Composite resin strip crowns


Composite is the material of choice for the restoration of primary anterior teeth. An anterior strip crowns with composite resin provides an aesthetic and durable restoration.

Method:

  1. Local anaesthesia and rubber-dam isolation should be used if possible. Alterna- tively, because of age and poor cooperation of younger children, the restorative work may be completed under general anaesthesia.
  2. Select the correct celluloid crown form depending on the mesiodistal width of the teeth.
  3. Remove the caries using a slow-speed round bur.
  4. Using a high-speed tapered diamond or tungsten carbide bur, reduce the incisal
    height by around 2 mm, prepare interproximal slices and place a labial groove at
    the level of gingival and middle thirds of the crown.
  5. Protect the exposed dentine with a glass ionomer lining cement.
  6. Trim the crown form and make two holes in the incisal corners by piercing with
    a sharp explorer.
  7. Etch the enamel for 20 seconds, and wash and dry.
  8. Apply a thin layer of bonding resin and cure for 20 seconds, ensuring all surfaces
    are covered equally.
  9. Fill the crown form with the appropriate shade of composite and seat with gentle,
    even pressure, allowing the excess to exit freely. The use of small wedges may be
    helpful in avoiding interproximal excess.
  10. Light cure each aspect (labially, incisally and palatally) equally.
  11. Remove the celluloid crown gently, and adjust the form and finish with either composite finishing burs or abrasive discs.
  12. Check the occlusion after removing the rubber dam.

Source: Handbook of Pediatric Dentistry, Third Ed


@drmehnaz🖊

Management of Dental Problems during COVID-19 pandemic

🎯 Decision making processes in patient management

🎯 What can dentists do to protect themselves and patients?

  • Hand hygiene has been considered the most critical measure for reducing the risk of transmitting microorganism to patients
  • SARS-CoV-2 can persist on surfaces for a few hours or upto several days. This reinforces the need for good hand hygiene and the importance of thorough disinfection of all surfaces within dental clinics.
  • Every surface in the waiting room must be considered at risk; therefore in addition to providing adequate periodic air exchange, all surfaces, chairs, magazines and doors that come into contact with healthcare professionals and patients must be considered “potentially infected”
  • It may be useful to make alcoholic disinfectants and masks available to patients in waiting rooms. The entire air conditioning system must be sanitized very frequently.

#protips:

1. How to wear and remove your mask?

Wearing a mask is mandatory for the clinician and support staff, the N95 has become a necessity. The most important requirement is to avoid touching the surfaces of the mask, if at all it is required to touch it for the first time, make sure it is with sterile gloves.

2. How to re-use N95?

We all know that the surgical masks should be disposed after each use. However these days it’s necessary for and supporting staff to use N95. Since the N95 is more expensive than the masks we wear on a regular basis, to dispose after each use may not be very economical.

So here’s how you can store your N95 if it is not soiled, you can label each box/bag with the name of the doctor who it belongs to and the days (as shown in the image below) and use it accordingly.

3. Are you wearing your mask right?

It is advisable to wear the mask before wearing the head cap so that the ears are completely covered, if the mask is worn over the head cap the elastic that goes behind the ear may tug on the cap and expose your ears.

4. A small tip on which masks you can avoid and/or wear in your clinics?

Nowadays a variety of masks are available, right from single to ten layers. Cloth masks are not surgically approved to be worn by a clinician based on its filteration capacity, and it is advisable not to use a single or two ply mask. The least you need is a two, 3 ply surgical mask worn one on top of the other.

The preferred choice always would be an N95 over which you can wear a 3 ply mask so that your N95 is protected from any splatter or aerosol and can be reused.

5. Are you using cloth masks while working at your clinics?

The four layer cloth masks are not scientifically proven for clinical use, these are good for general use, but not suitable for clinical use as there are no studies that have proven their effectiveness in clinical use.

6. Select the mask that fits you well!

Make sure the nose clip is fit well. Blow air to check if there is any leakage of air, the rim should be perfectly sealed. Poorly fit N95 can drastically reduce the filteration capacity to 30%. It is always better to wear your mask in front of a mirror.

7. Is it advisable to wear masks with filters?

The filter in the mask is a feel good factor for getting fresh air inside, but in conditions, where there is an active virus around it is advisable not to use, especially in clinical conditions.

8. Wearing a mask may cause a lot of symptoms right from the marks from the mask which is a sign that your mask has a good seal, to sweating, breathlessness, dizziness, increased heart rate and blood pressure, fatigue and increased CO2 saturation.

We recommend clinicians to start working with lesser number of hours and increase the work time gradually till you get accustomed to the new conditions.

9. Are masks with shields effective for use in clinical practice?

They are not scientifically proven because of the lack of fit and are not recommended for clinical practice.

10. Which shield are you using?

Shields have been proven to have adequate protection when worn over the N95, it acts as a second line of defence and avoid any splatter or aerosols on the exposed part of the face. Hence its strongly recommended to incorporate a shield while practicing by the clinicians. Pick the one that best suits your needs!

