mm medial from imaginary lineFinishing line jxn with major connector should be no greater than 90Jxn of minor connectors and bar clasps are 90 butt-joints Surveying RPD AbutmentsFacebow- device to record patient’s maxilla/hinge axis relationshipIs a record to orient the maxillary cast to the hinge axis on the articulator Hinge-axis facebow transfer enables the dentist to alter VDO on the articular Hinge Axis Facebow- used to record opening and closing of mandible Advantages of RPD chromium-cobalt alloys: corrosion resistance, high strength, low specific gravity, and VERY RIGID Chromium Base Metal Alloys for RPDSChromium responsible for corrosion resistance due to surface oxide layer Cobalt increases rigidity, strength, and hardnessNickel increases ductilityMeasured as % of elongation and determines how much margins can be closed via burnishingMetallic component of RPD with greatest potential for allergic reactions in mouth Alloy ClassificationType 1= used for small inlays Type 2= larger inlays and onlays Type 3= onlays, crowns, and short-span FPDsType 4= thin veneer crowns, long-span FPDs and RPDSAltered Cast Impression purpose is to obtain maximum support possible from edentulous ridges in Class 1 and 2 designs helps obtain soft tissue support to aid abutments in resisting functional stresses COMPLETE DENTURESStability- quality to be firm, steady, constant, and not subject to change position when forces are applied Resists dislodgement in horizontal direction and torsional forces Support- resists vertical seating forces provided by rests and denture bases Provided by occlusal rests and edentulous ridge areas Retention- resists force of gravity, sticky food, and forces associated with mandibular movement Provided by direct and indirect retainers Clasps in undercut areas of abutment teeth provide retentionBorder Molding: masseter muscle shapes DB areaOverextension of a mandibular denture base in distofacial area causes dislodgement during function Superior Constrictor Muscle- shapes Distolingual border molding*Most critical area in border molding a maxillary denture is mucogingival fold above maxillary tuberosity areaA custom tray is fabricated on a preliminary cast and trimmed 2mm short of mucosal reflection and frenaePrimary indicator of border molding accuracy is stability and lack of displacement of custom tray in mouth Palatoglossus, superior pharyngeal constrictor, mylohyoid, and genioglossus muscles influence border molding of lingual border of mandibular impression Maxillary arch bone loss= in a vertical and palatal direction (up and in)Mandible arch bone loss= in a vertical direction (down and forward/outward) [4x faster than in maxilla]Maxillary rim is 22mm and mandibular rim is 18mm Significance of Camper’s Line: occlusal plane, established by wax occlusion rims surfaces is parallel to Camper’s line and inter-pupillary lineBest impression technique for a patient with loose hyperplastic tissue is to register tissue in its passive positionMANDIBULAR COMPLETE DENTURES a primary support area is buccal shelf because of its dense cortical boneBuccal shelf- primary support area for mandibular dentureBoundaries are buccal frenum to retromolar pad crest of residual ridges to external oblique lineThe more keratinized tissue, the better denture support and comfort Marked resorption of alveolar ridge occurs if mandibular denture terminates short of retromolar pad Thin mucosa is found in mylohyoid area and over mandibular tori*DO NOT PLACE mandibular molars over ascending area of mandible because occlusal forces over inclined ramus DISLODGE mandibular denture Mylohyoid muscle can lift the mandibular denture when the tongue is protruded Retromylohyoid Curtain= superior pharyngeal constrictor and palatoglossusMAXILLARY COMPLETE DENTURESPrimary support bearing areas are residual ridges and palate Secondary support area is palatal rugae Posterior Palatal Seal extends through hamular notches in maxilla, and passes 2mm in front of fovea palatinae Immovable tissue compensates for denture processing errors The flatter the palate, the wider the posterior palatal sealExcessive depth of posterior palatal seal results in unseating of denture Compensates for polymerization and cooling shrinkage of denture resin during processing Fovea Palatini- usually slightly posterior to junction of hard and soft palates near midlineVibrating Line- marks division between movable and immovable tissues 2mm anterior to fovea palatinae and ALWAYS ON SOFT PALATEUse a Y-incision to remove palatal tori directly over tori Angular Chelitis: caused by loss of VDO, or vitamin B deficiency Combination Syndrome: when an edentulous maxilla is opposed by a partially dentate mandible, causing severe bone resorption of anterior maxillaUse a very flowable impression material to record flabby ridges like Zinc Oxide Eugenol PasteBurning sensation in mandibular anterior area is caused by pressure on mental foramen Premature occlusal contacts are the most common cause of generalized irritation of basal seatMain indication for immediate complete dentures is esthetics Major disadvantage of immediate dentures is not being able to have an anterior tooth try-in to evaluate esthetics Immediate dentures should be scheduled for relines at 5 months and 10 months post-extraction to compensate for contour changes Most important benefit of an overdenture is preservation of alveolar ridge For overdentures, retain mandibular canines because they provide SUPPORT, not retention Arcon Articulator (Articulated Condyle): articulator with condylar elements on LOWER member of articulator and condylar path elements on upper member Angle between condylar inclination and occlusal plane is fixed and remains constant Commonly used for diagnostic mounting of study casts Non-Arcon Articulator (Non-Articulated Condyle): has condylar elements on both upper and lower members Angle between condylar inclination and occlusal plane is NOT CONSTANT when open vs closed Non-adjustable small axis of rotationSemi-adjustable gives a closer approximation of axis of rotation Fully adjustable reproduces all border movements Working Side: teeth on side of mandible is moving towardBalancing Side: side opposite to side mandible is moving Protrusive: forward movement of mandible Christensen’s Phenomenon- space that opens between posterior teeth during anterior movement of mandible Protrusive Movement- accomplished when mandible is moved straight forward until maxillary and mandibular incisors contact “edge-to-edge”; mandible can protrude 10mmCurve of Spee: anterior-posterior curvature of mandibular occlusal plane Compensating Curve- anteroposterior and lateral curvature in alignment of occluding surfaces and incisal edges of artificial teeth used to develop a balanced occlusion Under the dentist’s controlAllows dentist to alter effective cusp angulation without changing form of manufactured denture teethHelps provide balanced occlusion Curve of Wilson: mediolateral U-shaped curve of occlusal plane of maxillary and mandibular posterior teethBilateral Balanced Occlusion: simultaneous contact of opposing upper and lower teeth in CR position Lessens or limits tipping or rotation of denture bases Maximum # of teeth contact in all excursions for denture stabilityDuring lateral excursions, opposing cusps contact on working side Bilateral balanced is occlusion for complete dentures Group Function (Unilateral Balanced Occlusion): all teeth on working side contact during working movement Only working side contacts from anterior and posterior teeth and no non-working side contacts Teeth on non-working side do not contact Teeth on working side contact during lateral excursionNon-working interferences= occur on inner inclines of FACIAL cusps of mandibular molarsWorking-side interferences= occur on inner aspects of LINGUAL cusps of maxillary molars Protrusive Interferences= occur between distal inclines of facial cusps of maxillary posterior teeth and mesial inclines of facial cusps of mandibular posterior teeth Purpose is to register the condylar path and adjust condylar guides of articulator so they equal patient’s condylar paths Establish VDO before making CR record Interocclusal distance/freeway space= 2-6mm Never increase freeway space more than 1.5mmExcessive vertical dimension is the usual cause of clicking of denture teeth Decreased VDO often results in cheek biting due to lack of horizontal overlap of posterior teeth VDR= VDO + FSIn lower compartment of TMJ, hinge-type motion occurs (ROTATION)In upper compartment of TMJ, translation occursCentric Relation: “ligament-guided” position that is supero-anterior position of condyle along articular eminence of condyle with articular disc interposed between condyle and eminence Most unstrained, retruded anatomic and functional position of mandibular condyle heads in mandibular glenoid fossa of TMJsBone-to-bone relationship, independent of tooth contact Avoid soft waxes as a recording material because they never become rigid and are likely to distort during cast mounting procedure Centric Occlusion (MICP): “tooth-guided” position defined as maximum intercuspation of teethMasseter muscles contract and tip of tongue touches roof of mouth during normal swallowing Condylar Guidance: totally dictated by patientProtrusive record is LEAST reproducible maxillomandibular record LATERAL MOVEMENTS= working condyle moves down, forward, and laterally, and non-working condyles move down, forward, and mediallyWorking condyle moves down, forward, and laterallyNon-working condyle moves down, forward, and medially The anterior determinant of occlusion is the horizontal and vertical overlap relationship of anterior teeth In a protrusive condylar movement, interferences can occur between DISTAL inclines of maxillary posterior cusps and MESIAL inclines of mandibular posterior cusps Centric Interference (Forward Slide): corrected by grinding mesial inclines of maxillary teeth and distal inclines of mandibular teeth Mutually Protected Occlusion (“Canine Guided” or Organic Occlusion): anterior teeth protect posterior teeth in all mandibular excursionsAn occlusal relationship that exists where the vertical overlap of maxillary and mandibular canines causes separation of ALL posterior teeth when the mandible moves to either side Anterior Guidance: result of horizontal and vertical overlap of anterior teeth The greater overlap, the longer cusp heightIncisal Guidance: measure of amount of movement and angle at which lower incisors and mandible must move from overlapping position of centric occlusion to an edge-to-edge relationship with maxillary incisors Influencing factors are esthetics, phonetics, ridge relations, arch space, and inter-ridge space Esthetics and phonetics are main factors limiting dentist’s control Supporting Cusps: maxillary lingual cusps and mandibular buccal cusps; broader, more rounded cusp ridges Non-Supporting Cusps (Guiding or Shearing): maxillary buccal and mandibular lingual cusps; have narrowed and sharper cusp ridges In a posterior cross-bite, supporting and guiding cusps are opposite The purpose of selective grinding is to remove all interferences without destroying cusp height The most common complaint after cementing a fixed bridge is sensitivity to hot and cold and indicates a deflective occlusal contact Primary centric holding cusps are the maxillary lingual cusps NEVER grind these cuspsDo NOT grind upper lingual or lower buccal cusps Selective Grinding in Working Side buccal cusp inner inclines of upper teeth and lingual cusp inner inclines of lower teeth Selective Grinding in Non-Working Side grind inner inclines of mandibular buccal cusps, NEVER GRIND MAXILLARY LINGUAL CUSPSNever adjust cusp tips, only marginal ridges and fossaSmile Line is parallel with the inter-pupillary axis and perpendicular to midline DENTURE TEETH SELECTIONLong axis of posterior teeth are inclined toward LINGUALLong axis of maxillary incisor crowns CONVERSE slightly towards midlineMandibular posterior teeth are placed over the crest of the residual ridge Maxillary anterior teeth are set facial to the ridge for phonetics and esthetics Primary role of anterior teeth on a denture is esthetics Maxillary and mandibular anterior teeth should NOT contact in centric relation Maxillary anterior denture teeth should be placed SLIGHTLY ANTERIOR to ridge Functional needs > esthetic needs for posterior teeth Most important factor to determine posterior tooth length is available inter-arch space Primary reason for using plastic teeth in a denture is because plastic teeth are retained well in acrylic resin Potential Problems with New DenturesCheek biting caused by posterior teeth being edge-to-edge, inadequate VDO, and biting corners of mouthLip biting caused by reduced muscle tone and/or large overbiteTongue biting posterior teeth set too far lingually*most effective time to test for phonetics is at time of wax try-in of trial denture “S” Sound: formed when tip of tongue approaches anterior palate and lingual surfaces of maxillary teethIf unable to make sound either maxillary incisors are set too far palatally or palate is too thick “Th” Linguodental Sound: tongue should slightly protrude 2-4mm between maxillary and mandibular anterior teeth to form this sound “F” and “V” Labiodental Sounds: formed by incisal edges of maxillary incisors and lower lip “P” and “B” Labial Sounds: formed totally by lips; from pressure behind lips; affected by anterior -posterior position of teeth, incorrect VDO, and labial flange thickness “T” and “D” (Anterior Lingual Palatal Sounds): if teeth are set too FAR LINGUAL, “t” sounds like “d”; if teeth set too FAR LABIAL, then “d” sounds like “t”“K” and “G” Velar Sounds (Posterior Lingual Palatal): produced when tongue touches posterior palate; teeth don’t affectWhistling during speech with dentures can be caused by either insufficient vertical overlap, excessive horizontal overlap, or area palatal to incisors is improperly contoured FIXED PARTIAL DENTURESTemporary Restorations Must Provide:Pulpal protectionPositional stabilityOcclusal functionEasily cleaned Non-impinging MarginsStrength and retentionEsthetics Custom indirect technique (outside of mouth) is preferred for making temporary crowns because it is more accurate, better fit, and protects the pulpCROWNSRetention prevents removal of restoration along path of insertion or long axis of prepResistance prevents dislodgement of restoration by forces directed apical or oblique and prevents any movement of restoration under occlusal forces Ideal taper for a crown is 5-6Main purpose of a buccal or lingual groove in a single crown prep is to improve crown retention Occlusal ClearanceGOLD crown= 1.5mm for functional cusps and 1mm for non-functionalPFM crown= 1.5-2mm functional cusps and 1-1.5mm for non-functional cuspsALL-CERAMIC crowns= 2mm clearance on prepsPFM Coping AlloyHigh Noble alloys: used to fabricate metal-ceramic restorations; consist of 98% gold, platinum, and palladiumPalladium-Silver alloys (Noble): 50-60% palladium + 30-40% silverNickel-Chromium alloys: 70-80% nickel + 15% chromium Readily oxidize and can create porcelain-to-metal interface problems Absolute minimum porcelain thickness is 0.7mm (ideal is 1mm)Crown MarginsBevel (Feather-Edge) Margin: best margin for a cast full gold restorationDifficult to read on impression and die and may lead to inaccurate extension and distortion of wax pattern Least marginal strength Chamfer Margin: preferred finishing line for cast full gold restorations Combines advantage of an easily definable margin on impression and die with minimal tooth prepPreferred gingival finish line for veneer metal restorationsShoulder Margin (Butt Joint): finishing line of choice for ALL PORCELAIN/EMAX crowns Shoulder provides resistance to occlusal forces and minimizes porcelain stresses Poorest finish line used with cast metal restorationsAll ceramic crown margin design is internally rounded shoulder All ceramic crowns have LOW FLEXURAL STRENGTHShoulder with a Bevel: allows a sliding fit to occur at margin Can be used for PFM with metal collars Used as finishline on proximal box of inlays and onlays Periodontium remains healthier when crown margins are SUPRAGINGIVAL If a margin must be placed subgingivally, the major concern is NOT TO EXTEND the prep into tooth’s attachment apparatus (invading biologic width)Crown lengthening may be done to surgically move the alveolar crest 3mm apical to the proposed finish line to maintain biologic width and prevent periodontal pathology Emergence Profile: axial contour that extends from base of sulcus, past the free gingival marginExtends to tooth’s HOC to produce straight line profile in gingival 1/3 of axial surface*Straight line access is the treatment goal when restoring teeth, because it facilitates access for good oral hygiene Porcelain’s compressive strength is greater than it’s tensile or shear strengths Dental porcelain restorations are BRITTLE and not capable of much plastic deformation High-fusing porcelains- used to make denture teethMedium-fusing porcelains- used for all ceramic and porcelain jacket crowns Low-fusing porcelains- used for PFM crownsMetamerism: phenomenon that causes teeth/porcelain to appear color matched under one light source, but very different under another light source Value: color’s brightness; MOST CRITICAL characteristics amount of lightness or darkness in a color Chroma: color’s strength or saturation; can be increased using stainsHue: basic colors like red, blue, yellow, green orange stain is most often used to change hueIncandescent light- lacks blue, but increased in red and yellowFluorescent light- decrease in red, but increase in blue and green PONTIC DESIGNContact area between pontic and ridge should be small and part touching ridge should be CONVEXPontic tip should not extend past MGJPontic should ONLY touch ATTACHED KERATINIZED GINGIVA to prevent ulcers Modified Ridge Lap Pontic: pontic of choice in “appearance zone” for maxillary and mandibular FPDsUses a ridge lap for minimal ridge contactAll CONVEX surfaces Saddle Pontic (Ridge Lap): forms a large CONCAVE contact with ridgeOverlaps facial and lingual aspects of ridge Unclean and uncleanable and causes tissue inflammation DON’T USE Hygienic Pontic (Sanitary Pontic): does not contact edentulous ridge Pontic of choice in non-appearance zonePoor esthetics Occlusogingival thickness must be at least 3mm with adequate space under it for cleaningConvex in all areas Conical Pontic: pontic of choice for a thin mandibular ridge in a non-appearance zoneRounded and cleanable Ovate Pontic: pontic of choice with a broad, flat ridge Used where esthetics is a primary concern Recommended location= maxillary incisor, canines, and premolars Extraction site pontic requires surgical prep INCLUDEPICTURE "/var/folders/14/kfphkf717_q461gqnnf3ht700000gq/T/com.microsoft.Word/WebArchiveCopyPasteTempFiles/40-Figure6-1.png" \* MERGEFORMATINET CANTILEVER BRIDGES- has an abutment at ONLY ONE END with a pontic attached to the other endIndications= must have very strong abutment and minimal or no occlusal contact on pontic Used for missing maxillary lateral, mandibular 1st premolar, and missing 1st molar Pier Abutment: freestanding abutment with edentulous spaces on each side that requires non-rigid connector Non-Rigid Connector: a broken stress mechanical union of a retainer and pontic Used only for a short-span bridge replacing one tooth Decrease/neutralize displacing forces on abutments by eliminating a fulcrum effect on pier abutment Transfers shear stress to supporting boneStress-breaking device in a 5-unit FPD is placed on middle abutment Key is placed on mesial of distal pontic Path of insertion of key into keyway is parallel to pathway of retainer that is NOT involved with keywayMaryland Bridge: conservative restoration with solid metal retainers that relies on etched inner surface in enamel of retainers for its retention Grooves give increased resistance form Requires an abutment mesial and distal to edentulous space Requires a shallow prep in enamel Grooves for a resin-bonded FPD provide mainly resistance form by preventing B-L rotation Indications= replace 1-2 missing mandibular incisors, replace maxillary incisors, used as a periodontal splint, replace single posterior tooth Prep Features= vertical stops are placed on all preps for resistance and rigidity; grooves increase resistance to displacement on anterior preps; light chamfer finish line is placed supragingival Advantages= reduced cost, no anesthesia, supragingival margins, minimal tooth prep Optimum Crown-Root ratio for a tooth to be used as a FPD abutment is 2:3 1:1 is minimum acceptable 1:2 is IDEAL crown-to-root ratioRoot configuration with widest F-L dimension is best abutment 1st molar is best abutment and canine is 2nd best have largest root surface area Roots broader F-L than M-D are preferred Divergent roots are better abutments than fused/conical roots Ante’s Law: combined abutment teeth root surface area must be equal or greater than edentulous space Long axis of FPD abutments must converse no more than 25-30Rigid connector is preferred for teeth with decreased periodontal attachment The absolute MAXIMUM number of posterior teeth that can be safely replaced with a fixed bridge is 3 An edentulous space involving 4 adjacent teeth other than 4 incisors is best treated with an RPD Electrosurgery: acceptable method of gingival tissue retraction, causing cells to be scorched Usually results in delayed healing due to lack of proper clot formation Objectives= coagulation, hemostasis, access to cavosurface margins, and reduces inner wall of gingival sulcus Indications= remove hyperplastic gingival tissue, in place of retraction cord Contraindications= cardiac pacemakers, metal instruments, flammable agentsPOSTS AND CORES: primary function of post is to provide a platform for crown to be retainedComposite cores have greater microleakage than amalgam cores Core build-up indicated if 50% of clinical crown is destroyed Endo treated teeth should NOT be abutments for distal extensions of RPDsPosts provide retention for a core Post’s diameter must not be >1/3 of root’s diameter at CEJ; must be a minimum thickness of 1mm tooth structure at mid-root and beyondCarbon and Glass Fiber Posts: flexible, absorbs and dissipates forces acting against tooth Ceramic Posts: more rigid, more flexure, resistance to remaining radicular tooth structure Post length must be 4-5mm from apex and at least as long as clinical crownMust leave at least 4mm of gutta-percha at apical end of canal The diameter of prep drill and post diameter determine if post is active Ferrule Effect: 1.5-2mm or so of sound root structure apical to core that margins of crown should engage to protect against root fracture Margin should be apical to dowel-core margin to enable crown to girdle tooth and brace it externally Post and core can be used for teeth with little or no clinical crown, but