This case presentation is about the emergency management of a traumatized patient. The questions related with this type of accidental cases may be asked in part one examination. I can guarantee you that at least once, you will be asked about the management of an accident case in viva voce session of ADC part 2 practical examination. You are supposed to prepare a treatment plan for this patient.
If you wish, you can submit your treatment plan in the comment box. If need arises, you will get a positive response.
Case Description:
This male patient, in mid 40s was brought to the emergency room with the condition shown in the picture. He was unconscious with a GCS score of three and without any history. He was intubated to maintain airway in the emergency room. As a member of the emergency management team, you were called upon to perform your role. You were the first person to reach the emergency room. While other members are on their way, what will you do to manage this case?
Extensive facial injury of a male patient of mid 40s.
The oral manifestation of leukaemia can be summarized as follows.
In acute leukaemia- localized or generalized gingival hyperplasia is generally observed.It mainly affects the interdental papillae and the marginal gingiva.
The proximal contact point or the area refers to the surface point or area where the proximal surfaces of neighbouring teeth come in contact. Contact point/area is usually found in the occlusal one third of the natural crown of the most of the teeth.
The researchers at the University of Chicago performed a study to check the purification ability of the cloth masks. They made masks by joining one layer of tightly woven cotton sheet1 and two layers of polyester-spandex chiffon2, which is a fabric commonly used in evening gowns. These masks filtered out 80% to 90% spray particles ranging from 10 nanometres to 6 micrometres in diameter at normal human respiratory flow rate and volume.
Diabetes Mellitus refers to a group of common metabolic disorders that share the phenotype of hyperglycaemia and are caused by a complex interaction of genetics and environmental factors. It is very different from Diabetes Insipidus. Diabetes Insipidus is a syndrome characterised by the production of abnormally large volumes of dilute urine due to decreased secretion or action of Vasopressin, a hormone secreted by the posterior pituitary gland.
The pathogenic process leading to hyperglycaemia is the basis for classification of diabetes mellitus into several types. Age or insulin dependence are no longer the criteria for differentiation. Type I and Type II are the two broad categories. In Type I DM there is destruction of pancreatic β cells and insulin deficiency resulting from autoimmune β cell destruction. Type II DM is characterised by variable degree of insulin resistance, impaired insulin secretion, excessive hepatic glucose production and abnormal fat metabolism.
The biomedical waste management in India should be the burning and worrisome topic for the public as well as hospitals and health care service providers. Bio-Medical Waste (Management and Handling) Rules 2016 and further amendments in 2018 and 2019 have made enough provisions to handle all the biomedical wastes by any entity involved in anything related with health care provision. This includes, hospitals with only OPD facilities, hospitals with indoor facilities, blood donation camps, free health camps, medical services being provided in the field excluding the active war zones as well as the ships in the international water with Indian registration.
The categorization of all biomedical wastes into four color categories namely yellow, red, white, and blue made the segregation easy and practical. It does not specifically say anything about the rules and regulations to be followed in reference to COVID-19. But when, the proper biomedical waste management protocols, standard precautions also known as universal precautions and the latest guidelines issued for the control of spread of Covid-19 by MoHFW are put together; we find ourselves equipped with enough tools to deal with all types of wastes and infections.
We shall read more about the Bio-medical Waste (Management & Handling) rules 2016 and further amendments in 2018 & 2019 in further articles.
The pontic, \pŏn΄tĭk\, is an artificial tooth on a fixed partial denture that replaces a missing natural tooth, restores its function, and usually restores the space previously occupied by the clinical crown. An ideal correctly designed posterior pontic should have the following features.
All surface should have convexity with proper finish.
The contact with buccal contiguous slop should be minimal (pinpoint)) and with pressure free (modified ridge lap).
Buccal and lingual shunting mechanism should conform with those of the adjacent teeth.
Occlusal table should be in functional harmony with the occlusion of all of the teeth.
The overall length of the buccal surface should be equal to that of the adjacent abutment teeth or pontic.
Figure 1. Schematic
presentation of various pontic designs; (a) Sanitary pontic; has no contact
with the edentulous ridge, (b) ridge lap pontic; forms a large concave contact
replacing the contours of a missing tooth, (c) modified ridge lap; shows
illusion of a tooth but it has all or nearly all convex surfaces for easy
cleaning and minimize plaque accumulation, (d and e) bullet/conical; rounded
and cleanable smaller tip in relation to overall size, (f) ovate; round end
design currently in use where aesthetics is a primary concern[1].
