Dental Study Guide - August 16, 2024

**[Green: Sinclair] [Blue: Uswa]** **[Pink: Chloe]** **[Week 1- August 16, 2024]** [Week 1- 10:00 AM - 12:00 PM: OS Review Ch 1, 2, 3, 5, 6, and 12, Review Ch 7 & 8: Principles of Routine Exodontia] - Elevating the periosteum is an initial step of an extraction. The No. 9 Molt periosteal el...

**[Green: Sinclair] [Blue: Uswa]** **[Pink: Chloe]** **[Week 1- August 16, 2024]** [Week 1- 10:00 AM - 12:00 PM: OS Review Ch 1, 2, 3, 5, 6, and 12, Review Ch 7 & 8: Principles of Routine Exodontia] - Elevating the periosteum is an initial step of an extraction. The No. 9 Molt periosteal elevator is designed to reflect bone in a single subperiosteal layer. The pointed end is inserted beneath the periosteum to separate it from the underlying bone. It is utilized to elevate, twist, and pry soft tissue. - The scalpel most frequently used in oral surgery is No. 15. It may come with a plastic handle and a fixed blade or a metal handle with a disposable blade. The blades tend to dull quickly during procedures and are intended for single use. When handling a blade, the pen grasp technique is recommended. To change blades, a needle holder should be used to securely grip the blade. - Rongeurs are another important instrument in oral surgery to perform osteotomy. They feature a rebound mechanism that allows the clinician to consistently cut bone. When using rongeurs the objective is to remove small amounts of bone in multiple bites. It is crucial that this instrument is never used to extract teeth, because it will dull the instrument. - The difference between a needle holder and a hemostat is their anatomical presentation. Hemostats have long beaks and parallel grooves (decreasing grip and control). They remove granulation tissue and retrieve small fragments but are NEVER used for suturing. A needle holder is stronger than a hemostat because it is cross-hatched. It is used for suturing and is known to have short blunt beaks. - Post-extraction tooth socket care is essential for optimum healing. As a clinician, it is important to remove any debris but avoid suctioning the socket. The patient should bite down on WET gauze for a minimum of 20 minutes. They should refrain from spitting and instead lean forward to gently wipe their mouth with gauze or a cloth when at home. [Week 1- 1:00 PM - 3:00 PM: Pedo/Ortho (Dr. Swearingen/Pryse)] 1. **Adult Maxillary Expansion lecture:** - Maxillary arch expansion is necessary for addressing skeletal imbalances and dentofacial irregularities, as well as for treating malocclusions. It is important to identify these imbalances earlier in life. Implementing early intervention through interceptive treatment during growth stages (facial and developmental) has an effective outcome for the patient. - Rapid Palatal Expander (RPE) such as a Hyrax appliance, has become the most common method for addressing maxillary TRANSVERSE deficiency. RPE influences various circum-maxillary complexes, including the zygomatic structures and nasal sutures. While RPE can be used to treat patients who have already reached growth milestones, it may lead to considerable dentoalveolar alterations if not carefully observed by the clinician. - Various designs of microimplant-assisted rapid palatal expanders (MARPE) have emerged with the rise of bone anchorage techniques.Research shows that bone-borne anchorage influences adjacent bone structures in the coronal and occlusal dimensions, helping towards a more parallel expansion. - Distraction Osteogenesis Maxillary Expansion (DOME) is a surgical technique for expanding the adult upper jaw. This minimally invasive procedure avoids complications associated with traditional surgical methods, differentiating it from Surgically Assisted Rapid Palatal Expansion (SARPE), which uses tooth-borne expanders. - According to research, Distraction Osteogenesis Maxillary Expansion (DOME) effectively reduced the severity of obstructive sleep apnea (OSA), improved nasal airflow, decreased daytime tiredness, and increased REM cycle in adults with a narrow palate and nasal floor. 2. **Pediatrics Abuse lecture:** - Dental neglect is known as the intentional failure by the guardian/caregiver of the child who needs necessary dental treatment leading to pain and infection. It is essential to distinguish between neglect versus a caregiver\'s lack of awareness when assessing whether a situation is a case of abuse. - Emotional or verbal abuse includes harmful actions or words, such as name-calling and isolation, and is often the hardest to identify. Oro-facial injuries are prevalent, with more than half of child abuse cases showing signs of craniofacial injuries. Once a caregiver is informed about the child\'s dental issues, intervention is necessary, especially if they have been made aware of the child\'s condition and available treatment options. - Documentation is a key step when notating child abuse. When a provider suspects abuse, the following should be documented: name and relationship of caregiver accompanying the child, detail of medical and dental history, photograph of injuries, time of observation, and method of reporting the abuse. - Oro-facial trauma is a significant indicator of child abuse, with over half of abuse cases