Manoj

MYOFACIAL PAIN DYSFUNCTION SYNDROME

2008-10-13T05:26:00.000-07:00

MYOFACIAL PAIN DYSFUNCTION SYNDROME

Temporomandibular joint disorders are among the most misdiagnosed and mistreated disorders in medicine. Though, a lot of research is constantly being carried out, TMJ problems raise many question, some of which remain unanswered or debatable, because of the complex nature of this joint.

MPDS is a pain disorder, in which unilateral pain is referred from the trigger points in myofacial structures, to the muscles of the head and neck. Pain is constant, dull in nature, in contrast to the sudden sharp, shooting, intermittent pain of neuralgias (chronic pain).But the pain may range from mild to intolerable.

SYMPTOMS

MPDS exhibits varied symptoms. One particular patient may complain of all the various symptoms, whereas in another patient only a single symptom may be present.

THE MOST COMMON SYMPTOMS ARE:
• Headaches
• Earaches
• Tenderness in the jaws
• Dry mouth
• Fatigue
• clicking or popping sound in the jaws
• Neck or shoulder pain
• Dizziness and lightheadedness
• Diminished hearing
• Ringing in the ears
• Fullness in the sinuses
• Limited jaw movement
• Pain in the eyes or the back of the eyes
• Tingling
• Numbness
• Blurred vision
• Twitches
• Trembling
• Nausea
• Vomiting
• Diarrhoea
• Constipation
• Indigestion

TRIGGER POINTS

Trigger points exists as a localized tender areas within taut bands of skeletal muscles and when stimulated by macro and micro traumatic episodes, they refer a characteristic pain pattern to a distant group of muscles, i.e. zone of reference.
Palpation of trigger points will give rise to a positive ‘jump sign’.

Factors which can cause trigger points:

• Sudden trauma to musculoskeletal tissues (muscles, ligaments, tendons, bursa)
• Excessive exercise
• Chilling of areas of the body
(e.g., sitting under an air conditioning duct; sleeping in front of an air conditioner)
• Injury to intervertebral discs
• Systemic conditions
(e.g., gall bladder inflammation, heart attack, appendicitis, stomach irritation)
• Lack of activity (e.g., a broken arm in a sling)
• Muscle strain due to over activity
• Generalize fatigue (perhaps, chronic fatigue syndrome may produce trigger points)
• Nutritional deficiencies
• Hormonal changes (e.g., trigger point development during menopause)
• Nervous tension or stress
• Obesity
• Depression
• Anxiety
• Poor posture
• Repetitive motion
• Hypoglycemia
• Menopause

PATHOPHYSIOLOGY [ETIOLOGY] :

The MPDS can be visualized as a vicious cycle of several contributing factors such as:
1. Muscular hyperfunction.
2. Injuries to the tissue.
3. Faulty alignment between the upper and lower teeth and jaws
4. Disturbed movement of the jaw joint
5. Displacement or abnormal position of the jaw joint or cartilage disc inside the jaw joint
6. Arthritis or similar inflammatory process in the joint
7. Para functional habits.
8. Disuse.
9. Nutritional problems.
10. Physiological stress.
11. Sleep disturbances.

TREATMENT:

Medical Care:

• Medications: Commonly used medications include NSAIDs, muscle relaxants, and tricyclic antidepressants. More recently, injections of botulinum toxin have been used, in some cases as an adjunct to arthrocentesis
o Ibuprofen and naproxen are commonly used NSAIDs. They work best when given on a regular basis and are not associated with addiction problems. NSAIDs should be prescribed on a regular basis for a period of 2-4 weeks and then gradually tapered. Narcotics are reserved for patients with severe acute pain and should not be used for more than 10-14 days.
o The commonly used muscle relaxants are diazepam, methocarbamol, and cyclobenzaprine; the lowest effective dose should be used initially. Adverse effects include sedation, depression, and addiction.
o Tricyclic antidepressants, in low doses, have been used effectively for a long time in chronic painful conditions. They act by inhibiting pain transmission and also may reduce nighttime bruxism. Amitriptyline and nortriptyline, in small doses, are the most common tricyclic antidepressants used for chronic painful conditions.
o Botulinum toxin is used both as a single treatment and in conjunction with arthrocentesis. No controlled studies exist of the use of this medication in TMD. Care must be taken to isolate the muscle properly and inject appropriate doses.
 Aspirin- 0.3-0.6g/4 hourly
 Piroxicam- 10-20mg/TDS
 Ibuprofen- 200-600mg/TDS
 Pentazocine-50mg/BD or TDS
 Diazepam- 5-10mg/BD or TDS
 Methocarbamol-500mg/BD or TDS
 Amitriptyline- 10-25mg/TDS

• Occlusal splints  To temporarily disengage teeth
 To create a balanced joint-tooth stabilization of mandible
 To reduce hyperactivity of musculature
 To improve vertical dimension
 To serve as a protective appliance
o Stabilization splints:
12 to 18 hours wear for upto 4-6 months.
Fabricated over maxillary teeth covering occlusal and incisal surfaces.
Reduces the load on retrodiscal area and thereby relieves pain.
o Relaxation splints:
For disengagement of teeth and only for short period (4 weeks).
Fabricated over maxillary incisor teeth.

o There are different kinds of splints known as night guards, bruxism appliances, or orthotics. Various kinds of splints are available; most of them can be classified into 2 groups—anterior repositioning splints and autorepositional splints. Physiologic basis of the pain relief provided by splints is not well understood. Factors such as alteration of occlusal relationships, redistribution of occlusal forces of bite, and alteration of structural relationship and forces in the TMJ seem to play some role.

o Autorepositional splints, also known as muscle splints, are used most frequently. Some sort of pain relief is seen in as many as 70-90% of patients using splints. In acute cases, the splint may be worn 24 hours a day for several months, later, as the condition permits; they may be worn at nighttime only.

Surgical Care:
The treatment of chronic TMD is difficult, and at some time during the course of the disease surgical options are discussed with the patient. Some of the surgical options are described here.
• Arthrocentesis

o Simple washing of the upper compartment of TMJ using arthrocentesis has been very effective in patients with a history of condylomeniscal incoordination; results have been comparable to those of arthroscopic surgery.
o The benefit of this treatment brings into question the significance of disk position in the etiology of TMD.
o A 22-gauge needle is inserted gently in the superior joint space and a small amount of saline is injected to distend the joint space, after which the fluid is withdrawn and evaluated. The joint then is redistended and a second needle is placed in the same joint space to lavage the joint; steroids and/or local anesthetics can be injected into the joint space at the conclusion of the procedure.

