Ellis classification (Tooth fractures)

Ellis classification (Tooth fractures)

Ellis Class I Enamel fracture: This level of injury includes crown fractures that extend through the enamel only. These teeth are usually nontender and without visible color change but have rough edges. Ellis Class II Enamel and dentin fracture without pulp exposure: Injuries in this category are fractures that involve the enamel as well as the dentin layer. These teeth are typically tender to the touch and to air exposure. A yellow layer of dentin may be visible on examination. Ellis Class III Crown fracture with pulp exposure: These fractures involve the enamel, dentin, and pulp layers. These teeth are tender (similar to those in the Ellis II category) and have a visible area of pink, red, or even blood at the center of the tooth. Ellis Class IV Traumatized tooth that has become non-vital with or without loss of tooth structure. Ellis Class V Luxation: The effect on the tooth that tends to dislocate the tooth from the alveolus. Teeth loss due to trauma. Ellis Class VI Avulsion: The complete separation of a tooth from its alveolus by traumatic injury. Fracture of root with or without loss of crown structure. Ellis Class VII Displacement of a tooth without the fracture of crown or root. Ellis Class VIII Fracture of the crown en masse and its replacement. Ellis Class IX Fracture of deciduous teeth. ------------------------------------ This Article has been edited By :: World Of Dentistry :: TEAM For any questions and suggestions please don't be hesitate to feedback us. Yours, :: World Of Dentistry :: TEAM

The Ideal Teeth Access Cavity Preparations for RCT (Root Canal Treatment)

The correct access preparation for RCT is as follows:

Upper Teeth:

central Incisors : triangular

lateral Incisors: ovoid

canines: ovoid

first premolars: ovoid

second premolars: ovoid

first molars: triangle

second molars: triangle

Lower Teeth:

central Incisors: ovoid

lateral Incisors: ovoid

canines: ovoid

first premolars: ovoid

second premolars: ovoid

first molars: triangle or trapezoid

second molars: triangle or trapezoid

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Blue Sclera "Definition and Diseases"

Definition:

Blue sclera is characterized by localized or generalized blue coloration of sclera because of thinness and loss of water content, which allow underlying dark choroid to be seen.

Diseases and Disorders:

1. Associated with high urine excretion:A. Folling syndrome (phenylketonuria)
B. Hypophosphatasia (phosphoethanolaminuria)
C. Lowe syndrome (oculocerebrorenal syndrome; chondroitin-4-sulfate-uria)

2. Associated with skeletal disorders:A. Brachmann-de Lange syndrome
B. Brittle cornea syndrome (blue sclera syndrome)-recessive
C. Crouzon disease (craniofacial dysostosis)
D. Hallermann-Streiff syndrome (dyscephalia mandibulooculofacial syndrome)
E. Marfan syndrome (dystrophia mesodermalis congenita)
F. Marshall-Smith syndrome
G. McCune-Albright syndrome (fibrosus dysplasia)
H. Mucopolysaccharidosis VI (Maroteaux-Lamy syndrome)
I. Osteogenesis imperfecta (van der Hoeve syndrome)
J. Paget syndrome (osteitis deformans)
K. Pierre Robin syndrome (micrognathia-glossoptosis syndrome)
L. Robert syndrome
M. Silver-Russell syndrome
N. Werner syndrome (progeria of adults)

3. Chromosome disorders:A. Trisomy syndrome
B. Turner syndrome

4. Ocular:A. Congenital glaucoma
B. Myopia
C. Repeated surgeries
D. Scleromalacia (perforans)
E. Staphyloma
F. Trauma

5. Miscellaneous:A. Ehlers-Danlos syndrome (fibrodysplasia elastica generalisata)
B. Goltz syndrome (focal dermal hypoplasia syndrome)
C. Incontinentia pigmenti (Bloch-Sulzberger syndrome)
D. Lax ligament syndrome
E. Minocycline-induced
F. Oculodermal melanocytosis (nevus of Ota)
G. Pseudoxanthoma elasticum (Grönblad-Strandberg syndrome)
H. Relapsing polychondritis

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Rarefaction (Definition and Examples)

Definition: A decreased density of bone such as a decrease in weight per unit of volume

Examples of Systemic diseases causing generalized jaw rarefaction

1- Rickets/Osteomalacia
2- Sickle Cell Anemia
3- Cushing syndrome
4- Hypophosphatasia
5- Hypophosphatemia
6- Massive osteolysis (vanishing bone disease)
7- Osteoporosis

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Medical Complications in Pregnancy

* Many changes occurs to female body during the pregnancy period, due to the hormonal changing:

* Some of the medical complications of pregnancy can include:

1- Hypertension:
- Very common and blood pressured becomes 140/90 mm Hg or greater.