presenting craniofacial and neck injuries. Common manifestations of abuse include facial abrasions and lacerations, often caused by objects like rings or fingernails, while burns are typically from forced ingestion of hot substances or contact with heated objects. Cigarette burns create distinctive, circular lesion that are uniform in size. - Abuse is harm or the threat of harm to a child\'s well-being, which can manifest as non-accidental physical injuries, sexual abuse, or emotional abuse. Emotional or verbal abuse often involves hurtful actions or words, while sexual abuse includes inappropriate touching. Physical abuse leads to bodily harm through various harmful actions, and medical abuse involves fabricating or inducing illness, commonly known as Munchausen Syndrome by Proxy. [Week 1- 3:00 PM - 5:00 PM: Caries Removal, Bonding, Restorative Topics (Dr. Erpenbach)] - Enamel is more mineralized (88% HPA) compared to the more organic Dentin (50% HPA, 25% Organic). There are 3 stages of dentin decay: the demineralization via weak acid that exposes the organic matrix, the degradation of organic collagen, and finally the loss of matrix stability and the entrance of bacteria. Once bacteria enters the dentin, it can be defined into 3 zones. Zone 3 is "infected" dentin and is soft and leathery with poor bonding. Zone 2 is "affected" dentin and can remineralize, having a higher bonding capacity than Zone 3. Zone 1 is made of "hard" reparative dentin and is the most internal layer. Caries are traditionally gauged by hardness/stickiness when probing, which is subjective and unreproducible compared to the use of caries detector dye that measures denaturalized collagen. - The peripheral seal zone is a concept used for improved bonding of restorations. It is 1-3mm wide and approximately 2mm from the DEJ. Made of normal superficial dentine, DEJ, and enamel, this zone can generate a bond of 45-55Mpa for sealing out bacteria. For reference, sound dentin bonds at 45Mpa, infected dentin bonds at 10Mpa, and affected dentin bonds at 30 Mpa. - The Caries Removal Endpoint (CRE) describes how far you can go removing caries w/o exposing the pulp. These measurements are about 3mm axially from the adjacent marginal ridge, and 5mm occlusally. - Direct pulp exposures occur when the pulp is fully exposed and bleeding, small ones can be repaired by placing a small amount of bond over them. Indirect exposures are when the pulpal proximity is close but not opened, and the pulp vitality is 3x that of direct exposures. Incomplete caries removal is the act of leaving a small amount of decay in the tooth when it is close to the pulp. This reduces the risk of exposing the pulp, lowers instances of post-op pulpal pain, has no increase in complication, and has greater success in maintaining pulp vitality. - There are two main bonding strategies: Etch-and-rinse, and Two Step Self-Etch adhesives. Two step etches and primes at the same time and lacks a rinse step, incorporating the smear plugs and resin tags together. It is not as susceptible to moisture variation, but it is more susceptible to chemical (hydrolytic) degradation. Etch-and-Rinse removes the smear layer via acid etching, uses "moist bonding" to maintain the collagen network, and allows for deep penetration of primer and bond into intertubular dentin for stronger adherence. **[Week 2: August 23, 2024]** [Week 2- 10:00 AM - 12:00 PM: OS Lecture: Ch 9 - Principles of More Complex Exodontia] - Luxation is directed toward **expansion** of bone and disruption of the PDL. The goal of luxation is to apply apical pressure to expand the socket. This displaces the tooth at the center for rotation to decrease the chance of apical root fracture. - The 5 major motions practiced during luxation are: APICAL, BUCCAL, LINGUAL, ROTATIONAL, TRACTIONAL. Apical force expands the socket at the center, buccal force expands the buccal plate, slight lingual/palatal force helps to expands the lingual plate, then a rotational force is applied with forceps and finally a gentle tractional force delivers the tooth. - For multiple extractions in one visit, the recommended sequence is to start with the MAXILLARY teeth, followed by the extraction of the most POSTERIOR teeth, and finally the ANTERIOR teeth, beginning with the canines. - Two types of extraction procedures are the Closed extraction (no flap raised) and Open extraction (flap raised). Closed extractions are indicated when there is adequate access and visualization of the surgical field and controlled forced can be applied to luxate and remove teeth. Open extraction is indicated when excessive force is required because of dense bone and the initial attempt with forceps has failed, or radiographs indicate hypercementosis or divergent roots. - If clinician leaves root tips behind they should be fragments measuring LESS THAN 4-5mm. It is acceptable for these fragments to be located deep within the bone and not directly beneath a prosthesis. The root tips must be free of infection. Avoid removing root tips if the potential risks of surgery outweigh the benefits, such as excessive bone removal, compromising vital anatomical structures, or displacing fragments into surrounding tissues or the sinus. [Week 2- 1:00 PM - 3:00 PM: Pedo/Ortho (Dr. Swearingen/Pryse) - Pediatric Expansion] - The early treatment protocol addresses skeletal, dentoalveolar, and neuromuscular imbalances to enhance the orofacial anatomy before permanent teeth fully erupt. Starting orthodontic treatment at a younger age often decreases the need for more complex procedures, such as tooth extractions or orthognathic surgery later in life. - The transpalatal width for an adult patient should fall between 36-38mm (up to 42mm is still appropriate) but for mixed dentition it should be between 33-35mm. The trans-palatal arms are the most frequently employed arch retention method in orthodontics for maintaining the expanded palate. - Orthodontic treatment for issues like crossbites or malocclusions should begin only when the child is old enough to cooperate. During treatment, the tell-show-do technique should be used which includes explaining procedures in age-appropriate language and demonstrating procedures. Positive reinforcement and patience are essential, ensuring the child feels comfortable and is not in pain. - Successful patient compliance happens through effective communication and educating patients. Education is necessary for both parents and children, and it must include clear verbal, visual, and written explanations. Developing systems to identify and modify non-compliant behavior and utilizing technology like texting for reminders can further motivate patients to follow through with their desired treatment. - CBCT (the most effective tool in a dental office) has provided clinicians the opportunity to collaboratively manage patients and share complex information with other specialties, improving treatment outcomes. This 3D technology enables orthodontists to visualize anatomy and understand the effects of tooth movement, allowing for precise treatment planning. **[Week 3: September 6, 2024]** [Week 3- 3:00 PM - 5:00 PM: OS Lecture: Ch10 - Management of Impacted Teeth (Objectives: Understand methods for removing multirooted, impacted teeth)] - The removal of impacted teeth is indicated during several circumstances: prevention of periodontal disease, dental caries, and pericoronitis, as well as to prevent root resorption caused by third molars pressing against second molar roots. Additionally, teeth that are impacted under dental prostheses are essential to remove so the prosthesis can sit properly. Clinicians should understand that in order to have a successful outcome of orthodontic treatment, extractions are required when indicated. - Mandibular third molar impactions can be classified based on the angulation of the tooth relative to the second molar, its relationship to the anterior border of the ramus (Pell & Gregory Class 1-3), and its relationship to the occlusal plane (Pell & Gregory A-C). Accessibility is the primary factor determining whether removal is necessary, and extractions should be referred to a specialist if they are surgically difficult to remove for a general practitioner. - The surgical procedure to remove impacted teeth begins with reflecting an adequate flap to ensure accessibility. Next, the overlying bone is removed to expose the tooth. The tooth is then sectioned for easier removal, then the sectioned tooth is delivered using an elevator. Finally, the clinician prepares the area for wound closure. - Several factors contribute to the increased difficulty of surgery of an impacted tooth, including a distoangular tooth position, long thin roots, divergent or curved roots, and a narrow PDL can complicate the procedure. - The surgical procedure for a mesioangular impacted third molar (most common and easiest to remove) begins by turning a flap to expose the tooth. Then, fibrous tissue in the retromolar pad area is removed, followed by the removal of bone to expose the crown. The tooth is then sectioned (anterior portion of tooth removed first, then distal segment is elevated and removed) **[Week 4: September 13, 2024]** [Week 4- 8:00 AM - 10:00 AM: Pedo/Ortho (Dr. Swearingen/Pryse) Importance of Health History and 3D Technology] [Week 4- 10:00 AM - 12:00 PM: OS Lecture: Ch11 - Post-Extraction Care and Patient Management (Objectives: Manage post-extraction complications)] **[Week 5: September 20, 2024]** [Week 5- 1:00 PM - 3:00 PM: Restorative (Dr. Wes, Armamentarium + Materials Science)] **Armamentarium** - Carbides are made of tungsten caries and "cut" tooth structure, reducing chatter and creating a cleaner finish. Diamonds are stainless steel bodies with diamond particles bonded to it. They grind away hard tissue, putting more wear on the burs and can cause overheating of tooth structure. - Bur shape is indicated by 3 numbers before the period in the number code. They come in various shapes and tapers, such as 856 which refers to round end taper burs. - Cutting Diameter is indicated by last numbers on the item code = max cutting diameter at widest point in mm. Ex. 016 refers to bur 1.6mm wide at widest point - Cutting Length is a 2-digit number between periods in the item code. 31 = standard bur length (\~19mm). - Bur design should match application. Shoulder burs (flat-end taper) best for forming shoulder margins. Some burs have special function like barrel for reducing occlusal surfaces and wheels for incisal