Its best to have separate shields for everyone working in the clinic, label the shields and use 4-5 times and disinfect the shields in between uses with a disinfectant.

11. Wearing protective glasses in such times is very important, for the clinician and the supporting staff. Make sure to have different glasses for each person. The glasses should seal the area around the eyes and protect them from any aerosols. A good fit ensures tight seal and no fogging, in addition check the quality to see the visibility too.

12. Are you providing your patients with protective eyewear?

It is of utmost importance to provide your patients with protective eyewear too. There are various kind of eyewear available that can be given to the patient depending on the treatment being carried out. Store the glasses in a box or ziplock bag after disinfection in between uses.

13. Are you washing your hands thoroughly?

One of the most important aspect of hygiene is hand hygiene which we as health care professionals also underperform. As much as 30% of all the surfaces of the hand and wrist remain unwashed if not done thoroughly (as shown in the image)

14. WASH YOUR HANDS!

Earlier considered as a luxury, these days using sensor based soaps/sanitizer dispensers and automatic taps are better, more safe in these times and quite affordable as well. If the installation of automatic taps and soap dispensers is not possible, we recommend taps which have push buttons that can be used with the non-dominant part of the hands. For sanitizers use dispensers which have foot pedals to avoid contact.

15. Virtual Care:

Its best to make sure first a TELECONSULTATION is done and then the patient is called in only if absolutely necessary. Level 1 includes consultation and planning if treatment of level 2 or 3 is required. Teleconsultation is also known as level 0 treatment. Make sure to check with the patient before giving an appointment if they have or had any symptoms in the past 10-15 days.

16. The New Normal:

If there is a chance to space your appointments it is a good idea, it would be better to donn and doff after each patient and go back to scrubs specially when you are performing procedures involving aerosols. The idea being if you are in a PPE the whole day you may end up touching surfaces that could be avoided. Once exposed to the patient you must assume that there is some microbial or viral load on your PPE. Therefore to reuse your PPE through the day donning and doffing with inter-spacing between appointments would be an intelligent idea.

17. Are you disposing your PPE the right way?

At the end of the day or whenever you deem fit to dispose the PPE follow a protocol in such a way that you don’t end up touching the front surfaces of the PPE which may have been exposed to aerosols. Pull through the sleeves catching the inner surface and then roll inside out always with a pair of gloves and dispose the PPE.

18. Four main chemicals will make all the difference

  1. a) Ethyl Alcohol: Ethyl Alcohol comes in various concentrations, make sure to be close to 70% if not 80%
  2. b) Hydrogen Peroxide: The dilution of hydrogen peroxide as recommended of 1% for mouth rinse
  3. c) Sodium hypochlorite: Commercially available in different percentage, the most common being 3% and 5%. Please do not buy large quantities of sodium hypochlorite, more than required per month as it will dissociate into hypochlorous acid, chlorine and then water in no time. Dilutions of NaOcl vary from 1, 0.1 and 0.01 depending on the intended usage. 1% can be used to clean floors and/or 0.1% for disinfecting surfaces.
  4. d) Povidone Iodine

19. Hypochlorous acid:

HOCl is the most effective disinfectant in the chlorine family and has been proven to be more efficient than NaOCl. HOCl’s lack of electrical charge allows it to penetrate the protective lipid membrane of an organism and quickly inactivate the viral protein. Hypochlorous acid is also known as electrolyzed water is considered by the FDA to be “the form of free available chlorine that has the highest bactericidal activity against a broad range of microbes” including MRSA, M.Tuberculosis, E.coli, Corona virus and many more.

The Management practice of the operating area:

The management practice of the operating area should be quite similar to what happens with other patients affected by infectious and highly contagious diseases. As often as possible, the staff should work at an adequate distance from patients; furthermore, handpieces must be equipped with anti-reflux devices to avoid contaminations, improving the risk of cross-infections.

Dentists should take strict personal protection measures and avoid or minimize operations that can produce droplets or aerosols. The 4-handed technique is beneficial for controlling infection. The use of saliva ejectors with low or high volume can reduce the production of droplets and aerosols.

The operatory may be contaminated with micro-aerosols that can stay in air for upto 15 minutes, make sure to open the windows in the operatory to facilitate air circulation before you take the next patient.

Transmission routes of 2019-nCoV and controls in dental practice

It is crucial for dentists to refine preventive strategies to avoid the COVID-19 infection by focusing on  patient placement, hand hygiene and all personal protective equipment (PPE)

Due to the characteristics of dental settings, the risk of cross-infections may be high between dental practitioners and patients. Due to the unique characteristics of dental procedures where a large number of droplets and aerosols could be generated, the standard protective measures in daily clinical work are not effective enough to prevent the spread of COVID-19, especially when patients are in the incubation period, are unaware they are infected or choose to conceal their infection.


Dentowesome | @drmehnaz🖊

SURGICAL GINGIVECTOMY

GINGIVECTOMY

Gingivectomy means excision of the gingiva. By removing the pocket wall, gingivectomy provides visibility and accessibility for complete calculus removal and thorough smoothing of the roots, creating a favorable enviornment for gingival healing and restoration of a physiologic gingival contour.

