REZA 2016 (NEW YORK )

BOARDS

OPERATIVE:
- Unfilled resin
- has a coefficient of thermal expansion that is 7-8 times that of a tooth.
- Changes temp slowly due to low thermal conductivity and diffusivity.
- Dead tracts - empty dentinal tubules with no odontoblasts. When they calcify they are called sclerotic dentin.
- Primary dentin - forms the initial shape of the tooth. Deposited BEFORE completion of the apical foramen
- Secondary dentin - formed AFTER the completion of the apical foramen. Formed at a slow rate as functional stress is placed on the tooth.
- Tertiary dentin - aka reparative or reactive dentin. Produced by secondary odontoblasts.
- Percolation - the cyclic ingress and egress of fluids at the restoration margins. Recurrent decay increases with increased percolation.
- Zinc Phosphate cement
- Shrinks slightly when setting
- Initial mixture is very acidic (pH 3.5) so can cause irreversible pulp damage
- Must place 2 coats of cavity varnish to prevent pulp damage
- Superior strength compared to other cements - mechanical interlocking
- Can be used as a secondary base over CaOH placed over pulp exposure
- Zinc polycarboxylate
- most soluble cement
- bonds by CHELATION - carboxylate groups chelate to calcium in the tooth
- lower compressive strength than zinc phosphate but higher tensile strength
- not irritating to pulp so no primary base is needed
- can be very thick
- short working time
- Glass ionomer cements -
- least soluble cement. Disadvantage is that it has a higher cement film thickness.
- Contains fluoro alumino-silica powder and polyacrylic acid
- Acts like a fluoride sponge and can absorb fluoride
- ZOE cements
- pH is near 7
- one of the least irritating of dental cements
- BUT do NOT place directly on pulp (direct pulp capping) or it will irritate pulp
- Soluble in oral fluids
- Difficult to remove from cavity preps
- Compromises composite bonding
- Calcium hydroxide
- Used as a base
- Effective in promoting the formation of secondary dentin
- Base - thickness of 1-2mm
- Used for their low thermal conduction
- Placed in deep portions of cavities to insulate pulp
- Cement - thickness of 15-25 microns
- Cavity liner - thickness of 5 microns
- Placed as thin coat over exposed dentin
- 2 groups
- Cavity varnish aka solution liner - ex Copalite
- Does not act as a thermal barrier.
- Inhibits polymerization with composites
- Reduces marginal leakage
- Suspension liner - CaOH or zinc oxide with resins. Ex. Dycal. Thicker than solution liners. Prevents thermal shock. Appears
radiolucent so can be confused with caries.
- Dentin - zones of caries
- Zone 1 - normal dentin -
- Zone 2 - sub-transparent dentin - demineralized due to caries, no bacteria are found, capable of remineralization
- Zone 3 - transparent dentin - further demineralized due to caries, no bacteria are found, capable of remineralization
- Zone 4 - turbid dentin - zone of bacterial invasion, tubules are filled with bacteria. NOT capable of remineralization
 - Zone 5 - infected dentin - outermost zone, decomposed dentin filled with bacteria. Must be totally removed.
- Bacteria
- Streptococcus species produce dextran sucrose (aka glycosyltransferase) which catalyzes the formation of extracellular glucans (dextrans and
mutans) from dietary sucrose.
- Lactobacillus species do not produce dextran - they produces a different extrapolysaccharide - lexan.
- S. Sanguis is the the most frequently isolated Streptococcus in the oral cavity. Also found the earliest.
- Enamel demineralizes at pH 5.5. Remineralizations occurs above 5.5
- Fluoride - concentrations above 4mg/L can be toxic.
- Acidulated phosphate fluoride gels - ph 1-4 - contraindicated on porcelain and composite restorations and implants because it can cause pitting
and etching of them. Most common in-office fluoride tx.
- If pt has porcelain, glass ionomer, or composites - use neutral 2% NaF. Acidualated fluoride and stannous fluoride remove the glaze from these
restorations.
- Sodium Fluoride - 2%, pH 9
- Acidulated phosphate fluoride - 1.23%, pH 3-4
- Stannous Fluoride - 8%, pH 2
- Excreted by kidney.
- Optimal public water levels are 0.7-1.2ppm
- Uptake is greatest in enamel
- Birth to 6 months - NO fluoride
- 6 months - 1 year - .25 mg only if conc is less than .3ppm
- 3-6 years - .50mg if conc is less than .3ppm, .25mg if if conc is less than .6ppm
- 6-16 years - 1mg if conc is less than .3ppm, .50mg if conc is less than .6ppm
- NO fluoride if water levels are greater than 0.6ppm
- Fluoride interacts with hydroxyapatite to form fluorapatite which is less acid soluble and more resistant to caries.
- Class III
- Composite resin is not recommended for Class III lesions on the distolingual of canines
- When preparing adjacent Class III lesions, prepare the larger one first but fill the smaller one first.
- Retentive grooves are placed along the gingivoaxila and incisoaxial line angles
- Sealants
- Use topical fluoride AFTER sealants because fluoride inhibits etching.
- Brittleness - has high compressive strength but low tensile strength. Ex. Amalgam.
- Creep - deformations over time in response to constant stress. Aka strain relaxation
- Modulus of elasticity - a measure of the stiffness or rigidity of a material. The higher the MOE, the stiffer and more rigid the material.
- Resilience - the energy that a material can absorb before the onset of any plastic deformation
- Elastic limit - the greatest stress to which a material can be subjected so that is will return to its original dimensions when the forces are released.
- Proportional limit - the greatest stress - a material with high proportional limit has more resistance to permanent deformation.
- Ductility - the ability of a metal to easily be worked into desired shapes. Ex - form a wire.
- Malleability - the ability of a metal to be hammered and compressed into a thin sheet without rupturing.
- Gold is the most ductile and malleable metal. Silver is second.
- Composites
- Inferior compressive strength and abrasion resistance compared to amalgams
- Polymerization shrinkage - causes internal stresses and gap formations at butt-joint interfaces
- C-factor - the ratio of bonded to unbonded surfaces. High C factor = cavity is more likely to be damaged.
- Composite resins are dimethyacrylate monomers and polymerize by the addition mechanism that is initiated by free radicals which are
generated by chemical activation or external heat/light.
- Chemically activated - self cure - benzoyl peroxide initiator
- Light activated - visible light has replaced UV light.
- Amalgam
- Brittle, but has good compressive strength
- A decrease in particle size will increase compressive strength and decrease setting expansion
- The more free mercury, the more setting expansion
- The more time of trituration, the less expansion and greater strength
- Mercury content greater than 55% decreases strength
- Coefficient of thermal expansion is TWICE that of tooth structure - so percolation occurs during temp changes.