- Hypertention is a dangerous complication that may effect both fetus and mother.
- Hypertensive pregnant women must rest as much as possible and treated with anti-hypertensive treatment.

2- Blood Hypercoagulability:
- Excessive thickening of blood, which can lead to venous thrombosis (occlusion of blood vessels),
- Disseminated Intravascular Coagulopathy (A rare, life-threatening condition that prevents a person’s blood from clotting normally).

3- Anemia:

- A deficiency of red blood cells. 

- Expansion of the blood volume may cause an apparent anemia but in about 20%.

- True anemia develops, mainly because of fetal demands for iron and folate.

- Pregnancy may complicate a pre-existing Anemias, especially the Sickle Cell Anemia.

4- Supine Hypotension Syndrome.

- In later pregnancy up to 10% of female patients may become hypotensive, if laid in supine position for 3 to 7 mins, when the gravid uterus compresses the Inferior Vena Cava and impedes blood return to the heart and may lead to syncope.

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Phlebitis and Thrombophlebitis

Definition:
Phlebitis means inflammation of a vein. TP ( Thrombophlebitis ) is the term used when a blood clot in the vein causes the inflammation. TP usually occurs in leg veins, but it may occur in an arm. The thrombus (clot) in the vein causes pain and irritation and may block blood flow in the veins. Phlebitis can occur in both the surface (superficial) or deep veins.

Sign and Symptoms:
1- Pain
2- Tenderness
3- Edema
4- Erythema
5- Streaking of The Limb

Ideal Treatment: 
1- Remove of the IV Catheter.
2- Elevate the Affected Limb.
3- Apply Warm, Moist Packs to the infected site.
4- Initiate IV Antibiotics.

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Oral Side-Effects of Chemotherapy

The most common oral complications observed after chemotherapy are mucositis, infections, neurological and dental alterations, dysgeusia, hyposialia and xerostomia (dry mouth), bleeding tendency, and the development of osteonecrosis. The soft tissues of the lips, the oral mucosa, tongue, soft palate and the pharyngeal mucosa are the most affected areas.

1- Mucositis:
- Mucositis is an inflammatory reaction of the mucosal membranes secondary to antineoplastic treatments such as radiotherapy (in 80% of the cases) and chemotherapy as treatment for solid tumors or lymphomas (in approximately 40-50%, particularly with the cytostatic agent 5-fluorouracil) or as conditioning treatment for bone marrow transplantation (in over 75% of the patients).
- Mucositis is regarded as a manifestation of leukopenia.
- The mechanism by which mucositis develops is not clear, though it is generally attributed to the fact that the oral mucosal cells have a relatively high mitotic rate, thereby establishing them as targets of the action of cytostatic agents.
- Mucositis usually appears 4-7 days after the start of highdose chemotherapy, and is of a self-limiting nature (provided Over-infection does not occur). It in turn disappears 2-4 weeks after the conclusion of cytotoxic chemotherapy.
- The drugs most often associated with the development of mucositis are doxorubicin, bleomycin, fluorouracil and methotrexate.

- Clinically, the condition manifests as erythema, edema or ulceration, with severe pain, bleeding and potential side effects such as xerostomia, the risk of both local (overinfection due to Candida) and systemic infection, malnutrition, fatigue, dental caries and gastrointestinal disorders over time.

2- Oral infections:
The main infectious processes are the following:

1. Bacterial infections: These are usually caused by gram-negative organisms. Signs of inflammation may be masked as a result of the underlying bone marrow suppression; consequently, oral hygiene protocols that reduce microbial colonization of the dentition and periodontium are important during the period of bone marrow suppression.

