General Medicine

Notes

Drugs Prescribing and Therapeutics

Oxygen (15 L/min)

Full size D cylinder : 340L ~ 22 mins
Full size CD cylinder : 460L ~ 30 mins
Full size E cylinder : 680 L ~ 45 mins

Drugs for Medical Emergencies

Adrenaline - 0.5 ml 1:1000 IM
Aspirin - 300 mg tab (75 g for prophylaxis)
Glucagon - 1 mg IM
GTN spray - 2 puffs 400 mcg / metered dose sublingually
Midazolam - 10 mg buccal
Oral glucose - 10 - 20 g fast acting glucose
Oxygen - 100% 15 L/min
Salbutamol - 4 puffs 100 mcg / actuation through large-volume spacer

Mild allergy - Cetirizine 10 mg tab / Chlorphenamine 4 mg tab / Loratidine 10 mg tab

Anxiety - Diazepam 5 mg tab 2 hr before procedure

Prescriptions

Cellulitis / spreading infection / systemic involvement

C. Amoxicillin 500 mg TDS 5 days
T. Phenoxymethylpenicillin 500 mg QID 5 days
T. Metronidazole 200 mg TDS 5 days (✖ warfarin, alcohol → disulfiram-like action)

2nd-line antibiotic for dental abscess

C. Clindamycin 150 mg QID 5 days (✖ diarrhoea)
T. Co-amoxiclav 250 / 125 mg TDS 5 days (✖ hepatic dysfunction, jaundice)
T. Clarithromycin 250 mg BD 7 days (✖ hepatic, renal impairment, pregnant, nursing, warfarin, statins)

NUG / NUP / Pericoronitis

C. Amoxicillin 500 mg TDS 3 days
T. Metronidazole 200 mg TDS 3 days

Sinusitis (self-limiting 2 1/2 weeks)

Ephedrine nasal drops 0.5% 10 ml 1 drop TDS max 7 days (✖ HPT, < 12 y/o)
C. Amoxicillin 500 mg TDS 5 days
C. Doxycycline 100 mg 2 cap (1st day), 1 cap OD 7 days (✖ hepatic impairment, pregnant, nursing, < 12 y/o, warfarin)

Pseudomembranous candidosis / erythematous candidosis / denture stomatitis

C. Fluconazole 50 mg OD 7 days (✖ warfarin, statins)
Miconazole oromucosal gel 20 mg / g 80g, pea-sized after food QID 7 days after lesions have healed (✖ warfarin, statins)
Nystatin oral suspension 100,000 units / ml, 30 ml, 1 ml after food QID 7 days - continue for 48 hrs after lesions have healed

Angular cheilitis

Miconazole cream 2% 20 g , apply to angle of mouth BD, continue use for 10 days after lesions have healed
Sodium fusidate ointment 2% 15 g, apply to angle of mouth BD, max 10 days
Miconazole 2% & hydrocortisone 1% cream or ointment, apply to angle of mouth BD, max 7 days (✖ warfarin, statins)

HSV infection

CHX mouthwash 0.2% 300 ml, 10 ml 1 min BD
H2O2 mouthwash 6% 300 ml, 15 ml diluted in half a tumbler warm water 2 mins TDS
T. Aciclovir 200 mg 5 times / day 5 days

VZ infection (within 72 hrs of rash - reduce severity of post-herpetic neuralgia)

T. Aciclovir 800 mg 5 times / day 7 days

Mild to moderate odontogenic pain

T. PCM 1000 mg QID 5 days
T. Ibuprofen 400 mg QID 5 days (✖ pregnant, peptic ulcer, hypersensitivity)
T. Aspirin 600 mg QID 5 days (✖ Xn/MOS, hypersensitivity, nursing, peptic ulcer, < 16 y/o)

Moderate inflammatory / post-op pain

T. Diclofenac sodium 50 mg TDS 5 days (✖ IHD, cerebrovascular disease, peripheral arterial disease, heart failure, hypersensitivity, aspirin, peptic ulcer)

Peptic ulcer (PCM alone not sufficient)

C. Lansoprazole 15 mg OD 5 days
C. Omeprazole 20 mg OD 5 days

Trigeminal neuralgia

T. Carbamazepine 100 mg BD 10 days

TMJ dysfunction (+ ibuprofen)