edges. **Materials Science** - **Fixed Materials Science** - **Fundamental Ideas in Materials** - *[Force (SI = newton)]* - One body interacting with another generates force via direct contact or distance (gravity) - Results in a translation or deformation depending on if body is free of constraints - 3 determining characteristics: - 1\. Point of application - 2\. Magnitude of force - 3\. Direction of force - Occlusal forces range from 200-3500N - Increases as hinge axis is approached - Pts lacking natural dentition (denture) generate less occlusal force - Greater occlusal force is generated at night in bruxism events than in day - *[Stress (σ)]* - When forces act on a constrained body, the body resist the force with a magnitude equal and opposite in direction to the applied force - Applied force and stress are distributed over an area of the body - Defined as force per area (stress = force/area) - Stress increases as force increases and area decreases - Measured in pascals or megapascals - Several thousands MPas are generated in mouth w small contact area - This is why premature contacts and tooth loss are damaging - Types of Stress are dictated by the direction in which force is applied: - ***Tension*** - two forces in opposite directions in straight lineA diagram of a mechanical scheme Description automatically generated with medium confidence - ***Compression*** - forces directed toward each other in same line - ***Shear*** - two parallel forces not along same straight line - ***Twisting*** - forces acting in a rotational movement - ***Bending (Flexure)*** -forces acting in different directions - *[Strain (ε)]* - When stress is applied to body, a corresponding DEFORMATION occurs - Tensile deformation = elongation - Compressive deformation = shortening - Strain is the change in length (deformation) per the original length of the body when it is subjected to a given load - Applies to ortho wires, implants, impression materials, composites, etc - ***Stress/Strain curves***: - Used to normalize material curves so comparisons can be drawn - Curve is independent of the geometry of the body and is consistent for a given material, can be used to compare material strengths - Plotted with strain on x-axis, stress on y-axis - *[Proportional and Elastic Limits]* - Relationship between stress and strain is linear and nonlinear - Point when curve becomes nonlinear is the **proportional limit (arrow)** - The **elastic limit** is the maximum stress that a material will withstand without permanent deformation - Below this, no permanent deformation occurs in a structure, and this area is called the **elastic deformation** space (body returns to shape) - In many materials, **proportional limit = elastic limit** unless the material is **superelastic,** which has a nonlinear region on the stress-strain curve but will return to its original shape - Beyond the elastic limit, increasing stress will lead to permanent deformation - Material now in the plastic region of the stress/strain curve - For some materials values for proportional or elastic limit will differ depending on if the applied forces were tension or compression - *[Yield Strength]* - Use when determining the point on a stress/strain chart where it becomes nonlinear is too difficult - **Yield strength** is the amount of stress that must be applied to permanently strain a material a given amount - The amount of permanent strain needed is arbitrarily selected is the **percent offset**, and most specifications use a **0.2% offset** - Determined by selecting desired amount of offset/strain on x-axis and drawing line parallel to linear region of stress/strain curve - Yield strength = where parallel line intersects stress/strain curve - *[Ultimate Strength]* - Point on the stress-strain curve where the material exhibits maximum strength (point C) - Fracture strength: - Stress at which a material fractures (point D) - In some ceramics ultimate and fracture strength are almost the same, but others like metals experience "***necking***" during tensile strength tests - Material elongates excessively - Stress/strain curve slopes downward - *[Elastic Modulus/Young's Modulus]* - Ratio of stress to strain representing **stiffness** of material within elastic range - Calculated with Hooke's Law: Elastic Mod = Stress/Strain - Uses same units as stress - If the slope of the linear portion of one material is steeper than the slope of the linear portion of another, then the steeper linear portion indicates a stiffer, more rigid material. - High modulus = more rigid - Gold alloy is similar to enamel - *[Resilience]* - The resistance of a material to permanent deformation - Total energy needed to deform the material to the proportional limit - Calculated as the area under the stress/strain curve - *[Toughness]* - Resistance of a material to fracture, not just permanent deformation - Area under *entire* stress/strain curve representing total energy needed to stress the material to its fracture point - *[Malleability]* - Ability of a material to be hammered into thin sheets w/o fracturing - *[Ductility]* - Ability of a material to be drawn into a wire by means of tension without fracturing - High elongation = deformation that results from application of tensile