with roots with adequate length, bulk, and straightness PORCELAIN VENEERSWhen bonding a porcelain veneer, silane is used to improve bond strength between resin and porcelain Veneer’s intaglio surface is etched to produce microporosities for micro-mechanical retentionUse 0.5mm depth cutter diamond bur for labial tooth reduction Best to have a supragingival margin IMPRESSION MATERIALSHydrocolloids: wet intraoral surfaces, but have limited dimensional stability since they are made of 85% water Reversible Hydrocolloid (Agar-Agar): physical state is changed from gel solid by applying heat and reversed back by removing heatAdvantages= easy to pour, no mixing required; inexpensive, cleanDisadvantages= must be poured immediately, weak in deep sulcus, very limited dimensional stability Irreversible Hydrocolloids (Alginate): elastic impression material with very limited dimensional stabilityAdvantages= inexpensive, easily mixed and pouredDisadvantages= unstable, fragile, must be poured immediately Sodium Phosphate- found in alginate powder controls alginate setting timeIf alginate impressions are placed in water for a while, they can absorb water and expand (IMBIBITION)When taking an alginate impression, wipe all critical areas with alginate areas buccal to maxillary tuberosities and retromylohyoid space Elastomers: impression materials with elastic or rubber-like qualities used for crown and bridge, secondary impressions for dentures, and inlays/onlaysset via a chemical reactionnon-aqueous polymer-based rubber impression materials with good elasticity Polysulfides (Rubber Base, Mercaptan, Thiokol): base contains a liquid polysulfide polymer mixed with an inert filler, accelerator is usually lead dioxide A tray for polysulfide rubber impressions that lacks occlusal stops may result in an inaccurate final impression because of permanent distortion during polymerization Sets in 12-14 minutes Moisture tolerance is acceptableExothermic reaction and accelerated by an increase in temperature or humidity Have good flow properties, high flexibility, and high tear strength. HIGHEST RESISTANCE TO TEARINGPolyvinyl Siloxanes VPS (Additional Silicones or Vinyl Polysiloxanes): upon mixing, there is an addition of silane hydrogen groups across vinyl double bonds and does not form by-products very dimensionally stableCan be poured up to 1 weekLatex gloves should NOT be worn when mixing PVS because sulfur in latex retards setting of addition silicone materials Excellent dimensional stability and very low permanent deformation Poor tear strength, lowest temperature rise, very high stiffness, very poor wettability by gypsum Temperature sensitive Most widely used and most accurate elastic impression materials Polyethers (Impregnum/Premier and Polygel): accelerator contains a cross-linking agent which produces cross-linking by cationic polymerization have shortest working and setting times contract slightly during settingAdvantages= excellent dimensional stability, clean, pleasant taste and odor, FAST SETTING, dimensionally stable, hydrophilic, tolerates moisture better than any other elastomer Disadvantages= most difficult material to remove from mouth most rigid/stiff material, poor tear strength, dimensionally unstable in presence of moisture, has highest temperature rise Elastomers are more accurate in uniform thin layers that are 2-4mm thick fabricate a custom tray Zinc Oxide-Eugenol: impression paste whose setting time is accelerated by adding a drop of water to mixTo retard setting, add inert oils Sets via a chemical reaction Advantages= can record soft tissue at rest, sets hard in 5 min, stableDisadvantages= messy to mix, very sticky, tissue irritant, not elastic, difficult to manipulate, not recommended for gagging patients Bite Registration material should offer a minimum resistance to patient’s jaw closure and have low flow at mixing GYPSUMMain constituent of dental plasters and stones is calcium sulfate hemihydrate All gypsum is produced by calcination Type 1= RARELY USED. Plaster of ParisType 2= used to make casts when strength is not important Produces porous and irregularly shaped particles Dental plaster is WEAKEST gypsum product Beta-hemihydrate Type 3= used for preparing casts of an alginate impression upon which dentures are processedProduced by heating gypsum under pressure with water vapor in an autoclave Heating gypsum in 30% solution of calcium chloride produces high strength Alpha-hemihydrate Produces least porous and strongest particles Type 4= used when making stone “dies”Used for fixed and removable bridges, cast RPDs, crowns, inlays, onlaysHigh strength, low expansion Modified alpha-hemi-hydrate Type 5= dental stone die; high strength and high expansion DENTAL CEMENTSAlways apply cement to both restoration and tooth Composite Resin: luting material of choice to cement a ceramic crown and can provide STRONGEST BONDZinc-Phosphate Cement: can also cement porcelain crowns Has good compressive strength High pH is a problem because 2 layers of varnish must be applied to protect pulp May cause pulpal irritation Has SMALLEST film thickness Zinc Polycarboxylate or ZOE: biologically compatible cements used on teeth with preps with adequate length and retentive features, or when prep depth raises concerns regarding pulpHas better resistance to solubility than zinc phosphate cement Glass Ionomer Cement (GIC): used for restoring teeth and as a luting cement Based on reaction of silicate glass powder and polyalkenoic acid Bond chemically to dental hard tissues and release fluoride Useful in restoration of carious lesions in low-stress areas such as smooth-surface and small anterior proximal cavities in primary teeth Has a coefficient of thermal expansion most closely mimicking tooth structure GC Fuji PLUS resin reinforced GI luting cement for final cementation of metal, PFM and metal free crowns, bridges, inlays, and onlays Bonds chemically and mechanically to tooth structure Releases fluoride, low coefficient of thermal expansion, and biocompatibility to tooth structure and soft tissues Resin-Modified GIC used in all composites and luting cementsGreat for Zirconium crowns RMGICs are conventional GIC with addition of HEMA and photoinitiators Proven bond strength, sustained fluoride release, low post-op sensitivity, moisture tolerant, ideal for PFM, zirconia, metal and pediatric crowns *Prolonged sensitivity to heat, cold, and pressure after cementing a crown or fixed bridge is usually related to occlusal trauma *Occlusion of gold restorations is best checked with SILVER PLASTIC SHIM STOCK DENTAL IMPLANTSEposteal- receives primary support by resting on boneEndosteal- placed into alveolar and/or basal bone; transects only one cortical plateSubperiosteal- placed directly beneath periosteum overlying bony cortex Transosteal (Staple Bone Implant)- penetrates BOTH cortical plates and full thickness of alveolar bone combines subperiosteal and endosteal components Intra-mucosal Implants- inserted into oral mucosa Implant MaterialsMetallic- most popular material today (TITANIUM)Ceramic and Ceramic Coated- can coat metallic implant with a plasma spray or coated to produce a bioactive surface Polymeric- only used as adjuncts stress distribution along with implant Carbon- has modulus of elasticity equal to bone and dentinBiointegration: direct biochemical bond of bone to titanium implant surface at electron microscope levelOsseointegration: direct attachment or connection of osseous tissue to an inert, alloplastic material without intervening with connective tissue; direct contact between bone and implant surface Main reasons implants fail to integrate= premature loading, apical migration of JE, overheating during placement, loose fitting implants, and patients with medical risk factors or contraindications Implants placed in mandible have higher success than those placed in maxillaLower success rates are associated with cancellous bone than with cortical boneCortical bone provides greater implant-bone contact and fixation Horizontal distance between adjacent roots minimum distance between roots is 1.5-2.0mm for adequate inter-implant-radicular bone space 2g of Amoxicillin orally 1 hour pre-op greatly reduces implant failure Place implant entirely in bone, ideally 10mmMust be at least 3mm both mesial and distally to implant if next to another implant, or at least 1.0mm if implant is placed next to natural tooth ideally want total space >7mm M-DBuccal and lingual of implant should have at least 1.0mm of bone Place implant at least 2.0mm away from vital structures Closed impression tray is best for single implant An open-tray impression works best for multiple implants For screw-retained abutments, at least 5mm of abutment height is advised Minimum bone height for predictable, long-term endosteal implant survival is 10mm and minimum B-L bone width is 5.5-6mm Immediate implant placement in a grafted maxillary sinus is indicated when GREATER THAN 6mm BONE WIDTH AND DEPTH Most significant risk factor for a patient with an implant is SEVERE BRUXISMMost ideal posterior tooth to replace with an implant is maxillary or MANDIBULAR 1ST PREMOLARBall attachments place less stress on implants and produces less bending movement than bar-clip attachments Ideal location for a mandibular 2 implant overdenture is the lateral incisor area with short attachments At least 12mm vertical restorative space is needed for mandibular implant-supported overdenture Each 1mm crown height space increase causes a 20% increase in cervical load on a fixed-implant prosthesis Increasing vertical restorative space and decreasing bar height, decreases maximum stress around implants when a unilateral load is applied OPERATIVE DENTISTRYDENTAL CEMENTS Glass Ionomer Cements- hybrids of silicate and polycarboxylate cements designs to combine fluoride releasing properties of silicate particles with chemical adhesive Powder reacts with a liquid to form a cement of glass particles surrounded by a matrix of fluoride elements Indicated to restore LOW STRESS AREASHas good adhesion to dentin GI has a lower compressive strength, tensile strength, and hardness than resin composites Advantages= releases fluoride, micromechanical bond to composite resins, high biocompatibility, good thermal insulators, low solubility in mouthDisadvantages= higher cement film thickness than zinc phosphate cement Used as a cement and permanent restorative material Often used for root surface carious lesions Composed of aluminosilicate powder and polycarboxylate liquid Conventional GIC- used as a luting agentLight-Cured GIC- used as a base or liner; has extended working timeResin-Modified (Hybrid) Light Cured GIC)- used for application where GI is a good choice; good esthetics, bond strength and coefficient of thermal expansion If placed less than 0.5mm from pulp may cause pulpal irritation, sensitivity, and pain Zinc Oxide Eugenol Cements- used as a sedative or temporary filling material, as an insulating base, and in interim caries treatmentEugenol has a palliative effect on PULPPowder is zinc oxide and liquid is eugenolIs soluble in oral fluids and is difficult to remove from cavity prepsDoes not require use of a varnish for pulp protection Provides excellent marginal sealContraindications= cannot apply to dentin/enamel before bonding, cannot use as a base or liner under composites since it interferes with polymerization, CANNOT be used under composites Type 1 ZOE- temporary cementType 2 ZOE- permanent cementType 3 ZOE- temporary filling material and thermal insulating base Good for basing large and complex cavities Type 4 ZOE- cavity liner Zinc Phosphate Cement- oldest luting cement with longest “track record” serving as standard Primary use is as a cement for cast restorations Initial mixture of ZPC is very acidic (pH 3.5) can cause irreversible pulpal damage if a cavity varnish is not placed on tooth prior to cementing crown Provides good pulpal protection from thermal, electrical, and pressure stimuliIf Zinc phosphate cement base is used when restoring a tooth, varnish is applied PRIOR to placing base Varnish reduces initial microleakage of an amalgam restoration Used as a luting agent for gold restorations and ortho appliances May be used as a liner when a strong one is needed Has been replaced by polycarboxylate or GIC Mixing very rapidly decreases cement’s final compressive strength Cool glass slab is used to increase powder-liquid ratioZinc Polycarboxylate Cement- first cement system developed with a potential for adhesion to tooth structure Compressive strength is slightly lower than zinc phosphate cements, but has a greater tensile strength Final strength depends on powder-liquid ratioThermal conductivity is low provides good protection against thermal stimuli applied to metallic restorations Advantages= can bond to tooth structure due to ability of carboxylate groups in polymer molecule to chelate to calcium in tooth Disadvantage= short working timePolycarboxylate cements may form a chemical bond to enamel PREPARATION BASES Bases: materials 1-2mm thick that functions as a barrier against pulpally irritating agents, provides thermal insulation below a restoration, and resistance to compressive forces of mastication Zinc phosphate cement- make sure to seal dentinal tubules with varnish before applying Zinc polycarboxylate cement- provides adhesion and does NOT irritate pulpGIC- provides fluoride release and adhesionCalcium Hydroxide Dycal- effective in promoting secondary dentin formation Primary Bases- placed on dentin next to pulpUse CaOH under amalgam and composite restorationsUse Zinc Phosphate or Zinc polycarboxylate under gold restorationsSecondary Bases- used in placing zinc phosphate cement over a CaOH base that was placed over a pulp exposure Cements used as bases should be stronger than when used as luting agents and mixed with max powder content possible A low powder-liquid ratio produces a low viscosity cement that is needed for luting agents Most important consideration for pulp protection in restorative techniques is thickness of remaining dentin Cements thicker than 2mm are bases and function to replace lost dentin structure under restorationsCements for luting have a final thickness of 15-25 micronsCavity liners have a final thickness of 5 micronsBases have a final thickness of 1-2mmCAVITY LINERS: used to protect pulp by creating a barrier between dentin and pulpally irritating agents by sealing dentinal tubules Cavity Varnish (Solution Liner or Copalite): seals dentin tubules without adding bulkMost commonly used and reduced initial microleakage of restorationNOT used under composite because it inhibits polymerization of resin Does not provide thermal protection Suspension Liner (Zinc Oxide Eugenol and Calcium Hydroxide): function to prevent penetration of acids and thermal shock and has adequate strength for use under permanent restorationsGood liner due to soothing effect on pulpCaOH (Dycal) can stimulate secondary dentin formation when placed near or in direct contact with pulpLeakage after insertion of an amalgam is reduced when a cavity varnish is used For home bleaching use 10% carbamide peroxide concentration active ingredient is H2O2Bleaching can affect color of dentin and enamelExtrinsic stains respond best to vital bleachingYellow stains respond BESTGray stains (tetracycline staining) respond WORSTCARIES The rate at which carious destruction of dentin progresses slower in older adults than in younger people is because of the generalized dentinal sclerosis that occurs with agingDental caries is initiated at tooth surface by growth of Streptococci These bacteria produce Dextran Sucrase (Glucosyltransferase) catalyzes formation of extracellular glucans from dietary sucrose Predominant Bacteria Found in PlaqueStreptococcus sanguisActinomyces viscosus and naeslundiiStreptococcus mutans, mitis, salivarisVeillonella, Lactobacilli casei, and Fusobacterium Properties of Cariogenic BacteriaAcidogenic and aciduricLactic acid produced by acidogenic bacteria is main cause of enamel decalcification Glucans are synthesized from sucrose Levans are polymers of fructose Main cause/etiology of caries is bacterial or plaque formation Initiation of dental caries requires a high proportion of Streptococcus mutans within dental plaque Streptococcus mutans produce large amounts of lactic acid, are tolerant of acidic environments, are vigorously stimulated by sucrose, and are the primary organisms associated with dental caries Developmental pits and fissures are most susceptible areas on a tooth for plaque retentionPit and fissure caries has highest prevalence of all caries Pulp’s response to carious attack or trauma from operative procedures depends on pulp’s blood supply and cellular activity Sclerotic dentin (peritubular dentin) pulp’s initial defense mechanism Acute Caries (Rampant Caries): characterized by rapidly progressing, little or no staining, soft-to-touch lesions, most common childrenChronic Caries (Slow or Arrested Caries): common in adults, progresses slowly, and lesion entrance is wide; characterized by dark pigmentation with leathery dentin, shallow lesion Root Surface (Senile Caries): found in older patients and attacks cementum and radicular (root) dentin; spreads laterally best way to prevent is to maintain the periodontal attachment Residual Caries: caries remaining in a completed prep by accident or on purpose Secondary (Recurrent) Caries: decay at and under restoration marginsGingival recession is most related to initiation of caries in elderlyActinomyces viscosus is most associated with root surface caries Zones of Carious Dentin (Innermost Outermost Zone)Zone 1 (Normal Dentin): innermost zone of normal dentin with no bacteria in tubules Zone 2 Carious Dentin (Sub-transparent Dentin): demineralization created by acid from caries, damage to odontoblastic process; capable of remineralization Zone 3 (Transparent Dentin): softer than normal dentin and shows further demineralization; capable of remineralization Zone 4 (Turbid Dentin): zone of bacterial invasion as dentinal tubules are filled with bacteria; CANNOT remineralize and must be removed Zone 5 (Infected Dentin): consists of decomposed dentin filled with bacteria; must be completely removed prior to restoration Zones of an Incipient Carious Lesion in Enamel:Translucent Zone- deepest zone that represents advancing front of enamel lesionDark Zone- areas of demineralization and remineralization Body of Lesion- largest area of incipient lesion that has areas of demineralization Surface Zone- relatively unaffected by caries Enamel demineralization occurs at pH 5.5Remineralization occurs as pH rises above 5.5Cementum demineralization occurs between 6.0-6.7 pHAn incipient carious lesion on an interproximal surface is usually located gingival to the contact area Maxillary 1st molar is the tooth most likely to benefit from occlusal sealant placement GOLD- most ductile and malleable metal; corrosion resistant Silver- 2nd most ductile and malleable metal after goldPalladium- increases hardness, elevates melting range, strong whitening effect on colorPlatinum- elevates melting rangeDuctility: metal’s ability to easily be worked into desired shapes depends on plasticity and tensile strengthUsually expressed in terms of percent elongation Ductility decreases as temperature increases Malleability: metal’s ability to be hammered into a thin sheet without rupture depends on plasticity increases as temperature increasesAlloy: mixture of two or more materials mutually soluble in liquid state; used in dentistry for cast restorationsBase Metal Alloys- based on active metallic elements that corrodeLess resistant to corrosion than noble metals Harder to cast and finish than noble metalsNoble Metals- very resistant to corrosion and do NOT oxidize on castingSolid Solution Alloys- metals freeze without segregation of individual constituents Have high homogenous structure and provide maximum strength Eutectic Alloys- have complete liquid solubility, but limited solid solubility Karat: # of “pure gold” parts of a gold alloy, based on 24 parts as a unit Fineness: measures on parts of pure gold per 1,000 pure gold is used only in gold foil restorations4 High-Gold Alloys: hold-gold alloys used for cast restorations are >75% gold or other noble metalsADA Type 1= highest gold content used for small inlays ; has high ductilityADA Type 2= >78% noble metals used for larger inlays and onlaysADA Type 3= >75% noble metals used for onlays and crowns ADA Type 4= >74% noble metals used for bridges and RPDS Gold Substitute Alloys: do NOT contain gold, but are “passive”, they form a protective surface oxide film layer that provides maximum corrosion resistance Advantages of Cast Gold Restorations: strong, ideal for occlusal rehabilitation gold to gold results in LEAST occlusal wearFor maximum retention of cast gold restorations, axial walls should be as parallel as possibleRetention is directly proportional to area of axial walls and their parallelism Axial walls should converge slightly from gingival walls to pulpal wall Cement’s main function in gold is to seal the cavityONLAYS: main advantage is it can permanently restore and reinforce a tooth by a conservative technique Indications:Restore large lesions involving more than 1/3 intercuspal dimension; but at least 50% of clinical crown remainsRestores brittle teeth Parallelism of vertical axial walls is primary retentive feature in an onlay prepSharp points and lines angles increase onlay retention A box offers a greater increase in surface area Capping is always preferred over shoeing Cap= complete coverage of cuspShoe= minimal or partial cusp coverage via a finishing bevel on cusp crest Axial walls in an MOD cavity prep for a cast gold onlay should converge from gingival walls to pulpal wallAlways bevel or plane cavosurface margins or wall junctions of an onlay cavity For onlay prep, wax bite chew-in is most effective means for verifying adequate occlusal clearance GOLD INLAYSAvoid undercuts in preps restoration will not seat if undercuts exist A dovetail should be made to prevent proximal dislodgement Advantages/Indications= low caries index, moderate size lesions with conservative outlines, rest seat retainers on abutment teeth Type A Wax- hard or low-flow wax rarely usedType B Wax- medium-flow wax used in some direct techniquesType C Wax- soft or high-flow wax (softest dental inlay casting wax) used in indirect techniques Essential ingredients in a successful inlay way= paraffin wax, gum dammar, and carnauba wax Casting cannot be more accurate than wax patternBevel- diagonal cut across cavosurface margin that is flat in 1 dimension only and curved in other dimensions involves external ends of enamel prisms Chamfer- a hollow ground bevel Plane- diagonal cut across cavosurface margin that is flat in all dimensions and may involve entire enamel thickness A cavosurface bevel is used when preparing a tooth for a cast gold inlay or