2. Fungal infections: Bone marrow suppression, oral mucosal lesions and salivary alterations contribute to the development of Candida albicans infection. The most common presentations are pseudomembranous candidiasis, followed by erythematous candidiasis. The treatment of these conditions involves the use of topical and/or systemic antifungal agents (Table 2) complemented with an antiseptic (chlorhexidine). The latter should be used at least 30 minutes before or after nystatin, since the combination of both may prove ineffective. In the case of more severe infections, the recommendation is a systemic antifungal such as fluconazole or ketoconazole.
The efficacy of such treatment is limited, and resistances may appear. In such cases intravenous amphotericin B or itraconazole via the oral route at a dose of 200-400 mg/day tend to be the drugs of choice.

3. Viral infections: In most cases, infections due to herpes simplex virus (HSV), varicella-zoster virus (VZV) and Epstein-Barr virus (EBV) are the result of the reactivation of a latent virus, while infections due to cytomegalovirus (CMV) can result from the reactivation of a latent virus or from a recently acquired virus.

- Infection due to HSV: The severity of the lesions increases drastically with the degree of immune suppression.
The treatment of HSV infection consists of the administration of 400-800 mg of aciclovir via the oral route 5 times a day or of 5-10 mg/kg via the intravenous route every 8-12 hours, for as long as the lesions persist.

- Infection due to VZV: Immune compromised patients may present involvement of several dermatomes, or alternatively the lesions may show a more generalized distribution, generally manifesting several weeks after the interruption of chemotherapy – in contrast to the situation with HSV.

A number of antiviral agents are used as treatment, depending on the degree of immune suppression of the patient and the resistances to these drugs (Table 2).

- Infection due to CMV and EBV: Lesions produced by CMV are characterized by the presence of multiple mild or moderate ulcerations with irregular margins. The initial lesions appear during the first periods of bone marrow regeneration and are characterized by nonspecific pseudomembranous ulcers covered by a fibrin exudate with a granulomatous base.

At present, ganciclovir is the treatment of choice for acute CMV infection. The risk of EBV infection usually manifests months after the interruption of myeloablative therapy used for transplant conditioning.

3- Neurotoxicity:
- A number of chemotherapeutic agents such as vincristine and vinblastine are able to cause direct neurotoxicity.
- Patients may experience deep and palpitating mandibular pain that tends to subside one week after concluding chemotherapy.

- A correct anamnesis is required, together with oral exploration and an X-ray study in order to distinguish such pain from pain of pulp origin.

- In some cases, dental hypersensitivity may appear weeks or months after the end of chemotherapy; in these cases, the topical application of fluoride or the use of a desensitizing toothpaste may help lessen the symptoms.

4- Dysgeusia:
- During chemotherapy, patients may experience an unpleasant metallic taste due to diffusion of the chemotherapeutic agent into the oral cavity.

- Dysgeusia as such initially manifests a few weeks after starting cytotoxic treatment, and is generally reversible within a few weeks.

5- Hyposialia and xerostomia:
- Hyposialia, attributable to the effect of chemotherapy upon the cells of the salivary glands, is transient and reversible.

- It appears particularly with the use of adriamycin, and can cause oral functional problems, especially in relation to speech and mastication. 

- These patients show alterations in the salivary components, with an increase in the levels of peroxidase and amylase, a reduction in total secreted immunoglobulins A and G, and the presence of the chemotherapeutic drug itself. all these factors favor the development of mucositis.
- As a result, patients should drink abundant water and use sugar-free sweets or chewing gum to increase salivation.
- In more moderate cases, sialogogues such as pilocarpine, bromhexine or bethanechol can be used.

6- Alterations in dental growth and development:
- Unlike radiotherapy, which only affects the cells within the irradiated zone, chemotherapy has a systemic effect.
- As a result, the developing odontogenic cells are susceptible to chemotherapy, even when far removed from the tumor site.

7- Bleeding tendency:
- Bleeding is due to alterations resulting from thrombocytopenia (in turn a consequence of bone marrow aplasia).

- Clinically, patients my present petechiae, ecchymosis, hematomas or diffuse bleeding.

- Rinses with 0.12% chlorhexidine avoid overinfection and can help eliminate the traces of blood, though caution is required in order not to alter the clots, since this could lead to further bleeding. 

8- Osteonecrosis:
- Osteonecrosis of the jaw (ONJ) is observed in patients treated with bisphosphonates (BPs).

- These drugs inhibit bone resorption and are administered via the intravenous route as treatment in application to bone metastases in cancer patients, in malignant hypercalcemia (tumorinduced hypercalcemia), or in patients with multiple myeloma – affording improved survival and quality of life.