forces typically indicated high ductility - A curve with a higher x-axis values (more change in length, strain) is more ductile than those with lower x-values (**brittle**) - **Surface Properties of Materials** - *[Hardness]* - Resistance to permanent surface indentation or penetration - A measure of resistance to plastic deformation measured **as force per unit of indentation** - *[Friction]* - Resistance btwn contacting bodies when one moves relative to another - Restraining force that resists movement between 2 materials is the **frictional force**, results from the molecules of 2 objects bonding where their surfaces are in close contact. - Different materials have a different **coefficient of friction** which are a function of their contact, composition, surface finish, and lubrication. - When an external force overcomes the frictional force, the result is one object moving past the other - Results in molecular bonds being made and broken, and microscopic pieces of the material can break off from the surface. This results in **wear** of the materials. - Materials with microroughness exhibit more friction, and therefore, more wear - *[Wear]* - Loss of material resulting from the removal and relocation of material through the contact of materials - Can result in production of small particals than can elicit an inflammatory response and cause shape changes to occur that affect function - Generally a function of opposing materials and the interface btwn them - (i.e. porcelain wears natural enamel heavily but may not wear another porcelain crown as heavily - **Metals** - Alloy Systems - Trends - Nickel - Porcelain vs Ceramic - Common Crystalline Phases: ZIRCONIA - Common Crystalline Phases: E MAX, LEUCITE, FELDSPAR - All Ceramic Systems - Strengthening Mechanisms - Reminders on Materials for Crowns [Week 5- 3:00 PM - 5:00 PM: OS Lecture: Ch16 - Management and Prevention of Odontogenic Infections (Objectives: Recognize and manage odontogenic infections)] - **[Week 6: September 27, 2024]** [Week 6- 1:00PM- 3:00PM- Dr. Pryce- Importance of Dental Recognition of Global Diagnosis] - [Week 6- 3:00 PM - 5:00 PM: OS Lecture: Ch 4 - Wound Repair, Ch24 - Soft Tissue and Dentoalveolar Injuries (Objectives: Treat minor facial and dental trauma)] - Soft tissue injuries, such as abrasions, should be cleaned with a surgical scrub, thoroughly debrided to remove contaminants, and treated with topical antibiotics. Contusions, resulting from blunt force trauma, typically do not require systemic antibiotics and should be assessed for fractures, particularly in the mandible. Lacerations involve a split in the skin and require careful management, including cleansing, debridement, hemostasis, and closure through suturing. - Wound cleansing involves mechanical cleaning to eliminate debris, often requiring surgical soap and a brush, along with anesthetic and saline irrigation to ensure thorough removal of water-soluble materials. Debridement is essential for removing damaged tissue. - Achieving hemostasis is crucial before wound closure to prevent hematoma. Bleeding vessels must be clamped or cauterized, and suturing varies based on the tissue type, using different suture materials for the epidermis , dermis, muscle, and mucosa. - Crown craze or crack refers to an incomplete fracture of the enamel without loss of tooth structure and does not require treatment. For horizontal or vertical crown fractures, if only the enamel is affected, treatment involves smoothing sharp edges, while exposure of dentin requires sealing the dentinal tubules with a bonding agent or glass ionomer cement and restoring with resin composite. In cases where enamel, dentin, and pulp are involved, the treatment should be to preserve the pulp vitality. - If the pulp degenerates, it can lead to tooth resorption and ankylosis. In teeth with closed apical foramina following odontogenic trauma, endodontic treatment should begin after about two weeks, using a mixture of calcium hydroxide and barium sulfate in the root canal, with radiographs taken and the mixture replaced every three months for 6-12 months. For teeth with open apical foramina, endodontic treatment should be delayed for several weeks to monitor pulp vitality and determine the need for treatment. If necessary, an apexification procedure may be performed if there is a lack of pulp vitality. **[Week 7: October 4, 2024]** ----------------------------------------- [Week 7- 1:00 PM - 3:00 PM: Pedo (Dr. Swearingen) Digital Photography and GERD in Pediatric patients] - Quality diagnostic images are essential for orthodontic planning. Clear images will help explain the treatment process to patients and monitor progress in case any adjustments need to be made in the treatment plan. - Ortho mirrors allow clinicians to capture arch and occlusion images to document treatment progression, assess occlusion changes, and communicate with patients of any treatment progression. - Dental treatment is treated in stages beginning with emergency care. Then, disease control (i.e. caries excavation) and finally maintenance of periodontium. It is after these steps, that a patient can move forward to orthodontic treatment. This sequence ensures that the patient's oral health is stable, allowing for