Indications:

  1. Elimination of suprabony pockets, regardless of their depth, if the pocket wall is fibrous & firm.
  2. Elimination of gingival enlargements
  3. Elimination of suprabony periodontal abscesses.

Contraindications:

  1. The need for bone surgery
  2. Situations in which the bottom of the pocket is apical to the mucogingival junction.
  3. Esthetic consiserations, particularly in the anterior maxilla.

SURGICAL GINGIVECTOMY

Armamentarium:

  1. Mouth mirror, probe
  2. Pocket markers, Kirkland and orban interdental gingivectomy knives
  3. Surgical blades, Bard Parker handle
  4. Surgical curettes, Gracey curettes, tissue forceps, scissors.
  5. Peiodontal dressings.

Surgical Technique Steps:

Step 1: The pockets on each surface are explored with a periodontal probe and marked with a pocket marker.

Step 2: The incision is started apical to the points marking the course of the pockets and is directed coronally to a point between the base of the pocket and the crest of the bone.

Step 3: Remove the excised pocket wall, clean the area, and closely examine the root surface.

Step 4: Carefully curette the granulation tissue, and remove any remaining calculus and necrotic cementum so as to leave a smooth & clean surface.

Step 5: Cover the area with a surgical pack.

Dentowesome|@drmehnaz🖊


Source: Carranza’s Clinical Periodontolgy, 10th Ed

Treatment Options for Drug-Associated Gingival Enlargement

Periodic Dental Check-ups: You can say good riddance to tartar, plaque, cavities and gum disease…..

Here’s an overview of various treatment options for drugs known to cause Gum disease/Gingival Enlargement.💊

To discover more w.r.t this topic head on to ✍🏻 – https://dentowesome.in/2020/07/03/gingival-enlargement/

Presentation Tip💡: Try to present your answers with flowcharts & diagrams rather than long paragraphs!! It will definitely have more impact & help you score well in exams..👍👇🏻

Surgical Approach (Diagrammatic View); MGJ: Muco-gingival junction; BL: Bucco-lingual; CT: Connective Tissue
Decision Tree for treatment of Drug-Associated Gingival Enlargement

Source: Carranza’s Clinical Periodontolgy, 10th Ed


Dentowesome|@drmehnaz🖊

Differential Diagnosis of Periapical Radiolucencies

PA radiolucencies identification made easy! Happy learning..😀📖

  • Periapical radiolucencies are most commonly odontogenic. Nonodontogenic radiolucencies tend to be not localized and span across the mandible or maxilla within the alveolus and sometimes extend inter-radicularly.
  • The most common PA pathologies can be diagnosed based on the vitality responses from the teeth. Ruling out the tooth associated pathologies is an important step in securing a diagnosis from differential diagnosis panel of PA radiolucencies.
  • Inter-relationship of possible results of periapical inflammation:

When formulating radiological differential diagnosis, features should be evaluated carefully, such as

  1. location
  2. locularity
  3. relation to dentition
  4. density of lesion
  5. margin
  6. type of radiological change (radiolucent/radiopaque/mixed)
  7. periosteal reaction
  8. cortical integrity, and
  9. clinical presentation.

🌫 General Radiographic features:

Location: With periapical inflammatory lesions, which are pathological conditions of the pulp, the epicenter typically is located at the apex of a tooth.

Periphery: Ill defined

Effects on surrounding structures: Periapical lesions cause widening of PDL space at apical region of the root.

PA Radiolucencies: (Classification)

PERIAPICAL RADIOLUCENCIES

Developmental

Lateral periodontal cyst

  • Definition: lateral periodontal cysts are cystic lesions that tend to occur on the lateral aspect of vital teeth. Epidemiology: lateral periodontal cysts account for fewer than 1% of the reported cases of odontogenic cysts.
  • Clinical findings: most lateral periodontal cysts area located in the mandibular incisor-canine-premolar area.
  • Radiographic findings: radiographically, lateral periodontal cysts present as a unilocular radiolucent lesion between the roots of teeth or associated with the lateral aspect of a tooth.
  • Management: surgical enucleation with preservation of involved teeth is an appropriate treatment of lateral periodontal cysts. Recurrence is rare. The multiloculated variant called botryoid odontogenic cysts has been reported to demonstrate a higher recurrence rate than its unilocular counterpart.

