Dental preparations before Head and Neck Radiotherapy

- The status of the dentition has a significant effect on post-treatment quality of life among patients with head and neck cancer that will undergo radiation.

- A dentition in poor repair will increase the risk of post-radiation complications, particularly dentoalveolar infections that could lead to osteoradionecrosis.

- All patients who will be treated with RT for oral/head and neck cancer should undergo a comprehensive dental evaluation prior to treatment.

- Carious teeth, teeth with deep restorations or in poor periodontal health, along with partial bony impacted third molars should be extracted prior to RT if in an area that is expected to receive a dose of at least 50 Gy.

- Teeth that are out of the radiation treatment field, but have a hopeless prognosis or is symptomatic should also be extracted.

- Extraction of healthy teeth does not appear to prevent the development of osteoradionecrosis.

- All indicated extractions should be completed prior to RT and primary closure over the extraction sites is preferred if possible.

- An adequate alveoloplasty should be performed to eliminated the possibility of bone edges ulcerating the mucosa as well as to make the mandible/maxilla ready for dentures.

- Ideally, all extractions should be completed approximately two weeks before the commencement of RT to permit proper healing.

- If the extracted teeth are outside of the treatment areas, however, radiation may be started sooner.

- The oral surgeon should attempt to do all the extractions within the portals of radiation at one sitting so as not to delay the cancer treatment.

- Postponing needed extractions of teeth that will be within the treatment area until after radiation is associated with an increased risk of non-healing and osteoradionecrosis.

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Unusual Breath Odors and What They Mean

The most common causes of Malodor (Halitosis) In children:

1- Most often the result of mouth-breathing, which dries out the mouth and allows the bacteria to grow.

2- Children who consistently breathe through their mouths might have colds, sinus infections, allergies, or enlarged tonsils or adenoids blocking the nasal passages, so a visit to the pediatrician is in order.

3- Thumb sucking or sucking on a blanket can also dry out the mouth.

To check other causes of Halitosis

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Here is a list of some very uncommon, but telltale, odors Take a whiff:

● Acetone – diabetes or acetone, alcohol, phenol, or salicylate ingestion
● Ammonia – some types of urinary tract infections, or kidney failure
● Asparagus – eating asparagus (very unusual in children;>))
● Bitter almonds – cyanide poisoning
● Cat’s urine – odor of cats syndrome (beta-methyl-crotonyl-CoA-carboxylase deficiency)
● Celery – Oasthouse urine disease
● Dead fish – stale fish syndrome (trimethylamine oxidase deficiency)
● Fresh-baked bread – typhoid fever
● Foul – tonsillitis, sinusitis, gingivitis, lung abscess, or dental cavities (some of these are actually quite common)
● Garlic – arsenic, phosphorus, organic phosphate insecticides, or thallium poisoning
● Horse-like (also described as mouse-like or musty) – phenylketonuria
● Rancid butter – odor of rancid butter syndrome (hypermethionemia and hypertyrosinemia)
● Raw liver – liver failure
● Sweaty socks – odor of sweaty feet syndrome (Isovalryl CoA dehydrogenase deficiency)
● Sweaty socks – odor of sweaty feet syndrome II (Green acyldehydrogenase deficiency)Violets – turpentine poisoning

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Toothache After Restoration

- Toothache after dental filling is common for most cases and dentists.
- Filling helps prevent further tooth decay and brings the tooth back to its normal function and shape.
- Most people experience mild to severe toothache after a filling treatment.
- The affected tooth may experience sensitivity to air, pressure, sweet foods, cold foods, or temperature after the procedure.

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Remedies for Toothache:

1- Try to avoid things that can cause sensitivity in your tooth.
2- Follow the instructions given by your dentist.
3- It is better to stay away from very hot or very cold beverages.
4- You should avoid eating candy and any type of sticky items after such a dental treatment.
5- After a filling, it is best to eat soft foods for some days as specified by your dentist.
6- Avoid using the tooth that has been filled for chewing.
7- It is extremely important to follow a proper dental care routine ex."Extra brushing or mouth rinsing"
8- Clove oil is one of the most popular and effective toothache remedies.
9- Saltwater mouthwash is a quick remedy for toothache relief.