The Pontic design can be classified into two types.
A. Pontic having mucosal contact
Sanitary/Hygienic/Fish-belly and
Modified sanitary type
B. Pontic with no mucosal contact
Saddle/Ridge lap
Modified Ridge Lap
Conical
Ovate
Sanitary or Hygienic Pontic or Fish-Belly
Sanitary pontic makes no contact with the edentulous ridge. It is made in an all-convex configuration, faciolingually and mesiodistally. The space between the pontic and the mucosa should be 2 or 3 mm[2]. It is most commonly used in mandibular molar replacement. It has the advantage of providing good access for maintaining hygiene with the disadvantage of poor esthetics.
Sanitary pontic design-note the convexity at cervical region
Modified Sanitary
The tissue facing surface of the modified sanitary design pontic has a hyperbolic parabola. The pontic is designed as a concave archway mesiodistally while the under surface is convex faciolingually. It in indicated in molar replacement, provides access to undersurface for good hygiene, alongwith poor esthetics.
Modified sanitary pontic design-note the concavity at the cervical region.
Saddle/Ridge Lap
It looks like crown of the tooth because it replaces all the contour of the missing tooth. It maintains a large concave contact with the underlying ridge and obliterates facial, lingual and proximal embrasures. Esthetic wise it provide best result but due to impossible access to under surface for cleaning, its use is limited for the replacement of maxillary incisors.
Modified Ridge Lap
Modified ridge lap combines esthetics with easy cleaning, and makes contact with ridge tissues in a shape of ‘ T‘ whose vertical arm ends at the crest of the ridge. This design is most commonly used in the area of the mouth that is visible during function, e. g. anterior teeth, premolars and sometimes maxillary molars.
Modified ridge lap pontic design: note the half concave underneath surface in contact with mucosa.
Conical
Conical pontic design is mostly limited to the replacement of thin knife edged ridges in the non-display zone of the mouth. It has a convex surface with only touching the centre of the residual alveolar ridge. It helps maintain good hygiene with poor esthetics. Conical design in indicated for the replacement of molars.
Image of conical pontic design- note the egg shaped design in green circle.
Ovate
Ovate pontic design is the most aesthetically suitable appealing design that looks like emerging from the gingiva. When ridge resorption is corrected by ridge augmentation, ovate design appears to be emerging through gingiva just like natural tooth. it is indicated for the replacement of maxillary incisors, canines, and premolars. It has the advantage of best esthetics, negligible amount of food entrapment and easy cleaning. The disadvantage is the requirement of surgical preparation of the receiving site before prosthesis fabrication.
Ovate pontic design-note the convex undersurface of pontic embedded in mucosa (green circle).
There are MCQs on pontic design in “Free silver Course“, which you may like to attempt.
Zinc as such does not participate in the amalgamation process or in the setting reaction of silver amalgam alloy with mercury during and after the completion of the restoration process.
The Central Bureau of Investigation (CBI) has filed an FIR against former Head of the Dental Department of All India Institute of Medical Sciences (AIIMS)-Patna, Dr. Shailesh Kumar Mukul. He is accused of resorting to “unlawful means in conspiracy with others” during the 2013 and 2019 period.
Coronavirus Disease-COVID-19: Seven Essential Norms You Should Follow to Help Yourself during Quarantine Period
The following category of people should stay at home under home quarantine status. This category includes a person with suspected coronavirus infection, those under investigation but not needing hospitalization. Also, the one who had had confirmed coronavirus infection was hospitalized earlier but now has been discharged and medically stable. These people should stay at home under quarantine conditions.
In this section, we shall discuss the composition, type and properties of the dental amalgams alloys used for restoration purpose in posterior teeth as per following format. The source of these notes, MCQs and explanation is Phillips’ Science of Dental Materials, 12th Ed and Sturtevant’s Art and Science of Operative Dentistry.
Zinc as such does not participate in the amalgamation process or in the setting reaction of silver amalgam alloy with mercury during and after the completion of the restoration process.
The 19th National PG Student Convention of Indian Prosthodontic Society is scheduled to be held from 5-7 April 2019 at Gandhinagar, jointly by Gujarat IPS State branch and Narsinhbhai Patel Dental College & Hospital, Sankalchand Patel University, Visnagar, Gujarat.