Inflammatory Lesions

Apical periodontitis, periapical abscess

  • Definition: spectrum of inflammation involving the PA area of teeth that results from pulpal infection by microorganisms.
  • Epidemiology: apical periodontitis is the most frequent inflammatory lesion related to teeth in the jaws.
  • Clinical findings: apical periodontitis can be classified as either asymptomatic or symptomatic; clinical examination of percussion and palpation of the tooth yields negative results in the former and usually positive results in the latter. The results of pulp sensitivity tests for both conditions, however, are negative. In the early stage of PA inflammation, the PA PDL can exhibit acute inflammation without abscess formation. This localized alteration may or may not proceed to abscess formation.
  • Radiographic findings: in apical periodontitis, radiographs may show a thickened PDL space. If an abscess develops after a long-standing apical periodontitis, radiographs reveal a radiolucent area around the root apex.
  • Management: apical periodontitis is an inflammatory disease caused by a persistent infection of the root canal system. The recommended treatment is the removal of the dead nerve and bacteria either through extraction of the tooth or root canal treatment. Antibiotics are recommended only when there is severe infection that has spread from the tooth into the surrounding tissues.
Mandibular left molar PA radiograph showing the initial apical changes in relation to the first molar secondary to a symptomatic gross carious lesion. If the offending causes remain, this will continue to an apical osteitis, resulting in loss of trabecular bone and possibly even cortical bone before it shows up radiographically.
Cropped panoramic radiograph showing localized osteomyelitis secondary to PA infection in relation to the mandibular left first and second molars (arrows).

Cystic Lesions

Periapical (radicular) cyst

  • Definition: radicular cyst is a cyst of inflammatory origin associated with a nonvital tooth.
  • Epidemiology: radicular cysts represent the most common odontogenic cyst. Radicular cysts are most commonly associated with at the tooth apex, but a lateral radicular cyst can be associated with a lateral root canal.
  • Clinical findings: radicular cysts are always associated with a nonvital tooth, and this is an important criterion for diagnosis.
  • Radiographic findings: radiographs often show a well-defined radiolucent lesion at the apex of a tooth. Radicular cysts can displace or resorb the roots of adjacent teeth.
  • Management: the treatment of radicular cysts can include nonsurgical root canal therapy to surgical treatment, such as apicoectomy.

Odontogenic keratocyst

CBCT panoramic reconstruction of maxilla showing a large well-defined lytic area coronal to the impacted right canine. Histologically confirmed as an odontogenic keratocyst.
  • Definition: an odontogenic cystic lesion with distinctive histologic features. Recently reclassified back into a cystic category in the recent 2017 WHO Classification of Head and Neck Tumours. Current evidence seemed lacking to justify the continuation of classifying it as a tumor.
  • Epidemiology: odontogenic keratocysts are the third most common cyst of the jaws.
  • Clinical findings: most common location of odontogenic keratocysts is the mandibular molar region.
  • Radiographic findings: odontogenic keratocyst size can be variable, ranging from a unilocular radiolucent lesion surrounding the crown of an unerupted tooth, resembling a dentigerous cyst, to a large size that results in facial deformity and destruction of surrounding structures. Lesions tend to grow in a posteroanterior direction, however, that results in a lack of cortical expansion.
  • Management: odontogenic keratocysts tend to be more aggressive in its growth pattern with a higher recurrence rate than other odontogenic cysts. Recurrence may be due, however, to incomplete removal or the presence of satellite (daughter) cysts. Treatment includes enucleation (with or without peripheral ostectomy, treatment with Carnoy solution), marsupialization, or resection.

Glandular odontogenic cyst

  • Definition: a developmental cyst with features that resemble glandular differentiation.
  • Epidemiology: glandular odontogenic cysts represent less than 1% of odontogenic cysts.
  • Clinical findings: there is a predilection for the mandible.But in the maxilla, the canine seems commonly involved. Swelling and expansion were the most common presenting complaints.
  • Radiographic findings: radiographically, glandular odontogenic cysts present as a well-defined unilocular or multilocular radiolucency associated with the roots of teeth; association with impacted teeth is rare.
  • Management: glandular odontogenic cysts have a tendency to recur especially when lesions are removed with simple enucleation.

Benign Tumors

Ameloblastoma

  • Definition: benign, slow-growing epithelial odontogenic neoplasm with unmitigated growth potential.
  • Epidemiology: ameloblastomas are the most common odontogenic tumors, excluding odontomas.89 In the United States, African Americans seem to have an overall 5-fold increase risk of disease compared with whites.
  • Clinical findings: tumor often presents as an asymptomatic swelling of the posterior mandible and can be associated with an unerupted tooth. Buccal and lingual expansion often is observed.
  • Radiographic findings: radiographs commonly show corticated multilocular (soap- bubble) radiolucency.
  • Management: the unmitigated growth potential and tendency to recur require operative management involving segmental or marginal resection. When treated by enucleation alone, much higher rates of recurrence are reported.
Panoramic radiograph showing a large well-defined, multilocular radiolucency extending from the area of first molar on the left into the ramus area. Note the expansion and thinning of the cortices. Ameloblastoma was confirmed histologically.

Malignant Tumors

Ameloblastic carcinoma

  • Definition: a rare, malignant counterpart for ameloblastoma. Not to be confused with metastasizing ameloblastoma, this is a histologically benign ameloblastoma metastasizing to distant sites. In the recent WHO Classification of Head and Neck Tumours, metastasizing ameloblastoma has been separated from ameloblastic carcinoma and included as a type of conventional ameloblastoma.
  • Epidemiology: incidence rate was 1.79 per 10 million person/year with male and black population predominance. The overall survival is 17.6 years.
  • Clinical findings: the most common site is the posterior mandible. Often, pain and expansion are the first clinical manifestations. Most cases arise de novo, but some arise in preexisting ameloblastomas.
  • Radiographic findings: radiographically, ameloblastic carcinomas can present as poorly defined, irregular radiolucencies consistent with a malignancy, or indistinguish- able from a benign radiolucency.
  • Management: generally considered radio-resistant tumor, radical surgical resection is the first line of treatment.

