Tài liệu Clinical Problem Solving in Dentistry pdf

The patient IS In the early mixed dentlhon stage and theteeth present are: 6£DCBl IBC0E6 &DC21 120E6 No upper left centrallllClsor is present,butthefe is a paleswelling high In the upper

1 A high

rate

• canes Extraoral examinationEXAMINATION

I Ie is a fit ,ltld heillthy-looking ildolcsccnt No lllen\<ll, SUblll,l11uibul,lr ur ntht'r c",rvicililymphnudesart.' palpable and the temporomandibular joints lppearnormal

sub-Summary

A 17-ycar-old sixth-form college student presents ,11

your general dental surgery with several carious

lesions, one of which is very large How should you

stabilize his condition?

Fi& J.l The lower right firstmolal Thegutta percha pollllllldlCates

b vi~ibl", and probing dl'pths Mt' 3111111 or less Th",l11andibulnr right first mobr is grossly carious and.1 sinus is discharging bUCC,llly There are no olhern:stor,ltiuns in nny il'dh Null-dh hn"",~nextracted

;md the third mol.lrs arc not visible.!I.smnlJ cilvity ispn:"ent on theOCdU~,11 ~lIrf.I(""of Ih m,mdibular rightSC("ond molnr

• What furtl,er e:wm;mllioJl IVol/liI 11011 Nlrry out?

Test of tooth vitality of the teethInthe region of thesinus Even thoughthefi,st mola, is the most likely cause.the adJacentleeth should be tested because more than onetooth might be TKlnvital The results should be comparedWith those of ttle teeth on the opPOsite Side Both hoVcoldmettlods and electriC pulp testnlg could be used becauseextensive reactionary dentine may moderate the response.TIlt'fir~tmol;lrfnil~to r ~pt)ndto ;lny tt'st.Alloth rIt>eth appt-'ar vital

INVESTIGATIONS

• What TIIllil/grlll/lls wOllld 11011 tllkl'?Crt/lainwhy

I'l1cIIvil'IV is rl'qllirt'd.

Complaint

Ill.' complains Ih.:l! a filling h<l$ (allen oul of a loolh on

the lower right ~i<.k,md h,,~ Idl a shilrp edge that

irrilJles his longue He is Olhcrwis.c "symptomilti"

History of complaint

The filling was placed 1OOul.:l year ,1g0ill a (,15U,,1 visit

lo Ihc dentistpredpil,'lcdbyacutl: hK,lh;lChl'Iri&;~'r~'(1

by hoi and cold foodand drink He did nol return to

complC'tc a course oflrmlmen\.He lost (onl,1([ when

he moved hou~e"nd is not regisler., j with a <.h:ntal

Reason takenPllmal'ilytodetect appfQ1llllalslllloceca,1l:!'S,ana Ills

case also ,equlled 10deledocclusal CilfieS

PreoperallYe assessment lor

elldodonbc treatment Of IOfextrocllOl1 shoukl rtOelI&essary

MIghtOeus.efulasagenet'alSUI\Il!yVM!W a newpalleot

andtodetefflllfll!thepreseoceandpoSIbonoffurd molal's

FIC 1.2 PenfIOItaiand blIew11lgftns.

• IVI"" "robft''''slin'i"I1,,",,' ill lI,ediagllosisof

Cllrie$ illthis Ill/tiellt?

OCclusalleslOlls arenowthe predorml)ar!t 10rm01canesIII

.»olescentsloIIovMgtheledutoon II calles n:ldence over

thepast decades.(kc)Jsa!canes may go oodetecled[)"1

IIIsua/eumnatlontor tworeasons First II starts onthe

fissure walsandIS obscuredbySOI.WIdsuperlitlaltnameI,

alld setoodly leSIOns caVItate late.rt at aR, probably

because lluorlde strengthens the overlying el)amel

SupenmpoS/bCll ofSOlaldenamel also masks small alld

medium-slzed IeS/OflS onb1te'oYlflgradiographs The smaI

occlusalcavrty11thesecond molar arousessuspICICIlthat

otherpitsandfis$ll"es 11themolars WllIbecarIOUS LWess

IeSIOllS are very large extenchng ,"tothe~third 01

dentine, they may notbedetected on bltewmg radiographs

• 111 ruiliogrnpll$ Un' show"ill figu", 1.2 WI,lltdo

yousu?

ThepenaplCaI radiograph showsthecal'lous IeSlOlt 11the

crown 01thelower light first molar tobeextensIVe

Il)vONlng the pulp caVIty The mesial contact has been

clll1"lPletety destroyed andthemolar lias drifted mesially

andtjted There are penapal radiolucencieS attheapices

ofbothroots INtonthemeSIal rootb81glcvger.The

radiokJcencleS are 11 contlfUly WIththepenodontal

.gament alld there IS loss of most ofthelamlla dura In the

bifurcation and around the apices

ThebitewlIlg radiographs confirm the carIOUS exposure

and IIIadditionreveal occlusal carteS 11 allthemaXIllaryand

rnanditlWrmolars-.,ththeexceptionoftheuppernght

fl'stmolar.No aoprounalcanes ISpresent

• Ifhtloor1II0rt'II'ell,were possibte Cllllsesuf IIII'

SiIllIS./ww might yOIiI/"rillew/ridlWIIS I/recllllse?

A guna perchaPOIfl\couldbellsertedritathesnusprIOr

to~theradiograph.asshowninrlitl"e1.1 A

rnedu'l'I-or~edporrtISIIwbIebuIre~1enough to

pass alongtheSlIlUS tractIftwisted sbghtly on lIlserbon

POints are radiopaque alld canbeseen on a radiograph

,

Fic 1.3 A>lother case, showlnllllutta pefchapo.tttrilCWljlhIIipathof

a SJnU$

extendingtothe source oftheinlecllOn asshown ,

anothercase 11 F'8ure 13

DIAGNOSIS

• W/rlllisyOllrdiI/8,msis?

Thepatientlias a nonvrlallower firstmolar'NI\:ha penaplCalabscess Inaddi\JOflhelias avetyIJghcanes ,ale., aPfMOUsIy amost canes tree dentJllOn

TREATMENTThe pali<mtishorrified to dlMU\er th.lthisdentition is

in such a poor "late, h.lving eJ(pt'rienced only one

epi'>Od~oftoolh.lcheinthepdst 11(' is kl.'('f1 todoallthilt C,ln bedune to Sol\"(' all tt't'th and ad«islon i~

made totrytof('Stor~the lowermolar

::=:::lJ A HIGH CARIES RATE

Table 1.3 Dletary adw:e

SpeedclearanceotlUgalS

Iromthe mouth

MethodsCheckmanufacturl!ls'labelsand iMlOd foodsWlthsugars such as sOC/ose, glucoseandfructose~stedearlyIIItheIngredients, Natural sugars (e.g,hooey,blown sugar) are as carlOgeJJic as purifiedOfadded sugars.'M1eoSWi!'I!tfoods are required, choose those containing sweelcring agents such as sacchafin.acesu~ame-Karid aSpaflame,Diet formulatlons contain less sugar than their standard counterparts, Reducethesweetness

01 drinks and foods Become accustomed 10 a less sweet diet overal

Try 10 redocc snilCking When s.nacks are requored select 'safe snacks' soch as cheese, CriSPS, frUit orsugar·free sweets soch as minIs or chewing gum (whICh notonlyhas no sugar 001 also stmulates salivaryflow and increases plaquepH).Use ar!Jflcial sweeteners in drinks taken between meals

Never~r1Ishmeals WIth asugarylood or dnnk Follow sugary foodsWIth a sugao-·lree drlf1k, cheWIng gum or

a protectIVe tood such as cheese

The patient should be adVIsed to use a tluonde·

containing toothpaste During the period of dietary change

Itwould alsobebenefiCial to use a weekly fluoride nnse as

well ThiS could be conllnued for as long as the diet IS felt

to be unsafe

Oral hygiene InstrUC\lon IS also Important, but may be

emphasized in a later phase of treatment It Will not stop

canes progression which is cntlcal tor thiS patient, and

there IS only a mild gingIVItiS

• ASSlllllillXKomi comp/iallcl' llI1d mofivatioll,flOW

Wil/YOII rl'storl'till'tullr pl'rmalll.'lItly?

The mandibular ril::ht first molar reQurres orthograde

endodon\lC treatment and replacement of the temporary

restoration with a core Retention for the core can be

prOVIded by reSidual tooth tissue, prOVided carious

destruction is not gross The restorative material may be

packed Into the pulp chamber and tile~rst 2~3mm of the

root canal II Insufficient natural crown remains,rt may be

Fir; 1.5 Peflapocal ra(hograph of the restored lower first motar

supplemented WIth a prefOlmed post In the distal canals.The distal canal is not ideal, being turther trom the mostextensIVely destroyed area, but It IS larger

The other molar teeth WIll need to have their temporaryrestorallons replaced by deflf1lll'IC restorations Canesinvolved only the occlusal surface but removal of theselarge leSions has probably left little more than an enamelshell Restoration of such teeth With amalgam would reQUirEremoval of all the unsupported, undermined enamel leavinglittle more than a root stump and a few spurs of toothtissue Restoration could be better achieved WIth aradiopaQue glass lonomer and composite hybndrestoratiOn The glass lonomer used to replace the missingdentine must be radiopaQue so that It is not confused WIthreSidual or secondary carles on radiographs, A compositelinked to dentine with a bonding agent would be analternative to the glass lonomer

• figllrl'1.5S/IOWS lire rl'storell lower first /IIo/ar 2

mOlltlls IIffcr eudoi/olltir trl'lltmel/' Wllllt i/o '1011

SI'C al/d w/rllt IOllg-tam problcm is i'vii/i'lIt?

There IS good bone healing around the apices and In theblfurcallon Complete healing wouldbeexpected alter 6months to 1 year at which time the success of roottreatment can be ludged

As noted in the initial radiographs the lower right~rstmolar has lost ItS meSial contact dnfted and tilted ThiSmakesrt impossible to restore the normal cOntour of themesial surface and contact pe4nl The mesial surface is flatand there IS no defined COntact point In the long term therE

is a risk of carles of the distal surface of the secondpremolar and the carles IS hkely to affect a WIder area oftooth and extend further glnglvally than canes below anormal contact The area will alsObedifficult to clean andthere IS a risk of localized penodontltis Tilting of theocclLIsal surface may also favour food packing mlo thecontact unless the contour of the restoration includes anarbficlally enhanced marginal rrdge

Large, about10x8cm, exten<ing fromtileseo;ondpremolar, back totheangle and invoMngall oftile r.:trnusupto

thesigmoi<:l notch, and fromtileexpan~uwer border01tilealveolar booetlown totheinlerKK6eI1ta1 canal.Multklclllar, prOOucingttlesoapbubbleappearance

Smooth,well defined and mostly wen corocated

Radiolucent With dlStnct radlQPaaue septa producingttlemultiocUiar appearance ThereISnoeYldence of separateareasatcalcrflcatron \YItIWlttleIeSIQll.

Gross hngual expanSIon of mand1ble, expanSlO<l buccally 'sontyseenwenIllUleocclusal films Markede~panSlO<l01tile supeJlOf ma<gln ofthealYeolarbone andttleanterKK marg" of the ascerlding ramus.TheIlMlM!dteethhave

a1S1l beendisplaced supenorty Theroots 01!he orrvot.ed te-elh are skglltty resorbed, but not as markedy asSIIggestedbythepeJiaPICal'JI\!W.Thecortex ooesnotappea.-tobeperforaled

Fill 2.4 Lower true occlusalview

RADIOLOGICAL DIFFERENTIAL DIAGNOSIS

• Wllilt isylJrlr IlrinciJlU1diffcnmtill/ dillgllosis?

I Ameloblastoma

2 Giant cell lesion

• Jllstify this,fiffenmtial dingllosis.

Ameloblastoma claSSically produces an expanslle

multilocular radiolucency at the angle of the mandible

As noted a!Xlve It most commonly presents at the age

of this patient and is commoner in his racial group The

radiographs show the typical mulhlocular radiolucency,

contalmng several large cystic spaces separatedbybony

septa, and the root resorption, tooth displacement and

marked expansion are all conSistent WIth an ameloblastoma

of thiS Slle

fill; 2.5 f'enap<cal >new of the lower right first permanent molar

A giant cell lesion, A central giant cell granuloma ispossible lesions can arise at almost any age but theradiological features and SIIe are slightly different, makingameloblastoma the preferred diagnOSiS Central giant cellgranuloma produces ane~pansileand sometimes apparentlymultilocular radiolucency, but there would be no rootresorption and Ihe lesion may be less radkllucentlbecause

It consists of solid tissue rather than CySIlC neoplasmJ, oftencontaining WIspy osteoid or fine Done sepIa subdMdlng thelesion into a 1100leycoml:l-like pattern However these typicalfeatures are not always seen The spectrum of radiologicalapearances ranges from lesions which mimiC odontogeniCand solitary bone cysts to those which appear identicilltoameloblastoma or other odontogeniC tumours Theaneurysmal !Xlne cyst is another giant cell leSion whichcould produce thiS radiographic appearance with prominentexpansion Adjacent teeth are usually displaced but farelyresorbed However, aneurysmal bone cyst is much rarefthan central giant cell granuloma In the jaws

• !VhatIypes of/,'simr(IT" less /ikl'1y IIm/w/IY?

Several lesions remain possible but are less likely either onthe baSIS of thell features or relatIVe rallty

A 45-year-old Africlln man pre~entsin the accident

and emergency dep,lrlment with an enlilrgcd jaw

You must m kc a diagr,osis and decide on trealmen!

HISTORY

Complaint

Thl;' pillicnl'S main complamt is th,ll his lower b.lck

tccth on the right sidc.1TC lOOSCilnd llhllhi~j,tW un till"

right fecb cnl"l');l'{l

History of complaint

The palient has Mn ,ware of the 1('('lh slowly

becommg looser 0\"1'. the pn::\'iou~ 6 mOl1th~. Tht'V

S«'m tobe'movinK' andiln'now at a different height

from his fronl teeth, m.lking Colling difficult Ill' is illf>O

ronccmcd Ih"t his}<lWis enlar');ed and tht'!\' 't.'I1\~ to

bereduced~paCt.'for hi , tungue He has recently had

tN-lower second mour ontherightcxlr,lCtC'd.[t"'I"

also100&-but cXlranion doe<;not!>et'ITl10han' cured

the ~"l'1.ling Although nol in pam, he h.,S fin.llly

dooded 10 SoCCk lre,llmenl

Extraoral examinationHt> i~ a fit-looking man with no ob\'ious f,lcialasymmetry but,1slightfullnessof the mandible ontlk'right, j'illpation re\t'dl~.1,mouth rounded bony h ln.l

t'nlal1;,mwnt on the buccal and hngu.ll aspects IJccp

ccrviC.ll lymph nodesarep.llpilbll' on tht' ri~ht"d."They all:' only ,li,l;htlv enl.111;00, soft, not tender ;mdfreely mobile

Intraoral examination

• lVlrat do yOIl seeillFigurl'2.1?