an effective and successful orthodontic treatment outcome. - GERD in children can present as smooth, translucent lesions that are easily confused with decay. It\'s essential to refer these patients to pediatricians or specialists to address the underlying cause and prevent additional dental problems. Taking action early can help ensure that children receive the comprehensive care they need for both their dental and overall health. - Addressing impacted or missing teeth often requires a combination of orthodontic and prosthetic procedures (i.e Maryland bridges or flippers). Treatment is influenced by aesthetic goals, individual patient preferences, and specific clinical factors that need to be considered. Ultimately, finding the right balance between functionality and appearance is key in delivering successful treatment to patients. [Week 7- 3:00 PM - 5:00 PM: OS Lecture: Dr. Abutineh- History of Dental Implants (Review: Ch 4, 7, 8, 9, 10, 11, and 16)] **[Week 8: October 18, 2024]** ------------------------------------------ [Week 8- 1:00 PM - 3:00 PM: Pedo (Dr. Swearingen) DR. GUPTA- CLASS III MALOCCLUSION ] - **[Week 9: October 25, 2024]** ------------------------------------------ [Week 9- 1:00-2:00 PM: Dr. Caldwell- Surgical Anesthesia] - - - - - [Week 9- 2:00 PM - 4:00 PM: Restorative (Dr. Wes, Crowns x3)] Cast Crowns - All Ceramic Crowns - PFM Crowns - Material of choice for long span bridges, survey crowns, etc. Made of complete metal coverage substructure veneered with a thin layer of porcelain. Indicated for extensive tooth destruction, more esthetic than cast metal but with the property benefits of metal. More predictable prognosis for long span bridges, survey crowns. Contraindicated where other options would be more conservative, periodontal dz, young pts with large pulp chambers. - Advantages are the strength of cast metal with the esthetics of ceramic, restorations can be very natural, have high durability with good marginal fit, retentive and resistant, can modify axial contours to meet needs (survey crowns). Disadvantages are the need for significant tooth reduction to fit the porcelain, inferior in esthetics to all-ceramic, have more perio concerns due to subgingival margins, stacked porcelain more prone to fracture, expensive. - PFM fabrication has a cast metal-ceramic alloy framework with a higher fusing range and lower thermal expansion than gold. A metal taht fuses higher and expands less with heat is needed as the por **[Week 10: November 1, 2024]** ------------------------------------------- [Week 10- 1:00 PM - 3:00 PM: Restorative (Dr. Wes, Immediates)] - Interims are designed for limited time use, made of a resin material and do not have a cast metal base. Immediates are placed immediately at the time of extractions, and are rarely relined and converted into a definitive prosthetic. Relining wrought iron clasps doesnt increase longevity, and would still have less retention and durability than a cast metal prosthesis. - The main goal of an interim is appearance and esthetics, so they have compromised stability and support. Can be used to maintain space for future implant seating and help prevent supra-eruption. Other goals are the re-establishment of occlusal relationships, tissue conditioning, interim restoration for function until permanent is ready, and for conditioning a patient for a prosthesis. - Interims are cheap, easy to design and make, require minimal prep, have a quick lab turnaround, and offer esthetics. They are not durable, function poorly and have unesthetic wrought wire clasps that will wear with time. Fabricated on unprepared teeth and are largely tissue borne. - Flex partials are made of thermoplastic resin (thermoplastic nylon) and have high physical strength, heat and chemical resistance, and are easy to modify to increase stiffness/wear resistance. Are esthetic and can be definitive for some cases. Flex partials are flexible, comfortable to insert, esthetic, light weight, hard to break, cheaper than cast metal, and not tooth borne. They are not as rigid or resilient as metal, are chromatically unstable and hard to adjust. - Combo partials have a cast metal frame + occlusal rests/cast clasps with a thermoplastic resin base instead of PMMA. The "Best of both worlds". Flex clasps are comfortable and esthetic, but partial is chromatically instable, the clasps lack resiliency, and it is expensive to make. Manufactured almost identically to cast metal. **[Week 11: November 8, 2024]** ------------------------------------------- [Week 11- 1:00 PM - 3:00 PM: Guest Lecture - Endodontics (Dr. Sam Alborz)] - Pulpal diagnosis determines the status of pulp. Normal dissipates within 2 seconds, reversible causes a sharp pain but resolves itself immediately, irreversible symptomatic has a prolonged sharp pain that changes to a dull throb, irreversible asymptomatic has a normal cold response after a carious pulp exposure, and necrotic has no cold response. - Periradicular diagnosis is tested through percussion or pressure test. Symptomatic periradicular periodontitis is tender to percussion but may not have radiographic findings. Asymptomatic Periradicular Periodontitis is normal to percussion with Rx present. Acute Periradicular Abscess shows clinical