Differential Diagnosis: 🔍

  • The 2 type of lesions that most often must be differentiated from periapical inflammatory lesions are Periapical cemental dysplasia & enostosis (dense bone island, osteosclerosis) at the apex of the tooth.
  • In the early radiolucent phase of Periapical cemental dysplasia, the D/D rely solely on clinical examination and a test of tooth vitality.
  • With long standing periapical inflammatory lesions, the pulp chamber of involved tooth may be wider than adjacent tooth.
  • More mature PCD show radio-opaque mass within radiolucent area which helps in D/D.
  • Also the common site for PCD is mandibular anterior region. External root resorption is more common with periapical inflammatory lesions than PCD.
  • When enostosis is centered on the root apex, it may mimic inflammatory lesion but the PDL space has normal width. Also the periphery of enostosis is well defined and does not blend with surrounding trabaculae.
  • Small radiolucent periapical lesions with well-defined periphery may be either granulomas/cysts.
  • Differentiation may not be possible unless other characteristics of cyst such as displacement and expansion of surrounding structure is not present.
  • Larger lesions >1cm are usually radicular cysts.
  • If the patient has had endodontic treatment or apical surgery, a periapical radiolucency may remain that resemble periapical rarefying osteitis.
  • Metastatic lesions such as leukemia may grow in periapical segment of PDL space with malignant bone destruction.
Periapical radiographs of case showing Enostosis (see arrows) in the mandibular left quadrant, in close proximity with the roots of the adjacent teeth
  • Enostosis are common findings that seldom require treatment; however, caution should be exercised when undertaking orthodontic movement in the area of a DBI due to a potential risk of root resorption. Accurate identification and multidisciplinary management are of utmost importance. Monitoring size changes is recommended until completion of patient’s growth.

Dentowesome|@drmehnaz🖊


References:

  1. https://link.springer.com/article/10.1007/s40368-020-00596-w
  2. https://www.researchgate.net/profile/Eugene-Ko-2/publication/
  3. SlideShare, Study Notes✍🏻

ODONTOTOMY

The extraction of a tooth requires the separation of its attachment to the alveolar bone via the crestal and principal fibers of the periodontal ligament. Also involved is a process of expanding the alveolar socket.

After the tooth has been removed, the form of alveolar process is restored by finger pressure. Bleeding is arrested by means of a pressure pack placed between the jaws, and the wound is allowed to fill with a blood clot.

EXODONTIC PROCEDURES:

The following techniques may be used for tooth removal:

  1. the forceps technique
  2. the elevator technique (https://dentowesome.in/2020/06/18/dental-elevators/)
  3. the open view technique

Odontotomy can be used to facilitate any of these three procedures.

ODONTOTOMY

  • In some instances the extraction may be simplified by cutting a tooth apart. This is especially desirable in the case of multi-rooted deciduous or permanent teeth with severely divergent roots.
  • It is also useful in cases where the crown is so decayed that only a shell remains. (As shown in the figure👇🏻)
  • If the roots are divergent, the bur cut, instead of being vertical, may be made parallel with one of the roots, and this part of the tooth then is extracted first.
  • The other roots may be removed either with forceps or an elevator.

Dentowesome|@drmehnaz🖊


References: Textbook of Oral Surgery – Daniel M Laskin

Differential Diagnosis of Sinus, Fistula & Abscess

Sinus

Latin: Hollow (or) a bay

A sinus is a blind tract leading from the surface down to the tissue. There may be a cavity in the tissue which is connected to the surface through a sinus. The sinus is lined by granulation tissue which may be epithelized.

A sinus has one open draining end and the channel ends in a blind ending. An example would be a dental sinus draining from a dental abscess to either the inside of the mouth or the skin.

Fistula

Latin: flute(or) a pipe (or) a tube

It is a communicating tract between 2 epithelial surfaces commonly between hollow viscous & skin or between 2 hollow viscera. The tract is lined by granulation tissue which is subsequently epithelized. A fistula may be an abnormal communication between vessels.

An example would be from the mouth (oral cavity) to the skin surface, usually of the face or neck, and this specific type is called an orocutaneous fistula.

These defects can cause aesthetic and functional problems due to the continuous leakage of saliva.
It is an abnormal epithelized communcation between maxillary sinus and oral cavity through perforation in the sinus wall

Fistulas and sinuses of the neck and face: classification

Fistulas and sinuses of the neck and face may be classified by cause.

Developmental

Fistulas and sinuses due to developmental causes are usually present at birth.

  • Thyroglossal duct cyst – the most common developmental cyst in the neck. The cyst characteristically moves upwards when the tongue is poked out or with swallowing. It may burst to form a sinus which usually opens just below the hyoid bone in the midline of the neck. It drains mucus.
  • Branchial cleft cyst – the most common developmental cyst of the side of the neck. A sinus may drain mucus or pus following rupture of an abscess. It usually opens on the side of the neck.
  • Preauricular sinus

Cysts

Cysts are lumps in the skin containing fluctuant contents. They may have an opening to the skin surface.