T. Diazepam 2 mg TDS 5 days

Mucosal Ulceration (e.g. RAS)

① Antimicrobial m/w

CHX
H2O2
T. Doxycycline dispersible 100 mg dissolved in water, 2 mins, QID 3 days (✖ pregnant, nursing, < 12 y/o)

② Local analgesics

0.15% Benzydamine m/w 15 ml every 1 1/2 hr max 7 days
0.15% Benzydamine oromucosal spray 4 sprays every 1 1/2 hr
5% Lidocaine ointment rub sparingly and gently on affected areas
10% Lidocaine spray apply as necessary with cotton bud

③ Topical corticosteroids

Beclometasone diproprionate inhaler 50 mg, 1- 2 puffs BD
T. Hydrocortisone oromucosal 2.5 mg dissolved next to lesion BD

👉 Suspected adverse drug reactions → reported to Medicines & Healthcare Products Regulatory Agency (MHRA)

Therapeutic index = safety of drug

Latency = from administration of drug → onset of action

Idiosyncrasy = abnormal physical reaction → food / drug

Drug best absorbed : ↓ molecular weight, unionized, lipid soluble

Mechanism of Action

Gentamicin : blocks protein synthesis 30s ribosomal subunit
Erythromycin : blocks protein synthesis 50s ribosomal subunit
Rifampicin : blocks mRNA synthesis
Vancomycin : blocks peptidoglycan synthesis
Penicillin : blocks cell wall synthesis
Sulphonamides : interfere with folinic acid production
Metronidazole : inhibits nucleic acid synthesis

Management of Patient on Bisphosphonate

👉 reduce bone resorption : hindering formation, recruitment and function of osteoclasts

👉 e.g. alendronic acid, zoledronic acid, etidronate disodium etc.

Bisphosphonate-related osteonecrosis of the jaw (BRONJ) = necrotic bone in Mx / Mb that has persisted for > 8 weeks and no history of radiation therapy to jaw

• delayed healing following dental extraction / oral surgery
• pain
• soft tissue infection
• swelling
• numbness
• paraesthesia
• exposed bone

👉 extremely rare condition

Guidance

① Avoid extraction / oral surgery if there is an alternative treatment option

② If any extraction / oral surgery is necessary, assess patient risk

low : before / taking bisphosphonate for prevention / management of osteoporosis

high : previous diagnosis of BRONJ, malignant condition, non-malignant systemic condition affecting bone (e.g. Paget's disease), rare medical condition (e.g. osteogenesis imperfecta), concurrent use of systemic corticosteroids / immunosuppressants, coagulopathy, chemotherapy, radiotherapy

Management of Patient on Anticoagulants

Antiplatelets - aspirin, dipyridamole, clopidogrel : interfere with platelet aggregation

Oral anticoagulants - warfarin, acenocoumarol, phenidione : inhibit vitamin K-dependent modification of prothrombin and other coagulation factors

Novel oral anticoagulants - dabigratran : direct inhibitor of coagulation factor thrombin, apixaban, rivaroxaban : inhibit Factor Xa (❌ require monitoring)

Injectable anticoagulants - heparin, dalteparin, enoxaparin, tinzaparin : bind to antithrombin III

Cranial Nerves

1, 2, 8 → sensory (nose, eyes, ears)
5, 7, 9, 10 → mixed

others → motor

Ⅰ Olfactory - cribriform plate

Ⅱ Optic - optic canal

Ⅲ Oculomotor - superior orbital fissure (SOF)

Ⅳ Trochlear - SOF

Ⅴ Trigeminal

• opthalmic - SOF
• maxillary - foramen rotundum
• mandibular - foramen ovale

Ⅵ Abducens - SOF

Ⅶ Facial - enter internal acoustic meatus (IAM), leave stylomastoid foramen (SMF) - salivation SM, SL gland

Ⅷ Vestibulocochlear - IAM

Ⅸ Glossopharyngeal - jugular foramen - salivation P gland, gag reflex

Ⅹ Vagus - jugular foramen - uvula pointing away, hoarseness, gag reflex

Ⅺ Accessory - jugular foramen - SCM, trapezius

Ⅻ Hypoglossal - hypoglossal foramen - pointing towards

Getting Started #5

What to read?