swelling with or without drainage and normal Rx. Chronic Periradicular Abscess has clinical swelling with or without drainage and a positive Rx and can have sinus tracts. BWs and PAs should be taken alongside a thorough clinical exam. - The gold standard for anesthesia is Intraosseous, which is delivered into the cancellous bone and has a quick onset and a longevity of 60 minutes. Intraligamentary is given in less volume, helpful for restorative, but will cause post-op sensitivity. It is injected at each corner of the tooth. In states of infection the lowered pH reduces the base form of anesthesia and decreases effectiveness of the anesthetic due to tetrodotoxin resistance sodium channels. In these cases intraosseous is still the best, followed by intraligamentary, and then intrapupal pressure anesthesia for "hot" teeth. - There are several types of teeth cracking to be aware of. Craze Lines are vertical lines on anterior teeth that are isolated to the enamel only. Fractured cusps extended from the crown to sub-gingival space (to cervical 1/3rd of crown), cross the marginal ridge, and involve two aspects of the cusp (MD-FL). These are treated with full coverage crowns. Cracks can be seen with transillumination and must be treated or risk bacterial penetration. Crown placement enhances longevity as these teeth can continue to separate without intervention. - Bitewings are taken for endo therapy to view the height of the pulp chambers, the extent of involve caries, margin quality for restoration, and attachment loss. Radiographs are essential in endodontics to determine optimal length of master files and gutta percha. It is essential that clinicians utilize rubber dams as it is the standard of practice (radiographs can be taken by removing metal frame or utilizing a plastic frame). **[Week 12: November 15, 2024]** [Week 12- 1:00 PM- 2:00 PM: Dr. Pryce and Student Doctor Graham- Pediatric Obstructive Sleep Apnea] - [Week 12- 2:00 PM - 4:00 PM: Restorative (Dr. Wes, Dentures and Survey Crowns)] **Denture Maintenance: Relines and Rebases** - Relines resurface the intaglio of a denture with new base material to create an accurate re-adaptation of the denture foundation when a loss of retention and stability is noted. Can be "hard" and done with permanent PMMA in the lab, or "soft" and done with a temporary soft acrylic/silicone chairside. Soft relines have a short lifespan and are good for immediate dentures once the sockets have closed to increase comfort and pt satisfaction. Have poor color stability, cleanability, attachment/bond, and wear resistance. Can be completed without negatively impacting occlusal relationships or facial esthetics and is a good option when mild-moderate tissue changes are noted. - Rebasing replaces the entire denture base of an existing prosthesis. Done to correct a loss of VDO, loss of facial tissue support, horizontal shift leading to incorrect occlusal relationship, and to reorient the occlusal plane. May need to reduce teeth to get a rebased denture to properly occlude (or remake entirely). - Diagnosis is determined when the patient presents complaining of looseness, soreness, chewing insufficiency and pain during function. Occurs soon after the delivery of immediate dentures, and time period since delivery is considered diagnostic. Tissue adaptation, and prosthesis stability are important to evaluate as well. - Ridge resorption in the maxilla causes the denture to move up and back, in the mandible the denture moves down and forward. - There are 3 main impression techniques: Static, functional and chairside. Static impressions use the denture lined with VPS as the impression tray and can be open or closed mouth. Open mouth doesn\'t need centric relation and relines the denture independent of occlusion (will require occlusion check). Closed mouth has the patient bite in centric relation and border molds. Functional uses a tissue conditioner as the impression material, and as the denture is used the impression shapes until the conditioner sets. Chairside is open or closed mouth using acrylic base material seated under the denture. Cannot use the ideal PMMA due to risk of chemical burns, and other materials are more porous, harder to keep clean and less color stable. Hard chairside relines not indicated, soft relines are useful. **Survey Crowns lecture** - Basic RPD Designs should return the arch to function and direct the forces developed during placement, removal and function in a way that minimizes damage to the natural dentition. RPDs are designed to distribute vertical load through rest seats (tooth borne) or denture bases (tissue born), and lateral forces created by retentive clasps are counteracted with reciprocal clasps. - Surveying and Designing is used to plan RPDs and evaluate the alignment of teeth, best path of insertion, and undercuts for retentive clasps. The goal is to find the most ideal anteroposterior and mediolateral tilt to allow for all of the design elements to be placed with minimal tooth alteration. - Survey Crowns are used for precise shaping of axial contours and when heavier modification of axial surfaces are needed (enameloplasty insufficient for reduction). - Tooth Modifications for RPDs include Guide Planes, Rest Seats, Retentive