Case Study – 22/07/21

The above picture is a radiograph of a patient who attends your surgery with a toothache.She complained of dull aching pain on the upper right, with some tenderness in the upper buccal sulcus. The pain is unaffected by thermal stimuli. Describe your assessment and likely diagnosis.

Clinical features

Obtain a complete history first. How long has the pain been present? Have there been previous episodes or is this the first? Carry out a complete examination. Test each tooth for sensitivity with a cotton wool pledget soaked in ethyl chloride. Use gentle finger pressure on each tooth, followed up by percussion if there is no abnormal response. Record the responses and note if you manage to reproduce the pain the patient is complaining of.

Radiology

The radiograph shows a large restoration in the molar and a post crown on the first premolar. In the premolar, the root filling looks insubstantial and there is a periapical granuloma present. At the level of the end of the post, there is radio-opaque material overlying the tooth and bone. Also at this level and further coronally, lamina dura is lost along the root surface.

Likely diagnosis

The lack of any aggravation of the pain by thermal stimuli suggests that this is not pulpitis. The dull aching pain, along with the tenderness in the buccal sulcus, suggests chronic periapical periodontitis is a likelier diagnosis. On radiological grounds, there is only one likely tooth with problems: the first premolar. The apical granuloma suggests chronic inflammation, but you should bear in mind that the radiograph is a snapshot in time and that the lesion could be healing (although the poor root filling suggests otherwise). The interesting finding is the collection of signs around the end of the post. The radio-opaque material overlying the root here is probably extruded cement from when the post was cemented. This at least suggests a perforation and may indicate a fracture of the root at this level. Clinical examination might reveal mobility of the crown if a fracture were present

ANAESTHESIA – LOCAL AND GENERAL WITH BRAND NAMES AND COMPANY MANUFACTURER

Anaesthetics – local & genral
….
1.Bupivacaine

Used as

👉 Percutaneous infiltration anaesthesia ,

👉 peripheral nerve block

👉Sympathetic nerve block
,
👉retrobulbar block ,

👉Cadual block

👉Lumbar epidural block

Brand names.

🙏Buloc by celon
Inj – 0.25 % & in 0.5 % ( 20ml )
.
🙏Bupivan by Sun pharma
Inj :- 0.25% (20ml)
0.5% ( 20ml )
0.5% ( 4ml )
.
🙏 Marcain by AHPL
Inj:- 0.5 % ( 20ml )
Inj :- 1 % ( 2ml )
.

  1. Halothane
    Inhalation anesthesia

👉 used in Induction & maintenance of general anaesthesia
.
🙏Fluothane by AhPL
I:vap :- 100% in ( 200 , 250 , 30, 50 ml ) soln
.
3.Isoflurane
Inhalation anaesthesia

👉 Induction & maintenance of general anaesthesia
.
🙏 Forane by abbott
Inhalant :- 100% in ( 100, 250 ml )

🙏Isorane by AhPL
I:sol :- 5mg/5ml in ( 100,250,30 ml )
.

  1. Ketamine
    Intramuscular
    & Intravenous anesthesia


.
,🙏Ketam by sun
Inj 10mg/ ml (10ml )
Inj 50mg / ml ( 2ml )
.
🙏Ketmin by Themis medicare
Inj 50mg /ml ( 10 ml )
Inj 50 mg/ ml ( 2ml )
.
🙏Ketsia by celon
Inj 100mg ( 2ml )
Inj 500mg ( 10ml )

Abbreviation
I sol :- inhalation solution
Ivap :- inhalation vapour

  1. Lidocaine ( used as )
    Epidural
    👉 as Epidural anesthesia
    Injection
    👉Pulp dilatation during phaco-emulsification cataract surgery
    Intraspinal
    👉Spinal anaesthesia
    as Intravenous
    👉Intravenous regional anaesthesia
    Parenteral
    👉 Sympathetic nerve block
    👉 Peripheral Nerve Block
    👉 Percutaneous infiltration anaesthesia
    Urethral
    👉Surface anesthesia
    Mouth / throat
    👉Surface anesthesia
    as for Opthalmic region
    👉Surface anesthesia
    Rectal & topical / cutaneous
    .
    Company names


    ..

🙏Gesican 2% gelly by AHPL ( 30ml )

🙏Lidopatch by zydus cadila
T:patch- 5%

🙏Xylocaine by AstraZeneca
T:sol:- 2% 100ml
Oint :- 5% w/w ( 20mg )
Jelly :- 2% w/w ( 30mg )
..