  • Dermoid cyst
  • Epidermal cyst

Traumatic

  • Accidental
  • Radiotherapy
  • Surgical

Infective

  • Actinomycosis
  • Bone infection
    Chronic osteomyelitis – most commonly associated with poorly controlled diabetes mellitus or following radiotherapy to the jaw for cancer or Paget disease of the bone. It may also complicate a chronic dental infection.
  • Dental infection
    • Chronic dentoalveolar abscess
    • Dental implant
    • Failed endodontic procedure

Lymph node

  • Cat scratch disease
  • Dental infection
  • Tuberculosis (scrofuloderma)

Neoplastic

  • Oral squamous cell carcinoma is the most common
  • Benign tumours of the mouth rarely form a fistula

Causes for persistence of sinus/fistula

  • Presence of a foreign body e.g. suture material
  • Presence of a necrotic tissue underneath e.g. sequestrum
  • Insufficient or non-dependent drainage. e.g. TB sinus
  • Distal obstruction e.g. biliary fistula
  • Persistant drainage like urine/faeces/CSF
  • Lack of rest
  • Epithelialisation of the tract e.g. AVF
  • Malignancy
  • Dense fibrosis
  • Irradiation
  • Malnutrition
  • Specific causes e.g. TB, actinomycosis
  • Ischemia
  • Drugs e.g. steroids
  • Interference by the patient

How is a fistula or sinus diagnosed?

In addition to careful history and examination, one or more of the following tests will usually be required to confirm the diagnosis and determine the cause:

  1. passing a probe into the channel
  2. radiology – may include plain x-rays, x-rays using contrast medium, CT or MRI scans
  3. microbiological assessment of swabs or biopsy material
  4. biopsy and pathology

Abscess

Collection of pus

Clinical Features & Diagnosis:

Features of acute inflammation; The four cardinal signs of inflammation are:

  • redness (Latin rubor) – below localization of abscess
  • heat (calor) – inflammed area is hot
  • swelling (tumor) – pus present inside abscess cavity
  • and pain (dolor) – throbbing type

Diagnosis of Dental Abscess:

  • The location of abscess will cause tenderness with palpation test
  • The abscessed tooth will be very sensitive to percussion
  • IOPA findings will suggest slight thickening of PDL space with radiolucency at apex

Dentowesome|@drmehnaz🖊


References:

  1. dermnetnz.org
  2. SlideShare
  3. Google.com
  4. Study Notes✍🏻

EXAMINATION OF A SWELLING & ULCER

A swelling is a value term that denotes only enlargement or protuberance in body due to any cause.

According to the cause a swelling may be congenital, traumatic, inflammatory, Neoplastic or miscellaneous.

Examination of a swelling should be accompanied by a complete history of the patient. Following points should be noted:

Duration: The clinician may ask ‘when was the swelling first
noticed’? Swellings that are painful and of shorter duration are mostly inflammatory (acute), whereas those with longer duration and without pain are chronic, e.g. a chronic periapical abscess.

Mode of onset: The clinician may ask ‘how did the swelling start’? The history of any injury or trauma or any inflammation may contribute to the diagnosis and nature of the swelling.

Progression: The clinician should ask ‘has the lump changed in size since it was first noticed? Benign growths such as bony swellings grow in size very slowly and may remain static for a long period of time. If the swelling decreases in size, this suggests of an inflammatory lesion.

Site of swelling: The original site where it started must be assessed.

Other symptoms: Pain, fever, difficulty in swallowing, difficulty in respiration, disfigurement, bleeding or pus discharge are the common symptoms associated with swellings in the orofacial region.

Recurrence of the swelling: many swellings do recur after removal of the tissue, indicating the presence of precipitating factor, e.g. ranula.

LOCAL EXAMINATION🔍

(A) Inspection

  • Situation: few swellings are peculiar in their position
  • Color: Black – Naevus/Melanoma; Red/purple: Hematoma; Bluish: Ranula
  • Shape: Ovoid, pear shaped, kidney shaped, spherical or irregular
  • Size: Mention in cms. – the vertical horizontal dimension
  • Surface: Cauliflower as in Squamous Cell Carcinoma; Filliform – Papilloma
  • Edge: Sessile/pedunculated/indistinct
  • Number: Multiple/diaphyseal
  • Pulsation: The swelling which is superficial to artery, in close relation with it will be pulsatile. Pulsatile nature of swelling is assessed with 2 fingers on mass.
Mnemonic: SETTLE
  • Skin: Red & edematous. Pigmentation of skin is seen in moles or after repeated exposure to X-rays. Skin over a growth looks like the peel of an orange.