- Although much less commonly, ONJ has also been observed in patients receiving treatment with oral bisphosphonates (used for the prevention and treatment of osteoporosis and in certain bone conditions such as Paget’s disease).

- The intravenous BPs most associated with ONJ are zoledronic acid (Zometa®) and pamidronate (Aredia®).
- Clinically, ONJ is typically characterized by pain (progressive and sustained, and sometimes requiring important analgesic doses to secure control – the patient being asymptomatic in the early stages).
- Since the treatment of ONJ is often unsatisfactory, management should aim to afford pain relief, control soft tissue and bone infection, and avoid or reduce the progression of bone necrosis.

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Melkersson-Rosenthal Syndrome

- Definition:
Melkersson-Rosenthal syndrome is a rare neurological disorder characterised by recurring facial paralysis or palsy, swelling of the face and lips (usually the upper lip), and the development of folds and furrows in the tongue.

- Does it develop in childhood ... ?
Onset is in childhood or early adolescence.

After recurrent attacks (ranging from days to years in between), swelling may persist and increase, eventually becoming permanent. 

The lip may become hard and cracked with a reddish-brown discoloration. 

The tongue may develop furrows.

- Causes:
The cause of Melkersson-Rosenthal syndrome is unknown, but there may be a familial link although a gene has not yet been identified.

- Treatment:
Treatment is symptomatic and may include medication therapies with anti-inflammatory medication and corticosteroids to reduce swelling.

Occasionally surgery may be recommended for severe cases to relieve pressure on the facial nerves and to reduce swollen tissue, but its effectiveness has not been established.

Facial Rehabilitation is available from specialist centers where physiotherapists and speech and language therapists specialized in treatment for people with facial palsy. 

The treatment is similar to the treatment for Bell’s palsy although the causes of the two conditions are different.

- Prognosis:
Melkersson-Rosenthal syndrome may recur intermittently after it first appears.

The person will therefore experience intermittent facial weakness which can resolve as the nerve recovers.

It can become a long standing problem as with each attack recovery is less satisfactory.

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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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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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Dental Management of Patients taking Digitalis

Definition:

Digitalis is a Cardiac Glycoside drug prescribed for patients with Congestive Heart Failure (CHF) Or Atrial Fibrillation.

Mechanism of action of Digitalis:
- It binds and Inhibits the Magnesium and Adenosine Triphosphate Dependent Na+ and K+ ATPase.
- The increase the influx of calcium ions.
- Then it Enhances the myocardial contractility.

Contraindications:
- Local Anesthesia with Epinephrine.
- Aspirin (As it decreases Digitalis absorption and displaces it at the protien binding sites).
- NSAIDs (As they decrease renal clearance of Digitalis).
- Macrolides and Tetracycline (As they increase the serum levels of digitalis causing toxicity).

What is safe with Digitalis .... ?
- Anesthesia: Mepivacaine.
- Analgesics: Acetaminophen (Alone, with Codeine, with Hydrocodone Or with Oxycodone)
- Antibiotics: Penicillins, Cephalosporins and Clindamycin.

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Russell-Silver Syndrome

- Definition:

Russell-Silver syndrome is a disorder present at birth involving poor growth. One side of the body also will appear to be larger than the other.

- Causes:
Up to 10% of patients with this syndrome have a defect involving chromosome 7. In other patients, there the syndrome may affect chromosome 11, 15, 17, or 18.
Researchers suspect that at least one third of all cases of Russell-Silver syndrome result from changes in a process called methylation.
Methylation is a chemical reaction that attaches small molecules called methyl groups to certain segments of DNA.
In most patients, the cause is unknown. Most cases occur in people with no family history of the disease.

- Incidence:
The estimated number of people who develop this condition varies greatly. Some say it affects about 1 in 3,000 people. Other reports say it affects 1 in 100,000 people. Males and females are equally affected.

