Analgesic Medications in Pregnancy

Precautions for Pregnant Analgesics:

A. NSAIDs should generally be avoided in pregnancy (despite Category B before third trimester)
- Second trimester use is likely safe
- Miscarriage risk in first trimester
- Premature Ductus Arteriosus closure in third trimester.

B. Tramadol should be avoided in pregnancy
- Second trimester use may be safe
- Fetal toxicity in animals (highest risk in first trimester)
- Respiratory problems and withdrawal symptoms in newborn (avoid in third trimester)

C. Opioids should be avoided in pregnancy unless there is no viable alternative
- First trimester use is associated with heart defects and Spina bifida

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Class B: No risk in controlled animal studies

A. Acetaminophen (Tylenol)
- Analgesic of choice in pregnancy

B. Narcotics (Class D if prolonged use or high dose)
- Nalbuphine (Nubain)
- Meperidine (Demerol)
- Butorphanol (Stadol)
- Fentanyl (Duragesic)
- Hydromorphone (Dilaudid)
- Methadone (Dolophine)
- Morphine Sulfate
- Oxycodone (Percocet)

C. NSAIDs (first and second trimester only)
- Ibuprofen (Motrin)
- Indomethacin (Indocin)
- Ketoprofen (Orudis)
- Naproxen (Naprosyn)
- Piroxicam (Feldene)
- Sulindac (Clinoril)

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Class C: Small risk in controlled animal studies

A. Narcotics (Class D if prolonged use or high dose)
- Codeine (Tylenol with codeine)
- Hydrocodone (Vicodin)
- Tramadol (Ultram)
- Propoxyphene (Darvocet)

B. Barbiturates
- Butalbital (Fiorinal)
- Class D if prolonged use or high dose

C. NSAIDs (first or second trimester only)
- Aspirin
- Etodolac (Lodine)
- Ketorolac (Toradol)
- Nabumetone (Relafen)
- Oxaprozin (Daypro)

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Class D: Strong evidence of risk to the human fetus

A. Aspirin
Used only with specific indications in pregnancy
Risk of neonatal Hemorrhage, IUGR, perinatal death
Low dose Aspirin may be safer

B. All NSAIDs (Third Trimester)

C. Prolonged use or high dose of any Narcotic

D. Prolonged use or high dose Butalbital (Fiorinal)

E. General Anesthesia - not in Briggs (1998)

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Preparations: Lactation Safe Analgesic Medications

A. Acetaminophen (Tylenol)
B. Ibuprofen (Motrin)
C. Tramadol
- Small amount crosses into Breast milk

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Preparations: Avoid Opioids in Lactation

A. Opioids that are converted to active metabolites by CYP2D6
- Codeine
- Hydrocodone
- Oxycodone

B. Risk of overdose in babies if mother is a ultra-rapid CYP2D6 metabolizer
- Ultrarapid CYP2D6 metabolism occurs in 10% caucasians, 3% african americans, 1% chinese and hispanic 

C. Preacutions if these Opioids are used in Lactation
- Avoid use beyond 4 days of life when milk intake increasing substantially
1- Consider pumping and dumping while taking the Opioid
2- Transition to Acetaminophen or NSAID as soon as possible
- Use the lowest effective dose of the shortest acting agent
- Limit dosing to immediately after feeding

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Removal Of Separated Endodontic Files Inside Canal

- First of all: the file type controls the treatment plan.
- Then, We should know the area that the files has been separated in,

If Coronal Third then the file should be by-passed or removed by the manual H files that engage it from a side,
If middle third then the file should be removed or even by-passed and flared as manual filing,
If Apical third then the file should be removed ONLY, or even may be left in place ONLY if it is sealed with the apical foramen, otherwise should be removed.
It Beyond the apex or pushed after separation to pass beyond the apex then it must be removed through the canal or through the surgical apicectomy.