- The tensile strength of amalgam is 1/5 - 1/8 of its compressive strength
- Contents
- 40-70% silver - decreases setting time, increases setting expansion, increases strength
- 25% tin - decreases expansion, decreases strength, increases setting time.
- 6% copper - ties up tin reducing gamma 2- formation, increases strength, reduces tarnishing, reduces creep
- High copper - 9-30% have less marginal break down and less likely to corrode
 - 3% mercury
- Ag3Sn + Hg Ag3Sn + Ag2Hg3 + Sn3Hg
- Gamma = Ag3Sn - the unreacted alloy, the hardest and corrodes the least
- Gamma one = Ag2Hg3 - forms matrix for unreacted alloy
- Gamma two = Sn3Hg - weakest and softest phase. Most susceptible to corrosion.
- Corrosion products - tin oxide and tin sulfide - help provide an excellent seal.
- Poor thermal insulator so ideally keep 2mm (1-1.5mm is ok) of dentin between amalgam and pulp - place CaOH \or ZOE as a base
- Investing
- Refractory filler - Silicon Dioxide (SiO2), 60% of the investment. Provides thermal expansion.
- Binder - 30% of the investment. Hardens and holds the investment together.
- Gold foil
- Annealed aka degassing to remove volatile surface impurities
- Gold Casting Alloys
- High gold alloys used for cast restorations are - greater than 75% gold or other noble metals
- ADA type I - highest gold content, 83% noble metals, easily burnished since very ductile
- ADA type II - greater than 78% noble metals, good for larger inlay and onlays
- ADA type III - greater than 75% noble metals, good for onlays and crowns
- ADA type IV - greater than 75% noble metals, good for bridges and RPD, the hardest of high-gold alloys
- Components
- Gold - resists tarnish and corrosion, increases ductility and malleability
- Copper - HARDENS casting
- Silver - modifies the red color
- Platinum - raises melting temp, increases tensile strength, decreases coefficient of expansion
- Paladium - raises melting temp, increases hardness, whitens gold
- Base metals - aka non-precious metals - high strength and low density but LESS resistant to corrosion
- Indirect pulp cap - CaOH base placed over a thin layer of questionable dentin that remains covering the pulp. SECONDARY dentin formation can form.
- Pins
- Should be placed 1-1.5mm inside the cavosurface margin and at least .5mm inside the DEJ.
- The optimal depth of the pinhole is 2mm
- Should be 2mm into dentin, 2mm within amalgam, 1mm from DEJ
- NO bends
- Burs
- Rake angle - The most important characteristic - the angle made between the line connecting the edge of the blade to the axis of the bur and
the rake face. Can be positive or negative.
- Clearance angle - the angle formed between the clearance face and a tangent to the path of rotation
- The greater the clearance angle, the less friction.
- Instruments
- Formula
- 1st number - the width of the blade in tenths of mm. ex. 1mm = 10
- 2nd number - the primary cutting edge angle
- 3rd number - the blade length in mm
- 4th number - the blade angle

PERIO
- Dehiscenece - a loss of the buccal or lingual bone overlaying the root portion of a tooth, leaving the area covered by soft tissue only.
- Cementum
- Radicular cementum - the cementum only found on the root surface
- Coronal cementum - the cementum that forms on the enamel covering the crown
- Cellular cementum - cementum containing cementocytes in lacunae within the cementum matrix. It occurs more frequently on the apical 1/3 rd
of the root and in furcations. It is usually the thickest to compensate for attritional wear of the occlusal /incisal surface and passive eruption of
the tooth.
- Acellular cementum - cementum without any cells in its matrix. Usually predominates on the coronal 2/3rds of the root. It is thinnest at the
CEJ. It plays a major role in tooth anchorage.
- The main function of cementum is the attachement of principle fibers of the PDL.
- Contains two types of collagen fibers
- Sharpey's fibers - terminal portions of the principal fibers of the PDL that are embedded in the cementum (run perpendicular to the
cementum) on one end and alveolar bone on the other end. They serve to attach the tooth to surrounding bone.
- Type I collagen fibers - are within the cementum itself and run parallel to the surface of the cementum.
- Gingival fibers of the FREE gingiva - 4 groups - the collagen fibers that extend from the cervical cementum of the tooth into the gingiva are called gingival
fibers. Aka supreacrestal connective tissue fibers. Their function is to support the gingiva and keep it closely adapted to the tooth surface and sustain it
against forces during mastication.
- Circular fibers - encircle the tooth around the most cervical part of the root and insert into the cementum and lamina propria of the free gingiva
and the alveolar crest. They resist ROTATIONAL forces.
- Dentogingival fibers - extend from the cementum apical to the epithelial attachment and course laterally and coronally into the lamina propria of
the gingiva.
- Dentoperiosteal fibers - extend from the cervical cementum over the alveolar crest to the periosteum of the cortical plates of bone.
- Alveologingival fibers - insert in crest of alveolar process and spread out through the lamina propria into the free gingiva.
- Transeptal fibers are sometimes classified as a separate group of gingival fibers.
- Gingival apparatus - describes the gingival fibers and the epithelial attachment.
- Gingival ligament - includes the dentogingival, alveologingival, and circular fibers.
- Indifferent fiber plexus - found in the PDL. They are small collagen fibers associated with the larger principal collagen fibers and run in all directions.
- The major storage sites of histamine are mast cells, platelets, and basophils.
- Diabetics has 15 TIMES the risk of developing periodontal disease as compared to the non-diabetic population.
- Hereditary Gingivofibromatosis - a rare genetic disease causing generalized gingival enlargement, often extensive enough to cover the teeth. There is a
lack of inflammatory cells, proliferating capillaries and vascular engorgement.
- The fibers in gingival connective tissue is composed of TYPE I COLLAGEN.
- The collagen turnover in the gingival is not as rapid as in the PDL but faster than the rest of the body.
- Collagen accounts for 60% of gingival protein.
- Vitamin C is needed for the hydroxylation of proline and lysine essential for collagen formation.
- Polishing - use a thin, watery mixture of polishing paste or polishing at a low speed with light pressure to reduce the abrasive action of the polishing agent.
- Pedicle - a glycoprotein deposit that coats the tooth and is colonized by bacteria
- Primary colonizers - gram-positive bacteria such as Strep sanguis, Step mutans, and Actinomyces Viscosus.
- Secondary colonizers - gram negative species such as Fusobacterium nucleatum, prevotella intermiedia, and capnocytophaga species
- Tertiary colonizers - porphyromonas gingivalis, campylobacter rectus, eikenella corrodens, actinobacillus actinomyecetemcomitans, and oral
spirochetes
- Junctional epithelium - a collar-like band of stratified squamous non-keratinized epithelium 10-20 cells thick near the sulcus and 2-3 cells thick at the apical
end
- In health it is usually .25-1.35 mm long
- Epithelial attachment - the inner layer of cells that attaches the gingiva to the tooth. Consists of internal basal lamina and hemidesmosomes.