🙏Xylocard 2 % by AstraZeneca
Inj (21.3mg/ml ) 50ml soln
.

🙏 Xylocaine viscous by astra zeneca
T:sol :- 21.3mg/ml ( 100ml )

🙏 Xylocaine topical 4% by AstraZeneca
T:sol :- 42.7mg/ml ( 30ml )

🙏Nummet by icpa
Spy :- 15% w/w ( 100g )

.
Some Combinations
Lidocaine + epinephrine

🙏 Lignosafe by stedman
( Lignocaine hcl 21.3mg & adrenaline 0.0125mg/ml )
Inj in 30ml

🙏 Xylocaine with adrenaline 2% by AstraZeneca
( Lidocaine hcl 21.3mg , adrenaline 0.005mg , nacl 6mg /ml )
Inj 30ml
.

Some other combination
🙏 Xylocaine 5% heavy ( lignocaine hcl 53.3mg/ml , Dextrose 75mg ) inj in 2ml
.

& Xylocaine soln ( same dosage as above ) T:Sol 100ml by AstraZeneca

🙏 Xylocaine spray by AstraZeneca
( Lidocaine hcl 100mg , ethanol 28.29% ) 500ml
.
🙏Xicaine by icpa
( Lignocaine 2 percent , adrenaline 0.022mg) inj 30ml
&
( Lignocaine hcl 2% , adrenaline 0.009 mg ) inj 30ml
.
🙏Asthesia by unichem
( Lidocaine 2.5% w/w , prilocaine 2.5% )
CRM (15,30,5 )g
.
Abbreviation
Crm :- cream
Tsol :- topical solution

CLINICAL EXAMINATION OF DENTIN HYPERSENSITIVITY

  1. Evidence of dentin exposure (gingival recession, loss of enamel)
  2. Sensitivity or pain on tactile examination of suspected teeth
  3. Evaporative stimulus: Suspected tooth is isolated using cotton rolls. If a momentary blast of air from air/water syringe causes sensitivity. It can confirm DH
  4. percussion sensitivity
  5. Pain lingering after the stimulus is removed
  6. Vitality tests to rule out pulpal involvement
  7. Radiographic examination to check for caries, pulpal or periodontal involvement
  8. Signs of fractured, leaky or poor restorative margins.

Reference: Clinical operative dentistry-principles and practice : Ramya Raghu, Raghu Srinivasan

CASE HISTORY 👩‍⚕️🦷

CASE HISTORY

“It is defined as planned professional conversation that enables the patient to communicate his/her symptoms, fears and feelings so as to obtain an insight into the nature of patient’s illness” 🤒

It includes the following sequence;

🔰Personal information: name, age, sex(M/F), occupation, address with contact no., O.P no. are noted.

It is recorded to create a rapport with the patient. To assess their socio-economic status, age-related risk factors.

🔰Chief complaint: It ascertains the principle reason as to why the patient is seeking medical attention.

Complaint is recorded verbatim in patient’s own words: symptoms,onset,duration, previous treatments, history of illness.

🔰Dental history: Helps in reviewing patient’s risk status and past dental experiences. It’ll add info. about patient’s current dental problems.

🔰Medical history: Helps identify conditions that could alter, complicate, or contraindicate proposed dental procedures. Following may be detected:

🔸️Communicable diseases: herpes simplex,chicken pox, mumps, tuberculosis etc. Should be questioned about contact with hepatitis B, HIV.

🔸️Allergies and drug history: Drug allergies ( local anesthetics like novocaine, analgesics, antibiotics)

Also certain medications 💊 can alter the treatment:

Ex:- Antiepileptic drugs – gingival enlargement

🔸️Systemic health: Cardiac abnormalities:- risk of bacterial endocarditis following dental procedures.

In such cases, prophylactic antibiotic cover is given.

Diseases of respiratory system:- may be on bronchodilators, antihistamines or steroid therapy. May interfere with anesthetic management.

Diseases of endocrine, neurological, hematological, infectious, reproductive, gastric, renal, liver, autoimmune, psychiatric should be noted.

🔸️Aging: In geriatric group, medications and illness can alter oral physiology, maintenance of hygiene and treatment plan.

🔰Social review: Helps to identify patient’s attitudes, expectations and motivation for dental treatment.

🔰Family and personal history:

Gives an overview of patient’s lifestyle.

