The following is a list of techniques used for gingival augmentation coronal to the recession (root coverage):
- Free gingival autograft
- Free connective tissue autograft
- Pedicle autografts: • Laterally (horizontally) positioned flap • Coronally positioned flap; includes semilunar pedicle (Tarnow)
- Subepithelial connective tissue graft (Langer)
- Guided tissue regeneration
- Pouch and tunnel technique
Subepithelial connective tissue graft (Langer) 🔎
- Larger and multiple defects with good vestibular depth and gingival thickness to allow a split-thickness flap to be elevated.
Adjacent to the denuded root surface, the donor connective tissue is sandwiched between the split flap as shown in the figure.
Surgical Technique Steps:
Step 1. Raise a partial-thickness flap with a horizontal incision 2 mm away from the tip of the papilla and two vertical incisions 1 to 2 mm away from the gingival margin of the adjoining teeth.
Step 2. Thoroughly plane the root, reducing its convexity.
Step 3. Obtain a connective tissue graft from the palate by means of a horizontal incision 5 to 6 mm from the gingival margin of molar and premolars. The connective tissue is carefully removed along with all adipose and glandular tissue. The palatal wound is sutured in a primary closure.
Step 4. Place the connective tissue on the denuded root. Suture it with resorbable sutured to the periosteum.
Step 5. Cover the graft with the outer portion of the partial-thickness flap and suture it interdentally.
Step 6. Cover the area with dry foil and surgical pack.
After 7 days, the dressing and sutures are removed. The esthetics are favorable with this technique since the donor tissue is connective tissue.
Source: Carranza’s Clinical Periodontolgy, 10th Ed
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..👍👇🏻
Source: Carranza’s Clinical Periodontolgy, 10th Ed
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
- relation to dentition
- density of lesion
- type of radiological change (radiolucent/radiopaque/mixed)
- periosteal reaction
- cortical integrity, and
- 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)
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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
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.
- 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.
- 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.
- 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.
- 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
• Well defined & regular-Benign Neoplasms
• Well defined & irregular-Malignant Neoplasms
• Ill defined & diffuse - Inflammatory swellings
• 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).
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
• 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.
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
• Serous discharge - Healing ulcer
• Purulent discharge - Spreading ulcer
• Bloody discharge - Malignant ulcer
• Discharge with bony spicules - Osteomyelitis
• Greenish diacharge - Pseudomonas infection
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.
- Thickening and induration is found in squamous cell carcinoma.
- Tenderness and pitting on pressure indicates spreading inflammation surrounding the ulcer.
Relevant Clinical Examination:
- A Practical Manual of Public Health Dentistry by CM Marya
- medinaz.com, http://www.rxpg.com
- Study Notes✍🏻
Steroids are a group of hormones produced naturally in the body.
The adrenal cortex consists of 3 zones:
- Zona Glomerulosa synthesizes Aldosterone, the most potent Mineralocorticoid in humans.
- Zona Fasciculata – produces hydrocortisone (a glucocorticoid)
- Zona Reticularis produces Adrenal Androgens
• Glucocorticoid secretion is regulated by ACTH produced in the anterior pituitary. Cortisol has a -ve feedback on ACTH production.
• In Addison diseases, Glucocorticoid secretion impaired & ACTH is ⬆️
🔷 Corticosteroid Action & its regulation
- Glucocorticoid – Hepatic Glycogen deposition
- Mineralocorticoid – Sodium, electrolyte-fluid balance.
- Glucocorticoid play critical role in body’s response to stress.
Release of cytokines (IL-1)
⬆️ cortisol levels
🔷 Steroid synthesis:
The substrate for steroid production is cholesterol. It is mobilized from the outer to the inner mitochondrial membrane by the steroidogenic acute regulatory (StAR) protein.
• Action: Anti-allergy, anti-inflammatory
• Therapeutic Uses:
- intralesional injection in dose of 20-50 mg/mL
- Topical application
- Tablet in dose of 100mg/day can be given systemically to relieve burning sensation.
- Tab. Cortisol(25mg) combined with dexamethasone(90mg) can be given at biweekly interval.*
Action: Fibrinolytic,Anti-allergic, anti-inflammatory*
It causes ⬇️ fibroblastic production & deposition of collagen*
- Topical application with orabase
- Intralesional injection of hydrocortisone acetate (25mg/ml)
- Topical application (0.25-0.5%) to the affected area
- Intra-articular injection (25mg/ml)
- 20-30mg/day in divided doses
• Trade Name: CORTEF, ORABASE-HCA
- Oral: 5 – 20 mg tab.