- The PRIMARY epithelial attachment refers to the attachment of reduced enamel epithelium to the tooth.
- The SECONDARY epithelial attachment refers to the attachment of the junctional epithelium to the tooth
- Sulcular eoithelium = aka crevixular epithelium - the stratified squamous epithelium lining the inner aspect of the soft tissue wall of the gingival sulcus
extending from the gingival margin to the junctional epithelium.
- Tooth mobility
- 0 = no mobility
- 1 = barely distinguishable tooth movement
- 2= any movement up to 1mm
- 3 = any movement more than 1 mm or teeth that can be depressed or rotated in their sockets.
- Periodontal health
- Gram-positive, non-motile, facultative anaerobes
- S. salivarius - the MOST ABUNDANT
- S. mutans and S. sanguis - appear only when teeth are present
- By age 4-5, the oral flora resembles that of an adult
- In perio disease gram negative, motile, strictly anaerobic bacteria
- Chronic gingivitis = porphyromonas gingivalis
- ANUG = two priniciple bacteria
- Spirochetes - treponema denticola - seen in the deeper areas of the lesions
- Prevotella intermedia
- Interproximal necrosis - ulceration of papilla and pseudomembrane formation on marginal tissues.
- NO attachment loss!!!!
- History of soreness and bleeding gums when eating or brushing
- Aggressive periodontitis
- Two most common organisms -= Actinobacillus actinomycetemcomitans and Capnocytophaga ochraceus
- Rapid and severe attachment loss confined to incisors and first molars.
- Absence of local factors such as plaque
- Free gingival graft - taking a section of attached gingival from another area of the mouth - usually the hard palate - and suturing it to the recipient site.
- Laterally positioned flap - aka pedicle flap
- Used to correct or prevent recession by providing root coverage
- Double papilla flap - a variation of the laterally positioned flap, except the papilla between the teeth on either side are moved over the exposed root.
Indicated when there has been recession on the labial or gingival but not in the papilla.
- Modified Widman Flap - a modification of the replaced flap. It is a FULL thickness flap. Used on SINGLE rooted teeth and on the surface of molars with
pockets or defects. Allows you to gain access to tooth and bone, reduce pocket depth, preserve KAG, and heal by primary closure.
- Repositioned flaps
- Includes replaced flaps, modified Widman flaps, and excisional new attachment proedcures.
- All heal by repair, all are pocket reduction procedures
- Free mucosal autograft - CT without epithelial covering, often used on canines where there is little keratinized gingival to create a band of gingival-like
tissue.
- Free gingival grafts - when healing, the epithelium degenerates forming a necrotic slough. Re-epithelialization occurs by proliferation of epithelial cells
from adjacent tissue and surviving basal cells in the graft tissue.
- The most critical factor in determining whether a tooth should be extracted or have surgery performed on it is the amount of Attachment Loss.
- Full thickness flap - include surface mucosa (including epithelium, basement membrane, and connective tissue lamina propria) and the contiguous
periosteum of the underlying alveolar bone. Used when the attached gingival is thin - 2mm or less in width.
- Partial thickness flap - includes only the mucosa, which is separated from the periosteum by sharp dissection. Alveolar bone is NOT exposed. This flap
is used in the preparation of recipient sites for free gingival grafts or when a dehiscence or fenestration is present on a prominent root. Used when the
attached gingival is thick - > 2mm
- Gingivectomy - when pocket depth is eliminated by resecting the tissue coronal to the pocket base. Must have lots of KAG.
- Periodontal file - primary function is to crush or fracture heavy tenacious accessible SUPRA-gingival calculus.
- Hoes - wide, straight cutting edge cannot adapt to curved tooth surface. Most effective on the buccal and lingual surfaces NOT mesial and distal surfaces.
- Sharpening instruments
- Avoid producing a wire edge by making sure the last stroke is drawn TOWARD the cutting edge, not away.
- The optimal internal angle between the face of the blade and the lateral surface of a universal curet and gracey curet is 70-80 degrees.
- Root sensitivity - most accepted theory is the Hydrodynamic Theory = the pain of root sensitivity results from indirect innervations cause by dentinal fluid
movement in the tubules which stimulates mechanoreceptors in the pulp.
- Attachment loss = probing depth + recession
- Attached gingiva = from the mucogingival junction to the free gingival groove (the base of the sulcus)
- The narrowest band of attached gingiva is found - on the facial surfaces of the mandibular canine and first premolar and the lingual surfaces
adjacent to the mandibular incisors and canines.
- The greatest width of attached gingiva is found in the incisor regions.
- To measure it - place the probe on the external surface of the gingiva and measure from the mucogingival junction to the gingiva margin = total
gingva. Then insert the probe and measure the probing depth. Subtract probing depth from total gingva = width of the attached gingiva
- Free gingiva = from the free gingival groove ( base of the sulcus) to the gingival margin
- Free gingival cuff - is lined by sulcular epithelium which is continuous with the oral gingival epithelium at the gingival margin.
- Free gingival groove = demarcates the junction between the free gingiva and the attached gingiva
- Mucogingival junction = separates the attached gingiva from the alveolar mucosa
- Site Specific Controlled Release Antibiotic Therapy
- Actisite = aka periochip - disinfectant or antibiotics used as an adjunct to scaling and root planning. Placed in the pocket to control perio
inflammation. TETRACYCLINE 12.7MG. For 7-10 days.
- Atridox = a biodegradable controlled release gel containing DOXYCYCLINE. Delivered via a syringe system to the pocket.
- Periochip = a gelatin chip containing 2.5mg CHLORHEXADINE GLUCONATE.
- Periostat = a twice a day, orally administered tablet containing 20mg DOXYCYCLINE. Promotes attachment level gain and reduces pocket
depth.
- PDL - is 0.2mm wide in health. Decreases with age.
- Consists of regularly arranged bundles of collagenous fibers - Collagen Type I
- Does NOT contain mature elastin - only immature forms - oxyltalin and eluanin
- The main type of cell in the PDL is the Fibroblast
- The alveolar bone directly surrounding the tooth cavity is called the Cribiform Plate.
- The layer of cribirform plate into which collagen fibers of the ligament are anchored is called Bundle Bone.
- Sharpey's Fibers - large collagen fibers that course between the cementum and the alveolar bone. They project into the cementum between groups of
cementoblasts. Lies perpendicular to the surface of cenentum.
- Epithelial Rests of Malassez - remnants of the epithelial root sheath that remains following the disintegration during root formation. Located in the PDL
- Plaque - Organic and inorganic solids constitute approximately 20% (mostly bacteria) and water accounts for 80%
- Pellicle - includes albumin, lysozyme, amylase, IgA, proline-rich proteins and mucins
- The source of minerals in supragingival calculus is saliva. And crevicular fluid in subgingival calculus.