Local anaesthesia means a no pain sensation in a particular area supplied by a specific nerve. The correct term is local analgesia but commonly not used? It is given with the help of 2 ml or 5 ml single use disposable syringes. The anaesthesia is an inseparable part of surgery. It provides maximum patient comfort and cooperation. Without anaesthesia, the advancement in surgeries could not have been achieved. In 3rd molar surgery a patient may opt for general anaesthesia or local anaesthesia. The local anaesthesia may be supplemented with sedation for increased comfort.
Advantages of Local Anaesthesia
Local anaesthesia has the following advantages over general anaesthesia.
It is safe, efficient and predictably effective in almost all patients.
It is inexpensive.
It is easy to administer.
For healthy patient, no monitoring is needed by equipment
The patient does not lose consciousness with an intact gag reflex during anaesthesia.
Procedures under local anaesthesia, hospitalization is not needed, therefore, for patients’, it is convenient.
To administer local anaesthesia, no preoperative fasting is required.
A patient can be discharged immediately without waiting for recovery or an escort.
Limitations of Local Anaesthesia
Despite the huge number of advantages, the local anaesthesia does have certain disadvantages. They are as follows.
It cannot be used in a non-cooperative patient; for example, younger children.
It cannot be used in a patient with fear of needles.
It cannot be used in an anxious or nervous patient.
It is only suitable for short procedures which are of less than 30-minute duration.
It cannot anesthetize the locally inflamed tissues.
Composition of Local Anaesthesia
The local anaesthetic solutions mainly contain the following contents.
Local anaesthesia base.
Hydrochloride salt for solubility and stability.
Buffering agents.
Preservatives; e.g., Methyl Paraben
How does local anaesthetics prevent the conduction of dental pain?
Local anaesthetics inhibit the generation of electrical impulses and their conduction along the neuronal axon membrane, by reversible blockade of sodium ion channels. There is a continuous imbalance of sodium and potassium ions between the cytoplasm of neurons and the intercellular fluid. This is maintained at about 25 times more potassium intracellularly and 15 times more sodium in interstitial space.
Mechanism of action
The molecule of local anaesthetic agent enters the neural cell through neurilemmoma from interstitial fluid by a simple diffusion process. Then in the acidic environment of a neural cell, it breaks itself in its components and acts on the sodium influx gate and blocks it, thus blocking the generation of action potential, thus blocking signal conduction along the nerve cell membrane. The local anaesthesia cannot act on sodium influx gates from outside the nerve cell. It must enter the nerve cell.
Question: What happens when the area surrounding the nerve gets inflamed?
Once the tissue is inflamed, the interstitial fluid becomes acidic in nature. In an acidic environment, the local anaesthetic molecule breaks down. A broken local anaesthetic molecule cannot pass through the cell membrane by a simple diffusion process and thus cannot produce its effect.
This is the reason a local anaesthetic cannot produce its effect in an inflamed tissue or is not so effective in an inflamed area.
Question: Why does LA not function efficiently in an inflamed environment?
Answer: The molecule of local anaesthetic agent enters the neural cell through myelin sheath from interstitial fluid by a simple diffusion process. Then in the acidic environment of a neural cell, it breaks itself in its components and acts on the sodium influx gate and blocks it, thus blocking the generation of action potential, thus blocking signal conduction along the nerve cell membrane. The local anaesthesia cannot act on sodium influx gates from outside the nerve cell. It must enter the nerve cell.
Question: What happens when the area surrounding the nerve gets inflamed?
Once the tissue is inflamed, the interstitial fluid becomes acidic in nature. In an acidic environment, the local anaesthetic molecule breaks down. A broken local anaesthetic molecule cannot pass through the cell membrane by a simple diffusion process and thus cannot produce its effect.
This is the reason a local anaesthetic cannot produce its effect in an inflamed tissue or is not so effective in an inflamed area.