General Medicine

Churchill's Pocketbooks Clinical Dentistry

• Pain and Anxiety Management
• Drug Prescribing and Therapeutics
• Special Care Dentistry
• Emergencies

Master Dentistry

• Control of Pain and Anxiety

Guidelines

• Medical Emergencies
• Drug Prescription for Dentistry

https://www.sdcep.org.uk/wp-content/uploads/2016/03/SDCEP-Drug-Prescribing-for-Dentistry-3rd-edition.pdf

• Patient on Bisphosphonate
• Anticoagulants Guidance
• Conscious Sedation

Oral Maxillofacial Surgery #2

Notes

Diseases of Bone

Fibrous Dysplasia

• normal bone replaced with fibrous tissue undergoes gradual calcification
• poorly defined margins
• painless expansion, neurological signs
• Mx > Mb
• Albright's syndrome - multiple bones affected, café-au-lait spots, precocious puberty, hyperthyroidism, hyperparathyroidism

Cemento-ossifying Fibroma

• young adult females
• Mb > Mx
• slow growing swelling, firm to touch, painless
• well demarcated from surrounding normal bone

Paget's Disease

• abnormal formation and resorption of bone
• middle and old  age
• M > F
• Mx > Mb
• enlargement and weakening of bone
• slow growing swelling of bones
• bowing of legs, spinal curvature
• bone pain
• hypercementosis and ankylosis
• ↑ alkaline phosphatase, normal serum calcium and phosphate levels

Giant Cell Granuloma (Central)

• non-neoplastic lesion of bone
• 1st to 3rd decades
• F > M
• Mb > Mx
• painless swelling, displacement of teeth
• well-defined, non-corticated margin

Hyperparathyroidism

• excessive amount of parathyroid hormone (PTH)
• middle age
• F > M
• renal calculi, peptic ulceration, bone pain, psychiatric problems, loose teeth
• cortical bone more severely affected
• brown tumors
• ↑ serum and urinary calcium, PTH, alkaline phosphatase levels
• ↓ phosphate levels

Osteogenesis Imperfecta

• multiple bone fractures after minor trauma
• soft tissue typically lax
• hernia
• blue sclera
• dentinogenesis imperfecta
• short stature

Osteopetrosis

• marble bone disease
• medullary cavity infills with dense bone
• maxillary sinus may fail to pneumatise
• partial fail of tooth eruption

Maxillofacial Trauma

Skin Sensations Changes :

supraorbital and supratrochlear - forehead

zygomaticofacial and temporal - lateral face and temporal region

infraorbital - cheek, lateral nose, upper lip, teeth / gingiva of maxilla

mental - lower lip and chin

Facial Skeleton Fractures :

Mandibular Fractures

• coronoid
• condyle
• ramus
• angle
• body
• parasymphysis
• symphysis
• dentoalveolar

Maxillary Fractures

Zygomatic Complex Fractures

• Arch
• Zygomatico-orbital
• Orbital

Nasal Fractures

• cartilaginous
• cartilage + nasal bones
• complex naso-orbital-ethmoidal

Oral Maxillofacial Surgery #1

Notes

Infection and Inflammation

Acute periapical periodontitis - loss of lamina dura / where PDL space previously widened → rarefying osteitis

Chronic periapical periodontitis - widening of PDL space with preservation of lamina dura

Hypercementosis - Paget's disease (multiple)

Space of Infection

Cellulitis

• painful, diffuse, brawny swelling → oedema
• overlying skin is red, tense and shiny
• trismus
• cervical lymphadenopathy
• malaise
• pyrexia
• airway can be compromised
• both sides of floor of mouth → Ludwig's angina

Actinomycosis

• infection with Actinomyces species, A. israelii
• multiple discharging sinuses
• penicillin → 3-week (acute) / 6-week (chronic)

Bisphosphonate-associated Necrosis of Bone

① history of current or prior treatment using bisphosphonate - osteoporosis, Paget's disease, osteogenesis imperfecta, bony metastatic disease

② exposed bone > 8 weeks

③ no previous history of radiotherapy

👉 poor wound healing, soft tissue breakdown, exposure of bone

Dry Socket

= Focal Alveolar Osteitis

Incidence : Mb > Mx

Aetiology : excessive fibrinolytic activity, impaired vascular supply, smoking, oral contraceptives, immune defects, surgical trauma, history of radiotherapy