- Calculus -
- Inorganic components - calcium and phosphates with small amounts of magnesium and carbonate. Hydroxyapatite predominates the
crystalline structure.
- Takes 12 days to form
- Toothpaste
 - Fluoride - sodium fluoride or sodium monofluorophosphate
- Abrasives - calcium phosphate or calcium carbonate - removes stains and plaque
- Surfactants or detergents - sodium lauryl; sulfate - creates a foam
- Humectants - glycerin or water - to retain moisture
- Binder or thickener - carrageenan or cellulose gum - to add texture
- Preservatives - sodium benzoate
- Chlorhexidine Gluconate 0.12% - can cause REVERSIBLE stains, can impair taste perceptions . Has low systemic toxicity.
- Has the greatest RESIDUAL concentration in the mouth after use - rapidly absorbed by teeth and the pedicle and slowly released
- Ex. Peridex and Periogard
- Stannous fluoride - antimicrobial due to tin ion. Anti-cavity.
- Quaternary Ammonium compounds - not as effective as others in reducing plaque or gingivitis. Best at eliminating bad breath. Ex. Scope or Cepacol.
- The bacteria that form plaque and calculus release toxins that stimulate the immune system to produce powerful infection fighting CYTOKINES - ex. TNF
Alpha and IL-1Beta and IL-4. The cytokines overproduce the enzyme COLLAGENASE which breaks down proteins, including the CT that supports teeth.
- Attached gingiva = keratiniezed, stippled, DEEP rete pegs, thick lamina propria, few elastic fibers, indistinct submucosa, firmly attached
- Alveolar mucosa = non-keratinized, unstippled, short and wide rete pegs, thin lamina propria, numerous elastic fibers, distinct submucosa, movable
- Cervical line contours
- Greatest on the mesial surface of anterior teeth - most on maxillary centrals
- CEJ curves toward the apex on facial and lingual surfaces and away from the apex on the mesial and distal.
- Oral mucosa
- ALL oral mucosa, whether keratinized or non-keratinized, is STRATIFIED squamous type.
- Keratinized - vermillion border of lips, hard palate, dorsum of tongue, gingival tissues
- Non-keratinzied - buccal mucosa, floor of mouth, lateral and ventral surfaces of tongue, gingival col, sulcular epithelium, alveolar mucosa, soft
palate.
- Masticatory mucosa - composed of free and attached mucosa of the hard palate. Keratinized with thick lamina propria.
- Lining or Reflective mucosa - thin, moveable, non-keratinized, thin lamina propria
- Mucogingival junction - the junction of the lining mucosa with the masticatory mucosa
- Perio probing - taken from the junctional epithelium to the margin of the free gingiva. Most important reason for using the perio probe is the determine
LOSS of ATTACHMENT.
- Interproximal areas - probe should touch the contact area and the tip should angle slightly beneath and beyond the contact area. Angle the
probe at 10 degrees at the interproximal so the tip of the probe is placed apical to the contact point of adjacent teeth.
- Recession - from CEJ to the marginal gingiva. Measured as a positive value.when apical to the CEJ but a negative value when coronal.
- Common on LEFT canines of RIGHT handed people (or right canines of left handed people)
- Gingival curettage - when the cutting edge of the curette is directed against the soft tissue wall of the pocket. Refers only to treatment of the pocket wall -
removing sulcular epithelium and inflamed connective tissue - NOT planning against the root of the tooth. Promotes soft tissue re-attachment.
- Perio curet
- The lower shank of the Gracey Curet is parallel to the tooth surface being scaled.
- The lower shank of the universal curet is tilted slightly toward the tooth.
- Naber's 2N or Hamp probe - used to detect and clinically diagnose furcation involvement
- Ultrasonic scaler - uses high frequency sound waves. g
- Magnetostrictive units have an ELLIPTICAL pattern of vibroatiion of the tip so all sides of the tip are active.
- Piezoelectric units have a linear or back and forth movement of the tip so only 2 sides of the tip are active
- Sonic scalers - air-turbine instruments. Uses air pressure from high speed handpieces to produce vibrations.
- Sonic instruments do NOT release heat the way ultrasonic instruments do
- Scaling and Root planning
- BOP is the best indicator of inflammatory perio dx. Absence of BOP is used to evaluate ScRP success,
- Cementum, dentin, and calculus are removed during root planning
- Alveolar process - consists of alveolar bone proper and supporting alveolar bone
- Alveolar bone proper - immediately surrounds the root of the tooth. PDL fibers attach to it. Consists of two layers - 1) Compact lamellar bone
2) Bundle bone
- Bundle bone - is the layer that the PDL fibers insert into
- Supporting alveolar bone - surrounds alveolar bone proper and gives support.
- Cortical plate - aka compact lamellar bone - forms the outer and inner plates. Thicker is mandible.
- Spongy bone - aka cancellous bone - fills in the area between the cortical plates. NOT present in the anterior part of the mouth.
- Principal fibers of the PDL - composedof bundles of type I collagen fibers
- Transeptal fibers - extend from tooth to tooth, CORONAL to the alveolar crest and embedded in the cementum of adjacent teeth. NO
attachment to alveolar bone. Help keep the teeth aligned and maintain the integrity of the dental arches
- Alveolar crest fibers - extend from the cervical cementum to the alveolar crest. Provides counterbalance to occlusal forces on apical fibers and
resist lateral movements
- Horizontal fibers - run perpendicular from the alveolar bone to the cementum. Resist LATERAL forces.
 - Oblique fibers - slant occlusally from cementum to alveolar bone. Resistant to masticatory forces (forces along the long axis of the tooth).
Found in the APICAL 2/3RD. MOST numerous - 1/3rd of ALL principal fibers!!
- Aplical fibers - radiate apically from cementum of tooth to bone. Offer INITIAL resistance to tooth movement in the occlusal direction. Prevents
tipping and dislocation of the tooth.
- Interradicular forces - ONLY found on multi-rooted teeth. Extend from cementum in the furcation to alveolar bone.
- Phenytoin (Dilantin) - highest incidence of drug induced hyperplasia. PLAQUE DOES cause the overgrowth so hygiene is important (unlike Hereditary
Gingivofibromatosis)
- Pseudopocketing - pocketing without attachment loss. Caused by expansion of marginal tissue coronally.
- Horizontal Classification of Furcations - GLICKMAN
- Grade I - furcation probe can feel the depression
- Grade II - CUL-DE-SAC lesion. Probe can enter under the roof of the furcation.
- Grade III - total bone loss with a tunnel opening of the furcation. But furcation is not clinically visible.
- Grade IV - grade III but furcation is clinically visible.