There is a large swellmg of the nght posterior mandibleV1slbleInthebuccal sulcus, Its antenor margin relatrvelywell defined andlevel WIththe first premolar The hngualaspect IS not Vls-blebutthe tongue appears displacedupwards and rnedaally suggesllng s-gndlcant Iiflguale~pansiorl, Therru::osaovertheswellingISof r'lOfmalcololl'.WIthoutcYldenceofIlflanvnatlOnOfnfecbol'l.TherearetworelatJvelysmaIamalgams ntheklwernghtfTlC:lI<.-

andsecondprCfJllkr

If YOU could CXdmme the p llient you would findth.:lt all hisupper right po"tcrinr tt'eth are extractedilnd that tht' lOIn'!"mnlarand pn;'Tllo!.US ilre2-3mmabo\-e the heightoftlit>OCdU~ll plane Both ll."Ctholrt'gr.lde 3 mobile but bolhdn'\it.11

• 1\'1lat(I'"tl,,· redspols 011till'llatjel/t's tOll8ue!

FuogdormpapJlae,Theyappear more prornllent wtIenthetongue IS bred as here,torII1stilncewherJ thediet IS notvery abrasive

0 "till'/Jasiso{wltatyOIlknowso{fir,what 'YI"'s

of cOllditiQUwo"ldyOllCfJl/I,irl", IIIIll'lm'S"n/lll'rl'?

Tilehtstory suggests a relatIVely slow-growing lesion, which

is therefore likely to be belllgn 'MIlle thiS IS not a deflrotlVerelalJOnshlp, there are no speclfK: features suggesbngmalignancy,suchas perfOlatlOO ofthecOlte~.softtissuemass u1cerabonof therllJCosa,runbness01 thelipor

devrI abon01teeltl.Thectlaracler01 the~node

enlargement doesnot suuest maIlgnancy,Thecorrmonest)3wlesionswr.ehcauseeJ:;pal'ISlOl'Iare

theodontogenICcysts.TheCOl'MlOllCStodontogenICcystliaretheladIclArlapcalrTfIarrmatoryJcyst,dentigerous

cystandoOOntogerckcratoeySl I ttISIS a radrcU.ar cyst IItCUdhaveansenfromtherutfTlC:lI<.-.1houghthe0CWsal

amalgamISrelalNeiysmaI andthere seems no reason to

•

Apostero-arJtenorIf'II.I 01theI'fWS

AIoweItrue(90")occlus,)i

AplnapICal 01thelow!fnght secOfld

premolarandIhetntl'fIOIar

loshow Ihe1e$lOIl1rom!hetate mpect.TheobiQue1aI« WlUdprtMde!hebetter

~IU:fIlIIhtnotaM!l'!he ant!nOrextmI.011Mlarir1tWn Theparo ctomographVlJOl.tIPflMde iIuseMSI.-vey0I1hrrest0I1he IIWStu: od11ha1parI01!tIIsellj)lnSlleIo!saonIllhrIn!oIlheolfCl'I b!11locus.hi~IIteral_ wastaken

TosI'Iowtill!elllrnt 01~lerall!xpanSlOll ofIheposterobody, angleor rllfroS,

ToshowtileIil1llualexpilIlSlOllwI'Ioch WIIllOtb! slble mthl!PA filWS VIeW l:letauSl!ofwoerllTlposlllOlloIlhe antenorbodyoftilem3I\dlble

To assessboneSI,IIIllOrlandposstilfoot fl!$Ofpbon.

suspett thatthetooth 15norMlaI AreSldualra<io.Aafcyst

arISIng ontheextractedse<:ondortt-d molalwoukl bea

POSsblrty Adentigerous cyst couldbethecauseIf the

thwdmolar IS l.Ile1Upted,ThepossdJlllty01iVIodonIogefIC

keratocyst seemsunlikely because tl'lese cystsdonot

normally cause much expansOO An odontogenIC tumour IS

apoSSible cause and an ameloblastoma wouldbethe most

bkely one, because It IS the commonest and arises most

frequently at ltus site and ifllhis age gf(q).ThereIS a

hqj;hefncidence1'1Afncans.hiameloblastoma IS much

IT'lOl'elikely !hananodontogenic cysttodisplacetheteeth

andmakethemgrosslymobile Agl¥lteelgfaWomaand

I'Un!rOUSotherk!saons arePOS~ butare alless 1ik@Iy

INVESnGATIONS

• RndiogralJlls lireubviouslyilllfilllll'd Wllicll

vil'ws WQllld !lOll c!IOOSt? WIlY?

$evefal differentVIeWSafe necessary toshowthefull

edentoftheIeSlOl'1.Theseare listedII the 'Radiograph

~bo. above

• ThtHfOllr diffl'rtnt vinas art' shown in Figurts

1.1-1.5 Descn'lJeIII/'radiographic ftaturts of tilt

I/'sion (show" ill '[, dun' of I/'sioll' box on p 11).

• \VIIYdo till' rools of thl' first lIIolllrIIml secllllli

prI'molflT II/'J"'/Ir 10 be so rcsorbel'illthe pcriflpirnl

view Wllell1/11'obliqlle lall'rIIlTlif'wshows

millil7lalrollt res0'1ltioll?

Theteeth are loreshortened becausetheylieat an angle to

thef*n.n.sf*n MSbeentakenus-li thebisectedangle

tednQueandsevera1lactDrsconlnbuletotheastortxJri:

• theteethnavebeendrsplacedbythe lesion,so the

crowns lie moreIIf1gua1y, andtheroots morebuccatr.

• thetngual expansm mille jaw makestilrnpacket

placement difficult,soIthas hadtobeseverely allgulated

away Irom the root apices;

• failure to take account of these two factors when

positioning and angling the X.fay tubehead

"

Fir; 2.3 Poslenor-antefllll"VIeWofthll!1'lWS

Fir 2.7 Histologocal appearanceofbto(lsyathigh power.

TREATMENT

• I-\lJlUl Irt'll/me"t will/If'Tf~q,,;re"?

Theameloblastoma is ctassified as a benign Ileoplasm.However, It IS locally Irwasllle and in some cases p.ermeatesthe mrdullary caVlty around the main tumour margin,Ameloblastoma shouldbeexcised with a I cm margin ofnormal bone and around any suspected perforations In thecortex If ameloblastoma has escaped from the medullarycavity, II may spread extensively in the soil tissues andreqUIres excIsion Wllh an even larger margin The lowerborder of the mandible maybeIntacl and is sometimes left

In place to aVOid the need for full thickness resection of themandible and a bone graft ThiS causes a low risk ofrecurrence, but such recurrences are slow growing andmay be dealt with conservatively after the main portion ofthe mandible has healed The fact thai the ameloblastoma

IS of the follicular pattern is of no Significance fortreatment

• IV/rillotller imagilrg iIllIl'Sligrll;o"sWlIUIrlhe

rlpprOpr;flfe for /Ids IIflf;CIII?

In order to plan the resection accurately the extent of thetumour and any cortical perforations must be Identified.Computed tomography (Cn and/or magnetic resonanceImagrng (MRIJ would show the fUll extent of the leSion Inbone and surrounding soft tissue respe<:tively

3 An unpleasant

• surpnse

lICCa~illns.She aho suffen (mm eczema, as do hermother ilnd her two children, Imd uses a topical steroidcream as required The p ltienl h,lS ,1 oonfirmcd hearlmurmur re<luiring antibiotic cover

Dental history

The p ltienl has beeni1regulnr allender for a number ofyears but has not previously re<:eivL'l.t antibiotic CIlverfor dental tre,ltment She hilS hild previous courses ofpenicillin from her general medic,ll praclilioner for

ch~tinfections

Summary

A 30-year-old l.ldy develops acute shortness of

breath following administration of amoxicillin

What would you do?

Fi• 3.1 The patll!nfs face asshestarts 10 feelllllWei.

Th patient has an appointment for routine denial

IrCillment involving sc.lling ilnd a rcslor,llion under

ltlC,l\anaL'Sthe~i,1 ilndillltibiuticprophylaxis.She took

a 3goral dose of amoxicillin 45 minutes ago

Medical history

You checked themediCil]history before ildministcring

the amoxicillin ;md so you know that the patient

is a wcll-controlled asthmatic taking s<,lbulamo] on

• Mud isOw Iikl'/Y IlitW,wsis?

Anaphylaxis, arising from hypersenSitIVIty to the amoxicillin

a typicalurt~analrash and Indicates a type 1hypersens~ivityreaction

• WII(I/wOIl/1IyOll '/0immelli"tely?

• Reassure the patient

• Assess the Vital signs Including blood pressure pulse andreSPiratory rate

• Call for help

• Obtain oxygen arid your practice emergency drug box

• WIl(ltaTI' till' siglls/III/Isymptoms of IIIl(1pllyla.ris?

The Signs and symptoms vary Wl\tl severity The claSSicalpicture is of:

• a red urticarial lash

• oedema that may obstruct the airway

• hypotenSion due to reduced peripheral resistance

• hypovolaemia due to the movement oflluld out of thecirculation Into the tissues

• small airways obstruction

• WlrfltdOl'S U,1ifllTi1l1ml'lm?

The word urtlcanal comes from the LaM for nellie (aslt Anurticarial rash has superficial oedema that may formseparate flat raisedbllster~lkepatches (as In Fig 3.1)Ofbe

diffuse In the head and neck It IS often diffuse because thetissues are lax Markedly oedematous areas may become'pale by compression of their blood supply but thebackground is erythematous Patlenls often know anurtlcarral rash by the lay term hives

• \\'Il11listill'IJlllIrogl'tltsiso/llllaphyllU'is?

AnaphyIaI:lsISan acutetypeIhyperseflS/tlVltyreacbon

tnggered11a senSItIZedndMdualbyan allergen.The

aletien entersthebssuesandbrldstonmunoglc:lbl*lE

(lgEJ that ISalreadybol.ndtothemace ojmasl eels,

pr6ellt11 amoslalltissues Br1dr1gofaletgen 1019£

n::lICes degr.nbtlOlland thereleaseoflarge iIfOOl.ntsof

IlIlarrrnaIOfy meQ;alors, parbclAar'y hlstan.-.e.Tlncauses

thevasodilatation, n:::reasedcapiarypermeablktyand

",""""""""

• Type' ll1YIJI'1'SCIISitivity is also,l.mJll'" us

immt'dialr "Yl>rr'St'IIsitil'ily Imt 011';1" was ddayl'd

{ur45 ",jill/II'S WIlY?

Acute anaphylactiC reactIOnsmayoccur WIthin secoods or

maybedelayed for up to an hour depending on the nature

of the allergen and the route ofe~posure.II lakes time for

an oral doseotantlblottc lo·be absorbed and pass through

the ClfcuiallOf110thetiswes,inthis case 45minutes The

reachon wouldbeexpected about 30 mmutes alter

Ifllramuscular admlnlslraboo 01 an allergen but almost

IllSlanlaneously aftef IltravascularadlTlll"IstratlOl'l.The tITle

ofonsetIS\.I'lPI'edlctable, Some aUergenssuchas peanuts

and latex can cause rapid reactlOf\S despitebem&applied

toplCaIy,Thevariability Ilonset of reactIM5expLwts why

pa\lefltSsholAd be observedfor anhou'after

~trabonofantbK!bcCOlIer.

On~'MTlinin~furth ~ignsnoted alxwe you discover

tholt the p lhent IS bn'athlcss and iI wh~7e(',Ill bo;:

heard dUring both in"piralion and :o:piration

indI-cating"nlilllairw3~'~obstruction Shefeelshot<lIld hds

.1 pulse r.lle of 120bc"ts perminut ilndbluod

prt'S-SUn'of 12tl/MmmHg.Sht'b conscious but the effects

al\',,"-'COmmg more severeand the r,l"h nowi1f(ects

1111the faceand neck region and h,l~"pn ad ontothe

upper,l"pe~.tof Ilw thorax.Theappearance of onc arm

i~ ~hownm rigur 3.2

fICo 3.2 Thl!~s_ 5rnn.tes

TREATMENT

• 1W,llttrtllt".",t wouldyOIlpt'rfon,,?

Mowthepabent toadopttheroost comfortablepoSlboolotbrealtw1gandgrve oxygen(5IitresperlTWlUtelbyfacemask

BeuosethefeISbronchospwn,grvethefollolmi:

augsinOfdel'

Adre~ (epiMphrIMII.lOOO, 500micrograms

Iltr~. TheeaSlllSt formtoadrlWwsterISapreloaded'Ephn'Of'Arlapen','NhichareavaiableforbothaOOtts1300ITlICfOgramsidoselanddiklrllllllSOfTIICfogramsidosel, AJternabvely, a Mn.J.Jet prepackedsyrllge andneedleassemblyOfa standard VIalof

adrenan sOOhon, both contallwlg1Il'lIIlgramII I1lVII~ltre

II :10001.maybeused.~Iowever. both01these lanermethods reQuire a delay In administration10Pfepare theinjectl()l1 You need tobefamiliarWIthwhIChever form IS held

In your practice as delay In calculating doses and volumes

IS clearly undesirable Adrenaline (epinephrlnel may also begillen subcutaneouslybutthe absorptl()l1ls slower and thiSroute ISI'lOlonger recommended Note that alltOlllj('(:tOfsare designed fOfsetf~strahon andsoprOVIdeashghtly lower dose ItIanISrecommended

Chtorphenamine (ehlorpheniraminellOmgIltravenously wdI cCOlteracttheeffects01h1s~

Hydroeorti5Ofle 100-200 mgintravenwstyOf

IltramJSClA¥ly

Intravenousnuicl Ontyreq edrI hypotet\SlCll develops, ASlItabIe regmeIII'CUdbe1litreofnoonals*le IlfusedCM!f

5 lTWlUteswrthcontnJOuSmonII.OfIflg01thevrtaISIif\S

Tlw pr'l""t'nlalion of drugs useful for an.lphylaxls isshownLnngure 3.3

• WIryII",sltill'/lnlgs bt·gil'l'/Ii/ltlris urtll'r?