- Note: Manual K file should be removed by H files, Manual H files is easier to separate inside canals and is very difficult to be removed from the canals,
while the rotary file is not liable to fracture unless with inexperienced endodontists and removal of it is nearly impossible (especially it is one of the first files in the sequence ex: S1 and S2 of Protaper rotary files),
all the files mentioned above can be removed by ultrasonic scaller that hits the dentin debris next to the broken file causing vibration and elevation of the file toward the crown (but if it is very fitting inside the canal and broke due to excessive force applied into the canal then it will not be elevated by ultra-sonic scaler),
Finally, we can remove the separated file by using the Gates Glidden (GG), by applying GG size 2 or 3 next to the file, taking care not to perforate the root, causing a small hole to apply a small H file inside to remove or by-pass the separated file.

- In All Cases:
Recall the patient for check up every 1 week, 1 month, 3 months and 6 months,
Using the Sodium Hypocloride is very effective in by-passing and removal of the separated files,
Using the Glyde is very effective in by-passing the separated files,
Try to pre-curve the the tip end of the file before inserting inside the canal with gentle pressure and clock and  anti-clock wise directions to by-pass the file so that you can remove it or complete filing,
Try to start trying to deal with the separated file with manual files size 10 then 8 then 6, taking in consideration that liability of those files to separate increases as the size decreases.

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Caldwell-Luc Operation

Definition:

It is a radical operation in the maxillary sinus performed through the oral vestibule.

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Indications:

1. Inflammatory Condition: ex. Chronic Maxillary Sinusitis.

2. Cystic Condition: ex. Removal of Antral Polyps and Cysts & Antro-Choanal polyps

3. Neoplastic Condition: Benign and Malignant Lesions.
A. Benign lesion:
· Odontogenic: Ameloblastoma & Adenomatoid Odontogenic Tumor.
· Non-Odontogenic: Osteoma & Polyp.
B. Malignant Lesion:
· Squamous Cell Ca
· Minor salivary Gland Tumor
· Adenoid Cystic Ca

4. Miscellaneous:
· Removal of any root fragments or, Antrolith
· Zygomatico-maxillary fracture involving the floor of the orbit & anterior wall of maxillary sinus
· Management of hematoma in the maxillary sinus· Closure of mouth-sinus communications (oro-antral fistulæ)
· Removal of antral mucocœles
· A route to the ethmoid and sphenoid sinuses.
· Visualisation of the orbital floor for decompression.
· Vidian (nerve of the Pterygoid Canal) neurectomy.
· Access to the pterygo-maxillary fossa (the space behind the maxillary sinus).

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Contraindications:
1. Not performed in patients below 17 years of age as there may be damage developing tooth bud in that region.
2. Acute Infection.
3. Systemic Diseases.

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Technique / Procedure:

1. Anesthesia: GA preferred.
2. Incision of anterior wall of maxilla especially over the canine fossae, the incision should be semi lunar or, U shaped.
3. Removal of bone & window creation, the breadth of the window should be not less than the diameter of an index finger.
4. With the help of a periosteal elevator & curator, the whole lining of the antrum will be excised along with the lesion (depending upon the type of lesion, fresh bone may need to cut
5. Debridement.
6. Irrigation with normal saline.
7. Drainage by naso antral tube, this is called antrostomy
8. Sometimes ribbon gauze impregnated with antibiotic solution or, paste is placed & removed gradually (within -5 days) to facilitate healing.

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Another Technique: (Endoscopic Entry):

1- First an opening is punched from the mouth into the maxillary sinus with a special instrument.
2- The surgical instruments can then be passed through this opening.
3- Then the endoscope is passed into the maxillary sinus via the nose so that the operator can obtain a good overview of the sinus.
4- Altered mucosa is removed by means of the instrument which is inserted in the maxillary sinus via the opening in the mouth.
5- In addition the opening of the sinus to the nose is enlarged in order to allow for better ventilation since this promotes the postoperative healing of the sinus.

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Complications:

Common Complications:

1- Facial swelling
2- numbness of the face (infra-orbital neurapraxia). This is numbness of the cheek and not weakness, which always occurs temporarily but rarely persists.
3- numbness (temporary / permanent) of the upper teeth and the associated Gingivae.