(B) Palpation

  • Temperature: Local temperature is raised due to extensive vascularity of the swelling; best felt with back of fingers.
  • Tenderness: Patient complains of pain due to pressure exerted by swelling.
  • Size, shape & extent: Mention in cms. – the vertical horizontal dimension
  • Fluctuation: If swelling contains liquid or gas it fluctuates.
Fluctuation test is positive if the two digits are pushed away in both directions.
  • Translucency: contains clear fluid
  • Compressibility: When pressure is applied to a swelling it decreases in size and when pressure is released swelling regains its size itself. Characteristic sign of VASCULAR HEMANGIOMA
  • Reducibility: Swelling reduces and ultimately disappears when pressed upon.

Surface: Can be👇🏻

• Smooth (cystic swellings)
• Lobular with smooth lumps (lipoma)
• Nodular (multinodular goitre)
• Matted (lymph nodes)
• Irregular (carcinoma)

Margins: Well defined/indistinct👇🏻

• Malignant growth - irregular margin
• Acute inflammatory swelling - ill defined margin
• Benign tumor - swelling slips & is indistinct

Edge👇🏻

• Well defined & regular-Benign Neoplasms
• Well defined & irregular-Malignant Neoplasms
• Ill defined & diffuse - Inflammatory swellings

Consistency: 👇🏻

• Soft - lipoma
• Cystic - Cyst or chronic abscesses
• Firm - Fibroma
• Hard - Chondroma
• Bony hard - Osteoma
• Stony hard - Carcinoma
• Variable consistency - Malignancy

EXAMINATION OF ULCER:

An ulcer is break in continuity of epithelium, skin or mucous membrane. A proper
history must be taken in case of an ulcer:

Mode of onset: The clinician may ask ‘how has the ulcer developed’? The patient may provide significant information about the nature and etiology of the ulcer such as any trauma or spontaneously.

Duration: The clinician may ask ‘how long is the ulcer present here’? It determines the chronicity of the ulcer. For example, traumatic ulcers in oral cavity are acute (occurring for a short period), but if the agent persists; it may become a chronic ulcer.

Pain: The clinician may ask ‘is the ulcer painful’? Most of the ulcers, being inflammatory in nature, produce pain. Painless ulcers usually suggest nerve diseases (such as peripheral neuritis, syphilis, etc).

Discharge: Any blood, pus or serum discharge must be noted.

Associated disease: Any associated generalized systemic problem may be associated with the ulcers of oral cavity (such as
tuberculosis, squamous cell carcinoma, etc).

LOCAL EXAMINATION🔍

(A) Inspection

Size & Shape:

• Tuberculous ulcer - oval with irregular border
• Varicose ulcer - vertical & oval in shape
• Carcinomatous ulcer - irregular

Number: Tuberculous, inflammatory ulcer may be more than one in number

Position:

• Arterial ulcer: Tip of the toes, dorsum of the foot
• Varicose ulcer: lower limb
• Perforating ulcers: over the sole at pressure points
• Non-healing ulcers: over the shin
• Rodent ulcer: upper part of face

Edge: An area between margin & floor. In spreading ulcer, edge is inflamed. Undermined edges destroy subcutaneous tissue faster than skin.

Beaded: As seen in rodent ulcer

Floor: This is the part of the ulcer which is exposed or seen.

• Red granulation tissue - Healing ulcer
• Necrotic tissue, slough - spreading ulcer
• Pale, scanty granulation tissue - tuberculous ulcer
• Wash-leather slough - Gummatous ulcer

Discharge:

• Serous discharge - Healing ulcer
• Purulent discharge - Spreading ulcer
• Bloody discharge - Malignant ulcer
• Discharge with bony spicules - Osteomyelitis
• Greenish diacharge - Pseudomonas infection

(B) Palpation

Tenderness: Characteristic of infected ulcers and arterial ulcers.

Induration: The edge, base and the surrounding area should be examined for induration

• Maximum induration - Squamous cell carcinoma
• Minimal induration - Malignant melanoma
• Brawny induration - Abscess
• Cyanotic induration - Chronic venous congestion as in varicose ulcer

Mobility: Malignant ulcers are usually fixed, benign ulcers are not.

Bleeding: Malignant ulcer is friable like a cauliflower. On gentle palpation, it bleeds. Granulation tissue as in a healing ulcer also causes bleeding.

Surrounding Area:

  • Thickening and induration is found in squamous cell carcinoma.
  • Tenderness and pitting on pressure indicates spreading inflammation surrounding the ulcer.

Relevant Clinical Examination:

Dentowesome|@drmehnaz🖊


References:

  1. A Practical Manual of Public Health Dentistry by CM Marya
  2. Slideshare.net
  3. https://www.medcampus.io/mnotes/examination-of-a-swelling-transmitted-vs-expansile-pulsations-
  4. medinaz.com, http://www.rxpg.com
  5. Study Notes✍🏻

HEMATOLOGICAL INVESTIGATIONS

Also known as: CBC; Hemogram

Sample Required?

  • A blood sample drawn from a vein in your arm or a fingerstick or heelstick (newborns)

Test Preparation Needed?

  • None

Why get tested?

  • To determine your general health status; to screen for, diagnose or monitor any one of a variety of diseases and conditions that affect blood cells, such as anemia, infection, inflammation, bleeding disorder or cancer.