- Symptoms:
Body asymmetry
Coffee-with-milk (cafe-au-lait) birth marks
Curving of the pinky toward the ring finger
Delayed bone age
Failure to thrive
Gastroesophageal reflux disease
Kidney problems, such as:
Horseshoe kidney
Hydronephrosis
Posterior urethral valves
Renal tubular acidosis
Low birth weight
Large head for body size
Poor growth
Short arms
Short height (stature)
Short, stubby fingers and toes
Delayed stomach emptying, and constipation
Wide forehead with a small triangle-shaped face and small, narrow chin

- Signs:
Triangular shaped face in Russell-Silver syndrome patient
Pointed chin that is not fully developed
Thin, wide mouth
Triangle-shaped face with broad forehead

- Tests:
There are no specific laboratory tests to diagnose Russell-Silver syndrome.
Diagnosis is usually based on the judgment of your child’s pediatrician.
However, the following tests may be done:
- Blood Sugar (some children may have low blood glucose)
- Bone Age Testing (bone age is often younger than the child’s actual age)
- Chromosome Testing (may detect a chromosomal problem)
- Growth Hormone (some children may have a deficiency)
- Skeletal Survey (to rule out other conditions that may mimic Russell-Silver syndrome)

- Treatment:
- Growth hormone replacement may help if this hormone is lacking.
- Making sure the person gets enough calories, to prevent low blood sugar and promote growth
- Physical therapy, to improve muscle tone
- Special education, to address learning disabilities and attention deficit problems the child may have

- Prognosis:
Older children and adults do not show typical features as clearly as infants or younger children.
Intelligence may be normal, although the patient may have a learning disability.

- Complications:
- Chewing or speaking difficulty if jaw is very small
- Learning disabilities

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Alveolar Osteitis "Dry Socket"

Definition:
- Inflammation of the alveolar bone (i.e. the alveolar process of the maxilla or mandible). Classically this occurs as a postoperative complication of tooth extraction.
- Occurs more commonly occur in the mandible than the maxilla, due to the relatively poor blood supply of the mandible and also because food debris tends to gather in lower sockets more readily than upper ones.
- It more commonly occurs in posterior sockets (molar teeth) than anterior sockets (premolars and incisors), where the created surgical defect is relatively larger, and because the blood supply is relatively poorer posteriorly.

Etiology:
This usually occurs where the blood clot fails to form or is lost from the socket, this leaves empty socket with bare bone with inflammation limited to the lamina dura "the bone which lines the socket".

Signs and symptoms:
- An empty socket, which is partially or totally devoid of blood clot.
- Bone may be visible or the clot may be filled with food debris which reveals the exposed bone once it is removed.
- Surrounding inflamed soft tissues may overgrow to cover the socket.
- Dull, aching, throbbing pain, which is moderate to severe.
- The pain may radiate to other parts of the head such as the ear, temple and neck.
- Pain starts from 2-4 days after extraction.
- Pain may persist for 10-40 days, but most commonly is 10-14 days with adequate treatment.
- The pain might be strong enough so that no medication can relief.
- Intraoral halitosis.
- Bad Taste.

Causes:
- Extraction site: Wisdom Teeth, specially the mandibular.
- Infection: Pre-existing infection in the mouth, such as necrotizing ulcerative gingivitis, chronic periodontitis or pericoronitis.
- Smoking: Smoking and tobacco use of any kind causes vasoconstriction of small blood vessels due to nicotine action.
- Surgical trauma: Excessive force or excessive tooth movements impair the repairing process causing the Alveolar osteitis.
- Vasoconstrictors: The use of Vasoconstrictors may increase the risk for alveolar osteitis, although it is used in local anesthetic solution to make a profound analgesia to the area, specially the areas of acute pain and inflammation.
- Oral contraceptives
- Radiotherapy: That decreases the blood supply to the area.

Diagnosis:
- Pain occurs 2-4 days after extraction.
- Usually part of a broken root or bone fragment is left in the socket.
- A dental radiograph (x-ray) may be indicated to demonstrate such a suspected fragment.

Prevention:
- Avoid excessive forces.
- Press on the alveolar plates to decrease the size of the socket opening.
- Instruct the patient to avoid cold food, beverages, toothpicks into socket, cleaning socket using the tongue or fingers and vigorous mouth rinsing.
- Rinsing with chlorhexidine (0.12% or 0.2%) or placing chlorhexidine gel (0.2%) in the sockets.
- Prophylactic antibiotics prior and after extraction for 3 days, although it's not recommended.
- Antifibrinolytic agents applied to the socket after the extraction.
- Debride the bony walls of the socket to encourage hemorrhage (bleeding) in the belief that this reduces the incidence of dry socket "there is no evidence to support this practice".
- Schedule extraction appointment for females taking oral contraceptives on days without estrogen supplementation (typically days 23-28 of the menstrual cycle).
- Scaling the teeth to be extracted prior to extraction.