- Bone grafts have relatively little effectiveness in treating furcations.
- Guided tissue regeneration is useful in Grade II furcations.
- Poorest prognosis is worst on MAX 2nd molars.
- Suprabony pockets
- Base of pocket is coronal to the crest of alveolar bone
- Destruction of bone is horizontal in nature
- Transeptalfibers are horizontal
- Supracrestal fibers follow normal bone contours
- Infrabony pockets
- Base of pocket is apical to crest of alveolar bone so there is a defect within the bone
- Bone loss is angular or vertical creating holes
- Transeptal fibers are oblique
- Supracrestal fibers follow angular pattern of osseous defect.
- Gingival pocket = pseudopocket - marginal tissue is expanded coronally. NO attachment loss.
- Perio pocket= true pocket - gingival sulcus is deepeded and there is APICAL migration of the epitheliual attachment (inner layer of the junctional
epithelium)

PEDIATRIC DENTISTRY
- Cystic Fibrosis
- An inherited recessive disease of the exocrine glands that causes the body to produce an abnormally thick, sticky mucous due to faulty
transport of sodium and chloride within cells lining organs such as the lungs and pancreas.
- Salt does not move properly due to defective channel for chloride to exit cells.
- Most affects pancreas, respiratory system, sweat glands.
- Symptoms - very salty tasting skin, persistent coughing, wheezing or pneumonia, excessive appetite but poor weight gain, bulky stools
- Steatorrhea - foul smelling stools
- Dx - Sweat test - elevation in sodium and chloride
- Die young in 20-30s due to lung failure.
- Dental - mouth breathing due to URI, open bite, high palatal vault,
- Pierre Robin Syndrome - hereditary disorder causing micrognathia, glossoptosis (downward placement or retraction of tongue), and high arched or cleft
palate.
- Primary teeth
- The sum of the M-D widths of PRIMARY molars in one quadrant is 2-5mm GREATER than the pre-molars that succeed them.
- Enamel thickness on occlusal surfaces of primary teeth is a uniform 1mm thick. Permanent teeth enamel is 2.5mm thick.
- Crowns are shorter
- Pronounced buccal and lingual cervical ridges
- Constricted cervical area
- Occlusal table is narrow facial-lingually
- Anatomy is shallower - short cusps, less deep fossa
- Prominent mesial cervical ridge - easy to tell right from left
- Roots - longer and more slender. Narrow mesiodistally and broad lingually. Very divergent and less curved. Little or no root trunk.
- Leeway space = the size difference between primary posterior teeth and permanent canine and premolars. Primary teeth are bigger causing space when
they fall out
- Mand arch - 3.1mm space.
- Max arch - 1.3mm space
- Ritalin = Methyphenidate - a mild CNS stimulate used to treat ADHD
- Measles - aka Rubeola - caused by paramyxovirus. Koplik's spots
- Rubella - aka German measles
- Small pox - aka Variola
- Diphtheria - caused by Corynebacterium diphtheria.
- Scarlet Fever - an exotoxin mediated disease caused by Group A beta-hemolytic streptococci. Causes "strawberry tongue" due to enlarged fungiform
papilla.
- Most common primary tooth to be retained - Mand 1st molars
- From age 6-12, the body;s kymph tissue is 200% of its normal adult mass. Lymphoid tissue decreases at puberty.
- Periodontium
- Cementum is thinner is primary teeth - it increases with age.
- Primary gingiva is more red, more vascular, thinner, and less keratinized. Less stipling. Rounded and rolled gingival margins.
- PDL runs parallel to primary teeth. PDL runs more horizontal in adults
- Tooth development
- Growth center = lobes - the area of the tooth germ where the cells are particularly active.
- Lobes are PRIMARY centers of calcification that form the crown of a tooth
- Represent cusps on posters teeth and mammelons and cingula on anterior teeth
- Separates by developmental grooves
- Minimum # of lobes from which ANY tooth is developed = 4
- ALL anterior teeth - 3 labial lobes, one lingual
- Premolars - 3 buccal and 1 lingual
- EXCEPT Mand 2nd premolar - 3 buccal and TWO lingual
- 1 molars - 5 lobes, one for each cusp
st

- 2nd molars - 4 lobes

- Pulpotomy - inflammation and degenerative change in coronal pulp
- Use CaOH in PERMANENT teeth when there is a pulp exposure but healthy pulp tissue and immature root development.
- Use Formocresol pulpotomy when carious exposure in PRIMARY tooth - moist cotton pellet for 5 minutes
- Pulpectomy
- On primary teeth - fill canals with ZOE so primary roots can resorb normally
- Direct pulp capping - rarely done on primary teeth because CaOH often irritates the pulp causing internal resorption. Can use MTA.
- Indirect pulp treatment - done on deep carious lesions adjacent to the pulp - leave caries to avoid pulp exposure and cover with CaOH and seal with ZOE
or glass ionomer.
- Contraindicated in primary dentition
- Contraindicated if already symptoms of pulpal involvement.
- Fractures - Ellis Classification
- Class I - simple fracture of crown involving little or no dentin - smooth enamel edges and restore
- Class II - extensive fracture of crown involving considerable dentin but no pulp - apply CaOH or glass ionomer to exposed dentin and restore
- Class III - extensive fracture of the crown with a pulpal exposure - apply CaOH and temp restoration immediately. If not immediate, do CaOH
pulpotomy until apex closes and then pulpectomy. Use ZOE NOT gutta percha.
- Class IV - fracture where entire crown is lost - CaOH pulpotomy until apex closes and then pulpectomy.
- Primary max central incisor - the only anterior tooth in either dentine to have shorter inciso-cervical height than mesio-distal width. Erupts with no
mammelons.
- Primary mand central - more resembles perm mand LATERAL
- Primary max lateral - just like central but smaller
- Primary mand lateral - SMALLEST primary tooth
- Mand central is smallest PERM tooth
- Primary max canine - differs from permanent max canine in that the Mesial Cusp Ridge is longer than the Distal Cusp Ridge. And the cusp on the primary
canine is longer than sharper.
- *** ALL other canines have longer Distal Cusp Ridge!!!!!
- Primary max 1st molar - Resembles premolar/molar. Often 4 cusps. MB cusp is widest and longest
- Primary mand 1st molar - has a prominent transverse ridge that unites the MB and ML cusps - separates the mesial portion of the occlusal surface
- Does not resember any other primary or permanent tooth
- MB cusp is the largest and longest - 2/3rd of the buccal surface.
- Primary max 2nd molar - has the greatest faciolingual diameter of ALL primary teeth.
- Primary mand 2nd molars - LARGEST primary tooth.
- Max 1st molar is largest perm tooth
- Eruption
- When a tooth erupts, -2/3 of the root is developed. Primary roots complete in 6-18 months after eruption. Permanent roots complete 2-3 yrs
after eruption.