• Arthroscopic surgery
Indications include internal derangements, adhesions, fibrosis, etc.It appears to be as efficient as open surgery, causes less surgical morbidity, and has few severe complications as compared to open surgical procedure. One retrospective short-term study found it to be safe, minimally invasive, and an effective treatment method, with 80% of patients reporting reduced pain and increased range of motion; in acute TMJ lock, however, arthroscopy and arthroscopic lysis and lavage of the upper compartment of TMJ produce comparable success rates.
o In one study, only 10.3% of 301 patients who underwent arthroscopic lysis and lavage had complications. More than 80% of complications were otological in nature; neurological complications were seen in 5 cases—of which 3 were fifth cranial nerves injury and 2 were seventh cranial nerve injury.
• Open surgery
o Open surgery was the main surgical option in the 1970s and 1980s, and the most common procedure was disk repositioning and complication; in cases of severe disk damage, procedures such as disk repair and removal were done using artificial or autogenous material.
o Myrhaug technique: Described in 1951, this procedure, by resecting the temporal condyle, creates a permanent and reducible chronic dislocation of the joint. One study found 70% good or excellent results in 60 patients. The main indications include (1) TMD not responding to all other treatments and (2) chronic subdislocations of one or both TMJ.
• Arthroplasty: This is the surgical procedure of choice for bony intracapsular ankylosis.

• Physical therapy: Apart from patient education and pain control, the main goal of physical therapy is to stabilize the joint and restore its mobility, strength, endurance, and function. Common modalities used to accomplish these goals are the following:

o Relaxation training using electromyographic (EMG) biofeedback: The patient first is educated about the contribution of stress and muscular hyperactivity to pain. An EMG monitor provides instant feedback to patients about the state of their muscle activity and allows the patient to easily correlate pain with hyperactivity of the muscles and decrease in pain with relaxation.
o Friction massage: The hypothesis is that temporary ischemia and resultant hyperemia, produced by firm cutaneous pressure during massage, helps inactivate trigger points. Friction massage also may help disrupt small fibrous adhesions in the muscle formed as a result of surgery, injury, or prolonged restricted motion.
o Ultrasonic treatment: ultrasonic waves produce tissue heating at a deeper level than moist heat; this increase in local tissue temperature leads to increase in blood flow and removal of metabolic byproducts responsible for pain and may help decrease adhesions by disrupting collagen cross-linkage. It also may help decrease intra-articular inflammation. To be effective, ultrasonic treatment should be done every other day, using about 1 watt/cm2 for approximately 10 minutes over the affected muscles and joints.
o Transcutaneous electronic nerve stimulation: Electronic stimulation of superficial nerve fiber overrides the pain input from mastication muscles and TMJ, causing release of endogenous endorphins. In some patients it provides longer duration of pain relief than the time during which the stimulation is actually applied.
• Cognitive-behavioral treatment: This consists of hypnosis, cognitive coping skills, and relaxation. Hypnotic susceptibility correlates with reductions in reported pain.
• Psychology: Chronic painful conditions worsen any preexisting anxiety or depression. In appropriate settings, psychological counseling may provide benefit.

ORAL COMPLICATIONS OF CHEMOTHERAPY & HEAD/NECK RADIATION AND ITS MANAGEMENT

2008-10-12T08:24:00.000-07:00

INTRODUCTION

Oral complications are common in cancer patients especially head and neck cancers.
Oral cavity is at high risk of side effects from chemotherapy and radiation therapy. Some of the reasons are:
 chemotherapy and radiation therapy stops the growth of cancer cells and by doing so , it also stops the normal cells lining the cancer.
 they also cause changes in mucosal lining , normal salivation and healthy balance of bacteria.
 wear and tear.
Preventive measures may lessen the severity of the complications.

LIST OF COMPLICATIONS:
1.Mucositis.
2.Bleeding.
3.Pain.
4.Taste changes.
5.Infections.
6.Dry mouth.( Xerostomia )
7.Dental caries & periodontal problems
8.Jaw stiffness.
9.Osteonecrosis.
10.Tissue & bone loss.
11.Malnutrition.

CLINICAL PRESENTATION OF THESE COMPLICATIONS:
1. MUCOSITIS:
 caused by both chemo & radiation therapies.
 red, burn like sores or ulcer like.
 sites: gums, tongue, buccal mucosa, roof & floor of mouth.
 pain, bleeding, super infections & difficulty in eating.

2. BLEEDING: caused by anticancer drugs
 bleed from areas of gum disease or from mucositis.
 bleeding during brushing, flossing or eating.
 may be mild or severe.
 sites: lips, soft palate & floor of the mouth.

3. PAIN:
 anticancer drugs can damage the nerve.
 tooth sensitivity.
 pain in jaw muscles.

4. TASTE CHANGES: ( dysgeusia )
 may be due to chemotherapy or radiation therapy.
 due to – damage of taste buds, dental problems, infections, dry mouth
 in chemotherapy patients- spread of drug within mouth.
 in radiation therapy – damage to taste buds
 changes in sweet, sour, bitter & salty tastes.

5. INFECTIONS:
 chemotherapy weakens the immune system.
 mucositis & dry mouth further causes infections.
(i) Bacterial infections:
- gram positive and gram negative cocci infections.
- periodontal disease and dental caries.
- may complicate endocarditis in valve disorders.
(ii) Fungal infections:
- common in patients under radiation therapy.
- antibiotics & steroids are often used by patients under chemotherapy, which changes the bacterial balance in the oral cavity  fungal infections.
- deep fungal infections.
- candidal infections.
(iii) Viral infections:
- herpes virus infection

6. DRY MOUTH ( Xerostomia ):
 occurs as a result of salivary gland destruction on radiation therapy.
 thick stringy saliva
 difficulty in speech, swallowing & taste.
 burning sensation.
 thirst, halitosis.
 cuts & cracks in lips.
 dental caries & periodontal diseases.  leathery tongue.