Surgical Removal of Teeth

Anatomical Structures

Mandibular 4, 5 region buccally - mental nerve

Mandibular 8 region lingually - lingual nerve

Maxillary 7, 8 buccally - pterygoid plexus

Palate - long palatine and nasopalatine artery

Indications for Third Molar Removal

• Pericoronitis - recurrent
• Unrestorable caries
• Non-treatable pulpal / periapical pathology
• Abscess and osteomyelitis
• Internal / external resorption of tooth / adjacent teeth
• Fracture of tooth
• Orthodontic
• Associated pathology - dentigerous cyst
• Field of tumor resection

Prophylactic removal of pathology-free impacted third molars → discontinued

Indications for Apicectomy

• Failure of conventional endodontic therapy
• Pathological change at apex of previously root-filled tooth - granuloma / cyst
• Failure during root canal treatment - overfilling, instrument fracture, lateral perforation
• Root unapproachable by conventional orthograde route - post-crowned tooth, calcified root canal
• Anatomical variations preclude normal endodontic therapy

👉 At least 3 mm of root apex should be removed

Vicryl suture - polyglycolic acid

Implantology

Osseointegration = direct and function connection between ordered, living bone and surface of a load-carrying implant

Materials

👉 Commercially pure titanium - CPT4, cold worked CPT4(cw) → ↑ tensile strength, ↓ fracture risk

👉 Titanium alloy - titanium, aluminium, vanadium (Ti6Al4V), ↑ strength ↓ manufacturing cost, non homogenous crystalline structure

👉 Titanium-zirconium alloy - ↑ tensile strength, good biocompatibility, homogenous crystalline structure - allow acid etching for improved bone healing response

👉 Zirconia - non-metallic, highly biocompatible, one-piece implant

Patient-specific Factors

• Suitability for surgery - cardiac, lung, liver, kidney disease
• Influence healing - diabetes, immunosuppression, corticosteroid therapy
• Smoking / alcohol abuse
• Periodontal disease / oral hygiene
• Mental health
• Age

Site-specific Factors

• Adequate access
• Avoidance of adjacent anatomical structures
• Absence of pathology
• Emerge through attached mucosa
• 1.5 mm between implant and tooth
• 3 mm between implants
• Ridge width 1 mm bone wall on all aspects of implant
• Bone augmentation - guided bone regeneration / onlay bone grafting / sinus lift
• Soft tissue augmentation - adequate volume of attached mucosa

Platform Switching

• Radiographic marginal bone loss of 1.5 mm during the first year, 0.2 mm each succeeding year
• ↓ diameter of restoration abutment in comparison to diameter of dental implant
• better preservation of soft and hard tissues

Type of Grafts

Autogenous grafts - patient's own tissue

Allografts - tissue from a human donor

Xenografts / heterografts - tissue from another species

Alloplastic materials - synthetically constructed tissues, biocompatible e.g. internal fixation plates and screws, resorbable materials, orbital wall / floor reconstruction materials, bone substitutes, contour materials, soft tissue crease / wrinkle obliterative materials

Guided Bone Regeneration (GBR) = directing the growth of new bone using barrier membranes that exclude the ingrowth of fibroblasts and epithelial cells, permit the more slowly growing bone to do so in a protected space

Oral Medicine #2

Notes

Salivary Gland Disease

Sialometry

unstimulated salivary flow : 0.3 - 0.4 ml/min

clinically significant xerostomia : ≤ 0.1 ml/min

drug ↑ : pilocarpine (radiation-induced xerostomia, Sjogren's syndrome)

drug ↓ : bendroflumethiazide (diuretic)

Radiology

Calculus?

• Plain radiographs
• Parotid glands - AP radiograph
• SM gland - true occlusal
• Ultrasound

Obstruction?

• Sialography

Mass?

• Ultrasound (first-line)
• CT / MRI

Abnormal function?