Less Common Complications:
1- Oro-Antral Communication / Fistula)
2- Post-Operative Nosebleeds (Epistaxis)
3- Overflow of Tears (Epiphora) due to blockage of the tear duct.
4- Tooth root injury leading to tooth death (Devitalisation) & Tooth Discoloration

Rare Complications:
1- Facial asymmetry due to persistent facial swelling.
2- Prolonged Maxillary Sinusitis.
3- Post-Operative bleeding from the sinus / nose requiring packing of the sinus / nose or even a blood transfusion.
4- Infection of the Naso-Lacrimal Sac (Dacryocystitis)
5- Post-Operative hypersensitivity or 'Burning’ pain over the cheek, Gingivae or teeth. (hypæsthesia / dysæsthesia of the Infra-Orbital Nerve).
6- Blindness (if the eye socket is entered) & reduced sharpness of vision & movement of the eye (ocular dysfunction).

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Medication:

Analgesic, Antibiotic, Anti-Histamin and Corticosteriods.

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Denture Support, Retention and Stability

Denture Stability: It's the resistance of the denture against Any-Direction movement.
Denture Retention: It's the resistance of the denture against movement away from the tissues.
Denture Support: It's the resistance of the denture against movement toward the tissue.

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Denture Support:
- Periodontal Ligament around the natural teeth should be 2.5 times more than the complete denture bearing area on the mucosa.

- To achieve the best support for the denture, try to make a maximum area as much as possible.

- The Primary Support Areas are:
A- Mandible: Buccal Shelf of bone and Retromolar Pad.
B- Maxilla: Horizontal Portion of the hard palate.

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Denture Retention:
- The Primary Retention methods are:
A- Border Sealing of the Denture.
B- Neuromascular Control.
C- Physical (Adhesive) forces: Salive-Denture base and Saliva-Mucosa.

- The Criteria of the great retentive force are:
A- The Salive film covers the whole surface area of the denture.
B- The Denture Base extends the full length in the sulcus.
C- Border Seal prevent the ingress of the saliva and air.

- Elements of the great retentive force are:
A- Total Surface area. (More surface area=More retention)
B- Viscosity of the saliva. (More Saliva Viscosity=More retention)
C- Distance between the denture base and the mucosa. (More Distance=Less retention)

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Denture Stability:
- Factors affecting the Denture Stability:
A- Denture Base Adaptation.
B- Ridge Anatomy.
C- NeuroMascular Control.
D- Occlusal Harmony.

- Ridge Anatomy effect the Denture Stability By:
A- Large, Square and Broad Ridges.
B- Steep Palatal Vault.
C- Firm Vs. Flabby Ridges.

- NreuroMascular Control effect the Denture Stability By making the denture borders to be polished to allow the tongue, cheek and lips to seat the denture during function.

- Occlusal Harmony effect the Denture Stability By:
A- Bilateral, simultaneous posterior tooth contacts in retruded jaw relationship.
B- Free of the Occlusal interferences.
C- Acceptable level of the mandibular occlusal plane.
D- Teeth set close to the natural teeth position.

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Denture Stomatitis (Denture Sore Mouth)

Definition:
- Denture-related stomatitis indicates an inflammatory process of the mucosa that bears a complete or partial removable dental appliance, typically a denture.
- It was known as: “chronic denture palatitis”, “stomatitis prothetica”, “denture related candidiasis” “denture-induced stomatitis” and “denture stomatitis”.
- The denture stomatitis occurs with patients of partial denture less than patients of complete denture.
- No racial or sex predilection exists.
- It can affect as many as 35-50% of persons who wear complete dentures.
- Denture sore mouth is common, but rarely sore.
- Caused mainly by a yeast (Candida) that is a normal inhabitant in the oral cavity, and it's not a transmitted disease.
- It can predispose to angular chelitis.
- It has no serious long-term consequences

Clinical Picture:
- Occurs in the maxilla more than the mandible, where the washing affect of salive is greater in the mandible.
- The Denture-induced stomatitis is assymptomatic, but patients may complain of halitosis, slight bleeding and swelling in the involved area, or a burning sensation, xerostomia, or taste alterations (dysgeusia).