7. Dental caries & periodontal diseases:
 due to xerostomia, bacterial infections, radiation induced .

8. Jaw stiffness:
 a long term complication of radiation therapy characterised by development of fibrosis leading to difficulty in opening the mouth.

9. Osteoradionecrosis:
 Radiation therapy --> end arteritis --->tissue hypoxia -->
-->hypocellularity -->devoid of fibroblast , osteoblast
and osteo competent cells
- Pain
- Swelling
- Trismus
- Exposed bone
- Pathologic fracture
- Oral-cutaneous fistula formation

10. Tissue and Bone loss:
 radiation therapy causes it.
 when soft tissue death occurs -->ulcers form -->grows ->> -->>pain -->infections
 when bone loss occurs --> pathological fractures.

11. Malnutrition:
due to:
- side effects of drugs like nausea, vomiting.
- sores in the mouth, dry mouth & pain

MANAGEMENT
PREVENTIVE MEASURES

Eating well balanced diet.
Proper oral hygiene.
Preventive oral health examination:
It consists of checking the following:
 mouth sores & infection.
 tooth decay.
 Gum disease.
 Dentures that do not fit well.
 Problems moving the jaw.
 Problems with the salivary glands.

1. Routine oral care:
- good oral hygiene reduces the complications.
- following are the guidelines:

 tooth brushing:
Choose toothpaste with care:
Use a mild-tasting toothpaste;
flavoring may irritate the mouth.
If toothpaste irritates the mouth,
brush with a solution of 1 teaspoon of salt added to 4 cups (1 quart) of water.
Use a fluoride toothpaste.
 Rinsing :
Rinse the mouth 3 or 4 times while brushing.
Avoid rinses containing alcohol.
One of the following rinses made with salt and/or baking soda may be used:
1 teaspoon of salt in 4 cups of water.
1 teaspoon of baking soda in 1 cup (8 ounces) of water.
½ teaspoon salt and 2 tablespoons baking soda in 4 cups of water.
An antibacterial rinse may be used 2 to 4 times a day for gum disease. Rinse for 1 to 2 minutes
If dry mouth occurs, rinsing may not be enough to clean the teeth after a meal. Brushing and flossing may be needed.
 Flossing :
Floss gently once a day.
 Lip care :
Use lip care products to prevent drying and cracking.

2. Oral mucositis :
 Swishing ice chips in the mouth for 30 minutes may help prevent mucositis from developing in patients who are given fluorouracil.

Routine Oral care:
dil. Hydrogen peroxide rinses
Kaolin-pectin, aluminium hydroxide & sucralfate.
Lip lubricants like lanolin.

Relieving pain:
Try topical medications for pain. (topical NSAIDS)
Topical anesthetics
Capsaicin & zinc supplements.

3. Bleeding :
Hemostatic agents.
Rinsing with a mixture of one part 3% hydrogen peroxide to 2 or 3 parts saltwater solution (1 teaspoon of salt in 4 cups of water) to help clean oral wounds. Rinsing must be done carefully so clots are not disturbed.

4. Pain :
Topical anesthetic
Analgesics & anti inflammatory drugs.
Antimicrobial.
Anticonvulsant.
Anxiolytic & antidepressants.
Muscle relaxant.

5. Taste changes:
zinc sulfate 45 mg by mouth 3 times/day
Taste buds recover after 6-8 weeks.

6. Infections:
 Bacterial infections:
Medicated and peroxide mouth rinses.
Brushing and flossing.
Wearing dentures as little as possible.
Antibiotics.
 Fungal infections:
mouthwashes and lozenges that contain antifungal drugs.
Topical antifungal agents. Eg, CANDID mouth paint.
Systemic antifungal drugs for deep fungal infections.
eg, Tablet- ketoconazole 200mg/day
 Viral infections:
Antiviral drugs.

7. Xerostomia :
The following rinse may be used to neutralize acid and dissolve thick saliva:
½ teaspoon salt and 2 tablespoons baking soda in 4 cups of water.
A dentist can provide the following treatments:
Solutions to replace minerals in the teeth.
Rinses to fight infection in the mouth.
Saliva substitutes or medications to stimulate the salivary glands.
Fluoride treatments to prevent tooth decay.

8. Dental caries & periodontal diseases:
 operative care & topical fluorides.
 Proper oral hygiene.

9. Jaw stiffness:
Physical therapy.
Pain treatments.
Medication

10. Tissue and bone loss:
Wearing removable dentures or appliances as little as possible.
No smoking & No consumption of alcohol.
Using topical antibiotics.
Undergoing surgery to remove dead bone
hyperbaric oxygen therapy.

11. Malnutrition :
High calorie, high protein
nutritional juices.
Enteral tube feeding.
Vitamin and mineral supplements.

12. Osteoradionecrosis:
Medical therapy in treatment of ORN is primarily supportive, involving nutritional support along with superficial debridement and oral saline irrigation for local wounds
Hyper baric oxygen.
Surgery.

CONCLUSION
Oral and dental care is important in all phases of treatment of patient with head and neck cancers, especially preventive measures are to be considered a lot

BASICS ON DENTAL IMPLANTS

2007-08-23T00:48:00.000-07:00

What are implants?
Implants are specially made posts that replace the roots of teeth that are missing and are used to support a new crown, fixed bridge or denture. It is made of titanium, a strong and lightweight material which has been shown to be compatible with the body and safe for use.

Why do we need to replace missing teeth?

Our teeth are an important part of our digestive system as it is needed for chewing food. It plays a role in speech .It is also an important part of our appearance. Finally, it prevents gaps and spaces from appearing between our teeth when a tooth is lost.

What are the advantages over conventional replacements?

The conventional methods of replacing missing teeth are Bridges or Dentures.

Bridges usually involve sticking false teeth onto our existing teeth. This may involve filing down healthy teeth to act as retainers which may compromise the health of these teeth. Bridges can also only be provided when there are sufficient strong remaining teeth. They are however a permanent replacement, although they are likely to need replacement every 10 to 15 years.

Dentures are teeth attached to a plastic or metal plate. They can often be cumbersome as they have to be taken in and out every day and for cleaning. They may not always retain in place well if the shape of the gums and bone in the mouth is not appropriate.