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Types of Toothache After Filling:

Pain around your fillings:
If you experience pain around the filling, you must consult your dentist again. This can be because the cavity was not filled properly.

Pain when you bite:
You will start feeling pain after the anesthesia wears off and it might continue for some time. If you experience immediate pain when you bite down, it could be because the filling was not shaped properly. When you bite, you put pressure on it. This usually happens when the filling is interfering with your bite, i.e. the filling is above your tooth level and touching the upper or lower teeth while you try to bite something. You must contact your dentist and have the filling reshaped.

Pain when your teeth touch each other:
This is a distinct pain that occurs when your teeth touch each other. The pain is caused because two different metal surfaces such as the silver amalgam in a newly filled tooth and a silver crown on another tooth touch each other. This pain usually resolves on its own within a short period, but if it's persistent, you must visit a dentist.

Referred toothache:
In this case, you will experience pain or sensitivity in teeth, besides the one that has been filled. If you have this type of pain, then probably there is nothing wrong with the treated tooth and the pain should go away on its own.

Constant toothache:
If the decay was very deep to the pulp of the tooth, then you might have constant toothache, especially while eating, that will last for some weeks even after the filling. This constant toothache indicates that the tissue is no longer healthy and you might have to get a root canal treatment for curing it.

Allergic symptoms after filling:
There might be an allergic reaction to the silver amalgam used in the filling. You will experience itching, skin rashes and other allergy symptoms in this case and the silver filling would have to be replaced with a composite filling. Allergic reactions to silver fillings are rare. The symptoms of amalgam allergy are much similar to those experienced in a skin allergy. These include skin rashes and itching. Getting the filling replaced with composite type of filling is the best solution in this case.

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Toothache after a filling usually subsides after a week or two. Mild toothache is common and you don't even need to opt for an over-the-counter painkiller. However, it is best to avoid eating whatever that causes pain. If toothache doesn't subside within two weeks after the filling or if your teeth have become extremely sensitive, you need to contact your dentist. Most probably your dentist will first recommend a toothpaste for sensitivity or apply a desensitizing agent to the tooth for pain relief. If this does not work, then a root canal treatment might be the solution to eliminate severe toothache.

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Cariosolv - Chemo-mechanical Caries Removal

1- CARIDEX

The chemo-mechanical system for caries removal was published in 1975 by HABIB et al.
It is marketed under the trade name of Caridex.
Chemo-mechanical caries removal uses sodium hypochlorite (NaOCl), a non-specific proteolytic
agent (monoaminobutyric acid) removing organic components at room temperature

2- CARISOLV

Carisolv consists of a red gel and transperant fluid.

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Composition:

- Red gel
glutamic acid,
leucin,
lysine,
sodium chloride,
erythrosine,
water and sodium hydroxide

- Transparent fluid
0.5% sodium hypochlorite

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The chemical action of Carisolv is similar to that of Caridex in softening the carious dentin but leaving the healthy dentin unaffected

In caridex it was shown that, NaOCl was dissolving not only necrotic tissue but also sound dentin.

Instruments:
Special instruments designed to scrape in two or in several directions, which reduce the friction during caries excavation

Mechanical Action:
While mixing amino acids react with sodium hypochloride and forms chloromines.
Chloromines seems to involve the chlorination of partially degraded collagen and the conversion of hydroxyproline to pyrrole-2-carboxylic acid, which initiates disruption of altered collagen fibres in carious dentin.

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Denture Reline and Rebase

Introduction:

A reline is a procedure used to re-fit the surface of a denture to the tissues of the mouth.
This is done by placing a new acrylic base into the denture, duplicating the new form of the oral structures in the mouth.
A reline will bring back comfort to the patient, stability to the denture and discourage food from going underneath it.
Relines are required for many reasons with the most common reason being gum resorption (shrinking of the oral tissues).
Gum resorption is caused by the normal process of aging or after natural teeth have been extracted.
A general rule of thumb is that dentures should be relined once every 2 to 3 years.
Relines are a normal part of denture maintenance and important to the health of the oral tissues and bone support of a denture wearer.
A reline is not always recommended for a denture, If a denture has lost some retention and the "bite" or occlusion has changed considerably, a reline will not be satisfactory in correcting the retention of this denture.