• Radioisotope imaging

Salivary Gland Disorders

Obstructive

• Extraductal - neoplasia, trauma
• Duct wall thickening - fibrosis → stricture, papilloma
• Intraductal - calculus

Sialadenitis

• Acute
• Viral (mumps - paramyxovirus)
• Bacterial (↓ salivary flow)
• Chronic
• Bacterial
• Relapsing - congenital duct abnormality
• Radiation
• Sclerosing (Kuttner tumor) - immune disorder
• Sarcoidosis - chronic granulomatous inflammation
• Sialosis - abnormal neurosecretory control

Sjogren's syndrome

• Primary
• Secondary + RA, SLE, progressive systemic sclerosis, primary biliary cirrhosis, renal tubular acidosis, mixed connective tissue disorder

👉 sialometry (salivary) and Schirmer test (lacrimal)

👉 autoantibodies against Ro (SS-A) and La (SS-B)

👉 labial gland biopsy → histopathological diagnosis

Salivary Gland Tumors

Benign

• Pleomorphic adenoma
• Wharthin's tumor (bilateral) = papillary cystadenoma lymphomatosum

Malignant

• Adenoid cystic carcinoma - spread along nerve
• Mucoepidermoid carcinoma
• Acinic-cell carcinoma
• Polymorphous low-grade adenocarcinoma - infiltrative but good prognosis

Salivary Gland Cysts

Mucous extravasation mucocele (most frequent) - lower labial

Mucous retention mucocele - upper labial

SM gland surgery : 

facial nerve damage → weakness of lower lip

lingual nerve damage → lingual paresthesia

Parotidectomy :

→ facial weakness

→ numbness of ear (great auricular nerve)

→ Frey's syndrome = sweating around the ear when patient eats (gustatory sweating)

→ salivary fistula

Orofacial Pain

Assessment

👉 History taking

👉 Examination : TMJ, muscles of mastication, cranial nerves

👉 TRO : cracked tooth syndrome, dentine sensitivity, pulpitis, periapical periodontitis, periodontal abscess

Disorders of TMJ

Examination

• movement - pain / obstruction / path / deviation
• palpation - pain
• auscultation - click / crepitus
• muscle tenderness - medial pterygoid cannot be examined

Radiology

• ✖ muscular parafunction
• ✖ internal disc derangements
• ✔ bony abnormality (RA / oeteoarthrosis)
• OPG
• Transcranial oblique lateral view (whole joint)
• MRI (disc)
• Arthrography

Arthroscopy - visual examination of upper joint space

TMJ Disorders

Facial Nerve Palsy

Upper motor neurone lesion → only lower part of face on opposite side (contralateral)

• Cerebrovascular accident
• Multiple sclerosis

Lower motor neurone lesion → whole face on same side (ipsilateral)

• Bell's palsy - Prednisolone 80mg/day x 5 + 5 days (tail off)
• Trauma
• Cerebellopontine angle tumors
• Malignant parotid gland tumor
• Otitis media
• Sarcoidosis
• Lyme disease

HIV Infection and Acquired Immune Deficiency Syndrome (AIDS)

Oral Medicine #1

Notes

Cysts and Odontogenic Tumors

Odontogenic keratocyst → basal-cell naevus syndrome

Gingival cysts = Bohn's nodules / Epstein's pears → spontaneous resolution

Pathology

Radicular / residual cyst -  a layer of simple, non-keratinizing squamous epithelium

OKC - stratified squamous epithelium, corrugated, parakeratinizing

Dentigerous / eruption cyst - a thin layer of squamous / cuboidal epithelium, some 2 - 5 cells thick

Gingival cyst - cuboidal / flattened epithelium resembling dental follicle

Nasopalatine cyst - pseudostratified ciliated columnar epithelium / stratified squamous epithelium

Nasolabial cyst - pseudostratified non-ciliated columnar epithelium

Surgical Management

Enucleation = removal of whole cyst, cavity dressed with bismuth iodoform paraffin paste (BIPP) on ribbon gauze

Marsupialization = a window is cut and removed from cyst lining, allowing decompression of cyst, slowly heals by bone deposition in the base of cavity

Ameloblastoma - epithelial

Odontome - mixed epithelial and ectomesenchymal

Odontogenic myxoma, cementoblastoma - mesenchymal

Mucosal Diseases

Conditions related to friction / trauma

• frictional keratosis
• smoker's palatal keratosis = stomatitis nicotina
• fibrous hyperplasia and neoplasia
• fibroepithelial polyp - leaf fibroma ↓

Ulceration

• Traumatic ulceration - mechanical, thermal, chemical
• Drug-related ulceration - nicorandil, indomethacin, phenytoin
• Recurrent aphthous stomatitis - minor (<10mm), major (>10mm), herpetiform