onlay mainly to improve marginal adaptationCavosurface margin bevel permits closer adaptation of gold margin From facial to lingual, the axiopulpal line angle of an onlay prep is longer than the axiogingival line angleMat gold is used for bulk filling of cavities Powdered gold can be placed in a very short time period and a gold foil veneer is NOT requiredThe cause of porosities or pits in a gold foil is related to improper condensing technique and using oversized pellets During condensation, surface hardness of gold foil is always increased Main indication for using a direct filling gold is a small initial Class 3 lesion has a high tensile strength and is the most nearly permanent of all restorative materials Direct Filling Gold IndicationsIdeal Lesion- no greater than 1-2mm into dentin, and minimal outline form Ideal pulp- at least 2mm of dentin between restoration and pulpIdeal periodontium- no tooth mobility, no inflammation, or degenerative processes present Class 5 Outline Form= trapezoidal or kidney shaped Retention for a Class 5 cavity prep for direct filling gold should be at occlusoaxial and gingivoaxial line angles Dental Investment Functions- a detailed reproduction of anatomical form, enough strength to withstand heat of burnout and actual casting of molten metal, and compensation expansion equal to alloy solidification shrinkage Components of Gypsum Bonded InvestmentsRefractory Filler- form of silicon dioxide that comprises 60-65% of investment; regulates and provides thermal expansion for investment Binder- using a thinner mix that contains more water of a gypsum-bonded investment will decrease setting expansion, increase setting time, increase porosity of set material, and weaken set material Modifiers Strength of dental investments for gold alloys is dependent on amount of gypsumThermal expansion is main cause of mold expansion Sprue: purpose is to provide an ingate or sprue in investment through which molten alloy can reach model after wax has been eliminatedBest to attach sprue at point of greatest bulk in pattern less chance of distortion Best angle to attach sprue pin to proximal wall of a wax pattern is 45Placement of sprue is most related to turbulence of molten gold in casting process Vacuum Investing: method of investing that is more dependable in preventing surface nodules/defects on a casting Nodules are caused by collection of air bubbles during investing Porosity of investment is reduced by vacuum investing due to increased density obtained Parts of Flame from a Gas-Air Blowtorch to Melt Alloys:Mixing zone- cool and colorless; air and gas are mixed before combustion Combustion zone- greenish-blue and surrounds inner core; oxidizing zone where partial combustion occursReducing zone- hottest area in flame and only part of flame that should be used to heat alloyOxidizing zone- where final combustion between gas and surrounding air occursMINIMAL reduction of working/functional cusps for protection from forces of mastication is 2.5-3mm for amalgam, and 1.5mm for cast gold restorationsMINIMAL reduction for non-working cusps for amalgam is 2mm while forming a flattened surface and 1mm for cast gold For PFM restorations: occlusal clearance is 1.5-2mm and 1.5mm facial and lingual reduction COMPOSITES Enamel is total-etched with phosphoric acid to roughen enamel surface which forms little tags 10-25 micrometers long to provide mechanical retention Enamel rods are most effectively etched at enamel rod endsA properly acid-etched enamel surface appears DULL WHITE & CHALKYAcid cleans surface of debris left after cavity prep to provide opportunity for better wetting of enamel by resin Conserves tooth structure, reduces microleakage, improves esthetics, and provides micro-mechanical retention Once tooth is etched, it cannot be contaminated with saliva, or you must repeat entire etching procedure Reduction of microleakage is most significant advantage of acid-etch technique Purpose of acid etching is to provide more surface area and a roughened surface Dentin Bonding SystemsEtchant- used to roughen enamel surface to provide mechanical retention; removes smear layerDentin Conditioner- removes smear layer of dentin and etches intertubular dentin to produce microspaces in dentin surface Primer- provides micromechanical and chemical bonding to microspaces created by conditioner Unfilled Resin Adhesive (Bonding Agent)- restorative material applied after primer, this layer can bond to composite or amalgam Unfilled resin has the lowest thermal conductivity and diffusivity Strength is low, and yield and tensile strengths are even lower Have a higher coefficient of thermal expansionHave greatest extent of marginal leakage related to temp change INCLUDEPICTURE "/var/folders/14/kfphkf717_q461gqnnf3ht700000gq/T/com.microsoft.Word/WebArchiveCopyPasteTempFiles/page805image21338832" \* MERGEFORMATINET 7th Generation- eliminates need for separate etching, rinsing, and mixing for light-cured productsminimizes post-op sensitivity3rd Generation- first generation to bone to tooth structure and dental metals/ceramics; has high post-op sensitivity Provisionals are usually cemented with ZOE cement Main disadvantage to using methyl methacrylate as a permanent restorative material are its low resistance to abrasion and high coefficient of thermal expansion Low wear resistance is the property of filled resins that is mainly to blame for failure of Class 2 composite restorationsMajor indication for posterior composites is a demand for esthetics by dentist and patient Composite resins are inferior to amalgam in compressive strength and abrasion/wear resistance, and do not provide any anti-cariogenic effectsFilled Composite Resins: replaced unfilled acrylic resins; has inert filler added to resin matrixHarder, stronger, more resistant to abrasion, with a lower coefficient of thermal expansion than unfilled resins Small size filler particles in composite resins results in better finishing and greater resistance to occlusal wear Smaller particles yield better finishing characteristics and greater wear resistance Function= to decrease coefficient of thermal expansion and polymerization shrinkage Increase tensile and compressive strengths, hardness, and improve wear resistance Difficulty in finishing composite resin restorations is mainly due to softness of resin matrix and hardness of filler particlesMost desirable finished surface for composites is obtained with aluminum oxide disks Silane (coupling agent) promotes adhesion between inert filler and organic matrix LIGHT CURINGIncremental curing decreases shrinkage of composite, decreases gap formation, decreases polymerization shrinkage, reduces marginal leakage, and decreases cusp deformation Visible light curing involves light energy in the range of 410-500nm with a peak intensity of 470nmCuring light is used at wavelengths of 400-500nm for adequate composite curing Most effective complete curing depth is 2mmVisible light used in polymerization of photoactivated materials can cause retinal damageResin can be polymerized through enamel PEARLSA class 3 DL lesion on a canine should be filled with amalgam or direct goldIf 2 adjacent teeth have class 3 lesions, prepare the larger lesion first, but fill the smaller lesion first In class 3 composite prep, retention points should be entirely in dentin Most important factor in preparing and restoring a class 2 composite lesion is moisture control Resin cements are cement of choice for composite inlays Composite resin is material most likely to cause an adverse pulpal reaction when placed directly in a deep cavity prepRetention in a cavity prepared for composite resin is gained by undercuts in dentin and acid etching All enamel cavosurface angles should be obtuse angles A patient’s history of cataract removal will determine if dentist needs to take precautions when light curingFinishing should NOT eliminate occlusal contacts Outline form for a Class 5 composite prep has rounded internal line angles Cavosurface margin for a composite restoration is chamfered when placed on enamel AMALGAMOutline Form- shape or form of cavity on surface of tooth Convenience Form- form cavity prep takes to aid operator in preparing, placing, or finishing restorationRetention Form- form cavity prep takes to resist dislodgment or displacement of restoration For class 2, resistance to dislodgement is provided by occlusal dovetail and retention grooves in proximo-axial line angles Retention grooves are placed in axiobuccal and axiolingual line angles Resistance Form- form cavity walls take to resist forces of mastication to prevent fracture of restoration and tooth Most common cause of fracture at isthmus of a class 2 amalgam is inadequate depth at isthmus areaAxiopulpal line angle is rounded or beveled to reduce concentration of stresses Trituration: increasing trituration time, reduces setting expansion of amalgamA properly triturated amalgam is shiny, wet, smooth, and homogenous An over-triturated amalgam mix is better than an undertriturated one Inadequate trituration creates a low strength amalgam mix and rough surface that accelerates corrosion When carving an amalgam restoration, trim margins with a sharp instrument that rests on tooth structure to prevent “ditching” the margins Principal purpose of trituration is to coat alloy particles with mercury Pins: function to retain restorative materialDo NOT increase strength of restorative materialRetention increases as pin diameter increases Optimal placement is at line angles of tooth where tooth-to-root mass is greatest Indications:Class 2 amalgam prep where one or more cusps have been lostVery large class 3 amalgam prepPrep for amalgam buildup over which cast restoration will be made When placing pins in an endo treated tooth, use only self-threaded pins or cemented pinsPins are inserted into DENTIN ONLY and placed 1.0-1.5mm inside cavosurface margin &at least 0.5mm inside DEJOptimal pinhole depth into dentin is 2mm Most frequently used pins are Self-Threaded Pin Systems Class 1 Amalgam Prep- M and D walls must DIVERGE slightly towards occlusal surface Class 2 Amalgam Prep- occlusal dovetail provides resistance to proximal displacement; create reverse S curve in outline conservative class 2 amalgam prep has a proximal cavosurface margin that forms a 90 angle with external surface most sensitive area of tooth during cavity prep is DEJ gingival cavosurface margin is beveled only if placed in enamel Class 5 Amalgam Prep- has non-parallel M and D walls of prep that are also straight and parallel mesial, distal, gingival, and incisal walls of cavity prep diverge outward retention form is provided by gingival retention groove along gingivoaxial line angle and an incisal retention groove along incisoaxial line angle INCLUDEPICTURE "/var/folders/14/kfphkf717_q461gqnnf3ht700000gq/T/com.microsoft.Word/WebArchiveCopyPasteTempFiles/page833image21077520" \* MERGEFORMATINET Matrix Band: primary function is to restore anatomical contours and contact areas One of most difficult teeth to adapt matrix band to is mesial of a maxillary 1st PM Thickness of a good class 2 matrix band should be about 0.002 inches INCLUDEPICTURE "/var/folders/14/kfphkf717_q461gqnnf3ht700000gq/T/com.microsoft.Word/WebArchiveCopyPasteTempFiles/page837image21344448" \* MERGEFORMATINET Delayed expansion of amalgam restorations is associated with insufficient trituration and condensation, and amalgam contamination by moisture during trituration and condensation Amalgam’s compressive strength is reduced when contaminated with moisture Amalgam has a coefficient of thermal expansion 2x that of tooth structure High mercury content is manifested in clinical amalgam restoration by severe marginal breakdownIf mercury content is more than 55%, a loss in strength occurs Removing mercury-rich matrix by proper condensation and carving produces a stronger and more corrosion resistant amalgam since it minimizes formation of matrix phases of amalgam Strongest phase of set amalgam is GAMMA phase Gamma (strongest phase) > gamma 1 > gamma 2 (weakest phase)Smaller particle size higher strength, lower flow, and better carvability Spherical amalgams high in copper have best tensile and compressive strengths Dental Amalgam CompositionSilver= decreases setting time, increases setting expansion and strength Tin= increases setting time, and decreases setting expansion; causes contractionCopper= increases hardness, strength, and resistance of amalgam to corrosionZinc= prevents oxidation of other metals while alloy is being prepared Mercury= reacts with other alloy particles to produce different phases mercury is used to initiate reaction with alloyMercury content >55% decreased strength Higher condensation pressure, smaller particle size, longer trituration time, and fewer voids increase amalgam’s strengthThe greatest potential hazard of chronic mercury toxicity comes from inhaling mercury vaporMain purpose of adding copper to an amalgam is to decrease the gamma-2 phase High copper alloys have less marginal breakdown and are less likely to corrode Spherical amalgam is BEST for PLACING AROUND A PINAfter 12% copper content, the gamma-2 phase is eliminated by forming a copper-tin phase with superior properties Creep: deformation with time in response to a constant stress One of the main causes for margin fractures on amalgam restorations Time-dependent High copper and low mercury content of an amalgam restoration decrease creep Undertriturated and overtriturated amalgam increase creep rate Higher the creep greater marginal deteriorationMarginal leakage of an amalgam restoration DECREASES as the restoration ages Proper amount time to wait until an amalgam restoration can be finished and polished is 24-48 hours Amalgam restorations should be finished and polished to reduce marginal discrepancies, create a more hygienic restoration, reduce marginal breakdown, which reduces chance of recurrent decay, to prevent tarnishing, and improve restoration’s appearance During polishing of an amalgam, heat damages pulp and draws mercury to restoration surface to create an inferior restoration use a wet abrasive powder in a paste form Cold sensitivity is the most common problem encountered after placing a dental amalgam restoration Restoring a cusp with amalgam requires at least 2mm of cusp to be removed to provide resistance form An MO amalgam restoration is more resistant to fracture if axiopulpal line angle is beveled or rounded Direction of M and D walls of Class 5 amalgam cavity prep is determined by direction of enamel rods Self-threading pins offer greatest degree of retention into dentin Threaded pins are used in large dental amalgam restorations to provide retention form When pins are added to an amalgam restoration, strength of amalgam is decreased When using a rubber dam, always isolate at least 3 teeth Rubber dam is INVERTED into gingival sulcus with floss and/or blast of air and a plastic instrument to prevent seepage of saliva Punching holes too close together in rubber dam may cause damage to gingival papillaThe hole to be punched in the rubber dam for the tooth being restored should be facial to the normal alignment with adjacent teeth Embrasures: there are 4 embrasures of each contact area- buccal/facial, lingual, occlusal/incisal, cervical/gingivalFunctions= spillway for food during mastication, make teeth more self-cleansing, and protects gingival tissue Loss of proximal contact between teeth can cause periodontal disease, malocclusion, food impaction, or drifting of teethFrom occlusal view, all posterior teeth have contacts located buccal to middle 1/3 Adhesion: attraction of unlike moleculesPredicted by measuring spreading or wetting of adhesive over substrate surfaceThe smaller the angle greater wetting and potential for adhesionCohesion: attraction of similar molecules Strain: actual change in shape or deformation that accompanies any stressCompression- squeezing of material by external forces Tension- pulling of a member or part of a member, resulting in an increase in lengthShear- sliding of one layer of a material relative to another layer of materialToughness: total energy absorbed to point of fracture – property of being difficult to break affected by yield strength, tensile strength, percent elongation, and modulus of elasticity Brittleness: vulnerable to fracture has a high compressive strength, but low tensile strength Modulus of Elasticity: measure of a material’s stiffness or rigidity Resilience: energy that a material can absorb before any plastic deformation Coefficient of Thermal Expansion: measure of tendency of a material to change shape when subjected to temperature changes Elastic Limit: greatest stress a material can be subjected to and still return to its original dimensions when forces are released Proportional Limit: greatest stress produced in a material such that stress is directly proportional to strain material with a high proportional limit has more resistance to permanent deformation than a material with a lower proportional limitYield Strength: stress slightly higher than proportional limit *property that most closely describes the ability of a cast gold inlay to be burnished is percent elongation EXCAVATORS: to remove caries and refine internal parts of a prepHatchet excavator- has cutting edge of blade directed in same plane of handle and is bi-beveledUsed primarily on anterior teeth for preparing retentive areas Hoe excavator- has cutting edge of blade perpendicular to axis of handleCommonly used in class 3 and 4 preps for direct goldAngle former- has cutting edge at an angle to bladeUsed for sharpening line angles Spoon excavator- used to remove carious dentin and carve amalgamCHISELS: mainly to cut enamelStraight, slightly curved, or bin-angle- used for planning or cleaving enamelBlade terminates in a cutting edge formed by a one-sided bevelEnamel hatchets- cutting edge in plane of handleDesigned to most effectively plane enamel of facial and lingual walls of a class 2 amalgam prepGingival margin trimmers- has a curved blade and angled cutting edgeUsed for beveling gingival margins, and for rounding or beveling axiopulpal line angle of class 2 prepsParts of Hand Cutting InstrumentsHandle- part of instrument held or grasped during activation of bladeShank- connects blade to handle; can be straight or angled Blade- working end of instrument, connected to handle by shank Nib- working end of a non-cutting instrument 1st #= blade width in tenths of a mm2nd #= primary cutting edge angle in centigrade3rd #= blade length in mm4th #= blade angle in centigrade Bur PartsShank- part that fits into handpieceNeck- connect head to shank; functions to transmit rotational and translational forces to headHead- working part of bur, cutting edges perform desired shaping of tooth structure Bur TypesSteel bur- used for finishing proceduresCarbide bur- used for cavity preps and performs best at high speedsDiamond bur- used during crown and veneer prepRake angle is most important design characteristic of a bur blade To be most effective, carbide burs should be rotating rapidly before contacting tooth On a carbide bur, a greater # of cutting blades less efficient cutting and a smoother surface Air may dehydrate tooth causing hypersensitivity by drawing odontoblasts into dentinal tubules PERIODONTICS Periodontium- tissues that surround and support teeth; consists of gingiva, PDL, cementum, alveolar and supporting bone main functions are to support, protect, and nourish teeth Alveolar Process: part of maxilla and mandible that HOUSES TEETH Cortical plate forms outer and inner plates of alveolar processes and is thicker in mandible than in maxilla Spongy bone is NOT present in anterior region of mouth Free gingival groove- separates free gingiva from attached gingiva Gingival Fibers- ONLY found within FREE GINGIVA and are continuous with the PDL Alveologingival Fibers- insert into crest of alveolar process and spread out through lamina propria into free gingiva Circular Fibers- resists ROTATIONAL FORCES applied to a tooth, and help form gingival ligament Fibers encircle tooth around most cervical part of root and insert into cementum and lamina propriaDentogingival Fibers- extend from cementum apical to JE and into lamina propria of gingivaDentoperiosteal Fibers- extend from cervical cementum over alveolar crest to periosteum of cortical bone plates Transseptal Fibers- connect 2 adjacent teeth Have no attachment to alveolar crestal boneMaintain integrity of dental arches Attached Gingiva: contains keratinized epithelium and lamina propria of dense, well-organized fiber bundles with few elastic fibersFirmly joined to underlying tooth structure, periosteum, and bone, and structured to withstand frictional stresses of mastication and brushing Narrowest band is found on a FACIAL surfaces of mandibular canine and 1st PM and lingual to mandibular incisors and canines Widest on facial surface of maxillary lateral incisorBoundaries defining ATTACHED GINGIVA= extend from MGJ to free gingival groove All oral mucosa is STRAITIFED SQUAMOUS EPITHELIUMNon-Keratinized Oral Mucosa- buccal and alveolar mucosa, tongue’s inferior surface, soft palate, floor of mouth, specialized mucosa, and lining mucosaAlveolar mucosa functions as a lining tissue, located apical to attached gingiva on F and L surfaces Keratinized Oral Mucosa- hard palate and attached gingiva Masticatory mucosa= free and attached gingiva, and mucosa of hard palateLining mucosa= mucosa that lines most of oral cavity EXCEPT gingiva, anterior palate, and dorsum of tonguePDL is a highly vascular and cellular C.T. that surrounds roots of teeth and bridges root cementum with alveolar boneNarrowest part is at middle of rootOccupies space between cementum and periodontal surface of alveolar boneMost abundant cells in PDL are fibroblastsOrtho treatment is possible because PDL continuously responds and changes Contains 2 nerve endingsFree, myelinated endings convey PAINEncapsulated, myelinated nerve endings convey PRESSURE Thickness decreases with age PDL is composed primarily of type 1 collagen fibers and contains 2 immature elastin forms- Oxytalan and Eluanin Oxytalan fibers regulate vascular flowPDL is derived from dental sac Principal fibers connect root cementum to alveolar boneSharpey’s fibers are anchored to cervical 1/3 of acellular cementumEpithelial Rests of Malassez- remnants of Hertwig’s epithelial root sheathOcclusal table is generally at right angles to tooth’s long axis PDL Principal FibersHorizontal fibers- run perpendicular from alveolar bone to cementum; resist lateral forces Alveolar crest fibers- extend from cervical cementum of tooth to alveolar crest; function to counterbalance occlusal forces on more apical fibers and resist lateral movementsOblique fibers- MOST NUMEROUS; resist forces along tooth’s long axisApical fibers- offer initial resistance to tooth movement in an occlusal directionInterradicular fibers- found ONLY in