Treatment:
1. Pain medication " Non-Steroidal Anti-Inflammatory Drugs".
2. Rinsing / cleaning the socket "removing any debris from the hole".
3. Applying medicated dressings. "antibacterials, topical anesthetics and obtundants, or combinations of all three"
4- Schedule a recall visiting every 3 days to rinsing and cleaning socket and changing the dressing.
5- Prescribe antibiotic to avoid infection of the socket.
6- Oral Hygiene Instructions.
7- Ask the patient to wash the mouth by water and salt or by prescribing Oral Mouthwash.

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Vitamin Deficiency and effects in Oral Cavity

- Certain vitamin deficiencies can have serious effects on your mouth and teeth.
- If your mouth is sore or your gums are bleeding, you might not be able to eat well. This can make any vitamin deficiencies worse.

- Seniors are more likely to have vitamin deficiencies because they may have problems absorbing nutrients from food.
- Younger people can also have conditions that cause difficulties absorbing nutrients.
- The physician can determine whether patient have a vitamin deficiency and how it should be treated.
- While dentist can identify oral abnormalities and determine whether a vitamin deficiency is the cause.

Here are some vitamin deficiencies that might affect your mouth and teeth.

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Vitamin B
Vitamin B deficiencies are one of the most common deficiencies that can affect mouth and teeth.

Signs and Symptoms:
- Burning sensation in the mouth, especially on the tongue (Most common oral effects).
- Difficulty in swallowing. The tongue may feel swollen.
- The tissue of the inner cheeks can be pale and may break apart easily and slough off.
- B-vitamin deficiencies also can lead to anemia (too few red blood cells).
- Severe B12 deficiency can cause neurological problems such as numb or tingling limbs.
- Folic Acid deficiency also can make your mouth feel like it's burning.and numb or tingling limbs.
- Folic acid is crucial to fetal development as well. Not having enough of this vitamin during early pregnancy can increase the risk of having a baby with neural tube defects. These are defects of the brain, spinal cord or both.

Risks:
- Angular Cheilitis:
A painful inflammation and cracking in the corners of the mouth. It usually is related to a fungal infection.
- Recurrent Aphthous Stomatitis:
Also known as recurring canker sores. Anemia, which can occur because of vitamin B deficiency, can increase your risk of these sores.
- Chronic Oral Mucosal Candidiasis:
A fungal infection in the mouth, caused by the Candida albicans fungus that is found naturally in the mouth. It does not normally cause problems. However, poor nutrition or poor absorption of vitamins drop down host immunity and tend to change the oral flora.
- Atrophic Glossitis:
A condition that causes the taste buds to break down, making the tongue look "bald." This condition affects the sense of taste. It can occur with a severe vitamin deficiency.

Sources of Vitamins B:
- Thiamin (B1): Pork, whole and enriched grains, legumes, nuts, dried beans
- Riboflavin (B2): Milk and milk products, eggs, liver, almonds, shellfish
- Niacin (B3): Protein-rich foods, meat, liver, poultry, fish, whole grains, peanuts
- Pyroxidine (Vitamin B6): Meat, poultry, fish, leafy green vegetables, bananas, whole grains, legumes, nuts, fruits
- Cobalamin (B12): Fish, meat, poultry, milk and milk products, eggs, fortified cereals
- Folic acid (also called folate): Leafy green vegetables, orange juice, legumes, broccoli, asparagus, fortified cereals, nuts

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Iron:

Signs and Symptoms:
- Burning sensation in the mouth and tongue
- Fungal infections in the mouth
- Tongue redness and swelling
- Sores and pale tissue in the mouth
- Iron deficiency can be caused by a poor diet or by intestinal problems that reduce iron absorption. It also can result from regular blood loss, such as from heavy menstrual periods or internal bleeding.
- Iron deficiency can cause anemia.

Sources of Iron:
- Lean meat
- Leafy green vegetables
- Beans
- Shellfish
- Whole-grain bread

N.B: People with significant iron deficiency may have to take iron supplements.

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Vitamin C
- Vitamin C is also called ascorbic acid.
- This vitamin is needed to make collagen, the main building block for many tissues.

Signs and Symptoms:
- Gingivitis.
- Fatigue and easy Bruising.