Adrenaline IS the IIte-saYlng drug and must be gIVen stJalghtaway, before cllculatory coUapse It IS rapidly actmg.Chlorphenamlne lchiorphcniramlne) IS less potent andslower acling and cannot alone counteract pulmonaryoedema or brOnchospasm, which Indicate a S('V(lrereactl()l1 Hydrocornsone IS the lowest pnoflty: It takes up

to6hours to act and isnolimmediately life saWlg

• Aftl'r givi"S ,./1 """0' ,In,xs,tilt' p"titllt fl'COVtN.

,lWllltW01l1iIyOIldo /It'xt?

• Abandondel1tal treatmerll

• Conllooe to ITlOIlIlortheVItalSlgIIS.

• Contl'1Je to adrrnsterOKygIlll,

• Arlanae transferofthe patJent10anappropnatesec60dary carefac*ty

• Ac:MsethepalIentof theneedlortOfrnalnvesbgallOnof

the.-probableaIeiIY.

FIC· 3.3 TytlItai Pftse!1labOns 01 drugs u$td to

tre~t aoapl¥.1AJ$,

A.Oxygenm.1~.

B tt,1llOCOllJloOOl' v~01~ powder\ofreconslJ\U1IOIl.,Wilt<!'\'\ofIfll!Cb«I.NOTs*'t,1dTwISle< ,Ih a cClfWefllJl;ln,J symge

C.Adreo.olllr· , EllIPe<It\lWOSiIble

uoqKlor~'1'fWlIt,boxed.n

belowwrththe oIISbC CO\ltlS~tromuchend PressdndIy1)1"(0theslm a'Idlhtspmg«ladedneedle1$ Jllled¥Ill thedfllK 1$qpcted ~ AtmIar

dew:e.!he~Illsasor~

needlethai~s outwhetlatutonattlltOllOOSIIeend1$rnssed Elolhdehoef300l1'IOotrilfTl$ ofadren*le

DAdreNllnt.,MIl+JelbmM,~ yf!Iow

oIISbC COl'tf1$ren'llMdlrom!he bade(1lIh!

&lass cllrtl'ldlt¥Illlht~IJ.:;Ige 1$sc.-ewed

11110the~J'I~bar'el,AvAJble.,twotypes,W'!tlnttdlthrtPd llrft ,eco" "tlldedlllldIMlh , kditt>'llI:lor •c-*NIllftCIe

(sIowtrtouse! MefItIJIOWllfIOnI:CO\ltland~nttdlt.41eq.M'td,use r ,

•NoIt """tl)I'ltI)I»-JIlt ISnow/lit rtCO'IWIItfld!d

_ lor<1Ilttn.Jlont~1M !hat

~,$SflIItIt IllO$f~used _

"II(

• Clm yOIlrl'lflT IOIlItill'i"w','llifllr crisis is ol'r,?

No,defirlltely not Theresponse oflhe patient needs to be

closely observed Adrenahne {epmephrtle} IS highly effectIVe

but tlas a very shorlhalf~lle Recurrence of bronchospasm

a drop In blood pressure or worsening oedema IndlcatCls a

need tor turther adrenahne (eprnephrinel This is likely tobe

needed about 5 minutes alter the previous administration

and It can be repeated again as often as necessary

However, the chlorphenamine (chlorphenlramlne) will start

to become effectIVe and no more thantwodoses of

adrenaline (eplnephnne) shouldbenecessary

late relapse, hours later, IS also poSSible Mast cells

also release other potent IIlllammatory mediators and some

have longha~~lVes.The hydrocorhSOfle prevents tfus late

relapse

• Clm/III",IIlII'lyIIIClkrl'/lctiOl/hI' cOII'roflrd

1I'itllol/t Illlfl'II'lli"r (rpi"rpllri"r)?

IttheontyfealtJ'es are a rashandrl'lIld swellng not

lIMlIw1gthe<1ll'Nay11maybeaJlpl'opl'Iatetogll/@

chlorphenarrnne (chlorphenll'arfllnel and hydrocortisone

Inthefirst rlstance and oDservt!theresponse

Howevel,,fbronchoSPasm, hypotenSlOfl 01 oedemaaround the airway develops, adrenaline (eplnephnnelWlil be needed Adrenaline (epinephnne) should beadministered as early as poSSible tobeeffective and

It IS better not to delay unless the signs and symptomsare very mild,

FURTHER POINTS

Adrenaline (e()lne()hnne) is the lJfoto\yplcal adrenergICaeolllst and hasbothalpha and beta receptor KtMty,Alphareceptor-medlilled actlOll 011 artenoles callsesvasocOllstncllOllaodthus reversesoedema Betar@Ct!ltOl-medrated acbons rlClude Incleas,ng the cllrdlacoutputby

"rlCreaSllgtheforce 01 cQlltrocbonandheart rale(beta11andbronc/lcJdiatabOll (beta 21 Mast etl degranJabOlllSalso suplJl"essed

A 30-year-old woman has gingival recession Assess

her condition and discuss treatmenl options

• receSSIon

Medical history

She is(lfit and healthy individual ilrld is not a smoker

• W/Ult f",lh ,sprdfk(I"/'slim.s !V,wltl yUllIIS~'to

How often do you brush your teeth? Provided brushing

is effe<:tlve, cleamng once a day IS sulficlent10maintaingingival health, However, most patients clean twoorltJreelimes each day and some brush excessIVely In terms offre<luency, duration and force used Trauma from brushing

IS considered a factor in some patients' re<:eSSIOO andrecession may Indicate a need to reduce ltJe frequency andduration of clealllng willie maintaining its effe<:tiveness InltJlS Illstance the pallent has a normal toothbrushing habitbut should clean no more ltJan twice each day and lor asensible period of lime,

Fi&.4.1 Theappearance ofthe lower r.cisors

HISTORY

Complaint

The patient is worried about thc gingival recession

around her lower (ron! leeth, which ~he feels is

worsening

History of complaint

She remembers noticing the recession for at least the

previous5ycar~.She thinksitha" wOT'Senoo over the last

12 months There has re<:enlly been somc sensitivity 10

hot ,md cold and gingiv.ll soreness, most noticc,lbly on

toothbrushing or cating iceCTe<lIll.

Dental history

The palil'lll has Mn a patient of YOUT prKtice fur

about]0YC.lrs ,md you have discussed her nxcssion,11

previous visits and reassured her She h"s(llow (<lries

rale ilnd generillly good oral hygi!:'"",

Have you had orthodontic treatment? A lower incisor ismissing, suggestmg ltJat some intervention may have takenplace Fixed orthodontics In the lower labial segment ISoccasionally associated WIth gingival recesSionInpatientsWIth thin buccal gingIVa narrow alveolar processes andcorrection of severe crowdirlg Plaque £ootrol may becompromise<! dUring the wearing of an orthodontlcapphance and, even over a relatIVely short period, thiS cancontribute to the problem In ltJlS instance the pabent hadundergone extraction of the mClsor but had not worn anappliance

EXAMINATION

Intraoral examination

• rill'appea,l1nce of tile lowe, incisors is slrowJIill

Figure4.1 IV/wt110 yOIl see?

- Missing lower lett central InCISor

- Unrestored teelh

- No plaque IS VISible except for a small amount at thecervical margin01the lower left lateral inCisor,

- Gingival recession affecting all lower incisOfs and, toa

lesser extent, the lower canines

- Apart from the abnormal contour, the buccal gingivaeare pink and heatthy and the Illterdental papillae arenormal

- Reduction in WIdth of keratinized (cornified) attachedgingIVal eplltJehum In places, attached gingIVa appearsabsent

• IV',1ltc1illical assessme"ts wOllld you make, how wOllld YOl/make lI,ellllllld why art' tlley illlportant?

SeeTab~4.1

Table 4.2 A1ternatrve lJe<llment

Trntment

hkJt~surterY10 c«reclther~.edtll!faliteral

peljcIepaft.~ papiIilap.01a coronilyrefJ(lSIbOIledIl1o

Thesenuy be used1'1 ~wth inefJ)OSllJOnil

I~tomec:MltSsuepalt

Thesen es~ tosmebC OPefilltJOlt$.

~surterYtoprowSeaWIder.oolootlJonalzone01

atlJthedaqrya.ThIsIherllpeUbt ~ prtMdes alOlle01

thd.erbUue'IIIhd11li more 'e5llitanltoMIte'~euIOIIandless

prone toSOlenesS WItl1IlO1ma1brusIq

Afree&l'lervall'aItIlithelJeaIJJ1erIl 01doce

I'rlMSlOlloIatlwllltf)4ltgIIlIrvaistenI01 _ _

casts are very helpful and shoold be repeated at

intervals

• Treat theden~nehyperSenSltMty RecesSlOfl alone should

notbepamful Ensure that the exposed root surface IS

suffellog neither early canesnorCfOSlOfl Ctleck!hediet

for sugars.aciddmks and foods and appty tOPICal

antihyperseoSltMtyagents.ThIsISaI'IOtherfeason to

peffeclthecleilllllgoftheseteeth

[n thiS CiiSC the p.ltient m.lint.lined good plilqUt'

control but tht> ~ion wo~ned ~Iowly 0\'£'1" a

period of 5('\'CI';1I ve.lrS until there WolS il lOCK o(

fuooion.ll iltlached gingiu

• I\'JI'" fill", 'I'f'atllll"tlts miglltwpossibll"? A11'"Ie!!

tffl'ctit.'t'?

Table4.2showsalternatIVefJealmeRls,

In thiSCilst' il fl't.'Cgingival grilft Wil~ plilC,-,,1 <In.! tlw

resulti~ ~hownin Fij;ufl> 4.2

FIC 4.2~.-.:e oIlhefJee~griltt6moottrs atter

EffediYene

MaybettlecM1'1carefuIyselectedtlSe1.The preserce01

adjatertI1tertlentalP«JILWandSlIl.1tIIe donorSIIes I!> ~

Totalrootcootr~ IS ~to «1Ieve¥ldlAWeOCtallle.

f!SllllQIIy 1'1the~term

ligNyeffecM, G1attqpaIataIl'UtOSIl'Ilothe nu:osa

1ftYeI1ls!he~Ill*\Ithe~ffOlllltleleeIh.Even~!helI'IIt'ial

marpllmIIllle atlathedplIrYa ~canferrlill'l heallhy •protected

!rom~emeI'It01otherlJlU'I'IICanpolMdeane.celen! cO$lllellt result.well made, but onlytonSldefed101 e.1ell5M!,eceswn1'1 III~YISIbIeareas.TheusuallOdicalJon istheupper IICISOISfolowl'lllpenodonIaI~eryWI\t'llo5s0'papiIae.Rarelyusedand001 applicable 10 lIIIs case

• Whllldflyuuset'; istlu'KI'I.!I s/IC'Ct'ss!lll?

Yes the graft appears successful Palafal coooectNt! tissueand overlyirlg epithelium has been placed apiCal to thelower InCisor gingIVal margin to prOVIde a WIderloneofattached kerabOlzed gillgilla, Be<:ause the palatal

conneclrve tissueIStl3flSfCfred theeplthebumretawts ItS

keratnlzed palate structure

• Dotstill' graft"HI'tofit'at till' gil/gival margin?

No.ThegraftformstheII'lgNai margn onthe10werleftlaterillinasorbutelsewhefe lies belowthe margll.PrCMded

thegraftISIirmtybol.nd downtothe~Il!.sue ItwistablkzethegngMJI lTl¥in itgawtstcisplac.ement011lip_ t

• IVily/luI "/lIce till' Xrafl111'1" till" rootas flP1'1lalld

COI'I'I'C' till'fTftUiOlI?

As noted In Table4.2,surgery to correcttherecesSlOl'lItself IS dltllcult to achieve and unpredictable espetllilyinthe long term, The root surface does not pro de a nutllentbed on which the free graft can survrve Grafts In thiSsituatIOn would have tobepedicled to ensure their nutrientsupply and also need to be placed so that they receJ\/f!some nutrient Irom an adjacent exposed connectIVe tiSsue

bed.A more predICtable result may be obtained by uSIng anN1terpt)Slt1onallsubeprthekailconnectIVebssuegratt Atreegraft IS most unlikei)' tobesuccessf~1fsmplyplacedewer

theroot $l.J'face,

• FiguN'''J sllQll's atlifft'l't'll!patil'III witll frct5Sioll Wlrat dol'Stiltappeartlllct 1('11 you?

ThereISapprounatet)'4fm101recessoobuccal)'onthelowernghtcarn!.Apa!IOthe gJ'1gJVaImargI'Ithere1$a

holenthe11llilYaitISsue PlaQueand~ngrval calc1*Js

1111;::::s;: CINe,VAl ~ECESSION

fl& 4.3 A differentpabent

•

{formedWIthina penodontal pocket! are\/lSlbleandthe

bSsue IS.,1Iamed.Thesma 'bndge' of bSsue at the

glOglVillmarg"ISnot attached10thetooth surface and¥it

eventualy breakdown.In!tIScase the rK!$$IOI'I1S

secondary to pocketformationinaplitquHlduced

penodonlrtJ$ Inf\armIalJOf1 associated WIthSl.OplIIYal

calc~has caused loss of Irl.ICh ofthebuccalbone

• HolOwould t"/ltmtn' oftl'is palif"n"s"union

di!frr?

Itwot*Idlffef~ IItheearly- stages.InllammallOl'llT"l/St

betreatedbyoral hygltfleimprovemeIltandSlAlgflgrvaldebfldemef11.If,aftef a penod 10 allow healrlg there ISresolution olll1flarrmallOO,thesrtuabOll IS very smilar tothatIIItilehrs! case and assessmefltand treatment woold

beIdenhcal There wouldbe1\0value III attempting tosurgically correct the lenestra\lonIn tile attached imiNa,

As discussed above, graflirlg onto tile rool surface IStechnicallycomp~~ and success IS unpredictable

A 9-year-old boy is referred to you in the orthodontic

department with an unerupted upp~r l~ft central

incisor What is the cause and how may it be treated?

fil 5.1 The appearanceofltiepallentonoresentabon

• TileappeflTaIlCe of tI,e mOlil1l;sshoWII;,rF;SlIrf J./ What do !lOll sel'?

The patient IS In the early mixed dentlhon stage and theteeth present are:

6£DCBl IBC0E6

&DC21 120E6

No upper left centrallllClsor is present,butthefe is a paleswelling high In the upper labial sulcusabo~etheedentulous space and the upper leftB.There has beensome loss of space In the region of the absent uppercentral InCisor

TIlere is a tenderlCY to an anterior open bile which isslightly more pronounced on the right

There is mild upper and lower arch crowding and aunilateral crossblle on the left If you were able to exammethe patient you woulddlsco~erthat this IS assoCiated With alateral displacement of the mandibular posrtion The lowercenlre line is shifted10lhe left

There are no restorations but the mouthISnot~ery

clean

• IV/latarctil£'possible callsesof all IlPPIl'£,Ut/!I

<lIJsellf uppercelll,,,1 ;IIcis",?