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Types of Relines:

A- Temporary Reline:
A temporary reline (tissue conditioner) is a silicone gel designed to last 1 to 4 months.
It is normally used in dentures of people who have had their natural teeth extracted or to improve the health of their tissues before new dentures are made.

B- Direct Reline:
A direct reline is also called a chair side reline.
The direct reline material is inserted in the denture and sets in the mouth as the patient waits in the dental chair.
The direct reline is offered in a hard or soft base, and are not meant as a long term solution to fit issues.

C- Processed Reline:
A processed reline is completed by taking an impression inside of the patient's existing denture duplicating the new form of the oral structures in the mouth.
This impression is then processed in our in-house laboratory for approximately 7 hours.
This is considered a permanent reline due to the high quality of material used and the precision of the fit achieved.

D- Soft Reline:
A soft liner is used mainly in full lower dentures and allows for more protection and comfort for people who have sensitive gums with little or no bone support.
The soft base is a liner that is bonded into your denture.
Your denture will adhere better to what remains of your gum, be less irritating to your tissues and give your denture more stability.
When constructing a denture, the Prosthodontist will take an impression for the soft base and process it into the inside of the denture.
The Soft liner material is a bonded medical grade rubberized base.
Soft liners will last approximately 2 years.
Remember: relines do not change the color or shape of the teeth or make them sharper for chewing, A reline replaces the fitting surface of the denture to make it fit better.

E- Rebase
A rebase is the process of refitting a denture by replacing the entire denture base.
This procedure is done by taking a new impression inside the denture, completely removing the old acrylic and adding a new acrylic base around the existing teeth.
This service is recommended for dentures that have had multiple repairs, discoloration or are very thin.

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Wilckodontics (Accelerated Osteogenic Orthodontics)

- Wilckodontics, also known as Accelerated Osteogenic Orthodontics, involves a periodontal procedure combined with orthodontics to reach end results of straight teeth 3 to 4 times faster than conventional orthodontic treatment.

- In the 1950s, periodontists were using corticotomy procedures to increase the rate of tooth movement. An oral corticotomy is a type of surgery where cuts are made in the jaw bone that surrounds and supports your teeth, called the alveolar bone.

- In the 1990s, the Drs. Wilcko, using CT scans, concluded that a marked reduction in mineralization of the Alveolar bone was the reason for the accelerated tooth movement following corticotomies.

- In 1995, Drs. Wilcko patented the AOO (Accelerated Osteogenic Orthodontics) technique.Unlike a usual corticotomy, AOO doesn’t just cut into the bone, but decorticates it.

- Brief about AOO steps:

1- That is, some of the bone’s external surface is removed.

2- The bone then goes through a phase known as osteopenia, where its mineral content is temporarily decreased.

3- The tissues of the Alveolar bone release rich deposits of calcium, and new bone begins to mineralize in about 20 to 55 days.

4- While the bone is in this transient state, braces can move your teeth very quickly, because the bone is softer and there is less resistance to the force of the braces.

-Research has shown that the results of AOO are as stable and long-lasting as conventional orthodontic braces. There seems to be more Alveolar bone present in patients who have undergone AOO, compared to before surgery, which is advantageous if your profile needs to be built up to improve your facial aesthetics.

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Advantages of AOO:
1- Shortened treatment time (3-4 times).
2- Decreased chance of root resorption following orthodontics * Increased Alveolar bone providing better support for your teeth and facial profile.
3- Less likelihood for relapse.
4- You can choose from metal, ceramic, or gold brackets, or even Invisalign.
5- Since teeth are moving through a softened bone, there is less discomfort associated with teeth movement (following each orthodontic adjustment) compared to traditional orthodontics.

Disadvantages of AOO:
1- More expensive than conventional braces.
2- Being a mildly invasive surgery, it has its risks.
3- Expect some swelling and tenderness immediately after surgery.
4- Need to recover for a week and must stay away from school or work.