- Permanent mand centrals - erupt 6-7 yrs
- Permanent max central - 7-8 yrs
- *** Rule of Four - helps you determine the number of teeth present at any given time. Eruption of 4 teeth every 4 months.
- 7 months -2mand centrals and 2 mand laterals (4 teeth)
 - 11 months -2max central and 2 max laterals (8 teeth)
- 15 months - 4 first molars (12 teeth)
- 19 months - 4 canines (16 teeth) *** CANINES erupt AFTER 1st molars
- 24 months - 4 second molars (20 teeth)
- Hertwig's Root Sheath - determines the number, size and shape of roots. Forms as the crown portion of the tooth nears completion when the outer
enamel epithelium and the inner enamel epithelium combine at the cervical loop region to form a bilayered structure.
- Tooth development
- Tooth development is initiated by the mesenchyme's inductive influence on the overlying ectoderm.
- The enamel of the tooth is derived from the ectoderm of the oral cavity. All other tissues come from the mesoderm/mesechyme.
- Ectodermal cells determine crown root and shape.
- Initiation - initial interation between oral epithelium and mesenchyme and formation of the dental lamina. Week 5.
- Bud stage - involves proliferation as the dental lamina grows into 10 buds per arch. Mesenchyme starts proliferating and shape of teeth
become evident. Enamel organ starts to form. Week 8.
- Cap stage - PROLIFERATION AND DIFFERENTIATION in two ways - 1) Morphodifferentiation - change into other shapes 2)
Histodifferentiation - branch into different tissues. Week 9-10.
- By the end of the cap stage, the tooth germ is complete!! Consists of enamel organ, dental papilla, and dental sac.
- Bell Stage - DIFFERENTIATION forming 4 different cell types in the enamel organ - OEE Cuboidal, IEE Columnar, Stellate Reticulum
Stratum intermedium. Week 11-12
- Appositional Stage - cells deposit specific dental tissues - enamel, dentin, cementum, pulp
- Maturation Stage - mineralization begins AT DEJ.
- Crowns of all 20 primary teeth begin to calcify, 4-6 months in utero. Takes 10 months to calcify.
- Permanent teeth begin to develop 4 months in utero. Max and mand 1st molars begin to calcify AT BIRTH.
- 3RD molars begin to calcify 8-10 yrs of age.
- Histogenesis - formation and development of tissues
- 1) Elongation of inner enamel epithelial cells of the enamel organ - causes mesenchymal cells to differentiate to odontoblasts
- 2) Differentiation of odontoblasts
- 3) Deposition of 1st layer of dentin
- 4) Deposition of 1st layer of enamel
- The last primary tooth to be replaced by a permanent tooth is usually MAX CANINE at age 11-12.
- Nitrous oxide - must always have at least 20% O2. CNS depressant. Combined volume of gases is 3-5L/min. N2O is LESS soluble is blood.
- Chloral hydrate - widely used for pediatric sedation. A sedative/hypnotic. Acts on the CNS to induce sleep. Onset is 15-30 minutes.
- Meperidine (Demerol) - a synthetic opiate agonist. Used to treat moderate to severe pain.
- Apexogenesis - a vital pulp therapy to encourage continued physiological development and formation of the root end. MTA is often used.
- Most common congenitally missing PRIMARY tooth - primary max lateral.
- Primary vs Permanent
- Primary anterior teeth crowns are wider MD and shorter inciso-cervically than permanent counterparts.
- Enamel ends abruptly at the cervical line on primary teeth rather than becoming thinner like in permanent teeth.
- The thickness of coronal dentin in primary teeth is that of permanent teeth.
- Do NOT need gingival bevel in Class II preps on primary teeth since enamel rods extend OCCLUSALLY from the DEJ in primary teeth.
- Primary teeth are LESS opaque on x-ray film due to higher inorganic content
- Amelogenesis Imperfecta - inherited, dominant, abnormal enamel formation. Dentin is normal.
- Type I = Hypoplastic - thin but normal enamel. May appear pitted. Aka Enamel Hypoplasia
- Type II - Hypomaturation - adequate amount of enamel but enamel doesn't mature. Appears rough and discolored.
- Type III - Hypocalcified - Normal amount of enamel but inadequate mineralization. Enamel is rough and gets worn down.
- Dentinogenesis Imperfecta - inherited, dominant, causes dentin to be under mineralized. Can affect deciduous and permanent dentition. Crowns are grey
and opalescent.
- Type I - associated with osteogenesis imperfect. Blue Sclera! Fragile bones, hearing loss.
- Type II - most common, NO OI
- Type III - Brandywine type - multiple PARLs and large pulp chambers.
- Concresence - fusion of cementum only
- Apert Syndrome - a genetic defect causing malformations in skull, midface, hands, and feet. Mandible is often retruded causing Class III malocclusion.
Tx is by Lefort III surgical procedure.
- Crouzon Syndrome - autosomal dominant, causes craniosynostosis, maxillary hypoplasia, short head, shallow orbits, calcified stylohyoid ligaments
- Rieger's Syndrome - delayed sexual development and hypothyroidism. Causes hypodontia, under-developed pre-maxilla, cleft palate, and protruded
lower lip.
- Treacher Collins Syndrome - aka mandibulofacial dysostosis - autosomal dominant, causes slanted palpebral fissures, malformed ears, severe mandibular
hypoplasia.
- Cleidocranial dysplasia - autosomal dominant, partial or complete absence of clavicles, defective ossification of skull, missing or supernumerary teeth.
Prolonged retention of primary teeth.
 - Ectodermal dysplasia - hereditary, abnormal skin, hair, nails, teeth, sweat glands. Teeth develop abnormally causing anodontia or oligodontia (partial).
Retained primary teeth. CONICAL shaped anterior teeth.
- Pediatric Abx prophylaxis - Amoxicillin 50mg/kg orally 1 hr prior to appt.
- Local Anesthesia
- Max dose of lidocaine - 4.5mg / kg per appt.
- Do NOT use Bupivacaine (Marcaine) on children - amide LA with high toxicity
- A 1.8ml 2% lidocaine with 1:100,000 epi contains - 36mg of lidocaine and 0.018mg of epi
- Because 1ml of a 2% solution contains 20mg of lidocaine. And 1ml of 1:100,000 epi = 0.010mg of epi
- Depress SMALL UNmyelinated fibers FIRST - conduct pain and temp
- Depress large myelinated fibers last
- The order of loss of function is - pain, temp, touch, proprioception, skeletal muscle tone
- Class II on primary - width of isthmus is 1/3rd the intercuspal width. NO gingival bevel.