Though bridges and dentures can serve us satisfactorily, Implants provide better support and usually results in more comfortable and stable replacement teeth. It provides better chewing efficiency and allows us to have permanent fixed teeth without trimming our own natural teeth for support, or having to remove the teeth every day. Implants also slow down the shrinkage of our jawbone which occurs as a result of tooth loss.

Are implants dangerous to health?

The materials used chiefly titanium is almost never rejected by the body. These have also never been a report of it being the cause of cancer or any life-threatening disease.

Can Anyone Have Implants?

Unfortunately, just having missing teeth does not automatically qualify someone to have dental implants. Some of the criteria that we need to look at are:

1. Is the patient’s general health satisfactory? What is the general condition of the mouth? The remainder of the teeth and gums needs to be stable in order to put in dental implants which are likely to work. If there are other areas of the mouth with dental decay, broken teeth, or gum disease these will need to be treated first before implants are placed. We will give you an idea of other work that may be needed in order to make the mouth stable. Placing implants in a mouth where there are other untreated dental problems can be a recipe for disaster.

2. Can the patient maintain a healthy mouth? The success of implants can depend on the ability of the patient to keep their teeth and gums clean. We need to be sure this will take place before implants are placed. We will always advise you on how to care for your mouth to allow you to have implants, and also how to care for your new teeth. Your commitment will be to follow our advice.

3. Is there sufficient quantity and quality of bone present to allow implants to be placed? Without the right amount of bone in the right place, it is difficult to place implants. Our diagnostic process will help to determine the availability of bone. This is usually done with the help of x-rays. In some cases, we may use a CT-type scan to obtain a 3-dimensional image for more accurate bone assessment. In cases where sufficient bone is not available a range of grafting techniques can be used.

These are some of the many factors which we look at in the assessment process. We believe that a thorough assessment gives the best chance of a successful result.

Is there an age limit to implants?

You can be too young for implants but age itself is not a barrier. The state of your health is an important criteria and your dentist will determine your suitability for surgery. After general health the most important criteria is probably whether there is sufficient quality and quantity of bone to accommodate implants

Complications of implants.
1. failure of the implant to integrate with the jaw bone.
2. failure due to :
--> overloading of implants due to either an insufficient number of implants in the first place .
--> too much stress being placed on the implants on account of a patient’s habit of excessively grinding or clenching their teeth.
3. post op. swelling & bruising.

Procedure:
We need to do a surgical procedure to bury the implant within the jawbone and allow the body to heal naturally.
After about 3-6 months, the implants will be strong enough to support the load of new teeth which is attached to them.
During the healing period, you will be provided with temporary "teeth" to allow you to carry on your way of life until the bone completely surrounds the implant.
This may be an adhesive-type bridge or a denture.
The procedure is normally carried out under local anaesthesia.
For patients who are anxious, intravenous sedation is also offered.
During the surgery, the local anaesthesia and sedation given practically eliminates all pain.
After the surgery, there will be some discomfort, swelling or bruising but with the appropriate medication, it is usually not unduly uncomfortable. However, it is important to note that different people can heal at different rates.

dental fluorosis.

2007-01-04T09:12:00.000-08:00

DENTAL FLUOROSIS:
A condition of emamel hypoplasia characterized by white chalky spots or brown staining and pitting of teeth due to an increased level of fluoride affecting enamel matrix formation and calcification by impairment of ameloblastic function.
CLINICAL FEATURES:
1. yellow to brown pigmentation

2.varing degrees of pitting and mottling

3.bilaterral symmetric distribution

4.varying levels of severity

5.a permanent disfigurement

6severe mottling may result in excessive wear and fracturing of the incisal and occlusal surfaces due to soft enamel.
Differential Diagnosis:

1.dental fluorosis

2.focal enamel hypoplasia

3.enamel hypoplasia from congenital syphilis

4.contemporaneous hypoplasia

5.hypoplasia due to vitamin D deficiency

6.incipient caries

7.amelogenesis imperfecta
Classification Criteria for Mild Dental Fluorosis - Dean's Fluorosis Index
Score Criteria :
Normal:
The enamel represents the usual translucent semivitriform type of structure. The surface is smooth, glossy, and usually of a pale creamy white color.
Very Mild:
Small opaque, paper white areas scattered irregularly over the tooth but not involving as much as 25% of the tooth surface. Frequently included in this classification are teeth showing no more than about 1-2 mm of white opacity at the tip of the summit of the cusps of the bicuspids or second molars.
Mild:
The white opaque areas in the enamel of the teeth are more extensive but do not involve as much as 50% of the tooth
Moderate:
All enamel surfaces of the teeth are affected, and the surfaces subject to attrition show wear. Brown stain is frequently a disfiguring feature.
Severe:
Includes teeth formerly classified as "moderately severe and severe." All enamel surfaces are affected and hypoplasia is so marked that the general form of the tooth may be affected. The major diagnostic sign of this classification is discrete or confluent pitting. Brown stains are widespread and teeth often present a corroded-like appearance

Treatment:

cosmetic veneers, professional bleaching or micro-abrasive treatment

WHAT IS TEETH BLEACHING ?

Teeth bleaching on a simple scale is the treatment of teeth using an oxidising or bleaching agent to lessen or eliminate stains by lightening the discoloration of the enamel or dentin of our teeth. Causes of teeth discoloration can be due to aging, consumption of staining substances such as coffee or tea, smoking, trauma and nerve degeneration. Other than self-treatment by using commercial products, professional dental treatment is strongly encouraged.

Professional Treatment:
1. Before treatment, the dentist will examine the patient orally and ensure that the patient has a set of healthy and unrestored teeth before deciding whether the patient is a suitable candidate for teeth bleaching.
2. There are two main ways to bleach teeth:
Procedure A:
• The dentist first takes an impression of the upper and lower row of teeth.
• Plaster models are made from these moulds and then trays to cover the teeth are made from the models.
• A small solution of bleaching solution is placed in the trays to be worn over the teeth.
The trays must be able to prevent the solution from concentrating over the gum, as the bleaching solution, when allowed to remain in contact on the gum for too long, will cause the gum to irritate or burn.
• The trays are worn over the teeth for a period of 11/2-2 hours daily for 3-6 weeks, with visits to the dentist scheduled every 2 weeks.
Procedure B— a more popular method
• It requires only one appointment.
• A safe bleaching solution is applied to the teeth and exposed to a small intense light that activates the bleach.
• After the above steps are repeated 2-3 times, the teeth are then polished.
• Procedure only requires 40 minutes.