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Branches of Maxillary nerve

Branches of Maxillary nerve

1. Middle meningeal nerve
2. Twiges to the sphenopalatine ganglion
3. Posterior superior alveolar nerve
4. Zygomatic nerve
5. Infra-Orbital Nerve
---- 5.A. Middle superior alveolar nerve
---- 5.B. Anterior superior alveolar nerve
---- 5.C. Terminal branches
--------- 5.C.1. Inferior palpebral nerve
--------- 5.C.2. External nasal nerve
--------- 5.C.3. Superior labial nerve

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3. Posterior Superior Alveolar Nerve
supplies
1- The Pulp
2- The Investing structures
3- The buccal mucoperiosteum of Upper Molars except MB root of 1st molar.

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4. The Zygomatic Nerve
Divides into two branches:
1- Zygomatico-Tempopral
2- Zygomatico-Facial

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5. The Infra-Orbital Nerve
Divides into:
1- The Middle Superior Alveolar Nerve
2- The Anterior Superior Alveolar Nerve
3- Terminal branches (Inferior Palpebral nerve - External Nasal Nerve - Superior Labial Nerve)

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5.A. Middle Superior Alveolar Nerve
Supplies
1- Pulp
2- Investing structures
3- buccal mucoperiosteum of Premolars & MB root of 1st molar

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5.B. Anterior superior alveolar nerve
Supplies
1- Pulp
2- Investing structures
3- labial mucoperiosteum of anterior teeth

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- Sphenopalatine Ganglion
Braches into:
1- Orbital nerve
2- Nasal nerve
3- Palatine nerve
4- Pharyngeal nerve

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- The greater (anterior) palatine nerve
Supplies palatal mucoperiosteum of maxillary molars & premolars

- The lesser ( posterior ) palatine nerve
supplies uvula, soft palate & posterior part of the hard palate

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- Nasal Branches
1- Long sphenopalatine nerve (nasopalatine nerve) - supplies palatal mucoperiosteum of maxillary anterior teeth
2- Short sphenopalatine nerve

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Read More About

- Innervations of the Mandibular teeth

- Branches of Mandibular nerve
- Innervations of the Maxillary teeth

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Innervations of the Maxillary teeth

Buccal Aspect: (pulp, investing structures and the buccal mucoperiosteum)

1- Posterior superior alveolar nerve supplies the maxillary third, second and the first molars except the mesiobuccal root of the first molar
2- Middle superior alveolar nerve supplies mesiobuccal root of the first molar, and the maxillary premolars
3- Anterior superior alveolar nerve supplies the anterior teeth

Palatal Aspect

1- The greater (anterior) palatine nerve It supplies the palatal mucoperiosteum opposite to the maxillary molars, premolars and canine.
2- The nasopalatine nerve It supplies the palatal mucoperiosteum opposite to the anterior region (including the canine)

Note: The accessory innervation of the Maxillary teeth is The upper anterior teeth cross innervation (Anterior Superior Alveolar Nerve crosses the midline from one side to another)

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Read More About

- Innervations of the Mandibular teeth

- Branches of Mandibular nerve

- Branches of Maxillary nerve

--------------------------

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Innervations of the Mandibular teeth

Inferior Alveolar nerve
It supplies the pulp and the investing structures of the Mandibular molars, Premolars and Anterior teeth

Lingual nerve
It supplies the lingual mucoperiosteum of all the lower teeth, anterior two thirds of the tongue and the floor of the mouth.

The long Buccal nerve
It supplies the buccal mucoperiosteum opposite to the lower molars.

Note: The accessory innervation of the Mandibular teeth is
1- The lower anterior teeth cross innervation (Incisive Nerve crosses the midline from one side to another).
2- The lower premolar may receive additional nerve supply from the cutaneous coli nerve (branch from the cervical plexus of nerves) for their labial mucoperiostieum.
3- The lower molars may receive additional nerve supply from the nerve to mylohyoid for the pulp and investing structures.

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Read More About

- Branches of Mandibular nerve

- Branches of Maxillary nerve
- Innervations of the Maxillary teeth

--------------------------

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Branches of Mandibular nerve

Innervations of the Mandibular Nerve

1. Main Trunk
2. Nervous Spimosum
3. Nerve to medial pterygoid
4. Anterior Division
---- 4.A. N. to Temporalis msc.
---- 4.B. N. to Massetter msc.
---- 4.C. N. to Lateral Pterygoid msc.
---- 4.D. Long Buccal N.
5. Posterior Division
---- 5.A. Auriculo-temporal N.
---- 5.B. Lingual Nerve
---- 5.C. Inferior Alveolar N.