- Cretinism - severe hypothyroidism in a child due to congenital absence of Thyroxine. Causes under-developed mandible, enlarged tongue, delayed teeth
eruption
- Congenital porphyria - teeth appear pink/brown naturally, but scarlet under UV light. Skin is sensitive to sunlight.
- Cleft palate - more common in females
- Class I - only soft palate
- Class II - soft and hard palate but not alveolar processes
- Class III - soft and hard palate AND alveolar processes on one side of premaxilla
- Class IV - soft palate and alveolar processes on BOTH sides of premaxilla
- Cleft Lip - more common in males. More common on left side.
- Class I - unilateral notching of vermillion border ONLY but not lip.
- Class II - unilateral notching of lip but not extending to floor of nose
- Class III - unilateral notching of lip that extends into floor of nose.
- Class IV - ANY bilateral clefting of lip
- Primary Herpetic Gingivostomatitis - inflamed gingiva, sore throat, fever, lymphadenopathy, and small fluid filled vesicles on mucosa. Debridement does
not help. Abx do not help.
- ANUG - interdental papilla become necrotic and punched out. Debridement and Abx reduce symptoms. Caused by spirochetes, fusobacterium and
prevotella intermedium
- Ludwig's Angina - when cellulitis involves submandibular, sublingual, and submental space. Medical emergency!
- Neuroblastoma - the most common malignant tumor seen in neonates
- Achondroplasia - most common form of short limbed dwarfism. Large head with short arms and legs. Prominent forehead. Children die in 1 st year of life.
Class III occlusion is common, severe teeth crowding due to small maxilla.
- Acute lymphocytic leukemia - ALL - aka "Leukemia of Childhood" - cells that normally develop into lymphocytes become cancerous and replace normal
cells in bone marrow. Most responsive to therapy!
- Hodgkin's Lymphoma - malignant growth of cells in lymph system.

ENDODONTICS
- MTA (mineral trioxide aggregate) - contains Ca and phosphate. Has a high pH so it induces hard tissue formation. Causes low levels of inflammation.
Difficult to manipulate and has a LONG setting time.
- Thermal sensitivity is the earliest and most common symptom of an inflamed pulp.
- Phoenix abscess - aka recrudescent abscess. Develops as an acute exacerbation of a chronic apical abscess when granulomatous zone becomes
contaminated or infected by elements from the root canal. Causes acute symptoms and large PARL. ALWAYS preceded by chronic apical perodontitis.
- Granuloma - growth of granulomatous tissue cause by pulpal death and diffusion of toxic products into periapical area. NO symptoms.
- Cyst - an inflammatory response of the apex that develops from a PRE-EXISTING granuloma. A central, fluid-filled, epithelium lined cavity. NO
symptoms.
- ** A granuloma and a cyst can only be differentiated by histological examination.
- Hemophilia is NOT a contraindication to RCT.
- Semi-lunar flap - aka submarginal curved flap - a simple, curved, horizontal incision. However - provides limited access and visibility, can easily be torn,
etc. Not esthetic so do not used for anterior root end surgery.
- Submarginal triangular - aka rectangular flap - requires at least 4mm of attached gingiva and healthy periodontium. Scalloped incisions in KAG with one
or two vertical incisions. Better access and visibility.
- Full mucoperiosteal flap - MAXIMUM access and visibility. Raised from gingival sulcus. Able to visualize bony defects, do ScRP, etc.
- Bleaching
- Superoxol - most common bleaching agent for RCT teeth. 30% aqueous solution of hydrogen peroxide and water. Directly oxidizes stain
producing substances. Use HEAT to liberate the oxygen in the bleaching agent. Chairside.
- Most common post op problem is acute apical periodontitis.
- Causes change in both enamel AND dentin.
- Walking Bleach technique - place paste of Sodium Perborate and 2-3 drops of Superoxol in tooth chamber for 4-7 days.
- Referred pain
 - Forehead - max incisors
- Nasolabial area - max canines and premolars
- Temporal region - max 2nd PM
- Ear - mand molars
- Mental region of mandible - mand incisors, canines, or PM
- Access openings
- Max central - triangular
- Mand molars - trapezoidal
- Tooth tips mesially and lingually so if access is drilled straight, often the mesial marginal ridge ad lingual surface are undercut
- # of roots
- 40% of mand molars have a 2nd canal in distal root.
- The lingual wall of mandibular teeth is most easily perforated when preparing an access opening due to the lingual inclination of these teeth.
- The mand 1st molar is the MOST COMMON tooth that requires endo!!
- The max 1st molar is the posterior tooth with the HIGHEST endo failure rate!
- SLOB - the object toward the lingual side (closer to the film) shifts to the same direction as the repositioned x-ray cone. Ex. X-ray cone is angled more
mesial, the lingual root shifts more mesial.
- EPT - stimulates nerve endings with a low current and high potential difference in voltage. Stimulates A-Delta sensory fibers in the pulp. Indicates if there
are vital sensory fibers present ONLY.
- ** In a COMBINED endo-perio lesion, do ENDO FIRST and then perio management.
- "Pink" tooth - a pinkish appearance of a tooth due to growth of granulation undermining coronal dentin. Considered pathognomonic of internal resorption.
- Transplantation - the transfer of a tooth from one alveolar socket to another
- Do NOT replant primary teeth - can damage permanent tooth
- File canals and place CaOH 10-14 days after replanting
- Replace CaOH every 3 months for 1 year
- After 1 year do RCT
- Only do if tooth is out of mouth less than 2 hours
- Orthodontic extrusion is sometimes used to repair resorptive lesions or perforations in the cervical area.
- Root submersion - involves resection of tooth roots 3mm below the alveolar crest and then covering it with a mucoperiosteal flap. Used if rampant caries
or perio problems in order to "save" the tooth.
- X-rays - stand at least 6 feet away in the area that lies between 90-135 degrees to the x-ray beam.
- E speed film - more sensitive to x-ray, faster film so requires less radiation exposure
- The higher the kVp, the lower the patient radiation dose
- External resorption - caused by periradicular inflammation, dental trauma, ortho forces, or bleaching of non-vital teeth
- Replacement resorption - when the root is resorbed and replaced by bone causing ankylosis
- Internal resorption - caused by dental trauma resulting in loss of vitality and subsequent infection, CARIES, cracked tooth, pulp capping with CaOH Do
pulpectomy
- Avulsion
- Less than 30 minutes results in little resorption. More than 2 hours results in EXTERNAL resorption.
- Milk storage is best - neutral pH.
- Do not touch tooth socket.
- Splint for minimum of 2 weeks so PDL can reattach
- Root anatomy
- Apical part of root contains more collagen - Type I and III - mainly Type I.
- Cell rich zone - inner most pulp layer, contains FIBROBLASTS
- Cell free zone or Zone of Weil - rich in capillaries and nerves. Contains Nerve Plexus of Raschkow
- Odontoblastic layer - outermost pulp layer, contains odontoblasts, closest to dentin.