"chicken-guinea"

2006-11-17T07:55:00.000-08:00

Other name: Chicken Guinea

Etiology:
Chikungunya is a relatively rare form of viral fever caused by an alphavirus that is spread by mosquito bites from the Aedes aegypti mosquito, though recent research by the Pasteur Institute in Paris claims the virus has suffered a mutation that enables it to be transmitted by Aedes Albopictus (Tiger mosquito). The name is derived from the Makonde word meaning "that which bends up" in reference to the stooped posture developed as a result of the arthritic symptoms of the disease

Clinical Presentation:
fever - can reach to 39°C, (102.2 °F)
rashes - a petechial or maculopapular rash usually involving the limbs and trunkarthralgia or arthritis affecting multiple joints headacheconjunctival infectionslight photophobia
Dermatological manifestations observed in a recent outbreak of Chikungunya fever in Southern India and Western India (Surat) includes the following:
Maculopapular rash
Nasal blotchy erythema
Freckle-like pigmentation over centro-facial area
Flagellate pigmentation on face and extremities
Lichenoid eruption and hyperpigmentation in photodistributed areas
Multiple aphthous-like ulcers over scrotum, crural areas and axilla.
Lympoedema in acral distribution (bilateral /unilateral)
Multiple ecchymotic spots (Children)
Vesiculobullous lesions (infants)
Subungual hemorrhage
Photo Urticaria
Acral Urticaria

Treatment :
No specific treatmentni vaccine available (for now)chloroquine for arthralgia associated with ChikungunyaAntiinflammatory drugs and analgesics to relieve fever and pain

infective endocarditis & its dental prophylaxis..

2006-11-12T06:18:00.000-08:00

Definition
Subacute Bacterial Endocarditis (SBE) is a bacterial infection that produces growths on the endocardium (the cells lining the inside of the heart). Subacute bacterial endocarditis usually (but not always) is caused by a viridans streptococci (a type of bacteria); it occurs on damaged valves, and, if untreated, can become fatal within six weeks to a year.
Description
Endocarditis has traditionally been classified as acute or subacute based upon the pathogenic organism and the clinical presentation. This distinction has become less clear, however, and the less specific term "infective endocarditis" is now more commonly used. Most patients who develop infective endocarditis have underlying cardiac disease, although this is frequently not the case with intravenous drug abusers and hospital-acquired infections. Important factors that determine the clinical presentation are:
1.the nature of the infecting organism
2.whether the infection is superimposed upon preexisting abnormal cardiac structures
3.the source of infection, since endocarditis in intravenous drug abusers and infections acquired during open heart surgery have special features
More virulent organisms, Staphyloccus aureus in particular, tend to produce a more rapidly progressive and destructive infection. Patients are more likely to present with:
#fever
#early embolization (vegetation dislodging from the heart valve and traveling through the blood stream)
#acute valvular regurgitation (back flow of blood in the heart)
#abscess formation (pocket of infection)
Streptococcus viridans, enterococci, and a variety of other bacteria and fungi tend to cause a more subacute form of endocarditis. Streptococcal infection tends to be more chronic, though the average incubation period is 1 to 2 weeks.
Causes
Subacute bacterial endocarditis (SBE) is usually caused by streptococcal species (especially viridans streptococci), and less often by staphylococci. SBE often develops on abnormal valves after asymptomatic bacteremias (bacteria traveling through the bloodstream) from infected gums, or from gastrointestinal, urinary, or pelvic procedures.
Symptoms
Most patients present with a fever that lasts several days to 2 weeks. Nonspecific symptoms are common. Cough, shortness of breath, joint pain, diarrhea, and abdominal or flank pain may be present. About 90 percent of patients will have heart murmurs, but murmurs may be absent in patients with right-sided heart infections. A changing murmur is common only in acute endocarditis.
Diagnosis
Endocarditis is suspected in a patient with a heart murmur and unexplained fever for at least one week, and in an intravenous drug abuser with a fever, even in the absence of hearing a murmur. A definitive clinical diagnosis requires blood cultures that grow bacteria. Echocardiography (ultrasound study of the heart) may visualize vegetations (growths) on heart valves.
Treatment
Cure of endocarditis requires eradication of all microorganisms from the vegetation(s), usually on the heart valve. Bacterial endocarditis almost always requires hospitalization for antibiotic therapy, generally given intravenously, at least at the outset. Most patients respond rapidly to appropriate antibiotic therapy, with over 70 percent of patients becoming afebrile (without a fever) within one week. Occasionally, therapy with oral antibiotics at home will be successful. Antibiotic therapy must usually continue for at least a month. In unusual cases, surgery may be necessary to repair or replace a damaged heart valve. Complications If bacterial endocarditis is not adequately treated, it can be fatal. This is dependent on the infecting organism. Even when treated, further damage to a heart valve may can to heart failure. In addition, blood clots can form and travel throughout the bloodstream to the brain or lungs.
Prevention
It is important that you tell your dentist or physician about any risk factors you may have for endocarditis. People with predisposing factors for bacterial endocarditis are those with:
prosthetic heart valves
previous bacterial endocarditis
congenital heart disease
rheumatic valve dysfunction
hypertrophic cardiomyopathy
mitral valve prolapse with valvular regurgitation
If these predispositions are present, the patient should be given antibiotics before most medical or dental surgeries and whenever any significant skin infection occurs. Your physician will recommend which antibiotic(s) to take before, and in some cases, after your procedure.