- Topical – 1% eye drop solution; 0.025 nasal drops, 0.25-2.5% skin creams
• Hydrocortisone acetate 25-50 mg/mL for soft tissue suspensions
• Hydrocortisone sodium phosphate: 50mg/mL IV, IM, SC
- Addison disease
- Hodgkin lymphoma
• Action: Anti-allergic, anti-inflammatory, immunosuppressive
- Rheumatoid arthritis: 10mg/day in divided doses
- Collagen disease: 1mg/kg
- SLE: IM/IV; Topical application 2-3 times daily
- Leukemia: ALL as maintenance dose
- Erythema multiforme, pemphigus, bullous pemphigoid, behchet’s syndrome
- Bronchial asthma: 40-60 mg
- Post-herpetic neuralgia
- Amyloidosis, cyclic neutropenia, purpura
• Trade name: DELTA-CORTEF, PRELONE
- Lichen planus: Topical application 3-4 times daily
- Erythema multiforme: 40-100 mg/day or inhalation doses
- Recurrent aphthae: Oral (2-4 mg/day)
- Desquamative gingivitis, OSMF, contact chelitis – intralesional (2-3 mL/day)
• Trade name: Kenolog cream
👉🏻Mainly used for adrenal cortical suppression
- Allergic diseases, serum sickness, urticaria, hay fever, angioneurotic edema: IV; topically 2-4 times a day
- Benign migratory glossitis: Topical application
- Shock, cerebral edema, occular diseases.
• Trade name: DECADRON
• Action: Anti-allergy, anti-inflammatory
• Uses: Lichen planus, pemphigus, Aphthae ulcer
Dr. Mehnaz Memon🖊
References: Self Notes, Image chart source: Classification of Drugs with DOC by Vikas Seth (Third Edition)
💊Analgesic is a drug that selectively relieves pain by acting in the CNS or on the peripheral pain mechanisms without significantly altering consciousness.
💊They are divided into 2 groups:
- Opiod/Narcotic/Morphine like
- Non-opiod/Non-Narcotic/antipyretic (Aspirin like drugs)
The antipyretic analgesics & NSAID’s are more commonly employed for dental pain because tissue injury and inflammation due to abscess, caries, tooth extraction etc. is major cause of acute dental pain.
🔆 ANALGESIC/NSAID’s IN DENTISTRY:
- The antipyretic analgesics used mainly for dental pain is Paracetemol.
- Paracetemol (Acetaminophen) is most frequently used to relieve toothache in Pregnancy. It has week anti-inflammtory effect & causes no teratogenesis in the developing fetus.
- Pain during invasive dental procedures is alloyed by a local anesthesic before & after is treated with NSAID’s.
💊 NSAID’s use during Pregnancy: (The devastating effects to the infant) 👇🏻
🔆Use of OPIOIDS in Dental Pain:
- Less used than analgesics
- Mostly codeine is used for dental patients because other opioids cause dullness & short lasting pain.
- Other alternative Opioid Analgesics used are – Tramadol, Pentazocine.
💊MORPHINE – Depressant actions‼️
- Sedation, mental clouding, lethargy, nausea, vomitting, diarrhoea.
- Respiratory depression, blurring of vision.
- Allergic conditions, rashes, urticaria, itching, swelling.
- May develop tolerance & dependance.
- Urinary retention – infants & elderly
- Asthma patients
- Hypotensive states
- Hypovolaemic states
- Analgesic, antipyretic, anti-inflammatory effect.
- Effectively relieves inflammatory tissue, injury related pain, signs of inflammation like pain, tenderness, swelling are suspected.
- Cellular metabolism is increased & due to increased Glucose utilization there is decrease in blood sugar.
- Has teratolytic & mild-antiseptic properties
- Irritates gastric mucosa
- Interferes with platelet aggregation & bleeding time prolonged.
- Nausea, vomiting, diarrhoea, blood loss in stools.
- Haemolysis in G6PD deficient patients.
- Nephrotoxicity & hepatotoxicity in long term use.
- Allergic reactions – rashes, urticaria, photosensitivity.
- Pregnancy & Infancy – Refer Image 3
- Nursing and pregnancy
- Serious bleeding
- Impaired renal function
- Drug (anticoagulant)
Dr. Mehnaz Memon🖊
- Flowcharts: Classification of Drugs with DOC by Vikas Seth (Third Edition)
- KD TripathiEssentials of Medical Pharmacology 7th Edition; Internet
This is the most dangerous of the malarias and patients are either ‘killed or cured’. The onset is often insidious, with malaise, headache and vomiting. Cough and mild diarrhoea are also common. The fever has no particular pattern.
- Cranial nerve palsies
- Opisthotonus (a type of abnormal posture where the back becomes extremely arched due to muscle spasms)
- Pulmonary edema
- Secondary bacterial pneumonia
- Cardiac failure (‘algid malaria’)
- Dysrhythmias with Quinine
- Acute renal failure
- Severe haemolysis results in haemoglobinuria (black water fever)
- Hepatic dysfunction & haemolysis lead to Jaundice
- Tender liver edge with hepatitis
- Pain in left upper quadrant with splenomegaly
- Anaemia – Normocytic Normochromic
References: Davidson’s Principles and Practice of Medicine Textbook; Image source: ResearchGate, Quizlet
Dr. Mehnaz Memon🖊
References: Davidson’s Principles and Practice of Medicine Textbook