Infections

Bacterial :

• Syphilis - primary chancres, secondary snail track ulcers, tertiary focal necrosis (gumma), syphilitic leukoplakia
• Tuberculosis - granular ulceration, secondary to pulmonary lesion
• Leprosy - raised red-white mucosal plaques (lepromas)

Viral :

• HHV 1 - primary herpetic gingivostomatitis, herpes labialis
• HHV 2 - genital ulcers
• HHV 3 - chicken pox, shingles
• Coxsackie virus - hand, food and mouth disease, herpangina
• Epstein-Barr virus (HHV 4) - hair leukoplakia
• Human papillomavirus (HPV 16 and 18) - squamous papillomas (warts)
• HHV 8 - Kaposi's sarcoma
• HIV - erythematous candidiasis, Kaposi's sarcoma, hairy leukoplakia, gingivitis, periodontitis, thrombocytopenia, bacillary angiomatosis, atypical ulceration, melanotic pigmentation, multiple viral papillomas

Fungal :

Angular cheilitis - candida + staphylococcus aureus + β-hemolytic streptococci

Lichen Planus

Lichenoid mucositis - lichenoid reaction, lupus erythematosus, graft-versus-host disease

Vesiculo-bullous Lesions

Granulomatous Disorder

• Foreign body
• Orofacial granulomatosis (oral mucosa) - lip swelling, lymphoedema, perilymphatic chronic inflammation
• Crohn's disease (GIT) - diffuse swellings of lips and cheeks, cobblestone mucosa, mucosal tags, angular cheilitis, slit-like ulcers, granular gingivitis, glossitis
• Sarcoidosis - submucosal nodules, erythema, granular gingival patches 
• Wegener's granulomatosis - strawberry hyperplastic gingival lesions, palatal ulceration, delayed healing

Potentially Malignant Disorders

• Oral submucous fibrosis
• Atrophic lichen planus
• Sideropenic dysphagia - Patterson-Kelly-Brown / Plummer-Vinson syndrome
• Dyskeratosis congenita
• Fanconi's anemia
• Leukoplakia and erythroplakia

Oral Cancers

Getting Started #4

What to read?

Oral Medicine

Churchill's Pocketbooks Clinical Dentistry

• Oral Medicine

Master Dentistry

• Cysts and Odontogenic Tumors
• Mucosal Diseases
• Premalignancy and malignancy
• Salivary Gland Disease
• Facial Pain
• Disorders of Temporomandibular Joint

Oral Maxillofacial Surgery

Churchill's Pocketbooks Clinical Dentistry

• Implantology
• Oral and Maxillofacial Surgery

Master Dentistry

• Infection and Inflammation of The Teeth and Jaws
• Removal of teeth and Surgical Implantology
• Diseases of Bone and The Maxillary Sinus
• Oral and Maxillofacial Injuries
• Dentofacial and Orofacial Anomalies

Guidelines

• Extraction of Wisdom Tooth

Orthodontics

Notes

Index of Orthodontic Treatment Need

UK National Health Service funds orthodontic treatment for children where IOTN is equal or greater than DHC = 3 and AC = 6

Cephalometrics

Anterior cranial base → most stable craniofacial structure to be used for superimposition, it completes the majority of its growth before 7 y/o

Wits Analysis

Males : BO is 1mm ahead of AO

Females : BO = AO

Balancing extraction = same arch, opposite side → maintain symmetry and centreline relationships

Compensating extraction = same side, opposite arch → maintain inter-arch relationship

Serial extraction : C → D → 4

Thumb Sucking Features

• Upper incisor proclination
• Lower incisor retroclination
• Narrowing of upper arch
• Mandibular displacement and crossbite
• Anterior open bite (often asymmetrical)

First Permanent Molars of Poor Prognosis

In lower arch, good spontaneous alignment following extraction of lower 6 if → lower 7 development reached bifurcation, angulation between crypt 7 and 6 is <30°, 7 crypts overlap 6 roots

Scissors bite = lingual crossbite of lower posterior teeth

Removable Appliances

Signs of non wear:

• Missed appointments
• Broken appliances
• Poor speech with appliance in situ
• Poor fit
• Still active at each visit
• Non signs of wear on appliance / soft tissue
• Patient displays difficulty inserting or removing appliance