Endocarditis prophylaxis recommended

1. Dental extractions

2.Periodontal procedures, including surgery, scaling, root planing, probing and recall maintenance

3.Dental implant placement and reimplantation of avulsed teeth

4. Endodontic (root canal) instrumentation or surgery only beyond the apex

5. Subgingival placement of antibiotic fibers or strips

6.Initial placement of orthodontic bands (but not brackets)

7. Intraligamentary local anesthetic injections Prophylactic cleaning of teeth or implants, where bleeding is anticipated
Endocarditis prophylaxis not recommended

1.Restorative dentistry (operative and prosthodontic), with or without retraction cord

2. Local anesthetic injections (nonintraligamentary)

3. Intracanal endodontic treatment (post-placement and build-up)

4.Placement of rubber dams

5. Postoperative suture removal

6.Placement of removable prosthodontic or orthodontic appliances

7.Oral impressions ,Fluoride treatments, Oral radiographs

8.Orthodontic appliance adjustment

9.Shedding of primary teeth

Prophylactic regimen that is proposed by AHA
Standard general prophylaxis
1.Amoxicillin
Adults: 2 g Children: 50 mg per kg Taken orally one hour before the procedure
Patient is unable to take oral medications
1.Ampicillin
Adults: 2 g Children: 50 mg per kg Given IM or IV within 30 minutes before the procedure
Patient is allergic to penicillin
1.Clindamycin (Cleocin)
Adults: 600 mg Children: 20 mg per kg Taken orally one hour before the procedure

2. Cefadroxil (Duricef) or cephalexin (Biocef, Keflex) †
Adults: 2 g Children: 50 mg per kg Taken orally one hour before the procedure

3. Azithromycin (Zithromax) or clarithromycin (Biaxin)
Adults: 500 mg Children: 15 mg per kg Taken orally one hour before the procedure
Patient is allergic to penicillin and is unable to take oral medication
1. Clindamycin
Adults: 600 mg Children: 20 mg per kg Given IV within 30 minutes before the procedure

2. Cefazolin (Ancef, Kefzol)
Adults: 1 g Children: 25 mg per kg Given IM or IV within 30 minutes before the procedure

rules for treatment

2006-11-12T06:16:00.000-08:00

6.0 RULES FOR TREATMENT
6.1 Existing restorations and bases not placed at this school must be removed from all teeth to be crowned.6.2 Amalgam cores are usually placed in Operative, but may be done in FPD clinic if the need arises during crown preparation, or if the tooth is to be a fixed partial denture abutment. Teeth planned for MOD onlays should not have amalgam cores. (Usually, if a cavity needs an amalgam core, it is too extensive to be restored with an onlay.) When substituting an inlay or onlay for an amalgam, be sure to change the Operative treatment plan.6.3 Rubber dam usage is recommended for the following procedures:
Excavation of deep caries
Preparation and cementation of inlays
Cementation of resin-bonded restorations
6.4 Pulp Exposures: If the pulp is exposed during crown preparation, endodontic therapy must be completed before the crown can be fabricated. Castings may never be cemented over direct pulp caps.
If you create an avoidable mechanical exposure, you will receive a "0" for the preparation step. The tooth must be endodontically treated and you must fabricate a core for no credit. The patient will not be charged for the endodontic treatment or the core placement. These procedures must be completed before you graduate.It is prudent to ask an instructor for assistance when excavating caries dangerously close to the pulp so that you will not be unjustly blamed for a mechanical exposure.6.5 Cores for Endodontically Treated Teeth
6.5.1 Endodontically treated teeth requiring crowns must first have a core placed according to the following general rules:
Single-rooted teeth: Restore with a cast dowel-core. Invest the pattern in BeautycastTM with no ring liner, and have the Support Lab cast it in AlbacastTM, a AgPd alloy.
Two-canal premolars may be treated either in Fixed with cast dowel-cores, or in Endodontics Clinic with prefabricated dowels and amalgam cores.
Molars with two or more sound cusps should be restored with pin-retained amalgam cores with amalgam extending a short distance into the canals. This may be done in Operative clinic. A cement base is contraindicated.
Molars with little or no coronal tooth structure: Restore with two prefabricated dowels, e.g. titanium Parapost PlusTM, and an amalgam core.
Molar fixed partial denture abutments: Restore with two prefabricated dowels, e.g. titanium Parapost PlusTM, and an amalgam core.
6.5.2 Endodontically treated teeth that do not require dowel-cores and crowns:
Non-vital anterior teeth with minimum destruction, no crown indicated: Place a simple composite restoration.
Non-vital posterior teeth with minimum destruction: Place an onlay over a cement base.
6.6 Provisional Restorations: A new provisional restoration must be approved by an instructor before it is cemented. An instructor must be given the opportunity to check every cemented provisional restoration before the patient is dismissed.As a rule, custom acrylic resin provisional restorations will be used. This means that you must have a custom matrix ready. Provisional restorations should not be relined directly on vital teeth if acrylic resin is used (e.g. Dentsply Caulk Temporary Bridge Resin).Exceptions to the above rules are:1. Dowel-core preparations in esthetically non-critical areas (e.g. mandibular second premolars) may be temporized with only a cotton pellet and CavitTM.2. Non-vital anterior teeth and premolars may be temporized with prefabricated polycarbonate crowns relined directly in the mouth.3. The patient's old permanent restoration can sometimes be relined and used as a provisional; but have a custom matrix ready in case the old restoration is destroyed in removal.4. BisAcryl (e.g. Integrity) may be used in a direct technique but only if it is pre-approved by the instructor with whom you are working.6.7 Tissue Management 6.7.1 Retraction cord: Epinephrine-containing retraction cord will only be used at the direction of the attending faculty.6.7.2 Electrosurgery is useful for removing small amounts of tissue that interfere with crown preparation, impression making, or cementation. A unit must be checked out from the dispensary. The instructor will perform the procedure. You may not perform electrosurgery until after you have taken an elective or a postgraduate course on its use.6.8 Impression trays:
Custom trays may be used for all cases and must be used for all impressions involving more than one prepared tooth.
Full Arch Stock trays may be used for single-unit cases.
Check-bite trays may be used to make twin-arch impressions for single posterior units only (no multiple units) after the student receives exemption from margination. Only the rigid metal # 72 Coe Check-Bite TrayTM is to be used. The patient must be able to close in centric with the tray in place. These impressions will be poured and mounted on a Foster Correlator. Mount the casts toward the anterior part of the Foster Correlator; i.e. do not mount the casts close to the hinge of the articulator. This tray is not to be used for surveyed crowns for removable partial dentures. If you wish to use this technique, you must purchase the Coe Tray and Foster Correlator.(shown below)
Coe Check-Bite Tray Foster Correlator