and Reciprocal Clasps. Guide planes are used when axial reduction is required that is more than enameloplasty can cover. Required for making a consistent path of insertion. Rest seats are prepared recesses in the tooth to take the occlusal rest of an RPD, allowing vertical forces to be transferred to the tooth. A rounded-spoon prep allows for reduced lateral forces, increasing flexibility. Retentive clasps engage undercuts to retain an RPD but should only engage when seating/removing and be passive at rest. Undercuts should not be recreated in crown preps for these clasps. Reciprocal clasps guide the prosthesis into place during insertion and support against horizontal forces by flexing its arms. - For patients that need a crown but already have an RPD, pick-up impressions can be used. Take a master impression of the crown prep with the RPD placed, then remove partial with the impression and sent it to the lab. The CEREC can also scan the original crown and recreate it, but this depends on the state of the crown and the crown must be ceramic which is not ideal for a survey crown. **[Week 13- November 27, 2024]** [Week 13- 2:00 PM - 3:00 PM: Oral Pathology (Dr. Shasteen)] - Leukoplakia (white plaque) is a clinical description rather than a diagnosis of specific tissue alteration. It is the MOST COMMON ORAL PRECANCER particularly concerning when located on the lateral borders of the tongue and floor of the mouth, and lesions with moderate to severe dysplasia carry potential of varying malignant transformation. A biopsy is required to determine the diagnosis for appropriate treatment management. - Geographic tongue, also known as benign migratory stomatitis, is a well-defined erythematous lesion. Patients often complain of a burning sensation that can worsen with certain foods. This is a chronic condition that has NO DEFINITIVE CUREFINITIVE CURE**.** Patients are advised to keep a food journal to identify triggers. Once it heals from one area, it can reappear in a different area. For treatment patients can utilize oral numbing medicaments for relief. - A dentigerous cyst (most common developmental ODONTOGENIC CYST) most commonly found surrounding impacted mandibular third molars. The cyst may become infected, leading to pain and swelling, especially with partially erupted teeth. Radiographically, it presents as a unilocular, well-defined radiolucency, although its appearance can vary with size and the presence of infection. - A mucocele most commonly results from rupture of a salivary gland duct, spilling mucin into surrounding soft tissues (caused by local trauma). Most frequently occurs in children and young adults, appearing on LOWER LIP. It has a bluish hue that can self-resolve; however, chronic cases may require surgical excision along with the removal of nearby salivary glands. - Squamous cell carcinoma is most commonly found on the **lateral border of the tongue**, (other high-risk areas: floor of mouth and ventral tongue). It particularly occurs in heavy smokers and drinkers. The lesion often originates as leukoplakia or erythroplakia. If suspected, a biopsy should be performed or referred as soon as possible. [Week 13- 3:00 PM - 5:00 PM: Guest Lecture - Pediatric Dentistry (Dr. Mark Britton)] - **Understanding the pt and parent/guardian is crucial.** \#1 Reason children complain about pain is due to Food impaction. Pain is due to food packing down deeper and deeper into the pockets. Education on hygiene is \#1, so home care recommendations for brushing, diet and eating behaviors is important. Not all patients or parents have the same dental IQ, so time for explanation is required and it is recommended to start children's professional dental care at Age 1. It is common for parents to blame each other in separate living situations for poor oral health care, or to blame "bad genes" instead of accepting responsibility. Do your best to mitigate these conversations and make them productive and informative in a polite way. - **Lip Chewing** is a common injury associated with anesthesia use in children and can be mitigated by the placement of a cotton roll or gauze in the mouth for several hours or until sensation properly returns. Helps prevent traumatic/dramatic appearing injuries. - **Information and Tips.** No difference noted in studies on numbing only one side vs both at the same time. Watch amount of anesthesia, laminated sheet with amount per weight is a helpful tool to have in all operatories. Internet searches show parents that children should lose teeth every year from 6-12 yrs, this is not always accurate. It is more accurate to say they go through "Phase 1" where you lose the front teeth and get the 6yr molars. At 10-12 the second round sets in - **Space loss due to Decay** is seen in patients with large interproximal decay. Stainless steel or space-loss crowns are used to treat. Space loss often seen when extracting 2yr molars and Denovo maintainers are useful for such cases. - **Sealants.** 80% of decay on permanent teeth is in pits and fissures, most primary decay is interproximal. Not all pts need sealants if the pits and fissures are shallow, if the pt has bad behavior, or if the need is a toss up. A pt is better off without a sealant than with a bad sealant.