The incisor may be missing orha~efailed to erupt Possiblecauses IrlClude the followtrl&,

• \-Vllaf spuific I/IU.'sfio/ls wOlltd !lOll ask til£' parel/ls?

The most Important Questions arc related to trauma.Avulsion or dilaceration would follow sigmficant traumawtllch IS likely to be recalled by the paren\ The parentshouldbeasked whether the deciduoos predecessor wasdiscoloured If it was this would provide eviderlCe of loss ofvitality, perhaps related to trauma Extrachon wooldbe

unusual and a cause shoold be readily obtained in thehistory

HISTORY

Complaint

The patient's upper left central incisor has not erupted

althoughlwis9 years old His mother is very concerned

about her son's nppenrancc nnd is nmcious for hilll to

betrenll'<:l

History of complaint

The uppl'r ldt deciduuus predecessur had been

present until ,1lxlUt4months ago It ",as extr,1Ctcd by

the pnticnt's gcncrnl dcntnl prnctitioncr in,Inattempt

to spero up the eruption of the permanent successor

Despite this, there has bc<-n no change in appear,lllce

The upper I""rmnnent centr,1l incisor un the upposite

side eruptccl normnlly nt7yearsofage

Medicalhistory

The p.lticnt has suffered from nsthmJ since he was

4 years old This is controlled using salbutnmol

(Ventolinl

Failure toerupt

Scar lrsStJe preventrng~hon

Su(>erruneral)'toothprellenlrng ~lron

lnsult\clenl 5pace as a resltl:ofcrowdingPathologlCailesion (e.g.cyst0.-odolllogenich.mOurl

'''''-to~'eeneral_ 01lilt~derrlIlIon.,estit*5h lheprese'lCtOfItl5tnct01lilt~

,-ToprOYIdt, mortdtUlIed _ 01liltftplll.l1pa1'lIWIrIhfIfoot II0ptlOluKY"¥rtk\IICenl~

suchas~aryttethOf ~1e$lOn$.These~ CUDIheloc:.lfllJDlC!l 01lilttomoer''Ph

Oflitob5aJ'l!dby~01othtrstructures IIlhf!p'noumc Ipe' _ Ife Uktnlhf!y shoI.*l ffICbltthf!~«Ittte'\tlffluse thtse lIl'tfedIImIIgedIIliltOflinalaccKltnlInIdlMJonlilt

stl!'odafd occiJsaIa«Ill"'OtlflllC _ canbe usedtogethtr to tstilbkshthe,tlabOflsho01~upll!d

strucl\.O'tS ,elaINetolilt dtnt.tl/lIcn uSingliltprfncJPltof(vertICall pao-ala" Obtto::tslyingntilftfto tht X-fay

tubt~abo~poMIOIledl appea,to~ InliltOPPOsott d1rccbonto thet!be rela\J'fflto11 fUledpool.Those

ffll'lherawaylpalatallypOsobolledlllPPtarto~'"l!Itsarntd t<:bonasthetOOe

Corlfitmstheprestnee01(lfIydfstor\lOfl 01thttoolh d dflacerated.andCOIlflrmsthe rtlalJOllsllpofthetooth_ _ _ _ _ _ _ _ _totiltlabial sweliogin11 ttwddrrltrlSlOrl

"

Fl&5.4 Lateflll_

• lV/wtisyour fi,wl dias,/Osis?

TheupperleftcentrallflClSOf IS dilacerated, ptobabty as a

resl.ftoIl1'1l11JS1Onof thedecOJousptedecessor1'1the

rvYsuslaned nI'lfant)'

folowedbylocalized SlWilCal exposure ofthecrown ofthe

tooth and applying edruslVe trachon WIth an orthodonticappliance,

• IVllat factors affect lilt' sr/l'dio" of 1.1 particular Irt!atllft-'Ilt?

• POSition and severity of thedllacl!l'a~on(see abovel

• Thesize of overJl!t

• Degree 01 crowding

• POS/tJOl'landconditionoftheotherpermanentteeth

• Thegeneral coodltJon ofthemouth

• The altitude of the child and parent

• AssllmillS 110""of tlltSt' factors l,rfi1e"ts till' iill'al 'reatml'lI!, wllat ll'oufilyou r'f'C"OtllII'l'lIdfor tllis CRsr?

In thiS casetheKfealtreatmenl is to extrude anda~gnthedilaceraled tooth M1to the arch

Thedilaceration appears tobentherootandrelatrvely

rTlIId Therefore, analt~shot*!be madeto reilainthelost space to accorrmodatetheCl!l1tralncisorcrown.ThISwould be best actuevedbye~tractlon01 both upper Cs andthe upper left B to encourage eruptlOfl 01 permanent lateralincisors,Somemonths laterthedilacerated tooth should

be$lA"£icalyexposedandan orthodontlc attachmentWIth a

lengthof goldclwwlplacedonItSpalatalSlXfacefOlextruSIon

TREATMENT

• \\7,"tal'rtl,l' optio"s for !I'ratttle"t?

IfthechIoKerabOn were severe.thetoothwcMdreQUWe

extraction Then either of the following OptionS could be

selected:

I NJgntheadfaCentteeth.IdeaIyWIthfixed appliances,

usngthecentral'l'lClSOl"space TheIaterallflCl:S()r"WOI KI

replacetheCl!f1lJairoSOfandcouldbemasked 10

slinulate It In the short tefm thiS couldbeaccomplished

by adhesive restoration but In the longer term a

permanent restoratlOrlwcMd benecessary The cafW\!!

rTllghtalsorteedrestoralJon or ITIilsioog so thatItwoukI

notappear ncongruous,especlalyn a pa\Jel'ltwrttl

slenderlateral ncrsors ThIs ""bOniS not Ideal because

the Imal appearance IS often poor

2 immediate replacement oftheextracted central incisor

bya dentu'e or actlesrve bridge w,th permanent

restoratIOn or poss.OIy a sngle toothmpIantn

~(see Case30)

It,00theradIOgraphs.the(IIlacerall()l'ldoesnot appear to

betoo severeOflieS In the apical portJon of the root,

consideratIOn couldbegIVen to aligrung the tooth

orthodonlJtaly.ThIs WOlAcIII'IYOIveregilnllgalr'flost space

"

• SJWIIIII a fixed OrrcllllJl'llbl1'IlpjllilWCt' lieIIsl'd?

As thetooth~tsare relativelysmpIeanlQ)efremovable appbnce canbe used atIllsstage Morecontrol

andmote acw-atetoothPOS/bOl'WliwoUdbeoKbevedWIth

afi~edappliance Howevl!l'.thepatient WIn probably requirelurther fixed appliance treatlnl!l'lt at a later age andthefineadlustment of toothpoSlboncouldbeperformed\hefl

• DI'!iig>'/I!iUi!llb't' I'l'mot'ub'e IlppliQ/lC:l'.

The appliance conSists 01:

- cribs onQlQ (O.6-mmwire)

- cribs onili la.7-mm wire)

- finger springs onlJ and II(O.5-mm WIre) to retract

and regain tile space for thel!.:

- a buccal arm to extrude II lO.7-mm Wlre) attached to

the gold chain bonded to ll.

• Figure5.6~how~tilt,po~i'iollof fill' dila(eflltl'tl

tooth afler "Pllfoximlltely /8mOlltlrs of'lctivl'

Irl'tl/ml'nt WllfIt fl/rthl'r Irl'atml'nt may I!e

lIeCe~~f1ry litf1Ifltl'r~'agt!of dl'lItal dl'velopmellt?

Ideally II would be approPriate torelle~ethe crowdingInthe

permanent dentltfon and align the leeth, correcllng the

unilateral posterior crossblte and ellmlnallflg the mandibular

displacement Details of appropnate treatment cannot be

finalized untillhe patient passes from mixed denfllion to

perma~f1l dentIlion at about 10-12 years of age

",ISSING INCISO~ ~

Fil 5.6 Alter 18 moolt1softreatment

"

6 A dry mouth

Summary

A 5O-yc.u-old l,ldy presents 10you in your hospital

Idelltify the (ause ,md plan treatment

HISTORY

Complaint

She complains uf dryness which makes tIl,my aspects

of her life a misery The dryness is both uncornfortilble

and renders eating nnd speech difficult She is forced

to keep a bottle of walerbyher~ide,11,111 time<;

History of complaint

She first noticed the dry mouth about 4 or 5 ye,usilgO

lhuu~hit may IHlve bL'Cll present for longer At firstit

WilS only ;Ill intermittent problem bll! uver the ].,,,, )

yc;us or so the dryness has become constJn! Re<:enlly

thl' mouth h;l'i bt'OUll" sore as well asdry

Medical history

The patient describes hersdf as gene,(llly fit ,mJ well

but has hild to ,lllcnd her medic,ll practitioner for poor

circulation in llt'r fin).;ers They blanch r,'pidly in the

cold and are painful on rewarming Shl.'ha~also u"",d

arlifici,llte,lrs for dry eyes for the last 2 ye;lrs but tak.es

no other mt,'dicMion

EXAMINATION

Extraoral examination

Shl.' is 11 w,,-,II-lonking I"dy without detectable cervical

lymphadenopathy There is no f.lcial il"ymml.'try ur

enlargement of the p<lrotid glands and the submandi·

bular gland~ilppe,U norm<ll on bimanual palpation

I[er eyes and fingers appeilr normill

Intraoral examination

• nrcIlppellrallce of theplltil'lrt'smouth isslrowlIill

riglm's 6.1 Illld6.2.Wlrllt rioyOIlsel'? Howi/oyOll

illt"'prct the {il/dillgS?

Thealveolar mucosa appears 'glazed' and translucent or

llun (atrophlcl suggesling long-standing xeroslomla Some

Fla: 6.1 Appearanceotthepat.",'s ante<Kl! leeth

Fla: 6.2 A<>Pearance01thepabenfs longue

oral debriS adheres between the teeth, agaIn suggesMgdryness, which causes plaQue to be thicker and OlOfetenacious There are carious leSIons and restorations at thecervical margIns of the lower anterior teeth indicating ahigh carles rate The tongue IS lobulated and fissured Bothfeatures suggest a lack of salrva

If you were able 10 examine lh pill;t:nt you wouldfind thai her mouth docs fccl dry Gloved fingers andmirror ,luhel"t' to Ihe mucos.l making examil1<llion un·comfort<lble Parts of the lllUCo:.a,~P"'Cially the palateilnu doNal longue appear redder thiln normal r-!usaliva is pooling in the f1l1or of tht: mouth and whalSolEvol C<ln be identified is frothy and thick Small

<HllUtlnl~ of clear but \'isdd SollivlI c.ln beexpres.sedfrom all four milin SillivitTy ducts

• lV/rl.1 arc ti,e COlIlllWII Illld importlllltcilusesof xerostomill 11I,,1 how<ll't.'tlteysullllividctl?

'In lrue xerostomia the salivary flow is reduced The term1alse xerostomia' deSCribes thes~nsabOO 01 drynessdespite normal salivary ootput

Fi& 6.3 Parotid SIalogram.

,

Fi& 6.4 Mloorsal""ary glalld biopsy:lowpower

• Tire mi'wr salivary glalll/ biopsy is sllOwuilt

Figllf'('S 6.4 lIlII/6.S WIlli! do YOll see?

The low power view shows several minor salivary glands A

minimum of6 8glands is required for reliable diagnosis

and thiS sample is suffiCient Evetl at thiS lOw magmfication,

dark lOCI of Inflammatory cells are visible (though they

cannotbeidentified as such} and It can be seen that the

klbular structure of the glands IS largely intact

The high power view shows one gland lobule Centrally

there are three small ducts surrounded by a dense

IymphOCytlC Infiltrate The Infiltrate is sharply defined and

within the lymphocytiC focus there is complete loss of

aCinar cells (acinar atrophy) Around the lymphocytes there

is a zone of essentially normal umnflamed mucous salivary

gland

Fig 6.5 MillO( sal""ilrY gland~opsy:high power,

• How doyOIl iJlterprf'l lI",sc 1Iisl010gi("iI/

lIpp,'lIrrmces?

The focal lymphocytiC slaladenitis centred on ducts andconcentric sharply defined ZOnes of aCinar atrophysurrounded by normal acini are characteristic01Sjogren'ssyndrome

DIAGNOSIS

• Wllllt is yo"r fiull/ dillgnosis?

The patient has primary Sjogren's syndrome The diagnOSISwas suspected on the baSIS of history and eXamination, and

IS confirmed by the characteristic Sialogram and biOpsyfindings The primary form of Sjogren's syndrome isIndicated by the lack of autOimmune/connective tiSSuedisease andthePOSltMty for ssA and ssB autoantibodies,The presence of Raynaud's phenomenon, the severity of thexerostomia and dryness of the eyes are also moreconSistent with the primary form In addltlOn the pallent hascandidOSls which IS the probable cause of the soreness

• Treat candidosis and follow up regularly for recurrence

• Preserve what salivary secretlOn remains; salIVa IS moreeffective than saliva suhshtutes,

- Sip waler rather than drinking It, so as 10 expandremalnmg saliva and not wash It from the mouth,

- Whenever possrble avoid drugs which causexerostomia

7 Painful trismus

Social historyThe patient used tobea keen ,1nd successful gymnast1lS a tCt'nagcr_

EXAMINATION

Summary

A 27-year-old woman is un.:lble to open her mouth

normally What is the diagnosis and how should she

be managed?

Fit 7.1 Thepatient on Pfesenlalioo showtngma~lmalOllening

HISTORY

Complaint

The patient is unable to open her mouth more than

half the normal distance

Extraoral examinationThe patient is apyrexi,li ,md appc,us "'ell There isnof.lci,lJ swclling and the skin (olnur nvcr the prcauricu-

br regions is normal There is tenderness on palpationover the right mndyle but110tendernessunth~·l",ftside.There is generalized muscular tenderness, particularly

of the right masscler and thc right I,lter,ll pterygoidmusclt$ Examiniltiunofthe fingers, wrists and elbowsshows an increased r.1nge of joint movement

Intraoral examination

• n,l' plIIicllt'S lIppClIrlllrce isshoWIJ illFigure 7.1.

SheisInjillg10opell her mml/htl! the milximum

eXIelll Wllat doyousee?

There is limited mouth opemng and a delllalion towards theright Side.Ifyou were ablc to cxamine thc patlcnt yoowould~ndthat the opening, measured between the tiPSot

the incisor teeth, is 23 mm Lateral excursions of themandible were measured at8mm to the fight and Imm tothe lett The patient readily achieved a normal POSlbon ofmaximum Intercuspatlon between upPt!r and lower teeth

DIFFERENTIAL DIAGNOSIS

• TIll'1'II/iI'1I1hilS Irismus. Wlrul istrismus?