6.9 Casts and Dies: Both the working cast and opposing cast for a fixed restoration are to be poured in a die stone (e.g. violet Silky Rock). Opposing casts must be current, i.e. made after the placement of major restorations. The patient's white diagnostic casts must be preserved as a legal record and are not to be used for fabricating trays etc., or as opposing casts for restorations.The types of casts and dies to be used are outlined below:
Type III gold restorations: Solid working cast and two separate dies.
Metal-ceramic restorations: Pour a polishing die and a solid cast. The lab will then Pindex the solid cast for you. Do not use the pindexed die for polishing.
6.10 Metal-Ceramic Restorations (MCR)You should not attempt a metal-ceramic crown until you have gained some experience with full cast crowns.
The standard indications for a MCR are:
Maxilla: First molar through first molar.
Mandible: Second premolar through second premolar.
6.10.1 MCR Coping DesignOcclusal coverage: Metal is functionally superior to porcelain, but porcelain provides better esthetics. The standard MCR is a compromise with metal supporting the heaviest contacts, and porcelain covering the most visible areas. Metal occlusal contacts are especially indicated on posterior MCRs if there is greater than normal tooth wear (bruxism, heavy musculature) or if there are posterior sliding contacts in excursive movements. If the restoration will occlude against resin denture teeth and there is space for the additional occlusal reduction required, the entire occlusal surface may be covered with porcelain.With a normal mutually protected occlusion, the standard extent of porcelain occlusal coverage is as follows:
Maxillary first premolar: Mesial half of occlusal surface and facial half of buccal cusp.
Maxiallary second premolar: Facial half of buccal cusp
Maxillary first molar: Facial half of buccal cusps
Mand. first premolar: Entire occlusal surface
Mand. second premolar: Mesial half of occlusal surface
Mandibular first molar: Mesial half of occlusal surface
If the patient desires more porcelain coverage than you and your instructor think advisable, explain the disadvantages (deeper tooth reduction, abrasion of opposing teeth, risk of porcelain fracture). If the patient still insists, his/her wishes may sometimes be complied with, but a notation should be made in the chart that it is against your advice. In these cases, it is a good idea to fabricate an occlusal splint to be worn at night to protect the restorations and opposing teeth.Porcelain margin vs metal collar: Porcelain margins are esthetically superior to metal collars, and so are routinely used on anterior teeth and maxillary premolars.Metal collars provide greater strength, are technically less demanding and are preferred on:
mandibular crowns distal to the first premolar,
maxillary molars,
weakened endodontically-treated teeth,
preparations that extend apically well onto the root surfaces
long-span fixed partial dentures.
6.10.2 Laboratory procedures for MCRs: The support lab will Pindex your master cast for you. You will trim the die and mount the casts. The shoulder area must be perfectly intact for stacking of a porcelain margin, so pour an extra die for finishing the casting.Note that there are THREE wax pattern checks: Full Contour, CUT BACK ON WORKING CAST , and Wax Pattern Margination. Invest the pattern in CeramigoldTM and turn it in to the Support Lab to be cast in OlympiaTM. It must be accompanied by a lab work authorization form and a gold card signed by at least a half-time instructor. At least half the fee must be paid before it can be cast. Normally, if the invested pattern is delivered to the lab by 4:00 p.m., it will be ready after 11:00 a.m. the next day. Pick up the coping for Untouched Casting check, preliminary finishing and try-in.After you have become a senior you may conduct the coping framework try-in for single-unit MCR's on the articulator rather than in the patient's mouth. In these cases, the shade must be selected at the impression appointment. The untouched casting for these cases must be evaluated by an instructor even if you have been officially exempted from that step. If there are any questions regarding accuracy of the coping, die, working cast or mounting, a try-in appointment will be necessary. A try-in appointment is still necessary for metal-ceramic bridges and multiple single-units.After the casting has been tried in and approved, it is ready for final finishing and porcelain application. Finish exposed metal surfaces with rubber polishing wheels and points, but use only Shofu pink stones on the areas to be veneered with porcelain.The work authorization for porcelain application must be signed by at least a half-time instructor after metal finishing. Show the instructor all the models and guides you plan to present to the lab. These should include:
Finished coping on articulated casts.
Extra dies with unblemished finish lines wherever porcelain margins are to be formed.
Putty index made on your full contour wax-up, or a stone cast duplicating the patient's dentition with esthetically correct provisionals in place.
Custom incisal guidance jig, if anterior guidance has been lost through tooth preparation.
Work authorization filled out as shown in section 7.9.
For porcelain addition, allow 5 working days for a single unit and 10 working days for a fixed partial denture.6.11 Resin-Bonded Bridges: Prior to the first appointment, do practice preparations on a stone cast of your patient's teeth. At the first appointment, prepare the teeth. Make a full arch elastomeric impression in a custom tray and pour dies and a working cast in a die stone. No provisional is necessary.Full contour wax-up and cut-back of the pontic must be graded on the master cast. A thin skeleton of Duralay will prevent the pattern from breaking. The pattern is marginated on the solid die and turned in to the lab with a work authorization to be invested, cast in Olympia, and polished.At the second appointment, the framework will be tried in, adjusted, and the shade selected. Return it to the laboratory for porcelain application. At the third appointment, the bridge will be tried in and any necessary modifications made in the form and shade of the pontic. Return the bridge to the laboratory for tin plating of the metal. Caution: Do not touch the metal surface toward the tooth after it has been tin plated.The abutment teeth are then cleaned with wet pumice, a rubber dam may be placed, the preparations are etched and the bridge is cemented with a resin cement. This resin sets quickly, so utilize an assistant. Use the opaque resin for anterior abutments to prevent metal show-through. The bridge must be held firmly in place and the contact areas cleaned with floss before the resin sets. After it has hardened, trim exposed cement with carbide finishing burs, and polish with white stones, discs, and rubber cups with pumice and fluoride-containing prophylaxis paste.(Note: Only one resin-bonded bridge will count toward the requirement of four fixed partial dentures for graduation.)6.12 All-Ceramic Restorations: Only those students who have been exempted from margination checks may do all-ceramic restorations (porcelain crowns, inlays and laminate veneers). These are indicated where esthetic demands are high. They are never to be used on RPD abutments. It may be necessary to utilize a laboratory outside the school--check with your instructor.Ceramic inlays and onlays do not count toward the three inlay/onlay requirement.6.12.1 Steps in the fabrication of porcelain laminate veneers:1. The preparation should be entirely in enamel. Make an elastomeric impression. A provisional restoration is usually not necessary.2. Send master cast to the laboratory for veneer fabrication. It will be returned etched and silane-treated.3. Try-in and adjust. Etch enamel.4. Bond with a shaded, light-activated resin cement.6.13 Dowel-Copings: The margins must fit very accurately as they will be exposed to a caries-inducing environment under an overdenture. Therefore, they are fabricated by an indirect technique on a cast and die made from an elastomeric impression.6.14 Diagnostic Wax-ups: In certain circumstances it is necessary to make a wax-up of the proposed restoration and/or the opposing occlusion on diagnostic casts. This helps in designing restorations for optimum esthetics (use ivory wax) and occlusal harmony, and provides the basis for fabricating provisional restorations and tooth-reduction guides (Citricon indexes).Diagnostic wax-ups are indicated when:
the final restoration will differ significantly from the existing dentition in form, size or alignment
the shape of the opposing teeth will be altered later with restorations (wax the opposing teeth to ideal form)
the opposing teeth will be replaced by a fixed or removable partial denture. In the latter case, the actual denture teeth that will be used in the partial should be set on the opposing cast to occlude against the wax pattern.
You will receive some point credit for a diagnostic wax-up (difficulty factor = 0.15 per tooth involved).6.15 Alternate Techniques and Materials: After you have completed your graduation requirements, you may wish to try techniques or materials not routinely used in this school. You must first get permission from the department chairman. You must demonstrate to him knowledge of the properties of any materials you want to use, and the material you supply must be in good condition.6.16 Emergencies and Untoward Incidents: The procedure for handling and reporting untoward events (accidents) is described in detail in the Protocol for Clinic Practice. Briefly, you must assist the patient, send for help from the faculty, and make a report to the Director of Clinics. Emergency numbers are posted in all clinics next to the phones (Oral Surgery 4079, Amcare Ambulance 232-1234, and University Hospital Emergency Room 271-4363).