multi-rooted teeth An inflammation in GCF flow is 1st detectable sign of inflammation Dentojunctional Epithelium: gingival epithelium that faces tooth, composed of non-keratinized stratified squamous epithelium Sulcular Epithelium- lines sulcus and connects directly with JEJunctional Epithelium- surrounds each tooth; collar-like band of stratified squamous epithelium firmly attached to tooth by hemidesmosomes Located entirely on enamel above CEJ in ideal gingiva Epithelial attachment consists of a lamina lucida, lamina densa, and hemidesmosomes Epithelial attachment DOES NOT contain rete pegs, but free gingiva does Greatest contour of cervical lines and gingival attachments occur on MESIAL surface of ANTERIOR teeth Autogenous Free Gingival Graft: Usually donor site from where graft is taken is an edentulous region or palatal area Graft epithelium undergoes degeneration after it is placed, then sloughs Free Gingival Graft: removing a section of attached gingiva from another area of mouth and suturing it to recipient site Used to increase zone of attached gingiva and possibility of gaining root coverageSuccess depends on graft being immobilized at recipient siteReceives its nutrients from viable C.T. bedMain reason for FAILURE= disruption of vascular supply before engraftment INDICATIONS:Prevent further recession and successfully increase width of attached gingivaCover dehiscences and fenestrationsPerformed with frenectomy to prevent reformation of high frenal attachments Covers root surfaces Widens gingiva after recession occurs Correct localized narrow recessions or clefts Free Mucosal Autograft: transplant is C.T. without an epithelial coveringOften used on canines where little keratinized gingiva exists to create a band of gingiva-like tissue Root amputations- separation of an individual root from crown; commonly involves maxillary 1st and 2nd molars Hemisection- vertical sectioning of tooth through BOTH crown and root usually done in the mandibular molar region, where crown is divided through the bifurcation region 50% of tooth is extracted if 1 specific root has excessive loss in osseous support, and remaining half of molar is now treated as premolar Distal Wedge Flap (Proximal Wedge): simplest distal flap procedure/approach used for retromolar reductionPerformed in these areas= maxillary tuberosity region, mandibular retromolar triangle area, and distal to last tooth in arch, or mesial to a tooth that approximates an edentulous area Basic concept involves making at least 2 incisions Osseous Recontouring Surgery: MAIN GOAL is to eliminate periodontal pocketsDoes NOT cure periodontal disease but provides patient with opportunity and access to maintain their own periodontium and dentition with route OHI procedures Should NOT be performed until etiology factors that caused osseous defects are arrested Most critical factor to determine if a tooth should be extracted or have surgery is AMOUNT OF ATTACHMENT LOSSPRIMARY OBJECTIVE of Surgical Flap Procedures in treating perio disease is to provide access to root surfaces for debridement Surgical Flap Goals to tx perio disease= to reduce/eliminate perio pockets, regrowth of alveolar bone, maintain biologic width, and establish adequate soft tissue contours Most common goal of all flap procedures is to provide access for instrumentation Without direct visualization provided by a flap, it is rare that a clinician can effectively root plane beyond 5mm of probing depth or into root furcations of lesser depth Surgery is contraindicated if patient fails to demonstrate adequate oral hygiene during initial therapyPeriodontal Flap: segment of marginal periodontal tissue that is surgically separated coronally from its underlying support and blood supply, and apically attached by a pedicle of supporting vascular C.T. Flaps should be uniformly thin and pliable, flap base must be about 2mm thick, and all flap corners should be ROUNDED Rules of Flap DesignFlap base is WIDER than free margin Incision lines should not be placed over any bony defect Avoid incisions that traverse a bony eminenceRound all flap corner Best indicator of success of a periodontal flap procedure is post-op maintenance and plaque control by patient Full-Thickness Flap: includes surface mucosa and periosteum of underlying alveolar boneInvolves reflecting ALL soft tissue and periosteum to expose underlying boneUsed where attached gingiva is thin (<2mm wide)Modified Widman Flap- full-thickness flap used in open flap debridement and regenerative periodontal proceduresObjective is to gain access to underlying bone and root surfaces, reduce pocket depth by establishing a new more coronal attachment level, preserve attached gingiva, and provide an environment for healing by primary closure Indications= pocket bases located coronal to MGJ, where there is little/no thickening of marginal bone, when esthetics are important Partial Thickness Flap: includes ONLY mucosa epithelium and a layer of underlying C.T.Mucosa is separated from periosteum by sharp dissection Used to prepare recipient sites for free gingival grafts Used when attached gingiva is thick (>2mm)Positioned Flaps: flap’s coronal margins are lifted apically, coronally, or laterally from area next to recipient site flap’s vascular supply is maintained Types of Positioned FlapsPedical Flap (Laterally Positioned Flap)- full-thickness flap performed to correct defects in morphology, position, or amount of attached gingiva Defect is covered by stretching flap laterally until free end comes over itIndications= areas of narrow gingival recession next to wide band of attached gingiva, used to correct or prevent recession by providing root coverage, creating wider band of gingivaApically Positioned Flap- full-thickness, mucoperiosteal flap with a high degree of predictability Objective is to surgically eliminate deep pockets by positioning flap apically while retaining attached gingiva Indications= moderate/deep pockets, furcation-involved teeth, and crown lengtheningContraindications= patients at risk for root caries On palatal surface of maxillary molars, need to trim flap margin to proper length during procedure Coronally Positioned Flap- full-thickness flap exclusively used to restore gingival height and zone of attached gingiva over isolated areas of gingival recession There is no necrotic slough of positioned flaps because they carry their vascular supply with them Gingivoplasty: reshapes gingiva and papilla of a tooth to correct deformities and provide gingiva with normal and functional form overall goal is to provide improved physiological tissue contour Gingivectomy: reduces pocket depth by resecting tissue coronal to pocket baseFinal aspect is to bevel wound’s coronal margin to provide most physiological shape and marginal thickness so good oral hygiene can be performed Indications= treating pseudopockets, suprabony pocketsContraindications= infrabony pockets, lack of attached tissueOstectomy: removal of osseous defects or infrabony pockets by eliminating bony pocket walls Bone removed is supportive in nature If crestal bone is removed it will weaken adjacent tooth’s bony supportOsseous Defects: pattern of bone loss from periodontitis can be horizontal or verticalHorizontal Bone Loss- bone loss parallels CEJ of adjacent teeth Suprabony pockets- pattern of bone loss is horizontalPeriodontal pocket is characterized by apical migration of epithelial attachment Pocket base (epithelial attachment) is CORONAL to crest of alveolar boneVertical Bone Loss- interproximal bone loss that does not parallel CEJ, and found around isolated teeth Pocket base is APICAL to crest of alveolar bone causing defect or hole in boneMore bony walls remaining, better prognosis1-wall defects= HEMISEPTUM are most difficult to treat (worst prognosis)2-wall defects= MOST COMMON (interdental crater)3-wall defects= BEST PROGNOSIS OF SUCCESS 4 wall defects= circumferential or moat defects offer best opportunity for bone graft containment 0-wall defects= alveolar dehiscences and fenestrations Infrabony defects/pockets are contraindications for mucogingival surgery When evaluating an osseous defect, only way to determine # of walls left surround tooth is by exploratory surgery 2 most critical factors to determine prognosis of a periodontally involved tooth are mobility and attachment loss Osteoplasty: reshaping or recontouring alveolar bone that does not provide attachment for periodontal fibers without removing supporting alveolar bone*chances of success are best in a 3-walled infrabony pocket and least successful in a through-and-through fucation defect on a maxillary molar Root resorption- most common side effect of an autogenous bone graft in managing an infrabony pocket Dehiscence- alveolar bone loss that leaves an OVAL, ROOT-EXPOSED DEFECT from CEJ apically features= gingival recession, alveolar bone loss, and root exposure Fenestration- opening/window in solid cortical plate of compact bone on buccal/facial surface that exposes tooth root bordered by alveolar bone along its coronal aspect Guided Tissue Regeneration: placement of non-resorbable barriers/resorbable membranes and barriers over a bony defect Blocks re-population of root surface by long JE and gingival C.T. to allow PDL and bone cells to re-populate periodontal defect Purpose of membrane is to block epithelium to allow time for bone regeneration If using non-resorbable barrier is used, remove 6-10 weeks after placement Periodontal dressings DO NOT enhance healing rate of tissues or have an effect on surgical outcomes All dressings are removed within 7-10 days Collagen accounts for about 60% of gingival protein Type 1 collagen is the most common type in the mucosa Junctional Epithelium: collar-like band of stratified squamous epithelium 10-20 cells thick near sulcus, 2-3 cells thick at apical end, and .25-1.35mm longHas 2 basal laminasProliferative cell layer is responsible for most cell divisions and is in contact with C.T.Barrier membranes help prevent long JE from forming Stages of Disease in Developing GingivitisTransient Stage- occurs 2-4 days after stopping oral hygieneMargination of PMNs occurs in vessels close to JESloughed epithelium cells and bacteria are found in gingival sulcus Developing Stage- contains serum proteins fibrin, immunoglobulins, complement, inflammatory cells, lymphocytes, and macrophages Lymphocytes are predominant cellChronic Stage- plasma cells predominant IgG is most abundant in gingival exudates in gingivitis ANUG- fusiforms, spirochetes, and Prevotella Intermedia are involvedTreponema denticola is intermediate-sized spirochete associated Fetid odor and spontaneous bleeding on probingInterproximal necrosis and gray pseudomembrane formation on marginal tissues No attachment lossHistory of soreness/pain and bleeding gums Signs & Symptoms= fetor oris, low-grade fever, lymphadenopathy, and malaise Neutrophil is dominant WBC involved Predisposing factors= history of gingivitis, smoking, fatigue, stress, poor nutrition, and immunocompromised Acute Gingivitis- gram (+) predominate Actinomyces filament and Streptococci species PMNs are 1st line of defense and 1st cells to migrate into gingival sulcus when inflammation caused by plaque formation is in initial lesion Acute InflammationVascular phase- involves basophils, tissue mast cells, and platelets that release histamineCellular phase- polymorphonuclear neutrophils predominantMacrophages appear late in cellular phase and represent a transition between acute and chronic inflammation Major histamine storage sites are mast cells, platelets, and basophils Histamine is important in vascular phase of acute inflammation Chronic Gingivitis- # of gram (-) anaerobic organisms increasesFusobacterium, Prevotella intermedia, and Capnocytophaga species predominate Increase in plasma cells and B-lymphocytes that invade deep into C.T. Chronic inflammation has an accumulation of lymphocytes, plasma cells, and macrophages PMNs are main cell components that cause chronic inflammation Neutrophils are most numerous cell in inflammatory exudates of an acute periodontal abscessPellicle- glycoprotein deposit derived from salivary constituents Pellicle formation is 1st step in plaque formation Components= albumin, lysozyme, amylase, immunoglobulin A, praline-rich proteins, and mucins Primary Colonizers= gram (+) bacteria Strep sanguis, Strep mutans, Actinomyces viscosusSecondary Colonizers= gram (-) species Fusobacterium nucleatum, Prevotella intermedia Tertiary Colonizers= porphyromonas gingivalis, campylobacter rectus, eikenella corrodens, AAOverall pattern observed in dental plaque formation is a SHIFT from an early predominance of gram (+) facultative aerobes to a later predominance of gram (-) anaerobes Most abundant bacteria in a healthy sulcus are streptococcus and actinomyces species At birth, oral cavity is sterile By age 4 or 5, oral flora resembles an adult’s oral flora Gingival changes evident during pregnancy result from effect of PROGESTERONE and an increase in # of mast cells associated with increases levels of Prevotella Intermedia Desquamative Gingivitis: chronic gingival disease characterized by erythematous, erosive, vesiculobullous, and/or desquamative involvement of free and attached gingiva outer gingiva desquamatesHereditary Gingivofibromatosis: a rare genetic disease with progressive proliferation of gingiva striking lack of inflammatory cells, proliferating capillaries, and vascular engorgement seenInflammatory Gingival Enlargement- has an increase in gingival size, distortion of normal form, and change in tissue toneSignificant increase in sulcular depth and pocket formation occurs Meds cause highest incidence of fibrous gingival hyperplasia Phenytoin/Dilantin, Cyclosporine A and Nifedipine Pseudopocketing- pocketing occurs WITHOUT attachment loss due to expansion of marginal tissue coronally PeriodontitisInflammation that affects and destroys attachment apparatusMarked by apical migration of JE from CEJ, loss of C.T. attachment & PDL, and bone destructionAlways begins with gingivitis To diagnose, radiographic evidence of bone loss MUST be evident More than 30% of bone mass at alveolar crest must be lost for a change in bone height to be seen on x-raysReduction of only 0.5-1.0mm thickness of cortical plate is sufficient to permit radiographic visualization of destruction of inner cancellous trabeculae Radiographic changes that are visible= loss of lamina dura, horizontal or vertical bone resorption, and thickening of PDL space Early periodontitis- areas of localized erosion of alveolar bone crestModerate periodontitis- destruction of alveolar bone extends beyond early changes in alveolar crestAdvanced periodontitis- extensive horizontal bone loss or extensive bony defects PNMs are the 1st line of defense and 1st cells to migrate into the gingival sulcus when inflammation caused by plaque formation in the initial lesion of gingivitis occurs Loss of attachment is measured from the distance between the CEJ to base of attachment Bleeding is most reliable indicator of gingival or periodontal inflammation Attachment loss is most significant factor of periodontitis because supportive structures are also destroyed Most common sign of occlusal trauma is tooth mobility Perio probe is inserted in long axis of tooth into pocket with gentle pressure (about 25gm of force) until resistance is met Clinical probing depth is ALWAYS GREATER than histologic sulcus or pocket depthCalibrated periodontal probe should have a tapered shaft 0.5mm in diameter at tip Glickman Furcation ClassificationGrade 1- incipient bone loss, furcation probe can feel depression of furcation openingGrade 2- partial bone loss, furcation probe tip enters under roof of furcationGrade 3- total bone loss/destruction with through-and-through opening of furcation Grade 4- total bone loss/destruction and furcation entrance is visible GTR can treat grade 2 furcations with good success Furcation involvement of maxillary 2nd molars have poorest prognosis after therapy Most common error during perio probing is excessively angling probe when inserting it interproximally beyond long axis of tooth Probe tip should be FLAT against tooth near gingival margin with probe parallel with long axis of tooth for insertion Patients at risk for subacute bacterial endocarditis must be pre-medicated before perio probing Bacteremia can occur even with mastication or brushing Tissue thickness is the primary determinant of gingival recession susceptibility Most common etiologic factor/cause of gingival recession is toothbrush abrasion Dentin is abraded 25x faster than enamelCementum is abraded 35x faster than enamel Hydrodynamic Theory- most accepted theory as to cause of root sensitivity Amount of attached gingiva is calculated by subtracting sulcus/pocket depth from width of gingiva from free gingival margin to mucogingival margin Aggressive PeriodontitisGeneralized- Prevotella intermedia and Eikenella corrodens predominateCharacterized by rapid, severe periodontal destruction around most teeth, with episodic, rapid, and severe attachment loss Localized- gram (-) anaerobes Actinobacillus Actinomycetemcomitans and Capnocytophaga species predominate Characterized by rapid and severe attachment loss confined to incisors and 1st molars Plaque is an accumulation of a mixed bacterial community in a dextran matrix ; composed of 80% water Strep mutans and Lactobacilli are primary plaque bacteria As plaque ages, # of gram (+) aerobic bacteria DECREASES and # of gram (-) anaerobic bacteria INCREASES Pellicle is composed of albumin, lysozyme, amylase, immunoglobulin A, proline-rich proteins, and mucinsPrimary Plaque Colonizers= Strep sanguis, strep mutans, and actinomyces viscosusSecondary Plaque Colonizers= Fusobacterium nucleatum, Prevotella intermedia, and Capnocytophaga speciesTertiary Plaque Colonizers= Porphyromonas gingivalis, Campylobacter rectus, Eikenella corrodens, AAChronic signs of periodontitis are mainly caused by bacterial products entering tissue and activating inflammatory and immune processes Calculus is most important plaque retentive factor Inorganic materials comprise 70-90% of calculus composition At least 2/3 of inorganic matter in calculus is crystalline salt Average time for entire calculus formation process to occur is 12 days Pellicle forms within minutes Main source of minerals of supragingival calculus is from saliva occurs most often on tongue side of mandibular incisors and cheek side of maxillary molars Source of minerals for subgingival calculus is crevicular fluid Endotoxin- constituent of gram (-) microorganisms that is an important agent in pathogenesis of inflammatory perio disease Plaque bacteria produces enzymes that may initiate periodontal disease= hyaluronidase, collagenase, chondroitin sulfatase, elastase, and proteases Collagenase- produced by Bacteroides species that catalyzes collagen degradation Hyaluronidase- produced by Streptococcus mitans and salivarius destroys amorphous ground substanceChondroitin Sulfatase- produced by DiptheroidsMost likely source of bacteria in diseased periodontal tissue is subgingival plaque Bleeding during circumferential probing indicates that crevicular epithelium is ulcerated due to active perio disease Bacteria associated with PERIODONTAL HEALTH are gram (+), non-motile, facultative anaerobes Bacteria most implicated in perio disease and bone lossActinobacillus ActinomycetemcomitansPorphyromonas gingivalisBacteroides forsythusTreponema denticolaPrevotella intermediaEikenenna corrodens, Campylobacter rectus, Fusobacterium nucleatum, Peptostreptococcus micros, Prevotella nigresens Pseudomonas and Eubacterium species Neutropenia- abnormal decrease in # of neutrophils in blood associated with acute leukemia, infection, rheumatoid arthritis, vitamin B12 deficiency, and chronic splenomegaly Possible immune factors are interleukin-1 beta, interleukin-4, tumor necrosis-alpha, and prostaglandin E-2In excess, cytokines cause inflammation, severe damage, and overproduce collagenase People with diabetes have 15x the risk of developing periodontal disease Purpose of SRP is to remove calculus, bacteria, and endotoxins When sharpening hygiene instruments with a flat stone, angle between blade face and stone is kept at 100-110A properly sharpened instrument with NO rounded surface area WILL NOT REFLECT LIGHT A sharp instrument requires fewer strokes, provides greater control and increases tactile sensitivity It is difficult to perform a thorough SRP on mesial surfaces of maxillary premolars, proximal surfaces of mandibular incisors, and trifurcations of maxillary molars Trifurcations on maxillary 1st molars are most difficult of all to root plane Best criteria to evaluate success of SRP is NO BLEEDING ON PROBINGPeriodontal Hoes & Files are used almost EXCLUSIVELY for HEAVY SUPRAGINGIVAL CALCULUS removalCutting edges are designed to function at RIGHT angles 90 to tooth surface May be used subgingival for gross calculus removal only if tissue is flexible and easily displaced Hoes- have a wide, single straight cutting edge that cannot adapt to curve tooth surfaces Entire cutting edge length must be kept against tooth Only used vertical pull-type strokes Cutting edge is angled 90 to tooth surface and is turned at a 90-100 angle to shank, and cutting edge is beveled at a 45 angle to end of blade Most effective on buccal and lingual surfaces Files- function is to crush or fracture heavy calculusFile is always followed by root planning with a curette Works best on buccal and lingual surfaces, next to edentulous areas, and to reduce amalgam overhangs Work well on distal of 3rd molars Use vertical pull strokes Periodontal Curette: instrument with either 1 or 2 cutting edges with rounded edge ends Well suited for subgingival calculus detection and removalLeast traumatic and most effective for non-surgical root planningMost effective way to use is with short, even working strokes, followed by longer strokes Final root planning strokes are longer and lighter than scaling strokes Universal Curettes (Crane-Kaplan 6, McCall 17/18, Columbia 4R/4L): remove subgingival calculus deposits on all tooth surfaces Have 2 cutting edges at 90 to root surfaceGracey Currettes- designed to smooth and debride root surfaces during root planning in specific regions of mouthHave only 1 cutting edge per working end with blade face offset and angled 60-70 to terminal shankStarting stroke is always coronal to edge of JEGracey 1-2= cleans anterior interproximal surfaces and buccal/lingual surfaces of posteriorsGracey 3-4= short mod of shank, cleans same regions as 1-2Gracey 5-6= cleans anteriors and premolarsGracey 7-8= direct buccal and lingual of posteriorsGracey 11-12= cleans mesial, buccal, and lingual surfaces of posterior teeth; cutting edge is on OUTSIDE of elbowGracey 13-14= cleans distal surfaces of posterior teeth; cutting edge is on INSIDE of elbowGracey 15-16= access to MESIAL surfaces of posterior teeth Gracey 