Main textbooks

Paul Coulthard, Keith Horner, Philip Sloan, et al. Master Dentistry. Volume 1,2, Oral and Maxillofacial Surgery, Radiology, Pathology, and Oral Medicine.

Churchill Livingstone 2003

Updated knowledge from library and Website.

Dental Caries

Tooth loss is common health problem.

What can cause tooth loss?

Reasons of tooth loss

Microbial tooth loss (dental caries, periodontitis) Non microbial tooth loss (trauma, congenital loss)

Dental caries An chronic infectious disease with progressive

destruction of tooth.

Prevalence and incidence

http://www.wrongdiagnosis.com/d/dental_caries/stats-country.htm(2004)

Almost everyone is affected by dental caries.

Etiology of Dental Caries

Micro-organisms

host & tooth

sugar

time

no caries

no caries

no caries

no caries

caries

1889, Miller: chemocoparasitic theory

MAJOR FACTORS 3 necessary requirements:

1) Microorganisms—bacteria, plaque

2) sugar --- carbohydrates

3) host & tooth---saliva, tooth

( and) 4) time.

Role of bacteria There are many kinds of bacteria in

normal oral cavity.

Mainly the bacteria causing caries are Streptococcus Mutans (MS).

Microorganisms:

Role of plaque

Plaque is a biofilm on the surface of the tooth (enamel).

Enam

el

EnamelPulp

Root canal

Cememtum Apical tissue

Dentin

Crown

Root

gum

Microorganisms

Role of Tooth

• Quality

• Position

• Structure

• arrangement

host & tooth

Role of saliva:

It plays role in remineralization on the teeth.

Saliva has the buffering action and cleansing effect.

host & tooth

Role of carbohydrates:

the most important cause; refined carbohydrates are directly

proportional with dental caries.

Sugar:

MINOR FACTORS:

Enamel composition Morphology of the tooth Habit of brushing teeth Immunity

Clinical classification of caries

According to three basic factors : severity and rate of progression

anatomical site(involving site) age patterns at which lesions

predominate

Tooth anatomyTooth anatomy

Root

Enamel

Pulp

Root canal

Cememtum

Apical tissue

Dentin

Crown

gum

Acute caries

Chronic cariesChronic caries Arrested cariesArrested caries

Rampant caries

Classification according to the developing speed

Classification according to the involving site

Occlusal caries

Root caries

Smooth surface caries

Linear enamel caries

Clinical Manifestation and Symptoms

• Visible pits or holes in the tooth

• Colour changing

• Soften

• Pain

changes in tissue color, texture, and structure

A B

C D

A Early caries may have

no symptoms

B be sensitive to sweet

foods or to hot and cold

temperatures

C very sensitive to

stimulator

D the acute pain

Examination

• Clinical observations (Visual change)

ProbingThe explorer tip can easily damage white spot lesions

Examination

Temperature Temperature testtest

X-rayX-ray

Transillumination

DiagnosisDiagnosis

Clinical signs visual – color, texture, shape, location, cavitation, Clinical symptoms

Diagnostic test--examination

TreatmentTreatment

Non-surgical - remineralization

Surgical - restoration

The different ways of treatment depend on the size and depth of the cavity, and how much structure has been lost.

Calcium hydroxide pulp-capping material lining material filling material

Prevention is the most important for dental caries.

Problem for review

What is the etiology of dental caries?

Be familiar with the definitions of dental caries and classification.

Simply describe clinical manifestation and symptoms of dental caries.

Endodontics

Etiology of Pulpitis

1-bacterial cause: caries, fracture, bacteremia, periodontal pocket

caries irreversible pulpitis

pulp

2-physical cause: sever thermal change (cavity preparation), large metallic restoration

5. Other cause:5. Other cause: internal resorptioninternal resorption

Possible Pulpal Diagnoses

Normal Reversible pulpitis Irreversible pulpitis—acute, chronic, polyp Necrosis Previous endodontic treatment

Reversible pulpitis

Clinically

1. sharp pain & respond to sudden changes in temperature

2. pain disappear as the stimuli removed last less than 20 sec3. easily localized & unaffected by body

position

Clinical Examination in reversible pulpitis

Thermal:Hypersensitive with mild pain<mild

Sweets:Sensitive< mild

Biting Pressure:None (unless tooth is cracked)

Treatment of Reversible Pulpitis Remove irritant if present If no pulp exposure: direct restore If pulp exposure:

Carious: initiate RCT Mechanical: >1 mm: initiate RCT <1 mm crown planned: initiate RCT <1 mm: direct cap or RCT

If recent operative or trauma – postpone additional treatment and monitor.

Irreversible Pulpitis

Reversible pulpitis are left untreated.