removable vs fixed bridge.....

2006-11-12T06:13:00.000-08:00

Treatment Planning for Single Missing Teeth

Single Tooth Replacement Options

Fixed Partial Denture (FPD)
Removable Partial Denture (RPD)
Interim or Transitional Partial Denture (Flipper)
Implant Supported Restoration
Resin Retained Bridge (Maryland bridge)
Cantilever Bridge

Indications for Single Tooth Replacement

Traumatically avulsed tooth
Congenitally missing tooth
Extraction of non-restorable tooth
External resorption

Removable Partial Denture

Advantages Disadvantages

·Indicated when acrylic will improve ·Requires an essential amount of metal
appearance (excessive bone loss) framework and tooth support to replace
· Least expensive one or two teeth
· Treatment of choice for patients who
have difficulty with hygiene

Fixed Partial Denture

Advantages Disadvantages

·Esthetics ·May involve irreversible preparation
·Covered at least partially by of minimally restored or virgin teeth
insurance ·Abutments susceptible to recurrent decay
·FPD feels more permanent than RPD ·Cost for remake if needs replaced
·Capable of directing forces ·Pontic emergence profile
along long axes of teeth ·Labial bone inadequacy
·Need floss threader
·Retention of diastema difficult

Transitional Partial Denture (Flipper)

Advantages Disadvantages

·provides esthetics, function and space ·no rest seats to prevent overseating,
maintenance for a limited period of can cause tissue erythema
time (may be used while implant sites ·resin subject to fracture and to imbibing
heal or as a space maintainer waiting for oral fluids
completion of growth)
·inexpensive
·may be treatment of choice for an
patient who can not sit through the
lengthy or physically trying appointments
needed to make fixed prostheses

Resin-Retained Fixed Partial Denture (Maryland Bridge)

Advantages Disadvantages

·conservation of tooth structure as ·debonding of the bridge
compared to FPD ·metal retainers may cause noticeable
·alternative to FPD for young patients darkening of abutment teeth
with large pulps ·emergence profile not as esthetic as
·alternative to implant crown for implant-supported crown
young patients who have not completed ·retention of diastema not an esthetic option
growth ·abutments can not have large carious
or large restorations
·patient can not have parafunctional habits
or poor posterior occlusion
·5-year survival rate (loss of retention)
approx 70% (Creugers, NHJ, et al : Clinical
Performance of resin-bonded bridges:
A 5-year prospective study. J Oral Rehabil 16:427,1989)

Cantilever Fixed Partial Denture

Advantages Disadvantages

·may prepare only one abutment tooth ·a cantilever will introduce lateral
(for example, leave a maxillary incisor forces which may lead to tipping, rotation,
intact when replacing a lateral using the or drifting of abutment
canine as the retainer

·may replace one tooth using two ·tooth preparation required (as opposed
abutments for a distal extension to implant)
situation when occlusion is favorable

Implant Supported Restoration

Advantages Disadvantages

· approximately same cost as FPD
·esthetic emergence profile ·requires two surgeries
·does not remove tooth structure ·requires additional planning
from adjacent teeth ·healing time
·may be retrievable ·need for interim prosthesis
·preservation of existing bone ·potential color shift with age still present
but only one tooth is involved
·gingival esthetics can be difficult,
especially in areas where regenerative techniques have been used to restore hard tissue
·patient must meet selection criteria as far as
current health status (absolute
contraindications include persons who are
acutely ill, persons who have uncontrolled
metabolic disease and pregnant women) and
available bone or candidate for grafting
(need 10 mm vertical bone
and 6 mm horizontal bone; 1 mm bone
lingual and .5 mm bone facial to inferior
dental canal; 1 mm from PDL of adjacent
teeth; 3 mm from mental foramen)

Indications for Implant Placement in the Partially Edentulous Patient

1. Inability to wear a removable partial denture
2. Long edentulous span (unfavorable for fixed)
3. Unfavorable number and location of potential natural tooth abutments
4. Single tooth loss that would necessitate preparation of undamaged teeth for a
fixed prosthesis