17-18= access to DISTAL surfaces of posterior teeth 60 angle of curette’s facial surface against tooth is ideal to remove plaque75 angle is ideal to debride calculus Rigid, thick shank: stronger, less flexible, and provides less tactile sensitivity; used to remove heavy calculus depositsLess rigid, more flexible shank: provides more tactile sensitivity; used to remove fine calculus and for root planningStraight shanks: used in anterior areasIdeal angulation of a curette’s facial surface is between 70-80 to tooth surface Stroke: action of an instrumenting the performing task it was designed forExploratory Stroke: used to assess smoothness/roughness of tooth surface and effectiveness of instrumentation handle is held lightly to increase tactile sensitivity Scaling Stroke: short, powerful “pull” stroke to remove calculusIf heavy lateral pressure is used with long, even strokes, it will produce a smooth, but “ditched” root surfaceUse longer, lighter root planing strokes Motion to initiate scaling stroke is generated from forearm Modified pen grasp is most useful for perio instruments Root Planing Stroke: long, overlapping strokes for final smoothing of root surface, usually in a “pull motion”Pressure applied becomes lighter, as surface becomes smoother Use vertical stroke first, then oblique, then horizontalLight pressure should be used to maximize tactile sensitivity Working stroke begins at apical edge of JE Gingival Curettage: surgical procedure performed when cutting edge of curette is directed against soft tissue wall of pocket Objective= to remove chronically inflamed, diseased epithelial lining and microorganisms from pocket to reduce edema and pocket depth Curette’s blade face is positioned at a 70 angle to soft tissue pocket wall or sulcular epithelium Most important factor to determine amount of shrinkage is degree of tissue edema At proper working angulation, the lower shank of a Gracey curette is PARALLEL to the tooth surfaceChisel- best designed to remove supragingival calculus deposits in interproximal areas has a single, straight cutting edge, and end of blade is flat and beveled at 45 angle Ultrasonic Magentostrictive Scalers: produce an elliptical or orbital vibration pattern of tip to break apart calculus Ultrasonic Piezoelectric Scalers: produce a rapid linear (back and forth) vibration pattern of tip lateral surface of insert tip is MOST ACTIVE due to its linear motion Sonic Scalers: do NOT release heat like ultrasonic instruments, but are AIR-TURBINE instruments that use compressed air pressure to produce ELLIPTICAL or ORBITAL tip vibrationsPrimary Occlusal Trauma excessive forces on a tooth with normal periodontal tissue support usually reversible once forces that produced it are controlledEarly effect of primary occlusal trauma is hemorrhage and thrombosis of PDL blood vessels Secondary Occlusal Trauma occurs from normal or excessive forces on a tooth with existing diminished tissue supportExcessive forces produced by bruxism can cause increased tooth mobility and is the biggest risk with implants Mobility Scale0 mobility= tooth NOT mobile1 mobility= tooth moves 0.5-1mm2 mobility= tooth moves 1-2mm3 mobility= tooth moves >2mm or is mobile and depressible in occlusal apical direction Primary reason for splinting teeth is to IMMOBILIZE excessively mobile teeth for patient comfort Teeth tend to loosen B-LExternal splints do NOT remove tooth structure very conservative Most common symptom a patient will report with a periodontal abscess is ACUTE PAIN that is constant, severe, and dull throbbing Greatest success of any perio surgery is achieving vascularity Tooth Brushing MethodsBass Method (“Sulcular Technique”): toothbrush bristles placed 45 to tooth surface at gingival margin Brush is moved in back-and-forth motionPreferred method of manual tooth brushing Bristles can penetrate a max of 1.0mm subgingivally Modified Stillman Method (“Roll Technique”): brush bristles are resting partially on cervical area of teeth and partially on gingiva pointing toward gingival margin Brush is moved in short back-and-forth strokes with brush moving coronally simultaneously Charter’s Method: toothbrush is placed against surface of teeth with bristles pointed away from gingival margin at 45 angle Oral irrigation devices are contraindicated in patients with perio inflammation Chlorhexidine Gluconate (0.12%) Peridex: MOST effective antimicrobial and anti-gingivitis rinse due to its high substantivity (lasting effect)Kills bacteria when used for 30 sec 2x/dayEffectiveness is explained by fact that it leaves greatest residual concentration in mouth after its useCan stain teeth and oral tissues yellowish-brown to brown color after prolonged use Endogenous Intrinsic StainsDentinogenesis Imperfecta translucent or opalescent gray to blueish-brown hueErythroblastosis fetalis intrinsic bluish-black, greenish-blue, tan or brown stainPorphyria intrinsic red or brown stainFluorosis causes white opacities, or light brown to brownish-black stainPulpal Necrosis intrinsic stain starts pink, then becomes orange-brown to bluish-blackInternal Resorption PINKISH intrinsic stain Tetracyclines period of stain susceptibility is 4-5 months in utero to 7-8 years oldExogenous Extrinsic StainsBrown stain- color is due to TANNINTobacco stain- dark brown or black from coal tar combustion productsBlack stain- caused by chromogenic bacteriaOrange stain- caused by chromogenic bacteria in plaque due to poor oral hygiene Green stain- caused by chromogenic bacteria, fungi, and gingival hemorrhage; associated with poor oral hygieneGreen-Greenish Yellow Stain- attributed to fluorescent bacteriaMetallic stain – common in industrial workers who inhale metal dust or due to orally administered drugs containing metal or metal salts ORAL SURGERY NERVE ANATOMYV3 of Trigeminal nerve innervates 8 muscles Mesencephalic nucleus mediates proprioceptionMain sensory nucleus mediates general sensationSpinal nucleus mediates pain and temperature from head and neck Proprioceptive fibers from muscles and TMJ are found only in trigeminal’s mandibular division.Cell bodies of proprioceptive 1st order neurons are found in mesencephalic nucleus Masseteric Nerve- nerve to masseter carries sensory fibers to TMJ’s anterior portionAuriculotemporal Nerve- provides major sensory innervation to TMJ’s posterior portion Sublingual gland is superior to mylohyoid muscle When floor of mouth is lowered surgically, mylohyoid and genioglossus muscles are detachedSuprahyoid MusclesDigastric musclesMylohyoid muscleGeniohyoid muscleStylohyoid muscleInfrahyoid MusclesThyrohyoid muscleOmohyoid muscleSternohyoid muscleSternothyroid muscle Carotid sheath contains carotid arteries, internal jugular vein, vagus nerve, and deep cervical lymph nodes Facial vein unites with retromandibular vein below border of mandible Internal jugular vein descends through neck within carotid sheath Must give a long buccal injection to extract all molars and 2nd PMBone of maxilla is more porous than mandibles, and can be infiltrated anywhere Inferior alveolar nerve and artery, and lingual nerve are found in the PTERYGOMANDIBULAR SPACE between medial pterygoid muscle and ramus of mandible If you cut facial nerve just after it exits the foramen, it causes loss of innervation to muscles of facial expression Branches of facial nerve to muscles of face are enmeshed in parotid gland External carotid artery terminates as maxillary and superficial temporal arteries Venous return of both dental arches in pterygoid plexus of veins Lingual artery supplies blood to tongue Inferior alveolar nerve and artery, and lingual nerve are found in pterygomandibular space Parotid GlandPurely serous glandDrained by Stenson’s duct which pierces buccinator muscle and crosses masseter muscle Receives parasympathetic secretomotor innervation from glossopharyngeal nerve Lymph drainage is through parotid nodes to deep cervical lymph nodes Mumps- viral disease of parotid glandParotitis- inflammation of parotid gland Whartons Duct= aka Submandibular Duct During its course, Wharton’s duct is closely related to the LINGUAL NERVE If you incise mucous membranes of the mouth floor, you can expose the lingual nerve, Wharton’s duct, and sublingual gland Lymphadenopathy is most common cause of swelling of submandibular triangle tissues Lymph drainage from sublingual and submandibular glands goes to submandibular and deep cervical lymph nodes If communication with maxillary sinus is moderate-sized (2-6mm) place figure-8 suture over tooth socketIf communication with maxillary sinus is large (7mm or larger) close opening with a flap Ampicillin treats sinusitis due to upper respiratory infectionsPenicillin and Amoxicillin treats sinusitis caused by odontogenic fociPterygopalatine FossaCommunicates laterally with infratemporal fossa through pterygomaxillary fissureCommunicates medially with nasal cavity through sphenopalatine foramen Communicates posteriorly with foramen lacerum through pterygoid canal Communicates superiorly with skull through foramen rotundum Communicates anteriorly with orbit through inferior orbital fissure Pterygomandibular raphe lies between buccinator and superior constrictor muscles Facial and maxillary arteries supply blood to buccinator muscle Condylar ankylosis is most common cause of TMJ ankylosis In condylar hyperplasia, mandible deviates away from affected side Lateral pterygoid muscles form ROOF of PTERYGOMANDIBULAR SPACE Most definite clinical sign indicating extension of odontogenic infection into masticator space is TRISMUS Trismus is also caused by passing the needle though the medial pterygoid muscle during an IANBRotational movement of TMJ occurs mainly between disc and mandibular condyles in lower synovial cavity Articular disc separates condyle and temporal bone divides TMJ into superior and inferior joint spaces and prevents bone-to-bone contact Clicking and popping when opening is caused by disk displacement with reductionPainful and limited opening <30mm WITHOUT SOUND is caused by DISK DISPLACEMENT WITHOUT REDUCTION Subluxation occurs when condyle head moves too far ANTERIORLY on articular eminence Temporomandibular ligament- prevents posterior and inferior displacement of condyle prevents mandible from excessive retraction or moving backward Sphenomandibular ligament- remnant of Meckel’s cartilage and landmark when administering IANBTMJ development occurs at 12 weeks in utero Myofascial Pain Dysfunction Syndrome often responds to an acrylic night guard (occlusal separator or occlusal appliance)Most common direction TMJ’s articular disc can become displaced is ANTERIORLY Disc Displacement WITH Reduction: “clicking joint” disc is out of place TMJ is rotating Reciprocal clicking on opening and closing is a sign Disc Displacement WITHOUT Reduction: no clickingClicking and popping has disappeared with limited opening and pain (<35mm)Patients have a consistent limited opening Patient deviates on opening to affected side Always treat conservatively NOT a reproducible reciprocal click Most displacements are anterior and medial Best way to palpate posterior aspect of mandibular condyle is externally over posterior surface of condyle with mouth open TMJ Surgical ApproachesPreauricular- best incision to expose TMJSubmandibular Approach- standard surgical approach to mandibular ramus and neck of condyleMOST common cause of TMJ Ankylosis is TRAUMA Highest incidence of fractures occurs in young males ages 15-24 from trauma Zygomatic complex is most common bone fractured in face, followed by condyle Angle of mandible is most common site of mandibular fracture OPEN REDUCTION- reduction of a fractured bone by manipulation after incision into skin and muscle over fracture site most common side is at angle of mandible Most common site for open reduction is at angle of mandible Condylar neck fractures are usually treated by closed reduction CLOSED REDUCTION- reduction of a fractured bone by manipulation without incision into skin Most often used when both fractured segments contain teeth Bilateral Sagittal Split Osteotomy: most commonly performed mandibular orthognathic procedure to correct mandibular retrognathia Mandible is split sagittally and can be used to either advance the mandible or set back the mandibleGreenstick Fracture: mandibular fracture that extends only through cortical portion of bone without complete fracture of bone one side of bone is broken, and other side is bent Simple Fracture- divides a single bone into 2 distinct parts with no external communication Compound Fracture- fracture that communicates with outside environment Most common complication of an open fracture is INFECTIONComminuted Fracture- multiple fractures of a single bone that can be simple or compound456120527600MIDFACIAL FRACTURESLeFORT 1 (Horizontal Fracture): horizontal segmented fracture of alveolar process of maxillaCauses an open biteMost commonly used to correct maxillary retrognathiaLeFORT 2 (Pyramidal Fracture): unilateral/bilateral fracture of maxilla; body of maxilla is separated from facial skeleton Signs= periorbital edema, ecchymosis, subconjunctival hemorrhage, nose bleedingCommon finding is paresthesia over distribution of infraorbital nerve LeFORT 3 (Transverse Fracture or Craniofacial Dysfunction): fracture in entire maxilla and one or more facial bones are separated from craniofacial skeleton Patients have restricted mandibular movement Zygomatic complex fractures are most common midfacial fractureZygomatic arch fracturesZygomatic bone fractures are 2nd most common fracture of facial bones behind #1= nasal bone fractures Maxillary fractures have a greater tendency to produce facial deformities than mandibular fractures Water’s view is best to evaluate orbital rim areas Water’s view, PA skull view, and submental vertex view are helpful to evaluate midfacial fractures Fracture HealingEndosteal Proliferation- occurs within a bonePeriosteal Proliferation- occurs within C.T. Primary (Bone-to-Bone) Healing- involves endosteal and periosteal proliferationSecondary Bone Healing- involves mostly endosteal proliferation Bone HealingHemorrhage- occurs first, associated with clot organization and proliferation of blood vesselsOccurs during first 10 days of healingCallus Formation- primary callus formed in next 10-20 days Functional Reconstruction- takes 2-3 years to completely reform a fracture Geudel’s Stages of General AnesthesiaStage 1 (Amnesia and Analgesia): conscious sedation beginning with administration of anesthesia and continues until loss of consciousness Best monitor of analgesia is verbal response Altered consciousness, loss of sensory from cerebral cortex occurs Stage 2 (Delirium/Disinhibition & Excitement): begins with loss of consciousness and includes onset of total anesthesia Stage 3 (Surgical Anesthesia): begins with establishing a regular pattern of breathing, total loss of consciousness, period when signs of respiratory or cardiovascular failure first appear Spinal reflexes are depressed and skeletal muscle relaxation occurs Agents Useful= Cyclopropane, Halothane, and Methoxyflurane Halogenated hydrocarbons are associated with liver damage if toxic doses are used Stage 4 (Premortem or Medullary Depression): characterized by maximally dilated pupils and cold, ashen skin Cardiac arrest is imminent Patients experience severe respiratory and cardiovascular depression/paralysis ASA Classifications of Patient Physical Status:ASA-1: normal, healthy patient ASA-2: patient with mild systemic disease or significant health risk factor smoking, excessive alcohol use, obese; no change in daily activity ASA-3: patient with severe disease that is NOT incapacitating; alters daily activity ASA-4: patient with severe systemic disease that is a constant threat to lifeASA-5: moribound patient not expected to survive without operationASA-6: patient is “brain-dead” and organs removed for donor purposes Medulla is last area of brain depressed during general anesthesia Most reliable sign of “oxygen want” while monitoring patient during general anesthesia is increased pulse rateEmergency most often experienced during outpatient general anesthesia is respiratory obstruction A patient with an acute respiratory infection is contraindicated for general anesthesia Eyes are taped shut prior to draping patient before surgery to prevent corneal abrasion Induction: phase of anesthesia that begins with administration of anesthetic and continuing until desired level of patient unresponsiveness is reached rates of induction and recovery depend on rate of change of tension in this tissue, blood supply to lungs, pulmonary ventilation, and concentration of anesthetic influence Dissociative Anesthesia: method of pain control that reduces anxiety and produces a trance-like state where the person is not asleep, but feels separated from their body Ketamine is primary medication used in dissociative anesthesia increases secretions of salivary and bronchial glands, BP, HR, and muscle toneMost effective agent in initial treatment of respiratory depression due to overdose of barbiturates is OXYGEN under positive pressure Barbiturates depress CNS, lasting 3-8 hours, depending on dose Brevital (Methohexital)- drug most commonly used to attain GENERAL anesthesia Metabolized in liver and excreted by kidney Hiccoughs is most common side affect due to rapid injection Primary advantage of IV sedation is ability to titrate individualized dosages Malignant Hyperthermia- occurs in patients undergoing general anesthesia characterized by a sudden, rapid rise in body temperature associated with signs of increased muscle metabolism Dantrolene is only known drug that treats Malignant Hyperthermia by impairing calcium-dependent muscle contraction, and controlling hypermetabolism manifestationsOptimum site for IV sedation for an outpatient is MEDIAN CEPHALIC VEIN 3 common signs that indicate that correct level of sedation has been reached with Valium= blurring of vision, slurring of speech, and 50% ptosis of eyelids (Verrill’s sign)Scopoloamine: acts by interfering with transmission of nerve impulses by acetylcholine in PNS and produces symptoms of parasympathetic system depression Very effective for preventing motion sickness Used as a sedative before anesthesia and as an anti-spasmodic Reduction of secretions occurs by competitive blockade of acetylcholine and other cholinergic stimuliAtropine is contraindicated for nursing mothers and patients with glaucoma 2 most important steps in initial management of laryngospasm are applying oxygen under + pressure and administering succinylcholineUNIVERSAL sign of laryngeal obstruction is stridor (crowing sounds)LOCAL ANESTHESIALocal anesthetics are MOST EFFECTIVE in tissues above a pH 7Local anesthetics are alkaloid bases combined with acids to form water-soluble salts Potency of local anesthetics increases with increasing lipid solubilityInflammation and infection cause tissues to become acidic Local anesthetics affect nerve membrane by DECREASING membrane’s permeability to Na+ and DECREASING membrane’s excitabilityLocal anesthetics “reversibly block” nerve impulse conduction and produce reversible loss of sensation at admin site MAXIMUM allowable dose of 2% Lidocaine with 1:100,000 EPI is 3.2mg lido/pound or 7mg/kg0.018mg of EPI are in each cartridge/carpule of 2% lidocaine with 1:100,000 EPIESTERS: metabolized in blood plasmaMainly used only as topicals Not available as dental anesthetic injections due to relatively high allergic reaction potential and incidence Benzocaine- most common topical anesthetic used in dentistry Cocaine- addictive CNS stimulant and ONLY local anesthetic that increases vasoconstriction activity of EPI and norepinephrine AMIDES: metabolized in liver Only local anesthetics available as dental injectables Have a longer duration of action, and are metabolized by P450 enzymes in liver Inactivated by monoamine oxidase enzyme Lidocaine: SAFE during pregnancy and lactation May manifest its toxicity clinically by initial depression and drowsiness 1st clinical sign of mild lidocaine toxicity is nervousness *Lidocaine and Mepivacaine may show cross-allergy Articaine (Septocaine): ONLY amide local anesthetic metabolized in bloodstreamComes in lower dose due to increased potency Onset of anesthesia after admin is 1-6min Complete anesthesia lasts about 1 hour for local infiltration and 2 hours for nerve blocks 7mg/kg is max recommended dose in adults and children Bupivacine (Marcaine): has longest duration of action of any dental amide availableGood for extended procedure and when post-op pain is expected Prilocaine: has an intermediate duration of action that is slightly LONGER, LESS POTENT, and produces LESS vasoconstriction due to its lower EPI content compared to LidocaineNot used for patients with hypoxic conditions or patients with liver disease METHEMOGLOBINEMIAMepivacaine (Carbocaine): has SHORTEST DURATION OF ACTION of all amidesNot good for dental procedures more than 25-30 minutes TOXIC to neonates Vasoconstrictors act at ALPHA receptors to produce constriction of arterioles Cocaine acts as intrinsic vasoconstrictor that increases PRESSOR ACTIVITY of both epi and norepinephrineLocal anesthetics depress small, non-myelinated nerve fibers 1st, and large, myelinated nerve fibers last General order of loss of nerve function from a local anesthetic is:Pain TemperatureTouch and pressureProprioception Skeletal muscle toneEpinephrine is drug of choice to manage acute allergic reaction involving bronchospasm and hypotension During IANB injection, needle passes through mucous membrane and buccinator muscle, and lies lateral to medial pterygoid muscle Most common cause of transient loss of consciousness in dental office is vasovagal syncopeTrendelenburg’s Position: patient is elevated on inclined plane, with head down and legs and feet over edge of tableNitrous Oxide: inhalation anesthetic with FASTEST ONSET of actionStored under pressure in steel BLUE cylinders Great to reduce anxietySafe for asthmatics calming effect causes bronchodilation Nausea is most common patient complaint Works on CNSExcreted solely by lungs, unchangedMain effects are on reticular activating and limbic systems 1st symptom is tingling of hands Correct total liter flow is determined by amount needed to keep reservoir bag 1/3-2/3 full Neurolept analgesia only produces an unconscious state if nitrous oxide is also administered Ventricular fibrillation is LEAST LIKELY to occur during anesthesia with nitrous oxide *Inhalation of 100% oxygen is contraindicated in a patient with COPDMost common emergency seen after using local anesthetics is syncopePrimary airway hazard for an unconscious dental patient in a supine position is tongue obstruction Drugs that can be given 1hr prior to dental appointment that are safe and effective to reduce fear:Diazepam (Valium) 5-10mgPromethazine (Phenergan) 25mgPentobarbital or Secobarbital 50-100mg Types of Shock- cardiac output is always reduced Cardiogenic Shock- commonly caused by myocardial infarction Shock is circulatory collapse resulting from pump failure of left ventricle, often caused by a massive myocardial infarctionHypovolemic Shock- produced by reduction in blood volume due to severe hemorrhage, dehydration, vomiting, diarrhea, or fluid loss from burns Septic Shock- due to severe infection caused by endotoxin gram (-) bacteriaNeurogenic Shock- from severe injury or trauma to CNSAnaphylactic Shock- from a severe allergic reaction *Concomitant administration of Meperidine and MAO inhibitors can cause life-threatening hyperpyrexic reactions that may culminate into seizures or comaMeperidine (Demerol)- potent, narcotic analgesic to relieve moderate-to-severe pain; most abused drug by health professionalsCBC and Urinalysis are two tests that should be performed prior to administering general anesthetic for surgery Minimal acceptable value of hematocrit is 30% for elective surgery Conditions that require Antibiotic Prophylaxis prior to oral surgery:Prosthetic heart valveRheumatic valve diseaseMost congenital heart malformationsPremedication is NO LONGER REQUIRED for patients after artificial joint replacement surgery Most frequently impacted teeth are mandibular 3rd molars Distoangular impacted 3rd molars are VERY DIFFICULT to removeHorizontally impacted 3rd molars are MOST DIFFICULT to remove Ideal time to remove impacted 3rd molars is when root is approximately 2/3 formed Cavernous Sinus Thrombosis: usually caused by a late complication of an infection of central face or paranasal sinuses Furunculosis and infected hair follicles in nose are frequent causes Usually occurs in ophthalmic vein due to absence of valves in angular, facial, and ophthalmic veins Submandibular space usually drains infections from mandibular premolars and molars since the apices lie BELOW mylohyoid muscle attachment Submental space usually drains infections from mandibular incisors and canines since their apices are ABOVE mylohyoid muscle attachment Main reason to use water irrigation when cutting bone is because heat generated by drill affects bone vitality#15 scalpel is UNIVERSALLY used for oral surgery. 