Thede~mhon of trismus is reduced opening caused byspasm of the muscles of rnastlcalion but the term is usedloosely for all causes of limited oPt!nlng True trISmusISusually temporary

Causes of limitatIOn of openlOg include:

• lVlrul<IretlrcC<lUSCS oftrismus?

History of complaint

She has hild sporildicp.linJc,<;clicks (rom her right jaw

joint fur many year~, Reomlly the click has oc'Come

louder nnd painful On occasions there has been some

hesitancy of o~nin~ iu~t al Iht;' P()~ilion where Illl'

dick would norm<lllybe felt Three d<lys <lgo, while

eating11 pilrticularly chewy piece of meat, she fclt a

~udd n pain in front uf th right ear and sinet' that

time she hilS been unilblc to open her mouth more thiln

about half way

Medical history

TIle ""tient isothcrw;~ewell hut she 1m;, ;,uffl'red frum

previous episodes o( knee pain andW,lSseen by a

rheu-matologist who diagnosed generalized hypcrmobility

afhajoints

Intra-arocularcauses

Exlla-articular

• causes

Intemal de<'angement oftheroot

Fractured condyleTraomallc Syn<MllSSe!>llc <J/thrrtlSOsteoafllYoSlsIntla.rnrnatOlY<J/thrlbS.(tS-rl>turnalOidorpSOflabc)

AnkyloSlS(secondary 10traumaor ,fec!l(JfllLeslOlls ofthecondyl<J/tleadle.g

osteochondroma)Trauma (e,g fractured mandiblenotinvolvingttlecondyle)Postsurgical r_aI of impacted lower thirdmo"

"

Fill 7.2 Movements oft!Ietemporomandibular~ntduriflgt!Ienormal opernng and cloSIng cycle, WIth reciprocal ciockrlgandr1closed lock.The

structure of the normal temporomandibuar imnt is soown ,n the upper panel, WIth the companents oftheartJculltr dISC and I04nt capsule The toprow shows thenormalopernng aoo cloSing cycle Rotation occursInthelower;OInt compartment aoo lTanslation int!Ieupper The mechan;sm ofreciprocal chcklng IS shownInthe middlelOW Wltnarrows Ondicatlng the sudden roovements of diSC and condyle that causeOPE'l\IIlg(0)andcloSlngre)cllcl<srt!s~t"ety The bonom row shows partial opening III a pabent With closed locI< as a result of anterlQf dlSlllacement of the disc withreduced translation and opernng.I,External auditory meatus;2,bdaml,"" regIon of d,sc;3,posterlQf band of dISC;4,intermediateloneofdISC;

5.antenQl b<l<1d of disc;6,~Isertionof lateral pterygOId

space and IS reqUired for opening and lateral excursion

Thus, In intra-articular causes of trismus there is usually

lImitation of movement111all dIrectIons, as In the present

case

Movements possible in intra- and extra-articular trismus

and locking are shown In FIgure7.3

• WI",t istlrl'mustlikl'f.v C/WSl'?

There is no history of surgery or trauma, no suggesUon of

fracture no InflammallOn Ulslble over the JOInt to suggest

arthrrtls and no systemIC cause for arthritis Traumatic

synovitis isapoSSIbility but does not usually causeselectIVe Impallment of movement; all jOint movements arepainful This leaves internal derangement Involving the intra-articular disc as the most likely cause The progreSSIon ofc1rcklng to locking WIth pain and Intra-artICular trismus ofrapid onset is typical of closed lock and fits WIth the pattern

of symptoms and SIgns seen In thiS case

In thiS case the patient IS stili able to translate the leftcondyle forward, causing deviatlO/l to the right on OJ)ening.lateral excurSIon to the light was normal at 8 mm.Therelore the cause 01 the restricted opemng is internalderangement of the light Joint

1;;;;;=~1 'AINFUl lltlS_UI

FIe.1.3 ~ pos$ibleinlI1tra a'ldexlJaiIl'tIa8lr15mlI5,Gleen illr0W5"ate ITIOYefIIeflISthal.e posstie.,.edolROWS!hose\IIfllch

ft~, left,1lIJ_!JClMr\lWlll,I$;dosed lockcausedby., eraly~chc lyelDwl ~ JlIr~UISlTII\;riylosIs

(reel)RIe!lIe>;tJ~ \I1StIU$; ~ 0< ~cAm.lSWUI' ~lJedl

f''1.1.4 T1werghtedrnaentbt~e IllIapl

atthengtt tempoI~IOI'lt AnormalJDII

IS ~on\beleft tile~s.,.-rtontile

retWIIh Ihemernalaucitc.y muIlr.ilibeledE, IIto$t«tnQlIe: _,~cortIalboneIIldthelis<allappe.-d.JrI<.h tileb-er~the<XlI'llt,ll!

temporalbone and liseare0UllIntd

INVESTIGATIONS

• IVllUt jllVNtiglltiollSlIlay 1If'/1/?

Plain radiographs WIllprobabtyshownoabnorma'-ty

because thefeISno changeIflthebonystrvetwes01the

PIllIfapa~processotherItIanIltemal

defangemenllS suspectedthen,adlography maybe

helpful.AdentalpanoramIC tomogram IS usual'!thet.SI

VIeWofcholeewithother tomographic prOjeCtions lI'lCkKlIng

sptrallomography and CT liMns ackhtJonal informallOO

AlternatIVely transpharyngeal or !ranscramal prOjettlons

gIVe clearN Vl(!WS bUI With a higher radialion dose

Magnetic re50nance imaging (MRI) would~the

maIposIlJoneddISCandthis may sometimesbehelpfuln

medunWltOtheIowel'IOIlt$PaCe,SerololY for rIletmalOld lactorandan autoanbbody profimaybeindicatedIfaPO/)'artII'opalhy IS SUSPeCtedHowever,somecauses of arthntlS are seronellalJ\le, forInstance psoriasIs and ankyloSln1l spoodylills

In thiS, and most other cases,theclinical PICture is

sU!OClef1t1yclearto make the diagnoSISandtheseIlllesbgatlor1s are not normaly requred,

A48-yNr.old man presentstoyOIl in general dental

practice with a gingival swelling What is the cause

and what would you dn?'

Intraoral examination

The patient is p<Jrtially dent'lt ,lmJ IMs rel<ltivdy f('wlInd "tensively restored teeth I Ie w('ars an upperparti.ll d('nture The root of the upper lateral incisor ispresent and itsl'Miou~slirfac li~osat the level of thealn'Olar ridge The teelh on each side of the lesionarcrcston.'<I with metaJ-ecr.ll11iccmwl\~.

Th('rei~ 11mildd ~rt't' of margin.ll gingiVitis Most

of th(' interdental p,lpill,leaTe round~'<Ialld m,ugin'llin(J.lmm,ltion is p~nt i1rtJulld crowns 1-l~'Cks uf

~ubhinf;i"<11 calculus lIr visible

m.ug.,ofthelateralincisorroot orthe

lIlterdental papilla mesl3lySl2e ,G.pprOKlmalely 10 " 7 mmShapeaooCO<1!W ~regltarroundedoodlM!.RISoot

POssbietosay whetherrtISpeOOnc:lUted or sesSIle, !tloughtromlIS

slleancllhefact that It oYerW!s the

lateral inciSOfroot,II is probablypeduncl.laled

Fit.8.1 AppearallCeof the swelmg PJtchy rell JoelpinllWIth athingrey

traosluceotsheen.Thesurfaceis

almostcert,)lll/ylkerJtell

HISTORY

Complaint

The p.lticnt compl<lins of " lump un th gum ilt the

froot uf his mouth on the left side_ It sometimes bleeds,

usu,llly ilftcr brushing or e<lting h<Jrd food but it is not

p.linfu1

History of complaint

nil'~lVe11ing hilS bt m pn.'S<.'nt for 4 months and hilS

grown slowly during this period.ItWM; never p'linful

but nnW ItK,ks unsif;htly The p.ltient gives no history

of othcr mucoS<l1 or skin lesions

• I'rolll tllC il/form"/i ,,i"JIll'historyrlllr/

1'.\"{wri'III/;OIl sofllr, whatisyour diffuClrlial

- Penpheral glanl cell granuloma

- SIllUS papilla (parulis)

Fill 8.2 HtstoioglCaI appearil<1Ce of the su,face taytfs ot tilee~cislOl1

-_.

TheIeSlOllIS itnoduleofuk:eratedmat~nggrar'lJla!JOfl

andfibrous tISsue

• Whal is tl'e dil'X""sis?

PyogenIC granuloma

OTHER POSSIBILmES

• IsIImort COIISl"rolltiut' 1I/'I'roach to trtat", "t,"m"r

jllstifil'll!

Yes: elmnahon ofthecausabW factors may lfIduce

conSIderableresokrtJon.However.the degree01resolubon

vanes;softer morevascUarlesionsstYril mostandlinnet

more ftlrousIewnstlarllyat31 RemovalofcaiclAJsand

wnprovedoral 1JyglCl'lC maycausepartialresc*ltJonand

leavea smanerleSIOnwtlICh IS eaSier toe~clseandbleedsmuch less Such a course of acllOO IS often appropriate forIreatment of pregnancy epulis, tloth because of the Wish10avoid the procedure don'!g pregnancy and becauseexclSlOl'l~rI1gpregnaocy carnes a rMofrectJTencc

DefntJveeJ;CISOl may thenbedelayedllOtiafterparulOOn.OCCaSlOllalyresokJbon ISaImost.c~le nI

non.ttlerIreatmenlis.rCQl.lIred

• If, 011umovilfS the/('si,"I,yOIl ft'lt /)01/('witIIi" iI, W/lllt WOll'" Illis sigllify!

WovenandIameIarbone,sometimes QI.lIte lafgejllCCe5.canlieW1t1wl1ibrOUSepuIldesandpyogenICgrarU::rnas

Bonemaybenoted one~CISOlor011tJSloIoglCalellarTllnatlOll SometrneS suchleSIonSate referred10asmlf1crahZlng epulldcs (or peripheral oSSlfylnglibromalfltheUS! Theprl!Sl!I'lCCof bone seems tobe 01no greatS1gruflcal'lCeandII may lndIcale that such lesioos ariseby

proliferationofthedeepfibrous Iissueof thepenostamSome cOflSlderIeSlOflScontanngbonemoreliIe1y 10recurItIanIhose'NTthout butthereISnogoodew:Iencc10supportthisbelle!

9 Pain on biting

Dental historyThe patient has been a regular att{'nder at vourpractice<;iocechildhood lie h,lS,1 smollJ number o(relatively small I\.'!;toration At hi., la.,t appointment.some-I months olgO you pl.lccd an amalgam Te'!>tora'tion in the 10"~right <;e('()nd molar

• Ba~don wllatyou knoll'alrt'lldy wilDt art' "II'

likelyClJusn? EJ.·"III;nWilY,

Summary

A 32-yCilr-old man presents 011 your general dcnl.:ll

prilctice surgery with inlermillent polin on biting

Identify the (,lust' and discuss Ire.llmen! options

F''1.9.1 Theltotlh IIIhelower"ghtQU.Jdrant

HISTORY

Complaint

liecompl.,il\~ofp.lin Ullbiting which b unpn t i,-l,lbll',

c~trcmclyp.linful ,md sharp but poorly locilli1'.oo. It

ori};inall"> in thl" Iuwl'rri~htquadrant <lnd 1<I~I~" \'ery

short lime, only as long as the t€('lh <Ire in conlact, and

isf;()p.linful that he 1415 become accustomed 10 eating on

the ldl TIll'p,liu unlyad,*",011 bitinghard food~or

dchb r.lll'1ydl'nchmghis teeth Apart from Iht'Se bh.lrp

electric shock-likepolinshe has no other symptoms

History of complaint

1llt'J"Iin i~ oil 1\.'('("111 plwnomel1011, having Ix-en fir;1

noticedilmonth or Iwo ago At first II was frequentbut

ithas become less ofiIproblemI'IOWth lthe has learnt

10.iI\'oid lriggmng tht' pain Ht' ha;, nul notict'tl tho.>

p.1tn betngprovokedbyhotor cold

Apulpal~inISthemostIIketycause becausethepaI1

appears to ollgnate11a toothandISpoorlyIoea/i.zed.Pall

of peoodontal kgamen!onalnshouldbewei localized.However.pulprtJs aPQears notbepresent~se!tlere IS

nosenSltMty to hotor cold PulpllJScausedbyplacement

of the recent amalgams and pain due to canesOfexposeddentine canbeexcluded for the same reasons

A crack in the tooth or electrogalvanic painan'!pOSSible causes suggested by pain on biling.Botharetriggered by tooth-tooth contact

Trigeminal neuralela shouldbeConSldered as anlX11i~eIy

noodental cause It causes paroxysmal stabbingOfelectrIC

shock~eIlKlal painInd1strlbubons oftlietngemnalnerve

andmaybeRbatedbylouchI1gorITIOVI1gtnggerzones It

IISUaIyaffectsthefTlidcIe.agedorelderly ThehrstOfY01pawlonblb1gISamoS!conc~ofa dental causebutII.canbe<ifficuIt10exckJde tngefTWlill nelJ"alglaInsomepatlenls, par!JCUaf1y'Il'hen triggerzoneslieIf1themoutf1Of

attacks are tnggered by eallng IfnodentaleatISe1$foood

thepossbllltyoftr'lemnalnelJ"a1g1iimay neediI.rttleI"

I'lVestJgalXln

Acuteperiodontitis caused by an occlusal hiehspot

ontherecently placed amalgamneedstobecOflSldered

However.altl'lough lhrscould causegreattenderness on

bIIlngrtwould be expectedthatthepalll fromthebrUised

penodonbll1lwould bepresent at other tmes.Also,suchperiodontaty-seflsed painwouldbewell localized

• IVIHlt IldditiOlurlqllt'stiollswouldyou Ilsk?lVI,y?

The patlenl shouldbeasked about clenchmg or bruxlng of

theteeth because the additional occlusal load can causefracture and WIll delelmlne treatment optlOl'ls

The p.1lienl Jl"'>Crilx-s a habit of nocturnal bruxismwith some t",nderness ofma~tic<ltorvmu"Cle<;<IItimL o(stress

EXAMINATION

ExtraoralexaminationThereisil suspicion of hypertrophy of the massett'fmusclesoncJenchin~.