Also known as: Hgb; Hb; H and H (Hemoglobin and Hematocrit)

Sample Required?

  • A blood sample drawn from a vein in your arm or a fingerstick or heelstick (newborns)

Test Preparation Needed?

  • None

Why get tested?

  • To evaluate the hemoglobin content of your blood as part of a general health check-up; to screen for and help diagnose conditions that affect red blood cells (RBCs); If you have anemia (low hemoglobin) or polycythemia (high hemoglobin), to assess the severity of these conditions and to monitor response to treatment

• When to get tested?

  • With a hematocrit or as part of a complete blood count (CBC), which may be ordered as a component of a general health screen; when you have signs and symptoms of anemia (weakness, fatique) or polycythemia (dizziness, headache); at regular intervals to monitor these conditions or response to treatment

Also known as: Thrombocyte count; PLT; Platelet distribution width; PDW; Mean Platelet volume; MPV.

Sample Required?

  • A blood sample drawn from a vein in your arm or a fingerstick or heelstick (newborns)

Test Preparation Needed?

  • None

Why get tested?

  • To determine the number of platelets in a sample of your blood as part of a health exam; to screen for, diagnose, or monitor conditions that affect the number of platelets, such as a bleeding disorder, a bone marrow disease, or other underlying condition.

• When to get tested?

  • As part of a routine complete blood count (CBC); when you have episodes of unexplained or prolonged bleeding or other symptoms that may be due to a platelet disorder

What is being tested?

  • Platelets, also called thrombocytes, are tiny fragments of cells that are essential for normal blood clotting. They are formed from very large cells called megakaryocytes in the bone marrow and are released into the blood to circulate. The platelet count is a test that determines the number of platelets in a person’s sample of blood. When there is an injury to a blood vessel or tissue and bleeding begins, platelets help stop bleeding.

Also known as: Leukocyte differential count; Peripheral differential; WBC count differential; Diff; blood differential; Differential Blood Count

Formal name: White blood cell differential

• Why get tested?

  • To help determine the cause of abnormal results on a WBC count; to help diagnose or monitor an illness affecting your immune system, such as an infection or inflammatory condition, or cancers that affect your white blood cells, such as leukemia.

• When to get tested?

  • As part of a CBC; when you have a routine health examination; when results of a CBC fall outside the reference range; when you have any number of signs and symptoms that may be related to a condition affecting white blood cells, such as infection, inflammation, or cancer, when you are receiving treatment that is known to affect WBCs, such as chemotherapy.

• What is being tested?

  • WBCs, also called leukocytes, are cells that circulate in the blood and the lymphatic system that help protect the body against infections. They are an important part of the body’s immune system and also have a role in inflammation, allergic responses, and protection against cancer. A WBC differential totals the number of each of the different types of WBCs in a person’s sample of blood.
  • There are five types of white blood cells, each with different functions.

  • Also known as: TLC; WBC count
  • Total WBC count is used as one of the index of presence of systemic infection and to rule out the possibility of leukemia & malignant neutropenia
  • Calculated with haemocytometer/ automated cell counts
  • RBCs are lysed by diluting the blood sample with dilute acetic acid leaving the WBCs intact.

  • Also known as: Red Blood Cell Count, RBC count
  • Red blood cells, also known as erythrocytes, make up the cellular part of blood, giving it its red color and also the ability to bind and carry oxygen to all parts of the body. Under a microscope, they appear to be circular and biconcave in shape.
  • Gives us the number of erythrocytes per cubic mm in circulating blood & Hb in blood.
  • Procedure done by office or chairside method and also automated procedure.
  • Hematological diseases of RBCs are anemia & polycythemia.

  • Categorized by mean corpuscular volume, anemia can be differentiated into microcytic, macrocytic and normocytic anemias. Normocytic anemia can be further divided into intrinsic and extrinsic RBC defect and blood loss.
  • MCV – Mean corpuscular volume is the average volume of red blood cells and is reflective of RBC size. When RBCs increase or decrease in size, the mean corpuscular volume changes; this helps physicians determine the type of anemia and its causes. Normal MCV is 80–96 µm³.
  • MCH stands for “mean corpuscular hemoglobin.” An MCH value refers to the average quantity of hemoglobin present in a single red blood cell.
  • MCHC is short for mean corpuscular hemoglobin concentration. MCHC refers to the average amount of hemoglobin inside a single red blood cell.
  • Hematocrit is the measure of the total volume % of red blood cells in the blood. The normal value for hematocrit is 45% for men and 40% for women. It is an important component of a patient’s complete blood profile.

Indications:

  • To prepare smears from paper points removed from root canals for evaluation of microcytic status of canal prior to filling.
  • A scraping or swab of an oral lesion is needed to confirm diagnosis of thrush
  • A scraping of gingival region or mucosal ulcer is sometimes used to confirm diagnosis of Acute Necrotising ulcerative stomatitis.
  • Identification of giant cells that accompany vesicular infections
  • Identification of Acantholysis

Dentowesome|@drmehnaz🖊


References: Google.com, lecturio.com, Study Notes✍🏻