Classification (Stages):
suggested by Newton in 1962, and states:
- Newton´s type I: pin-point hyperaemic lesions (localized simple inflammation)
- Newton´s type II: diffuse erythema confined to the mucosa contacting the denture (generalized simple inflammation)
- Newton´s type III: granular surface (inflamatory papillary hyperplasia)

Related disorders:
May be accompanied with other disorders of the same origin (Fungal), ex:
- Angular cheilitis
- Median rhomboid glossitis
- Candidal leukoplakia.

Aiteology:
The aetiology is best considered Multifactorial, but wearing the denture in the night is the major causitiva factor.
Other factors are:
1. Prosthetic factors:
- No denture stomatitis can exist without a prosthesis.
- Prosthetic traumatism is favoured by denture functional deficiencies

2. Infectious factors:
- The dentures can accumulate bacteria and yeasts, that cause the ecological changes:
- Bacteria proliferate: Staphylococcus species, Streptococcus species, Neisseria species, Fusobacterium species. or Bacteroides species has been identified in patients with denture stomatitis.
- Candida species, particularly Candida albicans, have been identified in most patients. Patients with denture stomatitis show higher intraoral concentrations of fungi than individuals without this disorder.

Predisposing factors:

1. Systemic factors
a. Physiological. (advanced age)
b. Endocrine dysfunctions.
c. Nutritional deficiencies.
d. Neoplasias.
e. Immunosuppression.
f. Ample spectrum antibiotics.

2. Local factors
a. Antimicrobials and topical or inhaled corticosteroids
b. Carbohydrate rich diet
c. Tobacco and alcohol consumption
d. Hyposalivation
e. Deficient oral hygiene
f. Wearing dentures (especially through the night)

Diagnosis:
- Clinical presentation of erythema and oedema on the palatal mucosa covered by the denture base (but not beyond) is a diagnostic finding.
- Take a smear of the palate to check for presence of Candida species, by staining with KOH, periodic acid-Schiff or by imprint cultures.
- Blood tests, microbiological studies or biopsy may be required.

Prevention:
• A routine basis inspection of the oral cavity for screening for this disorder, even when the lesions are asymptomatic.
• Properly denture sanitization and perform good oral hygiene
• Appropriate denture-wearing habits, instructing the patient to take his/her denture out of the mouth for 6-8 hours each day
• Patients with partial dentures should undergo periodic professional plaque control

Treatment:
• Good oral hygiene is mandatory.
• Local factors which promote growth of yeasts, such as smoking or wearing the dentures throughout the night, must be discouraged.
• Dentures should be removed for as long as possible and definitely overnight.
• Dentures should be brushed in warm, soapy water and soaked overnight in an antiseptic solution such as bleach, chlorhexidine or in any solution suitable for sterilizing baby´s feeding bottles.
• Denture fitting and occlusal balance should be checked to avoid trauma. A new prosthesis should be made, if necessary.
• Newton`s type I and II denture stomatitis have been successfully treated with low energy lasers to reduce inflammation of the supporting mucosa, Inflammatory papillary hyperplasia usually needs to be surgically removed before the denture is placed, and mild cases may respond to antifungal treatment.

• Antifungal medications are recommended when yeasts have been isolated, or when lesions do not resolve with hygiene instructions.

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Trismus

Introduction:

Trismus is a common presentation by the patient in routine dental practice. This condition causes difficulty in opening mouth which in turn impairs eating, interferes with oral hygiene, restricts access for dental procedures, and may adversely affect speech and facial appearance.

Trismus has number of potential causes and it’s important to recognize the underlying cause for effective management of this condition

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Definition:

Trismus in greek is Tonic contraction of the muscles of mastication.