Incidence of Cleft Lip and Palate

Failure of fusion : maxillary process and median nasal process

1 in 700, more common in males

Unilateral clefts → left side

Isolated cleft palate → 1 : 2000, females

Veau Classification of CLP

Class I : SP

Class II : S / HP

Class III : unilateral CLP

Class IV : bilateral CLP

Commonly Impacted Tooth

Third molars → maxillary canines → maxillary central incisors

Delayed Eruption of Permanent Maxillary Incisor

• eruption of contralateral incisor occurred > 6 months earlier
• the maxillary incisors remain unerupted > 1 year after the eruption of mandibular incisors
• significant deviation from normal eruption sequence

Canines undergoing normal eruption should be palpable in buccal sulcus by 10 - 11 y/o

Optimal Force Levels for Various Tooth Movements

Intrusion                  : 10 - 20 g

Extrusion                 : 35 - 60 g

Rotation                   : 35 - 60 g

Tipping                    : 35 - 60 g

Root uprighting       : 50 - 100 g

Bodily movement    : 70 - 120 g

Paediatric Dentistry

Notes

Paediatric Dentistry

Natal teeth - teeth present at birth

Neonatal teeth - teeth erupt within a month of birth

Permanent incisors develop slightly behind the roots of primary incisors, larger. Extra space is gained from :

• spacing of primary incisors
• permanent incisors more proclined
• ↑ inter-canine width

Preformed Metal Crowns (PMC) uses :

• 2 surface (or more) cavities in first primary molars
• More than 2 surface cavities in second primary molars
• Following pulp therapy in primary molars
• Failure of plastic restorative technique
• Initial restoration in amelogenesis imperfecta, dentigenesis imperfecta, severe enamel hypoplasia

Pulp Therapy

Indirect pulp capping - carious dentine without pulp exposure

Direct pulp capping - asymptomatic exposure, < 1 mm, < 24 hr

Coronal pulpotomy - traumatic injuries, pulp exposed, > 1 mm, > 24 hr

Partial coronal (Cvek) pulpotomy - removal of superficial (2 - 3 mm), calcium hydroxide place, induce calcific bridge. maintain vital coronal and radicular pulp, allow normal crown and root maturation

Full coronal pulpotomy - coronal pulp removed, calcium hydroxide placed over healthy radicular pulp stump

Pulpectomy - marked pulpitis, non-vital, pulpotomy has failed

Traumatic Injuries

Concussion = tooth traumatized but not loosened

Subluxation - tooth loosened in socket but not displaced

Extrusion = tooth displaced in occlusal direction

Intrusion = tooth displaced apically into socket

Lateral displacement = tooth pushed laterally, buccally or palatally

Avulsion = tooth totally displaced form socket

Abnormalities of Tooth Number

Supplemental teeth - duplication of teeth

Supernumerary teeth - conical / tuberculate

Hypodontia - upper lateral incisors / premolars / lower central incisors

Abnormalities of Tooth Position

Impacted first permanent molars - crowding

Abnormal position of crypts - lower second premolar

Ectopic upper canines - palatally or in line of arch, palpable by 9 y/o

Transposition - upper canine and first premolar, lower canine and lateral incisor

Abnormalities of Tooth Structure

Enamel

Enamel hypoplasia - ↓ thickness, deficient structure

Enamel hypomineralization - normal structure, not fully mineralized

(Local) infection, trauma, irradiation, idiopathic

(General) rubella, syphilis, childhood infections, excess exposure to fluoride

(Hereditary) amelogenesis imperfecta → X-linked

Dentine

Dentinogenesis imperfecta - ↓ number of wide irregular tubule, loss of scalloping at ADJ, opalescent bluish appearance

Cementum

Hypercementosis - Paget's disease

Hypocementosis - hypophosphatasia

Non-accidental Injury (NAI)

• Bruising in babies and children who are not independently mobile
• Bruises not overlying bony prominence e.g. cheeks, ears
• Multiple bruises in clusters
• Multiple bruises of uniform shape
• Bruises that carry an imprint of an implement
• Injuries sustained no consistent with history provided by parents
• Delayed presentation
• Lack of concern
• Frenal tears in child < 1 y/o
• Withdrawn / frightened child