10 A defective

denture base

Daleet

PorOSItythroughoutthe

denture Thedenture

maybe theIncorreetshape,

Cau5tl

~sufficlentmateoalpacked Into the flask, orInadequate flasklngPfessure Correel use ofthe trial packing stagesIloUde~monatethis

Summary

casting shown both have defeds caused by similar

mechanisms Cm you identify the problem ,md its

CJUSCS, which aredifferent in the two examples

GaseousPOroSIty

PorOSity appearsIII IIlIII

se<:t>ons ofthedentllfe,

whichoftet1havea'MIIte

andfrosty' appearance

VapofllatJO/l ofmonorTle<dllflllgPfocesslllg

h'lcorreetpolymer:monomerratiowhenProChlClngthedough, orfailing to packtheftasl<

atthedougl1 stage

fie 10.1 Thehtal-proces~ "acrylic', poIylmelt1y\methacrylale)

denture base

ACRYLIC COMPLETE DENTURE

• tIJIl'"'-/mWI'ss,,d'"crylic', I'Uly(UlI'lIlyllllf'III11Cryltltl')

dM/Ilft'Ims/' isshowlIillFigure 10.1 Wlwfdo yOIl

SCI' IImi holVdoyOIl jllterprct tltese observlltiQlrs?

The denture base has a cluster at small round holesIna

oorseshoe-shaped dlslribulion just Inside the teeth The

defects are more (requentln areas of thicker acrylic Each

detect appears toberound, some are completely enclosed

in acrylic while others commumcate With the surfacevia

sharpty defined holes

The presence of numerous small holes or defects Withinthe acrylic IS known as porOSity

• What aretill'types of porosity? How do they mal/ifest (lIrd what nre their muses?

The types of porosity arc presentedInTable 10.1,This denfure has suffered from gaseous porosity and theappearances are fYptCalbutrTl(l(e exlenSM' than usua/tj seen

• lV/1lI1 crwses mmrrmrer Irl Vi/lmri;:e,Illriusprocessing?

The ooiling point of methylmethacrylate IS lOO,3°e atstandard temperature and pressure If the boiling pOint ISexceeded then the methylmethacrylate vaporizes andbubbles produce porous defects The polymerization ofmethylmethacrylate IS exothermiC and Will contribute tovaporizahon if precautions are not taken to reduce thetemperature Because the process is heat-<lependent, It ismost likely to develop In thick sections of the denfure ar.d

in the last porlions fo be polymerized

• How isX"SCUIlSporosit.1J normally flrt'vwll'rl?

Methylmethacrylate shouldbepolymerized at a lowtemperature and under pressure Packing the dough underpressure raises the bOiling pOint of the methylmethacrylate,and polymerizationat n·cfor 16 hours (or 72'C for 21lou"sand lOO·C for a further 2 hours) followed by slow coolinggives hme fortheheat oftheexothermic reacbon todis~te

COBALT-CHROMIUM CASTING

• Arobalt-dlm",iu", tll'lItU"frIJlllt'TI'fJ~kis slIOTI'"

illris,m·l0.2.1\'1/11/110yOIlS('I'1l1lt1 how do you

illterprl't U'I'SI'cllI1l1gt'S?

The metal has oumerous small perloraling !loles Tiley are

of various sizes and some have coalesced 10 lorm large

defecls

Table 10.2 Commoo detects In cooalt-<:hrorlllumca~t,"g~

• WIlI1t al'(' tl.('rOIllIllOl.1It'(t'clsill rDbalt-dlrollliulIl

castill,f{? How may 111t'ylH'prrvt"ttd?

bubbleformalJOll ThIs ISanothe!exampleofporOSitybutIt

ismuchmore extensIVeItIanISSCel1'IrIfleothe.westment

IS too ltJck or gas dissolvesIf\the aIoy.In Ills case a

more Iu'lllamentaIrTWStakem rst havebeenmadeIIl'ldthecauseISprobablyuse oftheYo«lnglI'M!strrl@I1l materlill

IIaframework ISlI'M!stedIf\agypsum-bonded

investment,theIfIVeStmel\twt breall down at alowe'

temperaturethanthemehlOgpointofthealoy.TheCaSO.binder reactsWIththe5.0,refractO!)' to prodoceSOlgas.bubbles of which cause porOSity In the casling Gypsum-bonded Investments are used for gold-based alloys an(jphosphate-booded IlIIestments mustbe usedfor Co-Cr

T went/tow0I1!'Ie*'t

Back prCS5Ufe 01 • II !heIllOlJ(t

ln$Uffieleflt.atJy

Mouldtoo coldwtlencast

lnsutli<:lef1tca$hng forcekwestrnent eraeirngnteMmerrlbrukdown

Alltdlblesonwallpattern

StrMS I " dthewalloanem

-TooIT"Idl~ eJPafIWfl

usethecorrectl)OW(ler:IIQt.clrabO

00fl(liO¥erhelllthe*'t

EnslnS(nIt:Sartdthe tcmClliamtttr

EAslresp-ues are11thecorrectpo5IlKIluse " PO'OUSi1¥e'stmentorn;lldeVIrts

U~$UffielCflt alloy

Ensure the correct opefaoog temperBtlll'eEnsure the machlfl&IScorrectly set UPUsethecorrectl1Ye$tmentand donolheat too.apodyusethetorrectIlVI!SIrnenIanddonolOYerheat

use awettq-eent

Warmlhe'QJ ~beforemal~the~uselhecorrect aperiJlq\efl1lefatlft

use!hecorrettI1VeSllTlentfoo-!he*'t.and !hecoract

operdtlnll1eflllefiItIR

mother's knees all 01 which are more lamiliar than the

dental chair Place the mother where your dental light can

be used if the child will tolerate It If the child does not

allow her teeth tobeexamll'led In these poSitions then you

must conSider an examination under more controlled

conditions

• /low cOllldyOIlsafely restmilltlrccllild wit/Wilt

f~iXj,Il'"i"X Jw~ f,,~tJw~?

If you decide to perform a full examination on a reluctant

Childrtmust be done In a controlled caring and confident

manner With experienced nursing support and With the

consent and cooperation of the mother You must explain to

the mother exactly what you are gOing to do and repeat to

the child that you are just going to count teeth Then:

• Align the chair in a fairly upriglll position

- ~\tiemother to Sit In the chair as d she IS being

examined - the child will probably come with her,

• Ask the child to Sit on the mother's lap

• Explain to the child what you are gOing to do,

• Ask the molher to turn the child so that she is SlUing

across the mother WIth her head at the 10o'clock

POSltIOll

• Ask the mother to control the arms and hands

• Your nurse WIll gently control the feet

• Slowly and calmly lower the child's shoulders and head

onto your lap explaining what you are doing

The techl'llQue IS SMWI1ln Figure12.2,Note how hands

arid legs are gently restrained and the child remains in close

contact and able to see her mother ThiS position IS useful

not only for mild degrees of anxiety but also to examine

severely frightened children In pain who are determined to

resIst Understandably the child sometimes cries but not

always Although not ideal Cf)'lng often allows good access

to the moutll If the child will not open their mouth your

nurse tICkling their stomach WIll usually have the required

effect Your nurse will need to posrtion the operating light

carefully as light In the chlld's eyes is often upsetllng

Fig 12.2 Controlledexamlnal1011 tecl'lllQUC

Keep the examinallon £hort and immediately afterwards,whether the child IS upset or nol, reward her with words, (a'soft· reward) and a sticker or balloon, la 'hard' reward).This will encourage the child to alklw examinallon at thenext VISIt However,becareful not to give Inappropriatepraise for poor behaViour and inadvertentlygwcthermpression that bad behaviour is acceptable

In your brief examination you S€(! the "ppc"riIllCL~

shown inFigure 12.3.

• Tht' nJ!/lcamllccs 011 cxami"ilIiml IlrrslwlImill

l-"igllrr12,3. IVhat doyou sc,'alld whatdotilt'

Fig 12.3AppearancesonexaminatKlfl

13 Pain after

extraction

Summary

A 36 yeu old lOldy presents with severe pain,] few

days after toolh cxlr.lclion WhJI is the (.lUS(' and

what can be done?

Flt 13.1 Thelpptill'ilIIlCl'ofthesocket

HISTORY

Complaint

5he complains uf a di"I~~inglv ·\'l·I't' p.lin (mm an

C'xlr.lction socket III the left side of hcr m.mdibll', Tho.'

Ildin j IIK,lli/oo 10 the extraction sockct and is nOI

sensItive 10 hut or cold It i"a cun t,ml, dull, hurillpj

pain unrelieved by aspirin or P.u3cct.,mol

prep.na-tions It rrt·\'t"nl thtop<itil'nl po'rlorminjl;<l1l\' norm.,1

adl\"lh ,nd kept her awake last nip;hl

History of complaint

f1K:.pallent underwent SUrgiC.,1 remo\";11 of the IOWl'f

kft thin! 1Illll,IT!(Xllh at her dentist 4 day:: ago.-Ihe

exlr(lclion h.ul rmn-d mun.' dilikult than expected

,md in\'o[\'OO rcfX'JII>d att.:omptoo t'Je\-ahon and a

"milll,Ilnounlnf bunl.' n>mo\"al using.1 bur.I'ollowln~

the e>.lrachon, bll~in~ topped nnrnl.llly Th :>.traclion sit h.1d bu-n tl.'tlder but appan'tlth \\.t~hE.'aling Io\\h untilth p.lin Idrted y t rday.511\(:1,'then she h.ls 1150IlOtl«.>d h.llito<;i ,mda hold1."It·

Medical history'1 he patienl isothcrwlSCfit;mdwell She islalin~,Inoral contraCl.'ph\' dnd 1111 ,,'Iwr po<;iti\-elindm~~1n'1\'

1"('\" lledb~'the med'c.11 h,!>lof\'

EXAMINATIONExtraoral examination

Th p"lil'nl h,l" n""h'r,llt' <'xlr,lOr,ll s",dling 01 llwf:lei.ll soft lissut'So"l'r1vin~ tIll'I'xlratliol1 kl'l and

«()me «lIrl" discoloratioll of the skin bvc<ch"lllos'''.Thl'rI' i~ Iri~lIlu",llll! Ill' i ahll' to open her mouth

10 only 22 mill mlenllCl<;'l.l clearance Theft' art' nnpalpahl., hlmph IUllk" ill the dccp ccr\'ical cll.lin orsubmandibular trialll;l.,

Intraoral examinationHalih i i~ nntiu·,lhlt· rhl' ,lppeilrance of lilt>sock

15 shownIn Figure 0 I TIw 1.>lH'T It'll Ihird molarsocket contains no 11""u(', onlv food d -brb Tht.'~ur­ ruundin~ ~ofl li uf"<> are <;lightly swollen bul not

ThedlagllOSIS IS confirmed bytheexanYlallOOwhichshowsthatthebloodclot has been IoSIfromthesockel ~severecasestheboneofthesocket maybeel(llOSed,andtile boneofthedistallip01tilesocket can be seen nFlgtwe 13.1

HalrtOSlS IStile resulollooddebrisnthesockP.lbetnRdegradedbyapa'tJaIIy anaerobebactenaillota Thetnsrr.IsoS~tcertariy relatedtotile~lrauna01exlracbon

Table 14.1 !nveslogallons tobecamedout

To checktltevrtalotyof al fO\lluppe,and lowe'

flCisOfsandcanines (excludlllganyknownrool·fined

teelhl Late loss of V1talrly is a complication of trauma

and anyOfleot these teell1 couldhaveperiapical

infection andbethe causeofthe bad taste

The l'ltalrly of the lateral ncisOf needs tobeknown

to plan trea!mcflt DOCethediagnoSIS is established

To detectthepassble causes and assessbonelewis

aroundtheteel!l To dctermlOethepulpc3l1alrr10f phology

IIIcase root canal treatmentISleqUlred,andtheroot

morphology111casee~tracbOr1's necessary

ThepaMnt may II1Istake a glng aIsensabOfl fOf aVItalityreSj)Oflse

Root IfaClureSmaybedifficult to dentdydtile IfagnlCllts arenot separated,Asecond\IICWataslightly different anglemayallow detecbOn of a rOOI tractUfe IlMsoble Inthe~rslHowevel,I!lIS tooth IS50mobdetllatafroJrool fractureshoukl beread!tyIdentlfred

would appear to be Independent of the onglnal trauma

Teeth which suffer coronal fractures do not usually suffer

root fractures as well because less of the energy of the

blow IS transmitted to the rool However, If a root fracture

had been present for the last4years it might have

tnggered slow resorplion, comblmng both possible

causative factors

Anunsuspected lesion has destroyed the bone and/or

the tooth root apically, leaVIng support only coronally; thiS

IS a lemole POSSibility The tooth would then be mobile

about the remaimng intact periodontal ligament The

commonest lesion to do this would be a radicular cyst

arising on a rmnvital tooth

However thiS seems most unhkely as there is rm

expansIOn and the adjacent teeth are not displaced or

mo~le. Adifferent lesion remaInS a remote possibility

INVESTIGATIONS

• ~Vlwlim'estigatiOlls would yOIl carryoul? IVlIy?

IV/wI rlre the I'Qtelltilll/lrovtems?

See Table14.1

Onperforming111('tc~l~oflOOlh vilJlily you findlh,ll

it i;, impo;,sibll' to obtain a Tesponse from tIll'UP~TIl'ft

ccntr,ll ,md later,ll incisors AU other mterior teeth

ap~",vit,,1

• Tireperiapical radiograplris slrowu in rigure 14.1

IV/lilt 1'1yo"s,'.:?

The left laleral incisor is crowned but not root filled, A large

oval radiolucency fills the middle third af the root and

extends laterally ta replace Itle full WIdth 01 the rool and

communicate Wllh the periodontal ligament The marglllS of

the defecl are smooth and sharply defined The iam,na dura

around the apex appears Intact The bone level meSially

and distally IS coronal to the defect and there is no

eVidence of either hOrIZontal ar vertical bone loss Verylittleroot dentine remains below the crown and gingIVal margin.The upper left central InCisor IS root filled, The fillingappears well condensed and extends very clase to the Ideallevel, The root appears to have a curve at the apex There

IS a poorly defined radiolucency around the apex mostlyon

rts mesial side, where the lamina dura is missing.The canine has meSial carles and lIs aplcallam;na dura

IS Ind,sMc\, However no obVIOUS apical radIOlucency ispresent

• IVlrMiswrQng witlr tire tfIdiogtflplJill rigur/' 14.1?Aregular pattern IS superimposed over the whole film ThiS

is a developing artefact caused by some film processors(e.g Velopex) which use woven nylon bands to transpol"t

Fill: 14.1 PeriapICal radIOgraph of themob~eIater31'flCISOf'

15 Oroantral

fistula

Summary

A 42 year-old man presents with pain folillwing

extraction of an upper first molar, Wh.ll is theC.lllse

Jnd howwillyoulrc,lI him?