3 incisions used in oral surgery:Linear incision- straight-line incision for apicoectomiesReleasing incision- used to add a vertical leg to a horizontal creation incision for extractions, augmentationsSemi-lunar incision- curved incision for apicoectomies Flaps should carry their own blood supply, allow surgical access to underlying tissues, can be replaced in original position, and maintained with sutures and is expected to heal Sutures:Interrupted Suture Pattern/Method: offers strength and flexibility Continuous Suture Pattern/Method: provides ease and speed of placement, distributes tension over entire suture linePlace sutures 2-3mm apart, from mobile tissue to fixed tissue Plain Gut- susceptible to rapid digestion by proteolytic enzymes; retains strength for 5-7 days Chromic Gut- produces more resistance to proteolytic enzymes; retains strength for 9-14 daysSilk- used for intraoral suturingNylon- suture material of choice for facial lacerations*Non-resorbable sutures should be removed within 5-7 days*Most severe tissue reaction occurs with PLAIN CATGUT SUTURE material Strong apical pressure with a small straight elevator may displace root tips of maxillary premolars and molars into maxillary sinus Mandibular 3rd molars with a distoangular impaction are MOST DIFFICULT impaction to remove For impacted maxillary 3rd molars, mesioanglular impactions are most difficult to remove Dead space in a wound is any area that remains DEVOID OF TISSUE after closing wound eliminated by closing wound in layers to minimize post-op void, applying pressure dressings, using drains to remove bleeding, and placing packing into void until bleeding stops Forcep beaks are applied in a line parallel with long axis of tooth PALATAL is primary direction of luxation for extracting maxillary primary/deciduous molarsBUCCAL is primary direction for extracting adult maxillary molars Genial Tubercles: located on lingual surface of mandible; area of muscle attachment for suprahyoid muscles Most common cause of post-extraction bleeding is failure of patient to follow post-extraction instructionsTannic acid in tea bags help promote hemostasis A patient with dry socket develops a severe, dull throbbing pain 2-4 days after a tooth extraction Incision for Drainage in an area of acute infection is only performed after localization of infection Macrophage is most important inflammatory cell for wound healing 3% H2O2 is agent of choice to debride intraoral wounds Primary Intention (Primary Closure or 1st Intention): bone repair that involves both endosteal and periosteal proliferation Occurs when bone is either incompletely fractured or a surgeon closely reapproximates fractured ends of boneLittle fibrous tissue is produced with minimal callus formation Well-repaired and well-reduced bone fracturesSecondary Intention (Secondary Closure or 2nd Intention): occurs when a wound is large and exudativeHealing is slower and produces more scar tissueInvolves mostly endosteal proliferation Lots of fibrous tissue is formed and a callus is formed The greatest osteogenic potential occurs with an autogenous cancellous graft and hemopoietic marrow Bones, plates, biphasic pins, titanium mesh, and intraosseous wires are used to fixate bone grafts Most commonly used allogenic bone is FREEZE-DRIED OPTIMAL bone grafting material should be of autogenous origin Autogenous grafts are usually used to restore large areas of lost mandibular bones after oncological surgery or trauma Bone marrow for grafting defects in mandible and maxilla is usually obtained from ILIAC CREST Rejection of graft is MOST common when Allografts or Xenografts are used When placed in a subperiosteal environment, hydroxyapatite bonds physical and chemically to bone Gingivoplasty- surgical procedure to reshape gingivaOperculectomy- removal of operculum Genioplasty- procedure to surgically alter chin’s position Closed Reduction- closing space between a fractured bone without cutting through soft tissue or surrounding bone Most common indication for tooth transplantation is SEVERE DECAY of a 1st molarTransplant success is most predictable when root apices to be transplanted are 1/3-1/2 formed with open apices and bordering bony plates are intact Most likely cause of transplantation failure is chronic, progressive EXTERNAL ROOT RESORPTION10% Formalin- fixative of choice used for a routine biopsy specimen Enucleation- process by which TOTAL REMOVAL of a cystic lesion is achieved tx of choice for congenital cysts, mucoceles, and most odontogenic cystsMarsupialization is tx of choice for ranulas Secondary pulmonary hypertension is often caused by COPD A productive cough, often without wheezing, is the universal factor of chronic bronchitis Atelectasis is most common anesthetic complication occurring within first 24 hours after surgery under general anesthesia Pneumonitis and Atelectasis are two most common causes of fever in a patient who has had general anesthesia Inhalation of a selective beta2-agonist is preferred treatment for an acute asthmatic attackA true hemophiliac has prolonged (PTT), but abnormal prothrombin time (PT), and bleeding time (BT)Hemophilia A & B are inherited as an X-LINKED RECESSIVE trait where males are affected and females are carriers Thrombocytopenia- abnormally low # of platelets in bloodstreamExcessive bleeding causes formation of hematomas PT is the best test to determine if oral surgery can be safely performed on a patient taking COUMADIN If patient is taking an anticoagulant, they should stop for 5 days prior to extractions Osteoradionecrosis- most SERIOUS potential complication after extractions from areas previously irradiated Condition of non-vital bone in a site of radiation injury Osteomyelitis- bone infection characterized by progressive inflammatory destruction after formation of new bone Most often caused by Staph aureus Bone is predisposed by reduced blood supply In children, long bones are affectedIn adults, vertebrae and pelvis most commonly affectedChronic Osteomyelitis results when bone tissue dies due to lost blood supplyAcute Osteomyelitis occurs more frequently in mandible If CPR is effective, pupils will constrict Usually left ventricle fails first in Congestive Heart Failure, followed by right-sided failure Calcium levels are regulated by Parathyroid Hormone Low serum calcium levels result in hyperirritability of nerves and muscles Serum calcium is decreased in Diabetes Mellitus Serum glucose is increased in diabetes mellitus, adrenal tumors, increase GH, and liver dysfunction Glucocorticoid secretion is stimulated by ACTH produced in anterior pituitary Cushing’s Syndrome: disorder caused by prolonged exposure of body’s tissues to high levels of CORTISOL HORMONEMost common cause is pituitary adenomas Upper body obesity, rounded face, increased fat around neck, thinning arms and legsA person who has been on SUPPRESSIVE DOSES OF STEROIDS will take up to 1 year to regain full adrenal cortical fxnSevere acidosis always occurs during CPR#1 cause of KIDNEY DISEASE is DIABETES Safest time to render dental care is the DAY AFTER RENAL DIALYSIS Rheumatic FeverMajor Jones Criteria= carditis, arthritis, chorea, erythema marginatum, and subcutaneous nodulesMinor Jones Criteria= fever, arthralgias, history of rheumatic fever, EKG changes, and lab testsIn Rheumatic Fever, mitral valve is most commonly affected ENDODONTICSRoot fractures are only visualized on a radiograph if x-ray beam passes through fracture line inlays can cause fractures Vertical Root Fracture: cracks that begin in root and extend toward chewing surface and often present minimal signs and symptoms may go unnoticed for a whileTreatment= extraction or RCTDeep, narrow periodontal pockets, a halo-shaped radiolucency and thickened PDL space strongly suggest a vertical root fracture Mandibular molars have highest reoccurrence Most are caused by using too much condensation force during obturation with gutta-percha Anterior tooth root fractures, usually occur in a more horizontal plane and may be visible on radiograph Cracked Tooth Syndrome: characterized by a sharp, brief pain occurring unexpectedly ONLY when patient is chewing Can be indicated by V-shaped isolated deep pocket on probing Check with tooth sloth Split Tooth: often result of long-term progression of a cracked tooth cracked portion is removed and restored with a restoration or crown unless crack extends apical to crest of bonePain on biting or release of biting pressure indicates a cracked cuspMethylene blue die can be helpful to reveal crack Submarginal Triangular & Rectangular Flap: requires at least 4mm of attached gingiva and a healthy periodontium Raised by a scalloped incision in attached gingiva with 1 or 2 vertical incisions May be indicated for root-end surgery on an anterior toothAdvantages= better access and visibility than a semilunar flapDisadvantages= hemorrhage from cut margins and scarringFull Thickness Mucoperiosteal Flap: allows maximum access and visibility Flap is raised from gingival sulcus Can be indicated for root-end surgery on an anterior tooth Disadvantages= large flap may be difficult to reposition, suture, make alterations, and post-surgical gingival recession is possible Submarginal/Semilunar Curved Flap: simple and does NOT impinge on surrounding tissueNOT used for anterior tooth root-end surgery DisadvantagesLimited access and visibilityTearing of incision corners when trying to improve accessibilityIf lesion is larger than expected, incision lies over bony defect, and healing occurs by scarringIncision extent is limited by attachments Electronic Pulp Test: checks tooth sensibility/vitality by stimulating nerve endings with a low current and high potential difference in voltage Acute pulpitis- indicated by a lower than normal currentChronic pulpitis- indicated by a response at a higher current than normal Hyperemia- indicated by a lower than normal current Pulp Necrosis/Abscess- no response at any current levelDo NOT wear gloves when using EPTBuccal Object Rule (SLOB= Same Lingual, Opposite Buccal)Allows dentist to determine on radiograph which canal is buccal and which is lingualLingual surface is always closest to cone, and buccal surface is always farther from cone Root/canal farther from film moves in SAME direct that cone is directed Only perform RCT in teeth that do NOT respond to pulp testing Trauma causing deep intrusion to a permanent tooth causes pulp necrosis and conventional RCT is necessary Area of minimal scatter radiation= at least 6 feet away in area that lies between 90-135 to x-ray beamHigher kVp= lower patient skin doses or radiation Dental personal must never exceed max permissible dose of 50mSv per year per person Pulpotomy: removal of a portion of pulp, ONLY pulp chamber contents Indicated for:Cariously exposed primary teeth with health radicular pulpsTraumatic or carious exposure of permanent teeth with undeveloped rootsAn alternative to extraction when endo is not availableEmergency tx in permanent teeth with acute pulpitis NOT successful when performed on fully developed permanent teeth Uncontrolled bleeding is a sign of inflamed pulp tissue When doing a vital pulpotomy on a young, immature permanent tooth, if hemorrhage after pulpal amputation cannot be controlled perform amputation at a more apical level Apexification: goal is to INDUCE FURTHER ROOT DEVELOPMENT in a pulpless tooth by stimulating formation of a hard substance at root apex to allow obturation of root canal spaceTreats an open apex and necrotic pulpNecrotic tooth is NEVER left open to drain Apexogenesis: treats an OPEN APEX with a vital pulp tx with a pulp cap or pulpotomy and cover with CaOHCalcium Hydroxide: intracanal medicament whose action promotes formation of a hard substance at root apex by creating an alkaline environment that promotes hard tissue deposition If pulp exposure is small and short length of time (30min-1hr), tx of choice is direct pulp cap with CaOH and restoration PULP CAPPING: placing a sedative and antiseptic dressing on an exposed healthy pulp to allow it to recover and maintain normal function and vitality Dycal is most commonly used dressingOffers better success for accidental exposure of pulp and pulp of a young childRepair occurs when a dentin bridge forms at pulp exposure site Pulp capping is NOT recommended in primary teeth with carious pulp exposure due to high failure rate Perforations into furcations of multi-rooted teeth have poorest prognosis Success is recognized by formation of a complete barrier of dentin at site of pulpal exposure INDIRECT PULP CAP- CaOH base is placed on a thin layer of questionable dentin remaining over pulpPerformed when a carious exposure is anticipated DIRECT PULP CAP- place a CaOH base directly over pulp exposure Favorable favorsVisual evidence of un-inflamed pulp tissueAbsence of copious hemorrhage through exposureNo previous symptoms of pulpitisSmall non-carious exposure Clean cavity uncontaminated with salivaVERY SUCCESSFUL in immature teeth Should NOT be attempted on teeth with a history of pain, sensitivity to percussion, or PARL Access Prep ErrorsDuring mandibular molar access prep, 2 regions tend to be “overcut” resulting in an undesirable over prep of canal access=Mesial aspect under marginal ridgeLingual surface under lingual cuspsMandibular incisors and maxillary 1st premolars are EASIEST teeth to perforate during access prep Chemomechanical debridement of root canal system is MOST crucial aspect of RCT Achieving glassy, smooth canal walls is BEST and most reliable indicator of adequacy of root canal debridement Most common cause of root canal failure is incompletely and inadequately disinfecting root canal system 2nd most common cause of failure is leakage from poorly filled canal Complete canal debridement is MOST EFFECTIVE way to reduce canal microorganisms If an accessory canal is not totally filled during obturation, appropriate treatment is to observe tooth and evaluate every 3 months obturate 1mm short of apex (to APICAL CONSTRICTION)After RCT is completed on a tooth with a PA radiolucency, it takes 6-12 months before a marked reduction in size of radiolucency is evident on radiographDesired periapical tissue changes are regeneration of alveolar bone, deposition of apical cementum, and PDL re-establishment Indications for solvent-softened custom gutta-percha cones= lack of an apical stop, abnormally large apical portion of canal, or an irregular apical portion of canalMain reason for recapitulation during canal instrumentation is to clean canal’s apical segment of any dentin fillings not removed by irrigation Glass Bead Sterilizer- sterilizes endo files in 15 sec at 220CChloroform- reagent of choice to DISSOLVE gutta-percha Irrigants: destroy bacteria during endo therapyBactericidal action is much greater than action supplied by intracanal medicaments Sodium Hypochlorite (NaOCl)- most commonly used Used in concentrations of 1%, 2.6%, and 5.25%Gutta percha points can be disinfected when placing them in 5.25% NaOCl solution for 1 minGood tissue solvent, has some antimicrobial effects, and acts as a lubricant for root canal instrumentationToxic to vital tissues USE RUBBER DAM Hydrogen Peroxide- less solvent action than NaOCl; 2 modes of action:Bubbling action occurs when it contacts tissue and debris of canal foamLiberation of oxygen destroys anaerobic microorganisms Urea Peroxide (Gly-Oxide)- irrigant available in an anhydrous glycerol base to prevent decomposition Better tolerated by periapical tissue than NaOCl, has greater solvent action and more germicidal than H2O2EXCELLENT irrigant for treatment canals with normal periapical tissue and wide apices Best use is in narrow and/or curved canalsChelating Agents: aids and simplify prep of highly sclerotic canals after apex is reached with fine instrument Act on calcified tissues only with little effect on periapical tissue Act by substituting Na+ ions that combine with dentin to form soluble salts for Ca+ ions that are bound in a less soluble combination EDTA- removes mineralized portion of smear layer; remains active in canal for 5 days if not inactivated EDTAC- Cetavlon has greater antimicrobial action than EDTA, but more inflammatory potential to tissuesNaOCl inactivates EDTACRX-Prep- foamy solution that combines functions of EDTA + urea peroxideHas a natural effervescence that is increased by irrigation with NaOCl to help remove canal debris Zinc Oxide-Eugenol: cement used as a based root canal sealer; functions to fill discrepancies between core-filling material and dentin wallsForms a bond between gutta-percha and dentin wallsExerts antibacterial activity*Most root canal sealers are some type of ZOE cement capable of producing a seal while being well-tolerated by periapical tissues Mineral Trioxide Aggregate (MTA): most superior retro-filling materialSeals apical portion of root canalAlways placed after an apicoectomy A reverse filling (MTA) MUST always be placed when an apical seal may be faulty Apicoectomy: resection of most apical portion of root root resection= root amputationBuccal tissue is flapped back, buccal bone around root apex and root apex itself are removed, and area is curetted outBest accomplished by obliquely resecting most apical portion of involved root Retreating teeth with posts are MOST common reason for an apicoectomy and retrograde filling Periradicular Surgery IndicationsNon-negotiable canal, blockage or severe root curvature in which non-surgical treatment is impossibleComplication arising from procedural accidents that cannot be handled without surgical exposure of siteFailed treatment due to irretrievable posts or root fillings Horizontal apical fractures where apical end of pulp becomes necrotic Biopsy to diagnose non-odontogenic causes of symptoms Periapical Curettage: same as apicoectomy, but DOES NOT remove root apex removal and exam of diseased tissue and determining extent of lesion are objectives of apical curettage Superoxol: most common bleaching agent for endo treated teeth Bleaching effect is due to direct oxidation of stain-producing substances Heat liberates oxygen in bleaching agent Most probable post-op complication of tooth bleaching that has not been properly obturated is acute apical periodontitis Acute Apical Periodontitis: pain commonly triggered by chewing or percussion Indicates irritated apical tissues possibly associated with a vital pulp with a potential reversible pulpitis It is easier to retrieve an instrument if it is wedged coronal or at curvature of canal, but difficult if it has passed the canal curvature When an instrument breaks off in canal’s apical 1/3 and is lodged tightly with no evident PA radiolucency, remaining root canal space can be filled with gutta-percha, patient will be on a 3-6 month recallPrognosis of a tooth with a broken instrument is best if tooth had a vital pulp and no periapical lesion Filing- a push-pull action with emphasis on withdrawal stroke produces a canal that is irregular in shape canal must be filled with gutta-percha in a condensation procedureReaming- repeated clockwise instrument rotation produces a canal that is round in shapeCircumferential filing- push-pull filing action that scrapes canal walls to create a smooth, tapered prep enhances prep when a flaring method is used Hedstrom files: effective “H-Type” stainless steel cutting instrument made using a sharp, rotating cutter to gauge triangular segments out of a round blank shaft Successfully planes dentin walls much faster than k-files or reamersK-Files: most useful instrument for removing hard tissue to enlarge canals Files are made by twisting a blank square stainless steel rod producing a series of cutting flutes Strongest and cut least aggressively Reamers: used in canal preps to shave dentin using only a reaming action to enlarge canalsRemove intracanal debris with a clockwise reaming action and place materials into apical portion of canal using a counterclockwise rotation TOOTH AVULSIONTeeth replanted within 30min have very little resorptionTeeth replanted after 2hrs have extensive external resorption MAIN CAUSE OF FAILURE OF REPLANTED TEETH IS EXTERNAL ROOT RESORPTION Closed apex tooth that has been avulsed and dry for <1 hour replant and place a physiologic splint for 7-14 days Closed apex and avulsed > 1 hour, soak in NaF then treat like a closed apex tooth avulsed for < 1 hourOpen apex avulsed tooth and dry <1 hour rinse in doxycycline solution for 3 min, then replant and splint Open apex and dry for >1 hour, DO NOT REPLANT TOOTHHank’s balanced salt solution is best storage media Milk has max storage time of 6 hours Avulsed permanent tooth replanted by dentist within 2 hours of accident 10-14 days after replantation, clean and shape root canal, and place CaOH paste into canals Avulsed permanent tooth out