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Sensory braches of Mandibular nerve
1. Nervous spinosum nerve (trunk)
2. Long buccal nerve ( Ant. division)
3. Auriculo-Temporal nerve
---- 3.A- Parotid branch
---- 3.B- Articular branch
---- 3.C- Auricular branch
---- 3.D- Temporal branch
---- 3.E- Terminal branch
4. Lingual nerve ( post. division)
5. Inferior alveolar nerve (Incisive nerve - Mental nerve)
---- 5.A- Mylohyoid nerve
---- 5.B- Mental nerve
---- 5-C Incisive nerve

Motor braches of Mandibular nerve
1. Nerve to medial pterygoid muscle
2. Nerve to tensor palatini muscle
3. Nerve to tensor tympani muscle
4. Nerve to lateral pterygoid muscle
5. Nerve to masseter muscle
6. Nerve to temporalis muscle
7. Nerve to mylohyoid muscle
8. Nerve to anterior belly of digastric muscle

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Long Buccal Nerve:
Supplies
1- M.M. of the cheek Except the posterosuperior area which receive sensory fibers from posterior superior alveolar nerve
2- Skin of the cheek
3- M.M. of the lower buccal vestibule
4- Buccal mucoperiosteum of the lower molars

The Lingual Nerve:
Supplies
1- M.M. of the ant. 2/3 of the tongue
2- M.M. of the floor of the mouth
3- M.M. of the lateral lingual vestibule
4- Lingual mucoperiosteum of the all lower teeth

Mylohyoid nerve:
Supplies:
1- Motor Fibers supplies the (Mylohyoid muscle - Anterior belly of digastric muscles)
2- Sensory fibers supply the (Skin of the anterior & inferior surfaces of the mental protuberance)

Mental nerve: supplies the (Skin of the chin - Skin of the lower lip - M.M. of the lower lip)

Incisive nerve: Supplies (pulp & investing structures of the lower anterior teeth)

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Read More About

- Innervations of the Mandibular teeth

- Branches of Maxillary nerve
- Innervations of the Maxillary teeth

---------------------------

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Wisdom Teeth Pain and Other Common Symptoms

Why Do We Get Problems With Wisdom Teeth ?

Wisdom teeth pain symptoms, caused by their ‘impaction’, are a common problem. These ‘third molars’ are the last teeth to erupt into the mouth. There are usually four, one in each corner of the mouth at the back. They most commonly appear between the ages of 17 and 24, but can also erupt much later.

Symptoms are common here as they are the last molars to enter the mouth, there is often not enough space for them to fully come through. Therefore they may only partially erupt into the mouth or not come through at all.

When there is enough room, they will come through into the mouth normally and act as any other tooth. There may be some problems including dental pain as they are growing in, (you may thus occasionally need some mild pain relief – such as acetaminophen, paracetamol) but this will clear up once the tooth finds its final position.
Pain and other symptoms can arise when there is not sufficient room in the mouth. The tooth may become impacted ...

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What is an Impacted Wisdom Tooth ?

A tooth is described as impacted if it is blocked from erupting into the mouth fully. 

Thus it will lie at an angle instead of being upright, remaining tipped against the tooth in front of it.

Technically, any tooth can become impacted but it is wisdom teeth that are the most often affected, owing to their late eruption.
Impacted teeth can cause a range of problems, but it should also be noted that they may cause no problems at all.

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What Symptoms Might I Get ?

Minor Symptoms:

When a wisdom tooth is problematic symptoms may include:

- Pain and swelling of the gum overlying the impaction – this is due either infection of this operculum or trauma from the tooth above hitting into it, or a combination of both. For example, a swelling that arises from infection may make the upper tooth impinge onto the gum – traumatizing it more and causing a vicious cycle.

- Bad breath, due to infection and/or debris building up in the area.
- A bad taste in the mouth, for the same reasons.
- Pus coming out from the swollen gum area.
- Aches when you open your mouth, as you are stretching the inflamed tissues.
- Difficulty on opening your mouth.
- Tenderness when chewing or biting as this hurts the swollen gum area.
- Pain/ulcers on the inner cheek, where the pointy parts (cusps) of the impacted teeth may be digging into the soft tissues of the cheeks.
- Ear-ache, as pain can spread outward from the area.