Sources of Vitamin C:
- Citrus fruits
- Dark green vegetables
- Tomatoes
- Strawberries
- Peppers
- Cantaloupe

N.B: Smoking depletes vitamin C in the body, so smokers need extra amounts of this vitamin.

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Vitamin A:
Vitamin A helps skin cells grow and maintain themselves.

Signs and Symptoms:
- Delayed healing in the mouth.

Sources of Vitamin A:
- Fortified milk
- Liver (chicken, beef)
- Leafy green vegetables
- Orange and yellow fruits and vegetables (such as apricots, cantaloupe, pumpkin, sweet potatoes and carrots)

N.B: Vitamin A can be stored in body fat, so high-dose supplements are not recommended.
They can cause side effects such as joint pain, headache, diarrhea, fatigue, vomiting and liver damage.

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Vitamin D
Vitamin D works with calcium to maintain bone quality and strength.

Signs and Symptoms:
- Brittle Bones.
- Increase the risks of jaw fracture.
- Increase the risks of periodontal disease.
- A deficiency early in life could affect the formation of teeth.

N.B:
- Sometimes people with kidney disease also have vitamin D deficiency.
- The body will make its own vitamin D if it is exposed to sunlight for several minutes two or three times a week.

Sources of Vitamin D:
- Fish liver oils and fish
- Fortified milk and milk products
- Egg yolk
- Some cereals

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Vitamin K
- Normally, vitamin K is made by bacteria in your intestines.
- Vitamin K helps to make proteins that allow the blood to clot.

Signs and Symptoms:
- Easy bruising.
- Slow healing
- Excessive bleeding after extracted
- Excessive bleeding after scaling.

Sources of Vitamin K:
- Brussels sprouts
- Green leafy vegetables
- Broccoli
- Eggs
- Beef

N.B: A vitamin K deficiency may be caused by liver disease, long-term antibiotic use or other disease(s).

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Causes of Halitosis

- Food:
Such as garlic, onions, and spicy foods, exotic spices (such as curry), some cheeses, fish, and acidic beverages such as coffee can leave a lingering smell.
Most of the time this is short-term. Other foods may get stuck in the teeth, promoting the growth of bacteria, which causes bad breath odor.

- Tobacco Products:
Smoking and chewing tobacco can leave chemicals that remain in the mouth.

- Poor Dental Hygiene:
When a person does not brush or floss regularly, food particles remaining in the mouth can rot and cause bad odors. Poor dental care can lead to a buildup of plaque in the mouth, which causes an odor of its own.

- Health Problems:
Such as: Sinus infections, pneumonia, sore throat (pharyngitis) and other throat infections, thrush, bronchitis, post nasal drip, diabetes, acid reflux, lactose intolerance, and some liver or kidney diseases.

- Dry Mouth "Xerostomia":
Saliva helps moisten and cleanse the mouth, and when the body does not produce enough saliva, bad breath may result.
Dry mouth may be caused by salivary gland problems, connective tissue disorders (Sjögren's syndrome), medications, or breathing through the mouth.

- Mouth Infections:
Cavities, gum disease, or impacted teeth may cause bad breath.

- Dentures or Braces:
Food particles not properly cleaned from appliances can rot or cause bacteria and odor.
Loose-fitting dentures may cause sores or infections in the mouth, which can cause bad breath.

- Medications:
Many medications including antihistamines and diuretics can cause dry mouth, which can cause bad breath.
Other medications which may lead to bad breath may include insulin shots, triamterene, and paraldehyde.

- "Morning Breath":
Saliva production nearly stops during sleep, which allows bacteria to grow, causing bad breath.

- Other Causes:
Objects stuck in the nose, alcoholism, and large doses of vitamin supplements.

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Dental Management of Patients with Thyroid Disorders

Introduction:
- Patients who have thyroid disease present a treatment challenge to dentists.
- Awareness of the condition and current stage of treatment is important in understanding the possible modifications needed for dental treatment.
- Length and current state of therapy are important in understanding the metabolic control of patients.
- The main complications of both patients with hyperthyroidism and hypothyroidism are associated with cardiac co-morbidity.
- Other co-morbid conditions are D.M and asthma.
- Consultation with the patient’s primary care physician or an endocrinologist is warranted if any sign or symptom of thyroid disease is noted on examination.
- Dental treatment modifications may be necessary for dental patients who are under medical management and follow-up for a thyroid condition even if there are no co-morbid conditions.
- Stress reduction, awareness of drug side effects or interactions, and vigilance for appearance of signs or symptoms of hormone toxicity are among the responsibilities of the oral health care provider.