The Normal Mouth Opening Range:
Range- 40-60 mm (avg-35mm)
Males display greater mouth opening

The Normal Lateral movement is 8-12 mm

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Causes Of Trismus (Etiology)

Several conditions may cause or predispose an individual to develop Trismus.

1. Intra-Articular Causes:

A- Ankylosis
B- Arthiritis Synovitis
C- Meniscus Pathology

Ankylosis:
- True Bony Ankylosis: can result from trauma to chin, infections and from prolonged immobilization following condylar fracture
Treatment- several surgical procedures are used to treat bony ankylosis, Eg: Gap arthroplasty using interpositional materials between the cut segments.

- Fibrous Ankylosis: usually results due to trauma and infection
Treatment- trismus appliances in conjunction with physical therapy.

Trismus Appliances:

Indications:
A- Intracapsular (TMJ) pathosis
B- Bony interferences from styloid or coronoid process
C- The presence of foreign body
D- Muscle fibrosis or immature scar tissue

Types Of Trismus Appliances:

A- Externally activated appliances
- Dynamic bite opener
- Threaded, tapered screw
- Screw type mouth gag
- Fingers
- Tongue blades
- Continuous-dynamic jaw extension apparatus.

B- Internally activated appliances

- Tongue blades
- Plastic tapered cylinder

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2. Extra-Articular Causes:

A- Infection
B- Dental treatment
C- Trauma

D- TMJ Disorders
E- Tumors and Oral care
F- Drug Therapy:
G- Radiotherapy and Chemotherapy
H- Congenital / Developmental Causes:
I- Miscellaneous disorders

A- Infection
Odontogenic- Pulpal
- Periodontal
- Pericoronal

Non-Odontogenic- Peritonsillar abscess
- Tetanus
- Meningitis
- Brain abscess
- Parotid abscess

The hallmark of a masticatory space infection is trismus. Or infection in anterior compartment of lateral pharyngeal space results in trismus. If these infections are unchecked, can spread to various facial spaces of the head & neck and lead to serious complications such as cervical cellulitis/ mediastinitis.
Treatment- Elimination of etiologic agent along with antibiotic coverage

Trismus or lock jaw due to masseter muscle spasm, can be a primary presenting symptom in tetanus, Caused by clostridium tetani, where tetanospasmin (toxin) is responsible for muscle spasms.
Prevention- primary immunization (DPT)

B- Trismus Related To Dental Procedure:
Oral surgical procedures- extraction of lower molar teeth may cause trismus as a result either of inflammation involving muscles of mastication or direct trauma to the TMJ
Inaccurate positioning of the needle when giving inferior alveolar nerve block before extraction
Barbing of needles at the time of injection followed by tissue damage on withdrawal of the barbed needle causes post-injection persistent paresthesia, trismus and paresis
Treatment- in acute phase
Heat therapy
Analgesics
A soft diet
Muscle relaxants (if necessary)
When acute phase is over the patient should be advised to initiate physiotherapy for opening and closing mouth.

C- Trauma:
Fractures, particularly those of the mandible and Fractures of zygomatic arch and zygomatic arch complex,Accidental incorporation of foreign bodies due to external traumatic injury
Treatment- fracture reduction, removal of foreign bodies with antibiotic coverage

D- TMJ Disorders:
Extra capsular disorders – myofacial pain
Intra capsular problems – disc displacement, arthritis, fibrosis etc
Acute closed locked conditions – displaced meniscus

E- Tumors And Oral Malignancies:
Rarely, trismus is a symptom of nasopharyngeal or infra temporal tumors/ fibrosis of temporalis tendon, when patient has limited mouth opening, always pre malignant conditions like oral sub mucous fibrosis (OSMF) should also be considered in differential diagnosis

F. Drug Therapy:
Succinyl choline, phenothiazines and tricyclic antidepressants causes trismus as a secondary effect. Trismus can be seen as an extra-pyramidal side-effect of metaclopromide, phenothiazines and other medications.