Symptoms of Irreversible Pulpitis

Thermal: Hypersensitive-moderate to severe

Sweets: Moderately to severely sensitive

Biting Pressure: Usually sensitive in later stages

(periapical symptom)

spontaneous pain: Moderate to severe

DiagnosisIrreversible Pulpitis

Hypersensitive to hot or cold that is prolonged.

A history of spontaneous pain.

Vital or partially vital pulp.

may occur as a sequel of focal reversible pulpitis or occur due to acute exacerbation of chronic pulpitis.

clinically1- big cavity or margin of a restoration 2- sleep pain 3- spontaneous pain 4- pain lasts 5- difficult to localized

Acute pulpitis:

a result of acute pulpitis, or develops as chronic one.Clinically1-spontaneous dull, itching pain2-increased pain threshold (need strong stimuli) due to degeneration of the nerve fibers3- the pain lasts for about 2 h.

Chronic pulpitis

Chronic hyperplastic pulpitis(polyp)

Clinically:1- polyp2- occurs in a tooth with large carious lesion3- not sensitivity4- bleed easily5- may confused with hypertrophic gingival polyp

Treatment of Irreversible Pulpitis

Root canal treatment or extraction

Necrotic Pulp Pulp continued degeneration. no reparative potential.

Commonly have apical radiolucent lesion.

Maxillary first molar with large amalgam restoration and periapical radiolucencies around all three roots. The tooth was unresponsive to electrical and thermal testing.

Symptoms of Necrotic Pulp Thermal:

No response

Sweets: No response

Biting Pressure: Usually moderate to severe pain (not

symptom of necrotic pulp, but rather periapical inflammation)

Moderate to severe spontaneous pain

Diagnosis of Necrotic Pulp

Distinguishing features: No response to cold. No response to EPT.

Caveats Decreased sensitivity Periapical radiolucency is strong but not

conclusive evidence that pulp is necrotic.

Necrotic Pulp(additional considerations)

Antibiotic coverage Pain Management

Occlusal Reduction

Root Canal Treatment

The procedure involves removing inflamed or damaged tissue from inside a tooth and cleaning, filling and sealing the remaining space, to prevent re-infection.

Pre-operative film

Access and Working length

Completed RCT

case

Points you must know:

What is root canal treatment? Simply describe the clinical

manifestation of pulpitis.

The oral manifestation of HIV Infection

human immuno-deficiency virus (HIV)

retroviruses

acquired immune deficiency syndrome, （ AIDS）

Oral manifestations are often the first clinical feature of HIV infection.

The first AIDS case, worldwide ： 1981, AIDS China ： 1985, AIDS, Beijing,Argentina Shanghai ： 1987, AIDS Hangzhou: 1985, AIDS--hemophila 2009, 1272/236 (HIV/AIDS)

Epidemiology

Oral Manifestations observed in HIV

Fungal Neoplastic Viral Bacterial Other

Fungal Manifestations ----candidiasis

Can manifest in 4 different ways Pseudomembraneous

candidiasis Erythematous candidiasis Hyperplastic candidiasis Angular chilitis

Pseudomembraneous Candidiasis

Erythematous Candidiasis

Hyperplastic Candidiasis

Angular chilitis

Neoplastic Oral Manifestations

There are two types of neoplasms associated with oral manifestations in HIV individuals Kaposi’s Sarcoma (KS) Non-Hodgkin’s Lymphoma

Kaposi’s Sarcoma

Non-Hodgkin’s Lymphoma

Viral Manifestations

Herpes Simplex Virus (HSV) lesions Herpes Zoster Hairy leukoplakia Cytomegalovirus (CMV) ulcers Human Papillomavirus (HPV)

lesions

Leukoplakia

Herpes Simplex Virus (HSV) lesions

Cytomegalovirus (CMV) ulcers

Combination of HSV and CMV

HPV

Bacterial Manifestations

Linear Gingival Erythema Necrotizing Ulcerative PeriodontitisTuberculosis

Linear Gingival Erythema(red-band gingivitis)

Necrotizing Ulcerative Periodontitis

Necrotizing Ulcerative

Tuberculosis

Oral lesions in people with tuberculosis are seen rarely.

They have been reported as ulcers on the tongue secondary to

pulmonary tuberculosis.

Other Oral Manifestations

Aphthous Ulcerations (canker sores) Minor Major

Salivary Gland Disease Xerostomia

Aphthous Ulcerations

minor major

Salivary Gland Disease

Xerostomia

Conclusions

Lesions or other manifestations in the mouth may be the initial indicator of a persons HIV status or it may indicate a further decrease or worsening of an infected individuals immune system.

You must know: What is the main oral

manifestation of HIV infection? List the four categories of oral

manifestations that may present in HIV

Be familiar with fungal oral manifestation that may present in HIV infected individuals