FIt: 15.1 Thec~tracllO<l socket on Pfesentaboo

HISTORY

Complaint

Th patient b >ouffering dull thrubbinl,\ pain in his

upper ~'W and face on the left side only Prt'Ssurc

below his eye is painful and all his upper teeth on the

left are tender on biting" He has anas,l]db-eh,ugc and

blocked nose on the left

History of complaint

He has had the pain ror 2 wccks following extraction

of lhl' upper left (irsl mol"T by hi dentbt Th

I'xlr,lction was difficult and the rools required surgiCill

relllo",,!.ThereW,15littlepain immediatelyafterwards

but pain has slowly developt:.od SO that it is now

preventing him frotn sleeping Thepolinis constant

Medical history

He giws a history of~moking20 dg,uclt<."S a day for

24 YCilrs but considcrs himself fit ,lnd hC,lllhy

EXAMINATIONExtraoral examination

He bHhe",lthy loukin);Imm with nu f;lCial !>welling urlymphadenop,lthy There is a lightly blood-stilincddischmgc from the left nMes ilnd hiltitosis

Intraoral examination

• TIll! "1'lwlIra"('I'S I'" l,rl'S/'Il/lItio" "rl' slmwIl in

Figure15.1.Wlwl no you see 1II1d IlOw do you iuterprtttilefell/ures?

There IS a large defect In the alveolus at the site of the firstmolar socket the socket appears empty and the oralmucosa has grown to line the V1slble Sides of the socket.After 2 weeks the oral epithelium shouldha~eproliferated

toco~er the socket mouth but there mustha~ebeen afailure of clot formation and/or organization One poSSibility

is thallhe patient has a dry socket (see Case 13) No bone

is V1slble In the socket but It could be exposed aplcalty.However, dry socket is rareInthe maxilla and It IS morelikely that Ihe socket is communicating with the maxillaryantrum

DIFFERENTIAL DIAGNOSIS

• What causes for tllis/minnre possible alln why?

Sinusitis secondary to oroantral rlstula.Anoroanfralcommunication itself causes lillie or no discomfort butusualty Induces a degree of SinUSitiS The nature anddlstnbulion of pain and presence of nasal discharge aretypical of sinusitis This seems the most likety diagnosis.Fistula formation IS most commonty assoCiated Withextraction of maXillary~rstand second molars

Dental pain Before jumping to conclusions, it is worthconsiderrng whether the wrong tooth mayha~ebeenremo~ed. If the extraction was performed for PUIPltlS (which

IS often poorly localized! It is possible that at least some ofthe symptoms may arrse from the adlacent teeth You 'MIlneed to check whether additional symptoms suggest pain

of dental origin

• lV/lilt is ml oromltralfistll/Il?

An omanlral fistula (OAF) is a persistent epithelialize<lcommunrcatlon between the maXillary antrum aM themouth, presenf tor more than 48 hours The epithelralllning

of the~stulagrows from the gingival epithelium, periodontalpocket lining or the antral lining and It may take up to 7

Fig 15.3 Part oftheocclllrtomental VIeWfig 15,7l.The second molar has an inadequate root canal

treatment, probably associated WIth loss of apical lamina

dura and a small periapical radiolucency A pin has

pertoraled the distal root

• W1111tI'1SI'do YOIIIII'Flllohrow 1'/JOllt II", rOf!t

fragment?

l'Ihether It IS loose In the antrum or trapped under the sinus

limng or In granulallon tissue The root will have tobe

removed and rf It IS under the hrllng or trapped, It should De

possible to remove II through the socket If illS loose In the

antrum removal in this way may prove impossible,

necessllaling a later electIVe surgical procedure such as a

Caldwell-luc apprQ<lch,

• I/ow will yOll IluidelVlrl'rI'tire root is lIr1d

wllef/ler i/ is mobile?

Ifthefistula openmg IS large you might try to Vlsuallze the

fragment directly II not, a second radiograph at nght

angles to the periapical, such as an occlpltomental View,

woold~pto locahze It, A further view with the pallent's

head tilted would reveal whether or not the root moves

• 1\ section of tilt' occipitoll/entrll vicwis SllOlllU il/

fiXllre/5 l.Wlmf1111ym, sce mrlllww 110yOll

illtul1fet tirel/ppCl/mu(es?

The sinuses and faCial bones are symmetrical and there is

no expansKm of the maXillary antrum However, tile Sinus

on\heleft is much more radiopaque than that on the nght

lldlCatlng oedema and thlCkemng of the sinus IImng or

exudates within It, There is IlO flUid level viSible The root

fragment IS not VISible because It hes on the sinus floor and

IS obscured by the superimposed alveOlus,

DIAGNOSIS

• IVlmt is YOllrfirlllitliIlX'lOsis?

SmUSlhs secondary to oroantral fistula caused byedracbon

01the upper first molar, A root fragment has beendisplaced into the Sinus Apical penodonlills of the secondmolar may also contribute to the SinUSitiS but thiS IS achronic problem and a lower pnonty tortreatm~t.

TREATMENT

• How wouldYOlltn'lIlthis JlllIie"t?

• If pus IS present In the fistula or If symptoms are severe,consider treating the slnusl!ls first and c10slrlg the fistulalater after the SinUSitiS has partially resolved (It will notresolve completely unIJlthe fistula IS closed).Ifthere ISIong-standlrlg InfecllVe sinusllis, this mustbetreated prKlr

to surgICal closure otherwise healing willbecompromised

• excise the fistula otherwise remnants of the eplthehalIimng may proliferate to retarm the tract

• Remove the root fragment from the Sinus,

• Close the oroantral commumcatlCln surgically

• lVoulll Yll/Itn'ul thispulil'l" ill 8I'ru:r,Jl/'riIClice?Provided you are conMent 01 your ability to remove theroot fragment, there IS no reason why this cannotbedealtWIth In a general practice Situation, However, If tile root ISmobile in the antrum, the patient shouldbereterred tohospital,

"

• 11011' wOllld yOlll'XciW till' fistllla all/I"IIIOllf "II'

roo'?

lklderlocalaMesltle~, InCISearooodtheedgeofthe

socket"om gngr.ta rightdownlitotheantnm remowlg

.lithesoft tISsueIlthesocket asacyindefor

cone-shapedPIl!CeanddrawIIintothe mouth.0epenDrlg011the

SIZeof thebonydefectandtheamou'ltofboneresorplJDn

(usuallygreaterll'llongstandingflS!lAae1this opens1(1a

largeholeintothesftJS,With sucbon,good~anddr'ett

VlSIOIltryto IdentJlytherOO(ffagment andremoveIIwrth

Meforceps.suckertipor ottlerII'lSIrtI'J1enI.Takecarenol

to displaceItIllotheSlOUS.IfItbecomesdisplacedItmay

bepossible towashItout by f1uslwlg sallile II1totheSlOUS

AhernatlYetybettersurgICal access to the SlOUSmay be

achieved umg a Caktwell-luc approach under general

anaesthesia ThiS ISthemaUlreason for referrmg patients

With mobile fragments10hospital

Send the eXCised tract for histopathological examination

in case of unexpected underlying leSions,

• /fowwillyOIl (/OSftlrl' df'feel?

Thebuccal mucoperiosteal flap With advancement (buccal

advancement l1ap) ISthemost commonty used tedlOlQue

andIt hasmorethana90%success rate.ThetechnIQue IS

stKM'n111figure15.4 AlterexCIsingthefistula asabove,

proceed asfollows;

Maketwoinc:i5ionsbuccat,t, antenorandpostenor tothe

socket.paSSl'liPil'aIeIl(I!heattached gl'lf"laand then

splayingtoprlMdeaWIder basetoensureagoodblood

Sl(:lpIyfortheflap.TheIlne01theInCISlOIISmustbe

compatibleWIththeflapsidingpalatalytocoverthedefect

ntheaNeoIus.

Elevate the mucoperiosteal napyou haveoutW1edby

kttll111tilesoiltissues111 theplane beneaththepenosteum

Advance the !lap,Theflap cannot yetbepuledacross

thedefect becausethepenosteum cannot be stretched

Fold tile flap back to expose ItS penosteal surface ,md

make several shallow parallel incisions across the flap that

penetrateonlythepenosteum (about O.25 {).5mm '"

deptlU thiSmust be doneVCfYcarelJAyWIth theflapt.flder

slight tef1$1011.As thepenostNnISineisedtheIIat>WIIbefen to stretch,00notperioratetheflap orIIwiIerther becutofforhaYea COfTlPIDII'ISed bloodsupply.Make

sufflClef1llnClSIOr'ISto lengthentheflapsothat II C¥lleachacross tothepalatalSIdeof thedefect withnwwnal

10-14days

• IV/ult altf'rJlatit.1' flap dl'siglls art' I,ossib/t?

Thebuccal advancementI\apmayoot be posstlle menthebony defect ISverylarge orwhena preyoos attemptat

fepall'has failed,

AIl.IITtlerofother flaps art posstJleII'Id.Idll1ithe

palataliSlandflap.submJcosalpalatallSlandflap.comtllledbuccalandpalatalflapsand~pedicledgraftsflom thetongue.However,most01 theseleclnQues <Wec~andhaYebeenSl(lefsededbythebuccal fatpadted'lnlQue.DIagramsofthefOlate<!patatalllat> tedn:J,Je.the second

mostC()l'l'llnCftyusedmethod, areshownn flgUfe 15.5

Altemallvemethodsto closeoroantral fistlAae ale noted Ilthe'locall\ap deSIgn' box011p 73

• IVllat postoperativl' ilistn/dimlS art' rt'ljllirt'/'?

In addmon to the roubne Instructions gIVen after extractIOn,the patient mustbeplaced on anantral regime to reduce

fia·15.4 TheI:IutulllMncemelll lap.NoteIlowltltr*wl&IICI$lOIl$buccaIy tarl!'MdeIy.sNIowlflt:lSllJflof~ penostaJm,Ir-.mq:ofthe

SIp 10- eIroodfll~andltlt1m of p&tulbone(IIIwhchIIloe$

Buccal adIIancement ft1lll

(sellFigure 15.4)

Buccal fatpadtransfer.~above

andtheOOecai fatpadis dissocled

from\A1defthebuccal tlap on a

pedK;~and socureinthesocket

Palatal ftilP

Indications/advantagesRelatIVelySImPle,00ftapdonorSlte

to heal suitable for local analgesia

As above, atlle10~la larger defed

PossibleW'henOOecal flap has failed

or~ha\leIlsufficlentlengthtocO\ler a palatally~acedborledefeet

CoIIers the defeet, ,lt1 mast><:atorymucosa

Contraindications/dlsad~antages

NotIdei'llforlarge defeet adIIancing the nap reduces thedepthoftheresidual buccal sulcus.Alveolarrather~maslJCatory mucosa advanced ontotheridge Flap maybfeal< 00wn~\l1deftenslon

General anaeStheSla requiredfor fatpaddissoction

suk:us loss

TheIlapIS of thick tissueandISdJffic tomoblllizeThedonor Slte ISleftto granulate and tills IS parniul untl

"'"

Filii: 15.5 Thepalatal rotation flap Notehowthe ftap derrves Its

bloodsupply from fhe Palatal artery WIthin h The difficulty of roo:hng

the thICk flap IS clear Thee~posedboneWligranulate ands~uIdbe

cO\ICredWIth a pack durrng healing

inflammation and prevent a rise in air pressure in the

antrum The upper first molar IS situated In the lowest point

of the maxillary sinus Persistent Infection or Inflammalion

will induce exudates that will drain to this paint and cause

breakdown of the clot Increased air pressure In the Sinus,

for instance from sneezing or blowmg the nose, Wlil force

air or exudate through the alveolar defect as well as

phySically dlsrupling the clot and flap Decongestants

maintain the patency of the opening of the sinus to favour

drainage to the nose

A suitable antral regime wO\.Ild be:

• an absolute ban on blowing the nose for 48 hoors

• sneeze allOWlng pressure to escape through the mouth

• nasal decongestant (such as ephedrrne nasal spray 0.5%)

• decongestant Inhalantle.g.Karvoll

In addition, chlorhexldlne mouthwash shouldbegiven

The repair will fail if there is leakage of sahva and bactefla

past the flap from the ofal aspect No rinsing should be

performed for 24 hours

Fla: 15.6 Preoperative radiograph

• TIrepr('OlJerntille mdiogmplris slrowll ill rigurt'

15,6 IV/wI110yOIlsec?

Several features In the list of risk factors above are eVIdent.'fhere is a low antral floor in contact withtheroots, there islillie alveolar bone height and there is loss of lamina duraaround the tooth root apices

- - , " OAO~NTRHfiSTULA

• HowCOlillf alloroalltrtll co"",umirtltiO/I be

cOllfimlt'd tit till' timf! of £xlrae/iu,,? HolC' mig'"

II,isIltfp?

" anilfltralcommunecabonISpresent, anechoing'wind

ImneISOl.Ild'wiIbeheardIIitsmaIsuctionb9 ISheIcIlfl

the socket.I!le,~ofar bMg suckedfrom theantn.rn

asweiasthe mouth.•theC00lITUlIC3t1OO ISlarge you

maybeableto seelIltOtheaolnn1 ordef1tIfynasal

regurgrtallM of your Jngabon IUds orbloodfromthe

extraction SIte.Donotaskp,anentto/:lIcM' throughthetr

nosewI'IIehoIdrig11 TheSlflJS 8 may shl bentactbut

~beburstbythepressure¥ld a smaIconvnuricallOn

mlghlbeenlarged

KacorrmUl1lCalJon is suspe<:led slal:Mllzabon ot the

clot closure01thesocketWIth resorbable sutLlffSand

apprapnate warnings to the patient about bloWIngtilenose

should prevent a fistula developlIlG· Thisislikely tobe

eflectlVl! It the diameter of the cornmuOlcallOl1 IS 4 mmOf

less 1111 is larger, it should be repaired Immediately USing a

surtable flap techniQue to avoidSinusitiSand infectl()(l

develoPll'lg

"

FIC 15.7 ThelOOlfragmenr~onFigure15.2

16 Troublesome

mouth ulcers

Summary

A 38-year-old woman with mouth ulcers has noticed

d recent exacerbation in their severity You nced 10

make ,1diagnosis and decide on suilable

investiga-tions ilnd trCilllllen!