G. Radiology / Chemotherapy:

- Complications of Radiotherapy:
1. Osteoradionecrosis may result in pain, trismus, suppuration and occasionally a foul smelling wound.
2. When muscles of mastication are within the field of radiation, it leads to fibrosis and result in decreased mouth opening.
- Complications of Chemotherapy:

Oral mucosal cells have high growth rate and are susceptible to the toxic effects of chemotherapy, which lead to stomatitis.

H. Congenital / Developmental Causes:
Hypertrophy of coronoid process causes interference of coronoid against the anteromedial margin of the zygomatic arch.
Treatment-Roronoidectomy
Trismus-pseudo-camtodactyly syndrome is a rare combination of hand, foot and mouth abnormalities and trismus.

I. Miscellaneous disorders
- Hysteric patients: Through the mechanisms of conversion, the emotional conflict are converted into a physical symptom. Eg: trismus

- Scleroderma: A condition marked by edema and induration of the skin involving facial region can cause trismus

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Camphorquinone (CQ)

 - It is a photo-initiator that triggers polymerization of light-curing materials such as dental adhesives and composites.
- CQ does not become a part of the polymer network, suggesting that CQ can be leached out into surrounding environment including dental pulp and exert adversary effects on tissues.
- CQ treatment increases the levels of proinflammatory cytokines (eg, interleukin 6, interleukin 8, and matrix metalloproteinase-3 [MMP3].
- CQ also inhibits odontogenic differentiation and mineralization capacities of DPSC and MC3T3-E1 cells.
- CQ may trigger pulpal inflammation.
- Yellow coloured CQ influences the colour of the composite.
- Amines (Part of the CQ structure) also form by-products during photoreaction and can tend to cause yellow or brownish discolourations under the influence of heat or light.
- The researchers tried to solve the CQ's aesthetics, biocompatibility and toxicity issues, so that they decided to substitute the "simple amines" with polymeric or macromolecular amines.
- CQ can be replaced by polymeric radical photoinitiators carrying the photosensitive CQ groups in the side chain.
- Acylphosphine oxides such as Lucirin TPO are the most common available used commercial products.

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Dental Abscess

Definition:
Abscess is a (semi) liquid collection of pus lined by granulation tissue (if acute) or granulation tissue and fibrosis (if chronic).

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Pathological features:
- Contain PMNs/macrophages, lymphocytes (live and dead), bacteria (dead and viable), and liquefied tissue substances.
- May lead to rupture (‘pointing’), discharge into another organ (fistula formation), or opening onto an epithelial surface (sinus) .
- Incomplete treatment due to resistant organisms (myocbacteria) or poor treatment may lead to a chronic abscess.
- Complete elimination of the organisms in a chronic abscess without drainage can lead to a ‘sterile’ abscess (‘anti-bioma’).

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Typical causes:
- Suppuration of tissue infection (e.g. renal abscess from pyelonephritis).
- Contained infected collections (e.g. subphrenic abscesses).
- Haematogenous spread during bacteraemias (e.g. cerebral abscesses).

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Diagnosis:
Deep abscesses are characterized by swinging fever, rigors, high WCC, and i CRP. Untreated they lead to catabolism, weight loss, and a falling serum albumin. Ultrasound, CT, MRI, or isotope studies may be necessary to confirm the diagnosis.

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Treatment:
- Drain the pus e.g. incision & drainage (perianal abscess), radiologically guided drain (renal abscess), closed surgical drainage (chest empyema), or surgical drainage and debridement (intra-abdominal abscess).
- IV antibiotics (course may be prolonged).

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Amelogenesis Imperfecta

Definition:
Amelogenesis imperfecta is a tooth development disorder in which the teeth are covered with thin, abnormally formed enamel.

Amelogenesis imperfecta presents with abnormal formation of the enamel.
Enamel is composed mostly of mineral, that is formed and regulated by the proteins in it.
Amelogenesis imperfecta is due to the malfunction of the proteins in the enamel: ameloblastin, enamelin, tuftelin and amelogenin.
People afflicted with amelogenesis imperfecta have teeth with abnormal color: yellow, brown or grey.
The teeth have a higher risk for dental cavities and are hypersensitive to temperature changes.
This disorder can affect any number of teeth.