for > 2 hours:Ankylosis and external root resorption will probably occur within 2 yearsRCT is performed prior to replantation Soak tooth in 2.4% fluoride solution at 5.5pH for at least 20 min Gently curette blood clot out of alveolar socket and irrigate with salineRinse tooth with saline, replant, and splint for 4-6 weeks Teeth with complete root development should be treated with RCT ASAPEXTERNAL AND INTERNAL RESORPTIONExternal Root Resorption: caused by periradicular inflammation, dental trauma, excessive ortho forces, impacted teeth, bleaching of non-vital teeth chief cause of failure of replantation of permanent teeth Surface Resorption- caused by acute injury to PDL and root surfaceLimited to cementum and may heal itself External Inflammatory Resorption- external resorption in which an infected pulp may further complicate resorptive processCharacterized by bowl-shaped resorption areas involving cementum and dentin that rapidly progresses and continues if tx is ignored Replacement Resorption (Ankylotic Resorption): external root surface resorption that becomes substituted by bone, causing ankylosis in unsuccessful avulsed tooth replant cases Accompanies dento-alveolar ankylosis due to extensive trauma to tooth’s attachment apparatus Characterized by progressive replacement of root by bone Shows direct contact between dentin and boneExternal Cervical Inflammatory Resorption: presents as vascular granulation tissue that creates a cavity at CEJInternal Root Resorption (Inflammatory): caused by dental trauma, partial removal of pulp, caries, pulp capping with CaOH, or a cracked tooth Causes loss of pulp vitality Usually caused by inflammation due to infected coronal pulp Teeth have a history of trauma, crown prep, or pulpotomy Undifferentiated reserve C.T. pulp cells are activated to form dentinoclasts that resorb tooth structure in contact with pulpUsually asymptomatic and found on radiograph Root canals anatomy is altered and increases in size, looking like an irregular radiolucency Root canal “disappears” into lesionMay respond to pulp vitality tests, but when detected, a pulpectomy should be performed Pink Tooth= sign of internal resorption and sometimes a sign of cervical root resorption, characterized by a pinkish appearance of tooth due to granulation growth undermining coronal dentin Intentional replantation is considered ONLY when there is no other alternative tx to maintain a “strategic” tooth Replantation of a primary tooth is NOT recommended due to potential danger to permanent successor tooth from trauma Mantle Dentin: first formed dentin that is laid before odontoblast layer is organized; contains Van Korffs Fibers Inerglobular Dentin: separates mantle and circumpulpal dentin Primary Dentin: forms initial shape of toothMajority of primary dentin is circumpulpal dentinSecondary Dentin: formed after completion of apical foramen junction between primary and secondary dentin is characterized by a sharp change in direction of dentin tubulesTertiary Dentin: formed very rapidly in response to irritants composition is same as secondary dentin, but is more irregular and differs in location and deposition Sclerotic Dentin: calcified dentinal tubules As pulp ages, # of reticulin fibers decreases and size of pulp decreasesCollagen fibers and calcifications within pulp increase (denticles or pulp stones)Proprioceptors are NOT found in dental pulp Only response to dental pulp is PAIN Cells found in pulp= fibroblasts, odontoblasts, histiocytes (macrophages), and lymphocytes Cells found in DISEASED pulp= PMN’s, plasma cells, basophils, eosinophils, lymphocytes, and mast cellsApical portion of pulp contains more collagen than coronal portion Type 1 and 3 collagen is mainly found in pulpType 1 collagen predominates in dentin Odontoblasts synthesize type 1 collagenFibroblasts in pulp synthesize Type 1 and 2 collagen Central ZoneCell-rich zone: innermost pulp layerCell-free zone: rich in capillaries, nerve networks, and contains Nerve Plexus of RashkowOdontoblastic layer: outermost pulp layer that contains odontoblasts, and is next to predentin and mature dentin Absence of predentin layer predisposes dentin to internal resorption by pulp cells Cementum: functions in attachment of PDL principal fibers covers anatomical root surfaces of teeth and is formed by PDL cementoblasts protects root surface from resorption during vertical eruption and tooth movement contains Sharpey’s fibers and Collagen fibers most closely resembles bone no nerve innervationAcellular cementum- contains no cells, predominates on coronal 2/3 of root (found at CEJ) 1st cementum to be formed Thinnest at CEJMajor role in tooth anchorage Cellular cementum- contains cementoblasts, inactive cementocytes, fibroblasts from PDL, and cementoclasts Found on apical 1/3 of root Formed after tooth reaches occlusal planeRoot hypersensitivity decreases as tooth forms cellular cementum Cementum is thickest at root’s apical 1/3 and thinnest at coronal 1/3 Cementoid- peripheral layer of developing, uncalcified cementum Radicular Cementum- found on root surfaces whose thickness increases with age Thicker apically than cervically If vital cementum is resorbed or nicked in surgical procedures, defect is repaired by deposition of new cementum MANDIBULAR AND MAXILLARY ROOT ANATOMYLingual wall of mandibular teeth is most easily perforated when preparing an access opening If pre-op radiograph of a mandibular 1st PM shows pulp canal disappearing in midroot indicates 2 canals are present Pulpitis can cause referred pain to mental region of mandible Mental foramen lies in close proximity to mandibular 2nd PMMandibular Molars= trapezoidal outline of pulp chamber Look for a 4th canal if first canal in distal root lies more toward buccal, instead of in center Mandibular 1st molar requires endo more than any other tooth in mouth Pulpitis can cause referred pain to ear Maxillary lateral incisor has an oval access opening Pulpitis of maxillary lateral incisor can cause referred pain to forehead Pulpitis of maxillary canine can cause referred pain to nasolabial area Pulpitis of maxillary 2nd PM refers pain to temporal region and sometimes nasolabial region If 4th canal exists in maxillary molars, it is usually lingual to MB canal U-shaped radiopacity commonly seen overlying palatal root apex is most likely zygomatic process of maxillaDB canal of maxillary 1st molar is usually 2-3mm distal and slightly palatal to MB canal orifice Root submersion: involves resection of tooth roots 3mm below alveolar crest, then cover with mucoperiosteal flap submerged roots prevent alveolar resorption and maintain better proprioception As caries enter dentin, it spreads laterally at DEJ due to increased organic content and involvement of dentinal tubules Only reliable clinical evidence that secondary dentin has formed is decreased tooth sensitivity ABSCESSESPeriapical Abscess: results from a pulpal infection that extends through apical foramen into periapical tissues MOST COMMON DENTAL ABSCESS Localized collection of pus in alveolar bone at root apex after pulpal death 1st symptom is slight tooth tenderness that later develops into a severe throbbing pain Acute Osteomyelitis- occurs in jaws, caused by a dental infection Serious sequela of a periapical infection that results in spread of infection throughout medullary spaces Person has severe pain, temperature/fever, and regional lymphadenopathyTeeth in involved area are loose and sore“moth-eaten” radiolucency Periodontal Abscess: acute abscess that develops through periodontal pocket that involves alveolar bone loss, pocket formation, and periodontal pathologic conditionsTooth is usually palpation and percussion positive and responds to EPTGingival Abscess: RARE- occurs when bacteria invade through a break in gingival surface; caused by mastication, oral hygiene procedures, or dental treatment Chronic Apical Abscess: long-standing, low-grade infection of periapical bone with root canal being source of infection Radiographs reveal a diffuse radiolucency and PDL thickening RCT is conventional therapy Phoenix Abscess: apical lesion that develops as an acute exacerbation of a chronic abscess Develops as granulomatous zone becomes contaminated or infected by root canal elements Acute Apical/Alveolar Abscess: localized collection of pus inside alveolar bone at root apex after pulpal death1st symptom= slight tooth tenderness, that later develops into a severe throbbing pain to percussion Tooth won’t respond to EPT or cold tests, but MAY respond to HEATGranuloma: growth of granulomatous tissue continuous with PDL due to pulpal death Radiographically, a well-defined area of rarefaction Cysts: inflammatory response of periapex that develops from a pre-existing granulomatous tissueCharacterized by a central, fluid-filled, epithelium-lined cavity, surrounded by a granulomatous tissue and peripheral fibrous encapsulation Combined Periodontal-Endodontic Lesion: endo procedures are performed first, then perio treatment Common clinical finding of a periodontal problem is pain to lateral percussion on a tooth with a wide sulcular pocket Reversible Pulpitis: commonly caused by bacteriaPain is not spontaneous, but requires an external irritant to evoke a painful response Pains are sharp and brief, stopping when irritant is removed Tooth is percussion negative Pulpal hyperemia is congestion of blood within pulp chamber caused by physical, chemical, or bacterial insult When caused by bacterial insult, it is a limited inflammation of pulp Most effective way to reduce pulp injury during tooth prep is to minimize dehydration of dentin Irreversible Pulpitis: characterized by spontaneous pain with periods of cessation Pain varies from a mild and readily tolerant discomfort, to a severe, throbbing, and excruciating pain that is spontaneous, intermittent, and lingers after irritant is removed Pain not readily localized Lying down or bending over intensifies pain Usually hot and cold cause severe and lasting pain Thermal test is best aid to diagnosePulpal necrosis: may have no painful symptoms and does not respond to EPT at any current level, but tooth sometimes responds to heat, but NOT cold Significant Bacteroides species involved in pulpal-periradicular infection are Porphyromonas and PrevotellaPredominant species isolated from infected root canals= Eubacterium, Peptostreptococcus, Fusobacterium, Porphyromonas, and Prevotella species If performing a pulp-chamber-retained amalgam, must place amalgam 3.0mm into each canal for retention PEDIATRICSInhalation Nitrous Oxide: most frequently utilized route of sedation for kidsInitial N20 concentration is 20%Max concentration should not exceed 50%When started, flow rate is about 6L/min Correct total liter flow of N20 is determined by amount necessary to keep reservoir bag 1/3-2/3 full Earliest symptoms of conscious sedation is LIGHT HEADEDNESS Proper response to nitrous is feeling of floating or giddiness with tingling of digits Combined volume of gases being delivered should be at least 3-5 liters/minChloral Hydrate- drug used for pediatric dentistry by acting on CNS to induce sleep children often enter period of excitement and irritability before becoming sedated Midazolam- anti-anxiety drug that relaxes and makes kids sleepy max dose is 20mg given to child 30-45 min before procedure Potential side effects= nausea, vomiting, xerostomia, confusion, decreased coordination Contraindications= pregnant women, alcoholics, narrow-angle glaucoma, sleep apneaPULPAL TREATMENTPulpectomy: treatment of choice when an 11-year old child traumatized permanent maxillary central incisor and tooth becomes painful, with swelling, and a PA x-ray shows apex pathosis Tx of choice when there is a periapical pathology When performing on a primary tooth, canals are filled with ZOE pastePulpotomy: preserves radicular VITAL pulp tissue when entire coronal pulp is amputated, and allows resorption and exfoliation of primary tooth, but preserves role as a natural space maintainer Performed when coronal pulp shows evidence of inflammation and degenerative change due to microorganisms located there Calcium Hydroxide Pulpotomy Technique- treats permanent teeth when there is a pathological change in pulp at carious exposure siteIndicated for permanent teeth with immature root development and healthy pulp tissue in root canals Formocresol Pulpotomy Technique- treats primary teeth with carious exposure After coronal pulp is removed, cotton pellet moistened with formocresol is placed in contact with pulp stumps and remains for 5 minutes Success for a primary tooth depends on a vital root tipCauses surface fixation of pulpal tissue and odontoblast degenerationIndications= tooth sensitive to sweets, pulp exposure during caries removal, radiographic evidence of deep caries approximating coronal pulpDirect Pulp Capping: mainly used on permanent teeth Mild irritation mild inflammatory reaction that resolves itself Severe irritation internal resorption can occur Indirect Pulp Capping: indicated for permanent teeth with rampant caries and large carious lesions close to pulp that are not chronically painful PEDIATRIC DISEASES & CONDITIONSCleft Lip: occurs during 5th-6th weeks of embryonic life due to failure of maxillary and frontonasal processes to merge Class 1= unilateral notching of vermillion NOT extending into lipClass 2= unilateral notching of vermillion, cleft extends into lip, but NOT to nose floorClass 3= unilateral notching of vermillion, cleft extends into lip and floor of noseClass 4= bilateral clefting of lipCleft Palate: opening in roof of mouth where 2 sides of palate did not unite, occurring during 6th-8th weeks of embryonic lifeImpaired mechanism preventing normal speech and swallowingPatients have inability of soft palate to close airflow into nasopharynx Class 1= involves soft palateClass 2= involves hard and soft palate, NOT alveolar processClass 3= involves hard and soft palate, and alveolar process on one side of premaxillaClass 4= involves soft palate and continues through alveolar on both sides of premaxillaAcute Necrotizing Ulcerative Gingivitis: gingival disease characterized by painful hyperemic gingiva, punched-out erosions of interproximal papilla, covered by a gray pseudomembrane with an accompanying fetid/foul odorFusospirochetal infection caused by fusiform/fusobacterium, spirochetes, and Prevotella intermedia Painful infection with ulceration, swelling, and sloughing off of dead tissue from mouth and throat due to spread of infection from gumsAssociated with poor oral hygiene Affects YOUNG ADULTS ages 15-35 years oldPrimary (Acute) Herpetic Gingivostomatitis: vesicles form and rupture to leave shallow VERY PAINFUL ulcers covered with gray membrane and surrounded by a red halo Occurs only in young patients ages 1-5 years old Usually occurs in a child who has NOT had any contact with HSV-1Symptoms= fever, malaise, irritability, headache, dysphagia, vomiting, cervical lymphadenopathy On free and attached mucosa Dehydration is most serious potential problem Can result in spherical discrete vesicles Herpangia: acute infection caused by coxsackie A strain virusUsually occurs on back of throat- soft palate, tonsils, posterior palate Palliative treatmentRecession is main clinical finding in ATROPHIC GINGIVITISAcute Lymphocytic/Lymphoblastic Leukemia: most common PEDIATRIC CANCERCells that normally develop into lymphocytes become cancerous and rapidly replace normal cells in bone marrow Most responsive to therapy Apert Syndrome: cranial-limb anomaly characterized by specific malformations of skull, midface, hands, and feet Often associated with supernumerary teeth Features= prematurely fused cranial sutures, retruded midface, fused fingers and toes For kids with autism, GOAL is to get child comfortable with dental experience For ADHD kids, short-mid morning appointments after breakfast and taking RITALIN works best Achondroplasia: most common form of short-limb dwarfism disproportionate short stature, prominent forehead, depressed bridge of nose, small maxilla overcrowding of teeth, and class 3 malocclusion Cellulitis: acute infection of dermis and subcutaneous tissues causing pain/tenderness, erythema, edema, and warmth of affected area Most commonly caused by Group A Streptococci and Staphylococcus AureusCretinism (Child Hypothyroidism): deficiency disease caused by congenital absence of thyroxineCharacterized by defective mental and physical development Dwarfed bodies with curvature of spine and pendulous abdomen Severe mental retardation Underdeveloped mandible, overdeveloped maxilla, enlarged tongue, delayed tooth eruption, and longer retention of deciduous teeth Cystic Fibrosis: inherited disease of exocrine glands that causes the body to produce an abnormally thick, sticky mucus due to faulty transport of Na+ and Cl within cells lining organs Glands most affected= pancreas, respiratory system, and sweat glands Most reliable diagnostic tool = SWEAT TEST Combination of steatorrhea, chronic respiratory infections, and functional disturbances in secretion mechanisms of various glands Cleidocranial Dysplasia: disorder of bony development characterized by absent or incompletely formed clavicles, characteristic facial appearance, and dental abnormalitiesPresence of supernumerary teeth Retained primary teeth are an outstanding oral manifestation of Ectodermal and Cleidocranial Dysplasias Diphtheria: acute, contagious disease caused by Corynebacterium diphtheriaHemangioma: most common benign tumor of infants; vascular birthmarks where proliferation of blood vessels leads to mass resembling neoplasmLymphangioma: nodule or mass of lymph vessels occurring most often in neck and axilla Neurofibroma: firm, encapsulated tumor caused by proliferation of Schwann cells found on tongue, buccal mucosa, vestibule, and palate multiple lesions associated with Neurofibromatosis (Von Recklinghausen’s Disease)Nursing bottle caries most commonly affect Maxillary Incisors Pierre Robin Syndrome: hereditary disorder presenting with micrognathia, glossoptosis, and a high-arched/cleft palate Porphyria: abnormalities in production of heme pigments, myoglobin, and cytochromas 3 major findings= photodermatitis, neuropsychiatric complaints, and visceral complaints Diagnosis= child presenting with red urine, purplish-brown teeth, sensitivity to sunlight, and develops blisters and swelling on face and hands when exposed to sunlightRieger Syndrome: genetic disorder characterized by delayed sexual development, hypothyroidism, underdeveloped premaxilla, cleft palate, and protruding lower lipRecurrent aphthous ulcers and intra-oral herpes lesions are distinguishing on their location Recurrent aphthous ulcers on mobile mucosaIntra-oral herpes on tissue bound to periosteum Grand mal seizures typically last 2-5 minMeasles (Rubeola): viral illness characterized by fever, cough, and spreading rash due to PARAMYXOVIRUSKoplik’s Spots- 1-2mm yellowish-white oral lesionsGerman Measles (Rubella): benign viral disease, with symptoms of red, bumpy rash, swollen lymph nodes, and mild fever can manifest in oral cavity as small petechiae-like spots on soft palateMumps: contagious viral infection characterized by unilateral or bilateral swelling of salivary glands papilla on opening of parotid duct on buccal mucosa is often puffy and redSmallpox (Variola): viral disease that manifests by a high fever, nausea, vomiting, chills, and headache ulcerations of oral mucosa and pharynxScarlet Fever: arises from group A-beta-hemolytic streptococcal infection symptoms= strep throat, sudden onset of fever, sore throat, headache, nausea, vomiting, abdominal pain, muscle pain, fatigue, and strawberry tongue enlargement of fungiform papillae extending above level of white desquamating filiform gives appearance of an “unripe strawberry”TOOTH ABNORMALITIESAmelogenesis Imperfecta: teeth have thin, malformed enamel SOFT, THIN ENAMELTeeth appear yellow due to dentin visible through thin enamel Dentinogenesis Imperfecta: causes undermineralized dentin; crowns are bulbous with short roots, and teeth may appear gray or brown with opalescent dentin that obliterates pulp cavity Dens-in-Dente: “tooth within a tooth” caused by an invagination of all enamel organ layers into dental papilla most frequently involves maxillary lateral incisor Enamel Hypocalcification: enamel is soft and undecalcified in context, but normal in quantity due to defective maturation of ameloblasts teeth are chalkyEnamel Hypoplasia: enamel is hard in context, but thin and deficient in amount due to defective enamel matrix formation with a deficiency in cementing substance Common dental sequelae in a child with a history of generalized growth failure in first 6-months of lifeHypoplastic enamel is a dental manifestation of hypoparathyroidism, preventable by early treatment with Vitamin D Fusion or germination of teeth occurs during initiation and proliferation stages of tooth development Child Periodontium vs. Adult PeriodontiumChild periodontium has greater blood and lymph supplyAlveolar crest is flatter, and alveolar bone is thinner Gingival pocket depths are larger and attached gingiva is narrowerChild has rounded and rolled gingival margins TOOTH DEVELOPMENT AND ERUPTION Primary teeth begin to form at 6 weeks in utero and begin to calcify at 4 months in utero Stages of Tooth DevelopmentInitiation Stage (Bud Stage)- initial interaction between oral epithelium and mesenchyme forming dental laminaFused or germinated teeth occur during this stage Proliferation (Cap Stage)- tooth’s shape is evident and enamel organ is formed Fusion or germination of teeth occurs during initiation and proliferation stages of tooth developmentDifferentiation (Bell Stage or Histodifferentiation)- final shaping of tooth Dentinogenesis Imperfecta and Amelogenesis imperfecta occur during Bell StageApposition: cells begin to deposit specific dental tissues Calcification (Mineralization)- primary teeth begin to calcify during 2nd trimester of pregnancy Cariostatic effect of fluoride occurs during calcification stage Tetracycline stain is incorporated and discoloration occurs during calcificationsEruption- emergence of tooth through gingiva Ectodermal cells determine crown root and shape Korff’s Fibers: fibers in pulp periphery involved with formation of dentin matrix 416134913081000-9969521844000**When a tooth clinically erupts in mouth, 2/3 of root structure has formed Maxillary canine is usually last primary tooth to be replaced by a permanent tooth and tooth most likely to be crowded out of arch At birth, width of face has reached its greatest percentage of its adult sizeFLUORIDETopical fluoride is the primary preventive agent during adolescence Fissure sealants succeed by altering host susceptibility To prevent caries, Centers for Disease Control & Prevention recommends at least 0.7ppm of fluoride be present in drinking water. Max fluoride amount is 1.2ppm Optimal concentration of fluoride for