Before Treatment:
ASSESSMENT OF THYROID FUNCTION- Establish type of thyroid condition.
- Is there a presence of cardiovascular disease? If yes, assess cardiovascular status.
- Are there symptoms of thyroid disease? If yes, defer elective treatment and consult a physician.
- Obtain baseline thyroid-stimulating hormone, or TSH. Control is indicated by hormone levels, length of therapy and medical monitoring. If the patient has received no medical supervision for more than one year, consult a physician.
- Obtain baseline complete blood count. Give attention to drug-induced leukopenia and anemia.
- Assess medication and interactions with thyroxine and TSH.
- Make proper treatment modifications if the patient is receiving anti-coagulation therapy.
- Take blood pressure and heart rate. If blood pressure is elevated in three different readings or there are signs of tachycardia/bradycardia, defer elective treatment and consult a physician.

During Treatment:
- Oral examination should include salivary glands. Give attention to oral manifestations.- Monitor vital signs during procedure:
■ Is the patient euthyroid? If yes, there is no contraindication to local anesthetic with epinephrine.
■ Use caution with epinephrine if the patient taking non-selective β-blockers.
■ If the patient’s hyperthyroidism is not controlled, avoid epinephrine; only emergent procedures should be performed.
- Minimize stress–appointments should be brief.
- Discontinue treatment if there are symptoms of thyroid disease.
- Make pertinent modifications if end-organ disease is present (diabetes, cardiovascular disease, asthma).

After Treatment:
- Patients who have hypothyroidism are sensitive to central nervous system depressants and barbiturates.- Control pain.
- Use precaution with non-steroidal anti-inflammatory drugs for patients who have hyperthyroidism, avoid aspirin.
- Continue hormone replacement therapy or anti-thyroid drugs as prescribed.

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Papilloma

Description:
- A benign tumor derived from epithelium.papillomatous.
- Cauliflower-like projections that arise from the mucosal surface.
- It may appear white or normal colored.
- It may be pedunculated or sessile.
- The average size is less than 2.0 cm.
- No strong sex preference.
- The most common site was the palate-uvula area followed by tongue and lips.
- The durations ranged from weeks to 10 years.

Etiology:
- Immunoperoxidase stains have identified antigens of the "human papilloma virus" (HPV) types 6 and 11 in approximately 50% of cases.

Prognosis:
- Good, there is no evidence that papillomas are premalignant.

Differential Diagnosis:
- Intraoral verruca vulgaris,
- Condyloma acuminatum, and
- Focal epithelial hyperplasia.
Note: differentiation is done accurately by Microscopic Examination ONLY ...

Treatment:
- Conservative surgical excision, recurrence is rare.

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Mucocele (Mucous Cyst Of The Oral Mucosa)

Description:
- Benign lesion that appears in oral cavity "Oral Mucosa" causing elevation.
- The colour is somehow normal as the surrounding mucosa but can exhibit some bluish-white colour and sometimes it appears white.
- Other Term of the phenonmena ": mucus extravasation phenomenon, and mucus retention cyst.
- The mucocele is referred to as a ranula, when found in the floor of the mouth.
- More commonly found in children and young adults.
- It can be considered a polyp or a cyst.
- size ranges from 1 mm to several centimeters.
- On palpation, it may be fluctuant but can also be firm.

Etiology:
- Traumatic severance of salivary ducts permitting salivary escape into mucosa is the accepted etiology.
- ruptured salivary gland duct
- obstructed or ruptured salivary duct (Parotid duct) in the case of a mucus retention cyst.
- Inflammation of sinuses can also cause this condition

Location:
- Most commonly found in the surface of the lower lip.
- Inner side of the cheek (known as the buccal mucosa)
- On the anterior ventral tongue
- The floor of the mouth.

Histology:
Microscopically, mucoceles appears as granulation tissue surrounding mucin. Since inflammation occurs concurrently, neutrophilsand foamy histiocytes usually are present.

Prognosis:
Good

Differential Diagnosis:
- Salivary gland neoplasms (especially mucoepidermoid carcinoma).
- varix.
- hemangioma.

Treatment:
Surgical excision deep enough to include the underlying gland that feeds it.

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