So, you are ready to start your crown work for the patient who is eagerly waiting to regain the lost functional ability, phonation and aesthetics. The functional ability, aesthetic value, speech enhancement and self-confidence of the patient will enhance when you look for the following anomalies in the oral cavity and rectify them, before the commencement of the crown preparation. You can make your crown & bridge without giving a dam for these factors, and get the quick bucks. But, it would be a good idea to consider them before you jump on for crown preparation part. And believe me, in long run, you will gain the faith of your patient, converting into your most reliable source of referral and image builder. These factors are given below:
General overall health of the oral cavity
Expectations of the patient
Extremely tilted teeth
Mobile teeth
Type of occlusion
The type of crown you want to fabricate for your patient
When we start examination, we look for the general health of the oral cavity. Is it healthy? Does the oral hygiene acceptable? Does the periodontal status of the tooth concerned adequate? Is the tooth tilted, rotated, supra or infra erupted? Does the patient need oral prophylaxis? What are the other systemic diseases the patient is suffering with; for example, cardiac, endocrine, orthopaedic, and physiological? If any of the answer is yes, then the dentist needs to take care of them first, before the commencement of the crown preparation. Of course, few chronic diseases cannot be cured but they should be kept under control by the patient’s’ physician.
That preparatory phase, the phase that involve the work done inside the mouth so that the longevity of the prosthesis remains satisfactory, includes the scaling and root planing, the removal of hopeless mobile teeth, orthodontic correction of tilted tooth, and occlusal surface adjustment of the supra erupted tooth. The other decayed teeth should be appropriately restored.
You should also know that what type of crown you plan to provide or what type of crown the patient is wishing for? What are the expectations of the patients from a particular type of crown? Will the patient understand the significance of the particular type of crown? Does patient understand the inherent drawbacks of that particular crown? Does patient know and ready to accept the post insertion maintenance care?
The other consideration is the type of occlusion in a patient. Is it canine protected or group function? Will you be needing to alter it for the betterment of the function and longevity? Does patient has any TMJ issue?
NABH Accreditation Standards for Dental Healthcare Service Providers have been outlined in two parts: (A) patient centered standards & (B) organisation centered standards. Here we shall discussed the second chapter of patient centered standards.
National Accreditation Board for Hospitals and Health Care Providers (NABH) has laid down Accreditation Standards for Dental Healthcare Service Providers (DHSP). The entities that can apply for are dental teaching institutions, dental hospitals and clinics. The NABH dental standards have been laid down keeping the Indian beliefs and working environment in mind. The board has laid down the standards that focus on
The inferior alveolar nerve is also known as inferior dental nerve. It gives off a motor branch that supplies to mylohyoid muscle and anterior belly of digastric. Then it enters mandibular foramen and travels through the inferior alveolar canal. From inferior dental canal it supplies to mandibular third molar, second molar, first molar, and second premolar.
From the level of the second premolar, it moves forward as mental nerve and exits through mental foramen. The mental nerve supplies sensory nerve fibres to the chin and lower lip of that side. Within the mandible after mental foramen, it moves forward as incisive nerve and gives sensory supply to mandibular incisors and mandibular canines of that side.
Implant supported prostheses that include over-dentures, crowns and bridges are the treatment of choice in modern dentistry. They are very predictable in nature and have a track record of very successful life span serving their purpose. But, there are certain
People often ask me; can I get a fixed artificial teeth? While most of the time, they can get it, but in few unfortunate one, it remained impossible to provide a fixed partial denture due to their unfavorable oral conditions. In those cases, we suggest them, “you should take an implant supported prosthesis”.
These are light activated unfilled resins. Most are relatively viscous and do not set through loss of solvent. They set either by chemical or light activation.
Maxillary nerve is the second division of the trigeminal nerve. It divides into several branches. You will read here about those that are related to dentistry below.
Effect of Diabetes on Osseointegration and Dental Implants
The tenacious hyperglycaemia in diabetic people, hinder osteoblastic activity and modifies the response of parathyroid hormone that adjusts metabolism of Ca and P, decreases collagen synthesis during callus formation, induces apoptosis in lining cells of bone and increases osteoclastic activity due to untiring inflammatory response. It also stimulates deleterious effect on bone matrix and reduces growth and build-up of extracellular matrix. The subsequent result is reduced bone formation during healing.
Type -1 diabetes (insulin dependent) causes decreased bone formation, as well as reduced bone mineral density and higher bone resorption while Type -2 diabetes (non-insulin dependent) produces normal or greater bone mineral density in some patients. It has been detected that insulin not only diminishes the harmful effect of hyperglycaemia by controlling it but also stimulates osteoblastic activity.