The symptoms can occur for a few days and then clear up. It can then come back at any time, often with weeks or months between occurrences.

More Serious Symptoms:

More serious symptoms can develop:
Watch out for these signs, and note that they may develop quite quickly:
- Swollen glands under the chin (‘lymph nodes’).
- Swelling of the face and jaw, may indicate cellulitis.
- Muscle spasms in the jaw.
- Fever and general malaise.
- Such symptoms may indicate a severe, spreading infection which can be very serious if left untreated. - - --- Immediate advice should be sought from your dentist.

The cause of these problems is that when a wisdom tooth is impacted, a flap of gum will lie over it. As it is difficult to clean effectively under the gum flap, bacteria will proliferate here and the gum will become inflamed. This inflammation is known as ‘pericoronitis’.
Pericoronitis is usually relatively easy to remedy, as it usually remains localized. It is when it becomes a recurring problem (or if it ever gives rise to dangerous symptoms like those above) that extraction must be considered.

An impacted tooth can also be present in the mouth without you even knowing about it, because it may not be causing any symptoms. 

However other problems can also be associated with impacted wisdom teeth.
They are prone to decay. This is because food can trap around them and they are difficult to clean. 

The tooth lying beside will also be at increased risk of decay for the same reason.

The tooth may become sensitive and/or painful.
Likewise, the area is more prone to gum disease for similar reasons: it is difficult to clean.
Rarely, cysts and other such growths may form around an impacted tooth.
Therefore even when they aren't causing pain, or other noticeable symptoms, they should be checked regularly. 

Your dentist can make sure that all is well in the area, or if any damage begins to occur then the situation can be remedied sooner rather than later.

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Prevention of Symptoms:

The cleaner the area and your mouth in general is kept, the less likely that pericoronitis and other problems will occur.
Therefore general oral hygiene measures should be adhered to, including flossing in the area of the wisdom tooth and regular use of mouthwashes.

Your dentist can guide you on this.

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Significant Lab Tests in Dentistry

Hematological Tests:
1- CBC: Complete Blood Count with platelets and WBC differential.
2- ESR: Erythrocyte Sedimentation RAte
3- P.T./I.N.R: Prothrombin Time/International Normalized Ratio
4- P.T.T: Partial Thromboplastin Time

Renal Assessment Tests:
1- Serum creatinine (S. Cr.)
2- Blood Urea Nitrogen (BUN)

Diabetes Assessment Tests:
1- FBS: Fasting Blood Sugar
2- PPBS: Post Prandial/ Post Meal Blood Sugar
1- HbA1C: Hemoglobin A1C

Liver Assessment Tests:
1- Hepatic Serology
2- Liver Function Tests (LFTs)

Bone Assessment Tests:
1- Serum Calcium (Ca2+)
2- Serum Phosphorus (PO4)
3- Alkaline Phosphate (AlkP)

HIV/AIDS Status Assessment Tests:
1- CD4 Count & Viral Load (HIV RNA)
2- CBC w/Pits. & WBC Diff.
3- LFTs: Liver Function Tests
4- PT/INR: Prothrombin Time/International Normalized Ratio

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Schirmer's test

- Definition:

Schirmer's test determines whether the eye produces enough tears to keep it moist. 

This test is used when a person experiences very dry eyes or excessive watering of the eyes. 

It poses no risk to the subject. 

A negative (more than 10 mm of moisture on the filter paper in 5 minutes) test result is normal. 

Both eyes normally secrete the same amount of tears.

It is named for Otto Schirmer.

- Conditions:

Dry eyes can occur from conditions such as:

● Aging

● Dehydration

● Corneal ulcers and

● infections Eye infections (for example conjunctivitis)

● Vitamin A deficiency

● Sjögren's syndrome

● Secondary tearing deficiency (associated with disorders such as - lymphoma, leukemia, GVHD (graft vs. host disease, after a transplant), andrheumatoid arthritis)

● As a temporary or permanent side effect of LASER vision correction surgery such as LASIK or PRKThe inability of tears to drain into the nose can occur with:Some eye infections Blockage of the tear duct

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