Types:
1- Hypoplastic AI:
Inadequate deposition of enamel matrix.
Enamel matrix present is normal.
Enamel may be "Thin or Pitted".
The thin enamel may be "Smooth or Rough".
Generalized small pits scattered across surface of teeth or localized large area of hypoplastic enamel typically on the buccal middle third of the tooth.
Smooth enamel exhibits a smooth surface which is thin, hard and glossy or rough.
The enamel is more dense than that of smooth pattern.
Most commonly is autosomal dominant inheritance.

2- Hypmaturation AI:
Adequate deposition and mineralization of enamel matrix but inadequate maturation of crystal structure (mineral).
Soft enamel with similar radiodensity to underlying dentin .
Pigmented enamel has mottled , brown appearance .
Snow-Capped Teeth: Zone of opaque white enamel on the incisal / occlusal end of the teeth

3- Hypocalcified :
No mineralization occurs.
Enamel is soft and easily lost.
Enamel is dull, lustreless, opaque white, honey or browned colour.
Enamel and dentin appear radiographically indistinct.

4- hypomaturation hypoplastic:

Causes:
Amelogenesis imperfecta is a hereditary Disorder.

Symptoms:
The teeth enamel become soft and thin.
The teeth appear yellow.
The teeth become easily damaged.
Both baby teeth and permanent teeth are affected.

Differential Diagnosis:
The most common differential diagnosis with the Amelogenesis Imperfecta is the Dental Fluorosis.
- The variability of the fluorosis make it very difficult to differentiate.
- It varies from mild white "flecking" of the enamel to profoundly dense white colouration with random, disfiguring areas of staining and hypoplasia.
- Requires careful questioning to distinguish from Amelogenesis Imperfecta.
- Fluorosis may present with areas of horizontal white banding corresponding to periods of more intense fluoride intake and may show the premolars or second permanent molars to be spared (chronological distribution).
- The history will often reveal excessive fluoride intake either in terms of a habit such as eating toothpaste in childhood, or related to a local water supply.

Treatment:
The treatment depends on the severity of the problem.
The treatment starts from simple composite restorations until a Full crown restorations that will improve the appearance of the teeth and protect them from damage.
Treatment is often successful in protecting the teeth.
The teeth may have to be extracted and implants or dentures are required.
Generally, treatment is veneers , full coverage , overdenture, full denture or extraction and implant.

Complications:
The enamel is easily fractured and damaged, which affects the appearance of the teeth, especially if left untreated.

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Post-Operative Instructions Following Tooth Extraction

When the dentist perform an extraction, healing process after an extraction must be as comfortable as possible.

The removal of teeth is a surgical procedure, and post-operative care is imperative.
Your patient has to follow all instructions carefully to avoid any unnecessary pain and possible infection.
Inform your patient in case of any difficulties or concerns following the extraction, he/she has to call you or return to your clinic for a follow-up exam.

Immediately Following Surgery the instructions are:

1. Place gauze pad over the surgical area with slight pressure by biting down to stop bleeding.
2. Use the prescribed analgesics once the pain starts to raise up.
3. Do not suck on a straw, spit, or smoke.
4. Restrict your activities the day of surgery, and resume normal activity when you feel comfortable.
5. Place ice packs on the side of your face where surgery was performed.
6. For mild discomfort, use Ibuprofen (Advil, Motrin). DO NOT take more than 800mg every 4-6 hours.
7. Vigorous mouth rinsing or touching the affected area following surgery should be avoided. This may initiate bleeding caused by dislodging the blood clot that has formed.
8. Do not rinse your mouth for the first post-operative day or while there is bleeding.
9. After the first day, use a warm salt water rinse every 4 hours and after meals to flush out particles of food and debris that may lodge in the area.
10. Restrict your diet to liquids and soft foods which are comfortable for you to eat.
11- Tell the patient to start brushing teeth from next day, gently in the area of extraction and normally in the rest.

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