▪️Habits like chewing tobacco, quicklime, areca nut, pan masala, gutka, chronic alcoholism, chronic smoking etc.

▪️A detailed history of immediate family of the patient, with their age, general health, medical ailments, cause and age at the time of death of any deceased member is recorded. A family history of epilepsy, cardiac disorders, diabetes, bleeding disorders and tuberculosis is of particular importance.

Sometimes, dentist is the first person to recognize any disease in a patient 🌻

Are Dental Caries Reversible?

Manjusha Madkaiker

ARE DENTAL CARIES REVERSIBLE?

Dental caries is a multifactorial irreversible microbial disease of the calcified tissues of the teeth, which is characterized by demineralization of the inorganic portion and destruction of the organic substance of the tooth, which often leads to cavitation. Dental caries is one of mankind’s ancient and longest disease associated with the oral profession. Everyday around 2.3 billion people are affected by dental caries.

But since the late 20th century with new advancement in technologies there is slow but gradual progress in the development of the vaccine .1972, a caries vaccine was said to be in animal testing in England.

DISEASE ETIOLOGY- A CHANGING TREND

1. Acidogenic theory – this theory was proposed by WD Miller in the year 1881 which states the combined effect of acid and oral microbes leads to the decalcification of tooth structure .This theory was incidentally evolved, and according to this theory the microbes in the oral cavity metabolize the dietary starch and lead to production of organic acids that hence dissolves the tooth structure .

2.Proteolytic Theory – Proposed by Pincus in the year 1949 which states that the proteolytic breakdown of dental cuticle is the first step in the various process. He proposed that Nasmyth’s membrane and enamel proteins are mucoprotein which are acted upon by the sulphates enzyme of the bacilli and yield sulphuric acid, this acid combines with the calcium of hydroxyapatite crystals and thus destroy the inorganic components of the enamel.

3.Protelysis-Chelation theory – Proposed by Schatz in the year 1955. Chelation is the process which leads to the formation of covalent bonds which leads to poorly dissociated and/or weakly ionised compound .Therefore dental caries are considered as the bacterial destruction of organic components of enamel and the breakdown products of these organic components to have chelating properties and thus dissolving the minerals in the enamel even at the neutral/alkaline pH.

HYPOTHESIS ON THE DEVELOPMENT OF DENTAL CARIES

1. Nonspecific plaque hypothesis

In the end of 19th century the cause of dental infection was said to be due to non-specific overgrowth of all bacteria in dental plaque this was called as the nonspecific plaque hypothesis given by Black in 1884 and Miller 1890. This hypothesis was proposed irrespective of the virulence of the bacteria.

So, the best way of disease prevention in the 19th century was non-specific mechanical removal of as much plaque as possible by e.g., tooth brushing or tooth picking.

The new advancements in the 20th century lead to to isolate and identify bacteria led which resulted in the abandoning of the NSPH. But mechanical plaque removal remained the most efficient way of preventing disease.

2.Specific plaque hypothesis

This hypothesis proposed by that the use of antibiotics against specific bacterial species could cure and prevent caries. However, results even today, are not very promising, the antibiotics reduced the abundance of cariogenic bacteria but failed to eliminate them thus as soon as the treatment was stopped, abundance increased while a long period of treatment leads to antibiotic resistance.

3.Ecological plaque hypothesis

4.Keystone pathogen hypothesis.

CARIES ICEBERG

1. On top i.e. the floating iceberg represents the clinical cases.

2. The submerged portion represents the carriers.

3. The part in the waterline represents the apparent and unapparent cases.

4. And at the tip are the ones with multiple health problems.

THE VACCINE

Vaccines are an immunobiological substance designed to produce specific protection against a given disease. It stimulates the production of a protective antibody and other immune mechanisms. Vaccines are prepared from live, inactivated or killed organisms, and toxoids.

Immune response is divided Into

1. Primary response

2. Secondary response (booster response)

Although development of a vaccine for started around 30 years back, but no success was achieved due various reasons.

But the formation of dental caries can be prevented or the progression can be slowed by the use of fluoride, use of sugarless products and sealants, and increased access to dental care have had a significant impact on the amount of disease in people. Many of these approaches can be broadly effective. Hence the dental caries can be reversible to a certain extend. However, economic, behavioural, or cultural barriers have continued the epidemic of dental disease.

Integrating the caries vaccine after its development into public health programs could be beneficial in bring dental caries to a minimal level.