Fis: 16.1 Theappearance of000ulcer

HISTORY

Complaint

The patient complains of mouth ulcers which havE:'

been troubling herT(.'O:lltly

History of complaint

She h<lssuffcnxl from occilsiolli\l mouth llk ~, tI~w,l1y

oneill a lime, over ,1 period of more Ihnn 20 YC<Hs

However, recently Ihey ~L~1l1 to have become worse

and she now has severaL Normally she ignores them

hul, bec.1USC ",he WiI'" ilttending your surgery for il

filling, sht· thought she would a~k whl'tht'ril11ythil1~

eQuidbedone

Medical history

The p.llil'nti~otherwi<;.Cfit and well

• 'fileplllieullulSalr/'ndy/Irovirlerlsel'erlll pieCt's of i"fonllflliV/I "f VIII""fv~diffa"IIlill/ diu8rwsis Ilow rio yOll assesshl'~ 1I1c1'~SOil till' lJasis of ti, i"fomlllt;"", lIVlIillIble?

The pallent has noted an outsel of ulceralion early In lifewith recurrent attacks of Single ulcers or small crops 01ulcers There are very many causes of oral ulceratIOn butthese ulcers appear to be recurrent, that IS they appearperiodically and heal completely between attacks Recurrentulceralion has relaliVely few common causes

• IVllat are the CO"''''Oll (1II1SeS of rl'cllrrl'/Il ami

• Occasional cases of traumatic ulceration

• Ulcers associated with gastrointestinal disease

• How will y"u <lifferelliiatebchl'l!l'IItllest' cOllrlili01rs?

Almost entirely on the basis 01 tile~ndlngsIn the history.Some features of the examination, blood tests or a biopsymay be helpful In certain cases but the history IS mostimportant

• IV/1ll1feUlllres of the u/ceratiOIl11'0/11,1 yOIlask abo"t

10 dctl'rmi/ll'III,'di"Xr",sis?E.\pl"',,why forellc!l.

See Table16.1 ThiS pal lent's answers are shown in thenght.fiand column

• How11ft'"'''jor ",,,I ",i"vr HAS ,liff"""llfiHI,',I?

Byseverity rather than by anyone feature alone RAS may

be labelled as major because of the size of the ulcers, theirlong dura\lon or because they develop scamng on healing

• Fro'" u,ltklt Iyp" 0/"k('1'$ tlOl"S,It" /"11;,,,,,(lf~/1("'''

10lie slIfferillg?

sne'fIOU1dappeal" \0\\ave t'j\'llCalffi\I\OIRAS'Hl\\ctl\\as

Increased In severity recently

EXAMINATION

Intraoral examination

• Till' appellrallCC of 0/1(-' "!cl'r is sllowIIill

FiX"n-/6./ IV/ral rio you see?

'There IS an obVIOUS ulcer on the anterior botcal mucosa II

is shallow, a lew mililmetres In diameter and has a slightlyIrregular but welklefined margill The surroondmg mucosa

17 A lump in the

neck

Summary

A S5-+year-old man presents 'n your or.11 and

maxillo-facial surgery dcp.Hlmcnl clinic with a lump on the

left side uf the neck You must make a diagnosis

•

b

Fis:.17.1 aandbTheaPOearanceottMswe~lng,

HISTORY Complaint

The Pilliclli compl<lin" of the lump ,llld noliC<'S some

discomfort on swallowing, asifson1l'lhinl; isstllckin

hi" Ihrrnlt He ,1ssumcs the lump is the GlllSC,

History of present complaint

He thinh he fin.! noti ed the lump.lboul 3 monthsago It hilS illways been paink~s and is slowlyenl,uging The discomfort on swallowing is of n:.'O.'ll1

onset

Medical history

The pillienl isothenvist> fit ,md wdL He smokes 20cigarettes per dily illld drinks 10 units of <llcohol eachIVcl:'k as bftor

EXAMINATIONExtraoral examination

The i1ppcilrance of th sWl'lli"l:; is "hown in Figure 17.1

• \Vllilt Ill' yOIlset'? IVlIII'isIhe Iikt'ly origill of thr

The lesion lies over the deep celVlcal lymph node chainand could well arise from a cervical lymph node It IS toolow and too far posterior to be arising from Ihesubmandibular gland and probably too low to have arisen Inthe lower pole of the parotKl gland Other soft tissues ofthe neck could be the Origin, but a lymph node IS the mostlikely cause

rf yOll could p~lpah:tIlt' I""ion you would find that it

is approximately 8 cm by 6 cm in sil.l'andf~'t'l~finn onpalpatiun p', ibly ~lightly fluctuant It is mobile,not fixed to the overlying skin ur (k't'p~trllctur('S.Th.,p"ticnt docs not notice any tenderness on palpation.There are nu utlll'T sw",l1ings orenl~rgedlymph nodesp.llp.lb1e on either side of the tll'Ck

Intraoral examinationThe ",Ublll,llldibular glands art' pillp.lble bimilllually amI

appe~rsymmdrical BollI art:' mobile MId cle,lTlysep.1.riltefrom the swelling which lk-s posterior to the gl,lIId.The patient's mouth hilS been well restored in thepilsl but suffers from rtXent neglect <1nd sever,ll c.lTiousc,wities,1TCvisible There is no significant p€riodnnt,ll

dbc,l~withm~tprubill).; dcplhs 1l ~tlMIl 5111m,md

no mobile teeth The lower left first permanent molar

has lost a large restor<llion and has extensive caries

Thel"(' isnowfttb~ut' ~wclling, ~inusurh·ndl'rl1t.~in

the sulcus ad)olccnt to the apic(.'S of theroots.The tooth

b not knder ttl pt'TCu""ion The oral llIUCos.l ,lppt'.lrs

normal, andthe tonsil"i'lppeartobe symmetrical

DIFFERENTIAl DIAGNOSIS

• '''rtlt til'(' tlrtmostIikC'fy(1U1stSof tll(, 111"'1' and wl,y?

Metastaticmalil"ancyappearsliIetyandthisIeSlOllIS

sotyplcalol a cerw;a11ymphnodemetastaSIS thatItITUSt

beconSIdered10bemaIlanantln~provedotherwISe.~

ConiwlabOn01fean.-es suggestiveofmetastaSIS ISthe

patient's ageIshoUdbeCOIlSldefed aposSIblecause11 a~

pallm: aged0\Iel'451,theSItelconSlstenlWIthacemcaI

~node),thefwmCOOSlSIe1lCyandlackoflendemess

rlXabclllOthesbl«other Sl1uctlM'es\IIIOl*l beaImosI

conck.rsM-of~butISaIaleSIgIl,~patientISa

smokl!l"anddnnkl!l"andsohasann:reasednskof

malignancy Eitherasq.JafMUSCarclflOlTla«

adenocarcl'lOl'l13IS 1Iket)t Melanomaandother mallgnanoes

areh.rtherposSlblecauses

lympl'ladenitissecondary10alocalcauseIScommonand

sornJslbeconSIdered Hclwever ltlefeISnotenderness on

patpalJOTl tosuggest annflammatory cause,IIthiswerea

reactiveIlllammatoryenlargement,themost~ketysource

oIlllfe<:bonwould beadental.pharyngeal or skinnfe<:bon

ThepatJenttlas a potentialSOlJ"ceot dentairnecbOnIIIthe

Iowetleft NSt permanentmolarbutthetooth IS not tender

to perr;USSlQrlnorassociated WIth overt Infe<:lJOTI making It

anlJlhkely cause

Tuberculosis needs to be conSIderedbothas a possible

diagnosiSandas a faclor afle<:tlnll manallernent Mosl

pallentswrthcer\'ICallymphnodeenlargement caused by

tubercUloSIS have reactlVatlOn {'secoodary'orPOst-pnmary)

tuberculosIs In which a prevKll/S QUlescenllnfec\lon

becomes reactIVated ThiS locahzed InfectlOn mayor may

notbeaccompallled by pulmonary disease lhough there

may be radlologlal eVIdence01past tuberculosIs on chest

radiograph Cervical hJberculOllS Iymphademtls is common

IIIthose from the Indian subcontinent Atypical

mycobacteflal InfectJon IS a disease whICh often affecls the

cervicallymptl nodesbul IS almost always seen11'1children

ortheIIlVlll.llOsuppressed

• \\lJricll mMitimr,,1"lIr Il'ssIikrlyI"IIIISt'S"1"1"1110III"

considtrt>d II'lri'IlI'I'tr a ptlUl'rrt cOlI/pltlill!; of till

i'Il/IlTSl'lI/l'lIt tit IIris sitt? Wl,y tlrt' tllty IIIrlikely

call~Sill "'is caS{"?

NtmerousIeSlOllScouldarISe al thiS SlieandII ISnotusef~

to~stthemaI.Arunberofpossiblecauses (Table11.11

merll conSlderatJon becausetheyare common easilyexcluded or cause slgruficant morbidity

INVESTIGATIONS

• WI,at is till' most illl/wrttllit inlltstigtltion? 1\'lrirll

",('tllods "'iglrt"fuSt't1ll1ul wIlli'liTo""'fir

advalltagC's tlml distldvmrtagC's?

ThecntJCalreQUlfementwtlenmalignancyIS SUspectedIS 10obtalflllssue speedily b microSCQplCd1agflOSlS, " otherrneslJgatlOTlS are lesslIT'()Oftanlatthrsstage TwolechnqJeS are In corrmon use;the ft-nee<Ieaspwa!lon

biopsyandtheSl.Jl'gcallflClSlOfIaIbiopsy (Table11,2)

• 1\'IIat oUI('rinl'l."StigatiollS ",ig'"/nop4'rf0mltd,

~ithnnOlll or lit a lalertl,,'~?wilY?

seeTable 17.3

~thiscaseaSl.ItabIecombmbonoflfI'Ie5tlgibonswcddbe~a5PlTatlOn,dentalradiographs,VlIaIrtytestsandposs.blyIMtaSOUld scan.~SlIIogramwcdd

I13'o'ebeenperformedIfasaMryongllhadbeen thought

possilIeaftercJncaIexarTWlallOn.

1belower finol molar I\~""mital and d peridpicdlradiograph revealed apical radiolucency l'Iw smear(milla fine-needle aspirate is hown in !-igure 11.2

• W1IlIt dots tlr(' fi"t'''I't'dlt' Ilspirlltt' slrow tllllthow

do youi"t('rpl'('t tilt tlPp4'tlrtJIICt's?

The aspirate shows cells from the Icslon spread as a

~inglt'I"yt'r and ~laiT1t'1.lwith thc P.lp;Hlilul.l<IU ~t,lin,

This stains nuclei dark blue, I eratm orangt' and lht'cytoplasm of nonker.lliniztXl epithelial (('lis tUl'llUolsc.The cells OIl"(' <llmosl all epithelial <I>; ~hown by tht'irprominent cytoplasm <lnd by the pl\.'S(.'n((' of I eratm-

i~,lti"n(arruIH'l1 A) in "111.' nf them The l.lrger cdl.;

An S·year-Old girl has froldurcd her upper right

perm<luen\ cenlral incisor loolh

HISTORY

Complaint

l1lt"child is broughtInas an emergency b)' hermot~.

complilining of broken front tooth

History of complaint

Two hours prior\0prcscnl<llion the child had ,lippt"(l

at ;,chou!,hittin~ hl'r mouth One front tooth llppcilT'S

TIle (hild h ~ i1l1cnded the dentist In·t.'gUIMly but

has had no(,lriCS,and hilS no CXpcriCI1CC of opcr<llive

dentistry Her milt her Iilt~ that Ihe bro"l'll tooth h.'ld

notappcilred norm,l1 and may howe beendcc.w('d,

• ""/tIt additioIH1Iq/j~stjo"swouftl you u;d "III/WIllI?

Didthe patient lose consciousness?n.swcddn:kate

aleIatrYetysevereblowto the headandmegtltlI1dIc:ate

sigrllocant mtracrar-al trauma tithepabef1t lostConSCIOUsneSS, even for ashortperIOd,ltleyshoukI bereferred10hosprIaiwhereltleywooklaImoslcerta"ybeaarutted lor24hou's ofobservalJorl.In!hiscasethe

pabentdldnotlose consclOU'leSS

Was a pieceofthe tooth broken off and wasit found?

t.bqIragmentsofteeth may IIavebeen1Ihaled

swaIowed,embedded thelipor lost.IfafragmenthasbeenfOlA'ldII/Il,lSIbe matched10thefracllXetodeler~

vrtheIherotherPIKesremannllSs-Jgand thepabenl

If"IYeSbgated to localeandfefTl(M!thel)Ie{:es In!tiscase

no fragment was 10lA'ld,

Has the patient suffered trauma previously?Pl't!VlOUStralJll1a to thls tooth couldhaveresultedn arrested rootdevelopment, disturbed crown formationorpathologICalmobilitypriorto thiS InCldenl, dependingontheageandstage of denial developmenl at the time Such cllangescould aHcct treJtmcnt and mighte~plalnIhe parent'sobservation that the tooth was not normal In thiS case nopreVIOUS trauma couldberecalled by the parent

Was the damaaedtooth rultyerupted before theaccident? In earlynlllCed dentition lOCiSO(s onoppo5l\esKIes01themouthmaybeat dlNerent stagesoferupbOrl,

Atltusage1\would beexpectedthaterupbOnwould becomplete but thereISWIdelIaraalm11eruption date aridrate ItwouldbeposSIble to fMI1Ierpret lICompieteerupbonasiIl'In1ruSlOn -Y " theongnaldegree01eruptionwerenotknown.Inthls case.thec~srnotlltr

reported that both frontteethwere n.yen(lted

Whatobject or$Uriac didthechildhitwithIKtrmouth~If1uryon Sl(faces suchaspIaygrotnds.roadsand

pavementscarnesthefiskofcontamrlamgthewoundWIthdirtypartJcwtematerial Some\l'l1eSsuchlorelgnrnaler01evenentersI1traoral wounds,ThorougtJdebntlementwouldthenbefeQlM"ed.Itwouldalsobenecessary 10 check the

ch~d'sIfOOlUflizabOn status for tetanus prophylaxIs aridarrange a booster dosedreQUIred.In this case.thechild

hitthe edge ofiItable

EXAMINATIONExtraoral examination

rhe child is di"tr("<'il 'd but j rC,lJily eX,Hlline 1 TIll'rt'

i ,rne light~Wd1illbof tltl' upper lip but no extern"labrasions or laccr,llions

Intraoral examination

• 1111'apJH'arallcl'S 01 till' tl'l'tl a" showlI i"

Figu"IS.t WIlllt 110 you St"l'?

Tf'IegngrvalllssuesIablaltotheupperrightperrrIMl!fI\centralKISOroweerythematousandswoIen.TheCfCl'o\'f'lof

theIoottlappearstobeftSSII'Igandlessthan1 mm 01the