community water depends on AIR TEMPERATURE Fluorides often added to water supplies are sodium fluoride, sodium silicofluoride, and hydroflusilicic acid Deposition of fluoride occurs on smooth surfaces of teeth Fluoride’s main effect occurs AFTER tooth has erupted above gingiva Fluoridation of community water is credited for reducing tooth decay by 50-60% in US Professional Applied Topical FluoridesSodium Fluoride (NaF 2% or 5%= 22,600 ppm)- basic pH, more acceptable taste than stannous fluoride; MOST EFFECTIVE professional fluoride delivery system for patients with RAMPANT CARIES, GERD, BULEMIAStannous Fluoride- unstable solution that must be freshly mixed, tastes bad, stains silicate restorations, and is acidicDoes NOT etch porcelain restorationsMain advantage of topically applying an 8% solution of stannous fluoride instead of 2% solution of NaF, is a single tx may be given Acidulated Phosphate Fluoride (1.23%): professionally applied, can be applied to both arches at same time, DAMAGES porcelain restorationspH is in range of 1-4contraindicated on porcelain and composite restorations can corrode surface of titanium implants Fluorapatite- most stable reaction product of a topical application of fluoride Fluoride treatments should be applied for 4 minutes Fluoride conc in most dentrifices ranges between 900-1500ppmDental plaque adheres to teeth because DEXTRANS are insoluble and sticky Fluoride converts hydroxyapatite fluorapatite by substituting OH- for Fl-Fluoride inhibits glycolysis inhibits enzymatic production of glucosyltransferase Fluoride mouth rinses are shown to have greatest effect on NEWLY ERUPTED TEETH most beneficial to SMOOTH tooth surfaces Systemic fluorides are least effective on root surfaces Greatest conc of fluoride ions exists on OUTERMOST ENAMEL LAYER INCLUDEPICTURE "/var/folders/14/kfphkf717_q461gqnnf3ht700000gq/T/com.microsoft.Word/WebArchiveCopyPasteTempFiles/1_fluoride-dosage-chart_do-all-children-need-fluoride-supplements.jpg" \* MERGEFORMATINET Acute fluoride toxicity symptoms may appear within 30 minutes of ingestion and persist for up to 24 hoursFluorides are mainly eliminated from body via kidneys Ingestion of 15mg/kg of fluoride can be lethal to a childAdult lethal dose is 4-5gmLethal dose of fluoride falls in range of 20-50mg/kgFor an adult, LETHAL DOSE of fluoride is between 2.5-10g, with average lethal dose is 4-5gMost fluoride absorption occurs in stomach Most effective method to reduce dental caries in general population is FLUORIDATION of communal water supplyFluoride supplements are recommended if water fluoride content is <0.7ppm Fluoride supplements are NOT indicated after age 13STOP taking fluoride supplements at 16-18 years oldFor children with high interproximal caries, fluoride mouthrinse is most effective Dental Fluorosis: “irreversible” diffuse symmetric hypomineralization disorder of ameloblasts that occurs with exposure to fluoride when enamel is developing causes mottled discoloration and pitting of enamel Fluoride reduces rate of caries, by reducing enamel’s rate of solubility Most fluoride is absorbed in small intestines and excreted through kidneys 1.0ppm is optimum fluoride concentration in community drinking water Proximal tooth surfaces derive greatest benefit from fluoridationFluoride converts hydroxyapatite fluorapatite to decrease enamel’s solubility Hydrodynamic Theory: most accepted theory to explain unusual sensitivity and response of exposed root surfaces to various stimuli SEALANTSGenerally made of BIS-GMA RESINSUnfilled sealants usually don’t require occlusal adjustment Low viscosity sealants wet acid-etched tooth surfaces best Properties of sealants are closer to unfilled direct resins than to filled resins Principal feature of a sealant required for success is adequate retention *underdeveloped motor coordination is the most common cause of dental trauma in very young children’s primary dentition ages 1 ? to 2 ? years oldCrown Fracture ClassificationEllis Class 1 Fracture- simple crown fracture involving little or no dentinEllis Class 2 Fracture- extensive crown fracture involving considerable dentin, but not pulp Ellis Class 3 Fracture- extensive crown fracture with pulpal exposure Tx with pulp therapy via pulp capping, pulpotomy, or pulpectomy, followed by permanent restoration RCT using ZOE paste as a filling material is indicated Ellis Class 4 Fracture- fracture where entire crown is lost; treatment is pulpectomy Root fractures in apical 1/3 are often repaired without treatment and more likely to undergo self-repairHeavy wires are recommended when stabilizing teeth with fractured roots Splinting is NOT recommended in primary dentition Fractured maxillary anterior teeth occur most often in children with Class 2, Division 1 malocclusion (flared maxillary incisors)Thermal test is MOST RELIABLEFailure of tooth to respond to heat indicates pulpal necrosis Inter-proximal caries on primary teeth may result in eventual loss of primary tooth, loss of tooth structure and arch length loss Enamel and dentin are thinner in primary teeth amalgam preps are deeperThickness of coronal dentin in primary teeth is ? that of permanent teeth Enamel rods in gingival 1/3 of primary teeth extend occlusally from DEJ BEHAVIORAL SCIENCEMost personal behavior by dentist is touching patient on arm Premedication with a barbiturate may cause paradoxical excitement in a young childAnger is easier to treat than fear Parent has the greatest influence on child’s reaction at initial visit Fear is distinguished from anxiety on basis of person’s ability to locate the threatening agent “out there” and to recognize the clear presence of a behavior that will reduce perceived danger Justice- quality of being impartial and fairAutonomy- inform patients about treatment, be truthful, and protect their confidentiality Beneficience- to be kind and give highest quality of care one is capable of providing Fetal alcohol syndrome increases genetic risk of intellectual disability Cytomegalic inclusion disease is most common virus that can cause intellectual disability Good Samaritan Law: provides immunity from suit for health practitioners who render emergency aid to victims of accidents, provided there is no evidence of gross negligence Child abuse most commonly involves newborns and children up to age 3 PPO (Preferred Provider Organization): involves contracts between insurers and dentists; patients can choose their dentist depending on if dentist participates in PPO arrangement T-TEST: most common method to evaluate HYPOTHETICAL DIFFERENCE IN MEANS BETWEEN 2 GROUPS Sensitivity- ability of test to diagnose correctly a condition or disease that actually exists measures proportion of people with a disease who are correctly identified by a + test Specificity- ability of test to classify health defined by # of true negative results divided by total # of false positive + true negative results in a sample Prevalence- # of OLD cases of disease present in a population at risk at a specific period of timeIncidence- number of NEW cases of a specific disease occurring within a population at a certain amount of time DMFT (Decayed-Missing-Filled Teeth Index)- best caries index to use if major purpose of an epidemiologist’s research is to determine dental caries susceptibility DEFT= decayed, extracted, filled teeth DMFS= decayed, missing, filled surfaces Universal precautions are effective in preventing disease transmission from dental worker to patient, patient to dental worked, and patient to patient OSHA is concerned with regulated waste within the dental office OSHA regulates contaminated sharpsOnly in dental procedures is saliva considered a potentially infectious material HIV is most infectious target of Standard Blood PrecautionsHBV is most infectious bloodborne pathogen HBV infection occurs by sexual intercourse, prenantal transfer, and percutaneous inoculationHCV is transmitted primarily in infected blood via accidental needlesticks, blood transfusions, or drug addicts sharing contaminated syringes Anti-retraction valves are used on handpiece and air-water syringe hoses to prevent retraction of fluid back into tubingAcceptable maximum exposure level allowed by OSHA for nitrous oxide is 1000ppmMaterial Safety Data Sheets (MSDS)- documents that contain information concerning a hazardous chemical Medical records MUST be maintained for duration of employment plus 30 yearsEnvironmental Protection Agency- regulates waste transportation from dental office Bactericidal- directly KILLS bacteria Sterilization- process of KILLING all microorganisms; complete destruction of all forms of microbial life Dry heat destroys microorganisms by causing coagulation of proteins Antigens most responsible for an immediate Type 1 allergic reaction to natural rubber latex are protein ORTHODONTICSPRIMARY TEETH OCCLUSIONFlush Terminal Plane- NORMAL relationship of primary molars Relationship of primary 2nd molars determines future antero-posterior position of permanent 1st molarsMesial Step- equivalent to angle class 1 malocclusionDistal Step- equivalent to angle class 2 malocclusion Edge-to-edge is most common initial relationship usually becomes class 1 molar relationship When erupting, permanent teeth move occlusally and buccally Physiologic occlusion- occlusion that adapts to stress of function, and can be maintained indefinitely Pathologic occlusion- occlusion that cannot function without contributing to its own destruction3 Planes of Space to Classify Malocclusion= Antero-posterior, Transverse, and VerticalSkeletal Open Bite: malocclusion most often associated with mouth breathing Not self-correcting, worsens with time As a child matures, their facial profiles become less convex Malocclusions are more identifiable in children ages 7-9 because eruption of permanent incisors reveals tooth-arch length discrepancies Steiner AnalysisSNA Angle: angle formed at intersection of 2 lines that show maxilla’s position relative to cranial base; indicates a good skeletal pattern, SNA angle is about 82SNA > 82 = maxillary prognathismSNA < 82 = maxillary retrognathismSNB Angle: angle formed by intersection of SN and NB; defines sagittal location of mandibular denture base; 80 angle is compatible with skeletal harmonySNB angle > 80= mandibular prognathismSNB angle < 80= mandibular retrognathism ANB Angle: norm for this critical angle is 2 difference between SNA and SNB normsANB angle > 4= class 2 skeletal profileANB angle < 0= negative class 3 skeletal profile Class 1 is the most common occlusion and associated with an orthognathic facial profile where nose, lips, and chin are harmoniously related Most common cause of class 1 malocclusion is a discrepancy between tooth structure and amount of supporting bone length Most prevalent characteristics of Class 1 malocclusion is crowding due to insufficient alveolar arch length Crowding > 4mm in mandible extractions usually needed Crowding < 4mm stripping interproximal enamel from each anterior tooth Class 2, Division 1: maxillary central and lateral incisors are in extreme labioversion [protruded]Class 2, Division 2: maxillary centrals are slightly retruded, and maxillary laterals are usually flared and overlap central incisors Sunday Bite- forward postural position of mandible adopted by people with Class 2 to try to improve their bite Ectopic Eruption: when a tooth erupts in the wrong placeMost commonly occurs in eruption of maxillary 1st molars and mandibular incisors More common in maxilla Associated with a developing skeletal class 2 malocclusion Ectopic eruption of a permanent maxillary 1st molar is often treated by a brass wire separating device placed between primary 2nd molar and permanent 1st molar to cause permanent 1st molar to tip distally Ectopic eruption of mandibular lateral incisors can cause transposition of lateral incisor and canineExistence of a forward shift of the mandible during closure to avoid incisor interference is found in “Pseudo” Class 3 malocclusionsBimaxillary Dentoalveolar Protrusion- present when teeth protrude in both jaws; there will be severe dental and lip protrusion accompanied by severe lip strain Crossbites are associated with a jaw-size discrepancy, hereditary, reverse over-jet, and a scissor bite Scissor Bite (Bilateral Lingual Crossbite): results from a narrow mandible or wide maxillaAnterior Crossbite: often indicates a skeletal growth problem and a developing class 3 malocclusion Most often associated with prolonged retention of a primary tooth Most essential factor related to correcting an anterior crossbite is amount of M-D space available A tongue thrust swallow is the result of displaced incisors, not the cause Anterior Open Bite: most common sequelae of a digit sucking habitUsually asymmetrical with normal posterior occlusion More common in blacks than whites Deep bites are more common in whites Posterior crossbite in the mixed dentition should be corrected ASAPMost common active tooth movement in primary dentition is to correct a posterior crossbite [TRANSVERSE PLANE]Maxillary Mandibular Plane Angle: angle between mandibular plane and maxillary plane that is normally 27The greater MMPA, the longer the anterior facial height A steep mandibular plane angle correlates with long anterior facial vertical dimensions and anterior open bite malocclusionPredisposes patient to class 2 malocclusion A flat mandibular plane angle correlates with short anterior facial vertical dimensions and anterior deep bite malocclusionPredisposes patient to class 3 malocclusion Most stable area to evaluate craniofacial growth is anterior cranial base because of its early cessation of growth 369189012128500Frankfort-Horizontal Plane: constructed by drawing a line connecting porion and orbitale; best representation of natural orientation of skull Mandible grows upward and backward in response to translation which occurs downward and forwardUlnar seaside or hamate bones are landmarks to obtain an estimate of timing of adolescent growth spurt Supervising a child’s development of occlusion is MOST CRITICAL from ages 7-10yrs Moyer’s Mixed Dentition Analysis: size of unerupted canines and premolars is predicted from size of mandibular incisors that have already erupted into mouth Maxillary primate space= between lateral incisors and caninesMandibular primary space= between canines and 1st molars One of the MOST COMMON causes of malocclusion is inadequate space management after early loss of primary teeth In both maxillary and mandibular arches, permanent incisor tooth buds lie lingual and apical to primary incisors Permanent teeth normally move occlusally and buccally while erupting Leeway Space: difference in total of M-D widths between primary canine, 1st molar and 2nd molar AND permanent canine, 1st PM, and 2nd PMMandibular leeway space averages 3-4mmMaxillary leeway space averages 2-2.5mm Serial Extraction indicated in severe Class 1 malocclusion in mixed dentition that has insufficient arch length Severe arch deficiency in permanent dentition (>10mm) almost always requires extractions to properly align teeth Stages Primary canines removed 1stPrimary 1st molars removed 2ndPermanent 1st PMs removed last 6-15 months is interval between extractionsTo aid in support and retention, a lingual arch is used in mandible and Hawley appliance in maxillaKEY TO SUCCESS= extract 1st premolars before permanent canines eruptMOST COMMON impacted anterior teeth are MAXILLARY CANINES Distal aspect of lateral incisors root guides eruption of canines Most common site for a supernumerary tooth is between maxillary central incisors Conditions associated with multiple supernumerary teeth= Gardener’s syndrome, Down’s syndrome, Cleidocrainial dysplasia, and Sturge-Weber Syndrome Hyperparathyroidism causes premature exfoliation of primary teeth 98% of 6-year olds and 49% of 11-year olds have a maxillary diastema caused by either a tooth-size discrepancy, mesiodens, abnormal frenum attachment, or a normal stage of development A maxillary central diastema of 2mm or less usually closes spontaneously If diastema is caused by an abnormal frenum, it is best to align teeth orthodontically and then do frenectomy Types of Tooth Movement Accomplished with OrthoTipping- tooth crown moves in 1 direction, while root tip/apex is displaced in opposite directionBest accomplished with a removable appliance and most easily with anterior incisors Translation- coupled force is applied to crown to control root movement in same direction as crown movement Extrusion- displacement of tooth from socket in direction of eruptionIntrusion- tooth movement into socket along tooth’s long axis; very difficult to accomplishTorque- controlled root movement F-L or M-D while crown is held stable Rotation- revolving tooth around its long axis Supracrestal fibers are associated with relapse after ortho rotation of teeth Most clinicians believe the collagen fibers in supra-alveolar tissue are primarily response for relapse of orthodontically rotated teeth and for re-development of spaces between orthodontically moved teeth Collagen fibers are main components of attached gingiva ORTHODONTIC APPLICANCES For an orthodontic appliance to be effective in translating tooth roots, it MUST be capable of exerting a torque Properties of an ideal wire material for ortho purposes= high strength, high range, high formability, and low stiffness Quad Helix- a fixed appliance that consists of 4 helices used for posterior cross-bite cases with digit-sucking habitIndications for using BANDS instead of bonded brackets:To provide better anchorage for greater tooth movement For teeth that need both lingual and labial attachmentTeeth with short clinical crownsTooth surfaces that are incompatible with successful bondingFixed Edgewise Appliance: consists of bands on all teeth, tubes on last molar, and brackets on all other teeth 1 labial arch is used at a timeGreatest application in treating comprehensive malocclusions of adolescent permanent dentition Components= siameses twin bracket, Broussard buccal tube, straight wire bracket and bracket with a .0222 x .028 rectangular slot Used for molar uprighting Stabilization should last until lamina dura and PDL reorganize which takes about 2 months for simple uprighting, and up to 6 months for uprighting and osseous surgery or graftsTime required to upright a molar takes between 6-12 months Common dental condition that can benefit from ortho treatment prior to prosthetic treatment is long-term loss of a mandibular permanent 1st molar Best way to upright a 2nd molar that drifted mesially is tipping its crown distally and opening up space Whip-Spring Appliances: used to de-rotate one or two teeth Space Maintainers that REPLACE 1 PREMATURELY MISSING PRIMARY TOOTH“Band & Loop” Space Maintainer- most often used when primary 1st molar must be prematurely extracted Loop prevents mesial migration of primary 2nd molar Limited strength allows only single tooth-space maintenance Distal Shoe Space Maintainer- used when a primary 2nd molar is lost BEFORE permanent 1st molar erupts Prevents mesial migration Space Maintainers that REPLACE MULTIPLE PREMATURELY MISSING PRIMARY TEETH Lingual arch space maintainer- used to maintain space when multiple primary teeth are missing and permanent incisors have eruptedDoes NOT restore function, and should be made completely passiveprimary 2nd molars or permanent 1st molars are bandedNance appliance- used for BILATERAL LOSS of primary maxillary molars Prevents mesial rotation and drifting of permanent maxillary molars Partial denture- most useful for bilateral posterior space maintenance when permanent incisors have not erupted Also used for missing anterior teeth when esthetics are a concernRemovable ortho appliances are generally restricted to TIPPING teeth Indications of Removable Appliances: retention after comprehensive tx, limiting tipping movements, and growth modification during mixed dentition Hawley Retainer: MOST COMMON removable retainer used in orthoIncorporates clasps on molar teeth and an outer bow with adjustment loops that span from canine to caninePalatal coverage of a removable plate makes it possible to incorporate a BITE PLANE lingual to maxillary incisors to control bite depth Can be made for upper and lower arch Patient may have difficult pronouncing linguoalveolar consonants for a few days after getting a maxillary Hawley Begg Appliance- uses round wires that fit loosely into bracket’s vertical slotFrankel appliance- removable functional appliance used for abnormal soft tissue patterns One of greatest advantages of using extraoral headgear is it permits posterior movement of teeth in 1 arch without adversely disturbing opposing arch High-pull headgear: produces a distal and upward force on maxillary teeth and maxilla indicated for Class 2, division 1 malocclusions that have an open bite Cervical-pull headgear: produces a distal and downward force against maxillary teeth and maxilla can cause possible extrusion of maxillary molars indicated for Class 2, division 1 malocclusions Straight-pull headgear: places a force in a straight distal direction from maxillary molar indicated for Class 2, division 1 malocclusions Reverse-pull headgear: has extraoral component supported by chin, cheeks, forehead indicated for class 3 malocclusions Finger Springs- best method for TIPPING maxillary and mandibular ANTERIOR TEETH Most common problems= lack of patient cooperation, poor design leading to a lack of retention, and improper activation Z-Springs- used for tipping anterior teeth, but deliver excessive heavy forces and lack range of motion Cross elastics from maxillary lingual to mandibular labial can be used to correct a single-tooth crossbite Anterior crossbite in primary dentition usually indicates a skeletal growth problem Bone growth occurs only by appositional growth Major site of growth of mandible is condyle Resorption occurs along anterior surface of ramus and bone apposition occurs along posterior surface of ramusMandible’s main growth site is in condylar cartilage Bone deposition in maxillary tuberosity region is responsible for lengthening of maxillary archThe space between jaws into where teeth erupt is provided by growth at mandibular condyles Intramembranous ossification- forms flat bones of skull, part of clavicle, maxilla, and mandible Endochondral ossification- forms short and long bones, ethmoid, sphenoid, and temporal bones of skullLATE MANDIBULAR GROWTH- theory that best explains why there is a strong tendency for mandibular anterior crowding in late teens and early 20’sMandible undergoes more growth in LATE TEENS than the maxillaMost rapid losses in arch perimeter are usually due to a mesial tipping and rotation of permanent 1st molar after removal of primary 2nd molar Most reliable indicator of readiness of eruption of a succedaneous tooth is extent of root development determined by radiographic evaluation ................
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