- Mantle dentin - first formed BEFORE odontoblast layer
- Circumferential dentin - most of the dentin
- Secondary dentin - forms AFTER tooth erupts and throughout life - causes pulp to get smaller over time
- Tertiary dentin - aka reparative dentin - irregular, laid down due to injury or irritation
- Primary function of the pulp is DENTIN formation
- Myelinated fibers - sensory
- Unmyelinated fibers - motor, regulate blood vessels
- Parallel sided and tapered posts are preferred. Threaded screw posts can cause fractures.
- The minimum (most conservative) preparation to restore an endodontically treated tooth to prevent fracture is an onlay that covers the cusps and
marginal ridges.
- Pulp chamber retained amalgam - you need to place amalgam 3mm into each canal.
- Perio probing
- Conical shaped - typically a perio problem. Bone loss begins at crestal bone level and progresses apically forming a cone.
- Dx test - pain to LATERAL percussion usually means perio problem
 - Narrow sinus tract type - normal probings around rest of tooth with one point that drops to apex. RCT
- Blow out type - normal probings around rest of tooth with one point that drops to apex. RCT
- # of Canals
- 59% of Max 1st molar have MB2 canal - just lingual to the orifice of MB1
- 25% of mand 1st PM have 2 canals with two foramina.
- 97% of Mand 2nd PM have only 1 canal
- Max 2nd PM have a higher incidence of accessory canals (60%) than Max 2st PM.
- Mand canine - root canal is THIN mesiodistally but WIDE labiolingually
- Cementoma - most frequently seen in the anterior region of the mandible. Does not affect pulp vitality. Aka periapical cemental dysplasia
- Traumatic bone cyst - not a true cyst since no epithelial lining. Seen in young people, asymptomatic, scallops, teeth are vital
- Globulomaxillary cyst - seen between lateral incisor and canine roots. Teeth are vital.
- Broaches - contain barbs notched out of the instrument shaft. Use with caution because if forced apically, the barbs can bend and engage the walls of the
tooth and can't be removed. NOT used for canal enlargement.
- Hedstrom files - very effective cutting instrument. Can plane dentin walls faster than k-type files or reamers.
- Pulp capping - pin point accidental exposure. Repair is accomplished by the formation of a dentin bridge at the exposure site. Can make subsequent
endo difficult due to severe calcifications in the root canal. Dycal.
- Solvent Softened Custom Cones - studies show that it does NOT result in a better apical seal. Used when there is a lack of an apical stop or an
abnormally large apical portion of the canal.
- After endo, it usually takes 6-12 months before a marked reduction in the size of the radiolucency is evident on an x-ray.
- If penicillin does not help resolve a periapical abscess, try clindamycin.
- Sodium Hypochlorite - conc. of 5.25% or less.
- Endo Retreatment
- A crown-down sequence of instruments is used - coronal to apical
- Rotary instruments are faster and improve access earlier over heated instruments
- Use LIGHT apical pressure with NiTi rotary
- Remove over-extended gutta percha cones by extending the file periapically
- Chloroform is the agent of choice to dissolve gutta percha. (Eucalyptol is less effective)
- EDTA - Ethylene Diamine Tetra-Acetic Acid
- A chelating agent with the capability to remove the mineralized portion of the smear layer
- Can decalcify up to 50micrometer thin layer of the root wall
- Used in 17% concentration
- RC- Prep and EDTAC are forms of EDTA
- EDTAC is EDTA with the addition of Cetavlon - a quaternary ammonium compound - inactivated by NaOCl
- RC-Prep is EDTA with urea peroxide.
- Has a self limiting decalcifying process that stops as soon as the chelator is used up - acts on calcified tissues and sclerotic canals
- Will remain active for 5 days if not cleaned out with NaOCl
- Has a limited value as irrigation solution
- Broken instrument
- If the instrument protrudes past the apex, raise a flap and remove the instrument surgically followed by gutta percha filling of the canal.
- If the instrument breaks off in the canal, but minimal canal enlargement has been done, obdurate to the point of blockage and then do an
apicoectomy and retrofilling.
- If the instrument breaks off at the apical 1/3rd and there is no PARL, fill the remaining canal, inform the patient and place on 3-6 month recall.
- Filing - push-pull action with emphasis on the withdrawl.
- Reaming - repeated clockwise rotation of the instrument, produces a round canal.
- ZOE sealer - fills in the discrepancies between the core filling material and the dentin wall. Disadvantages - stains, slow setting time, non-adhesive, very
soluble.
- Mand incisors and Max PM1 are most often perforated.
- Acute osteomyelities - most often occurs due to a dental infection and result in bone necrosis. Causes severe pain, high temp, lymphadenopathy, moth
eaten appearance
- Maxilla - well localized to area of initial infection
- Mandible - more diffuse and widespread
- Max lateral incisor - root is often curved or dilacerated.
- Max central, lateral, and canine all have distal axial inclination - incline bur to distal so mesial portion of the root is not perforated.
- Mand central incisor - root is narrow mesiodistally but wide labiolingually. May have TWO canals present.

RADIOLOGY
- kVp - Kilovoltage - controls the SPEED of ELECTRONS. Has nothing to do with the number of electrons. Changes the potential difference between the
anode and cathode. 65-100 kVp
- controls the QUALITY of the x-ray beam
- increasing kVp causes the resultant x-ray to have a longer scale of contrast (and reduces the subject contrast - ex, thick jaw bones)
- mA - milliamperage - controls the TEMP of the tungsten filament which increases the NUMBER of elections. 7-15mA
- controls the QUANTITY of x-rays
- Density - increases as mA, kVp, or exposure time increase.
- Contrast - low contrast = many shades of gray - is preferred with dentistry. Only affected by kVp - higher kVp means more shades of grey
- Dental X-ray Tube components
- Filament is located in the cathode - made of tungsten wire
- Copper is used to house the anode because it is a good thermal conductor and can dissipate heat from the tungsten target
- Molybdenum cup - aka the electron focusing cup, electrostatically directs electrons from the filament in the cathode to the focal spot on the
anode.
- Primary radiation - the radiation generated at the anode of the x-ray tube. Follows the inverse square law measured from the focal spot.
- Secondary radiation - aka scattered radiation - arises from interactions of the primary radiation beam with the atoms in the object being imaged. Degrades
the image.
- Scattering
- Coherent scattering
- Photo electric absorption
- Compton scattering - majority of scattering xrays
- MPD - Maximum Permissible Dose - 0.5REM for general people. 5 REM for people working near radiation.
- Collimation - diameter of the x-ray beam can be no more tha 2.75 inches in diameter
- Image magnification - reduced by using a long cone, increasing the distance of the x-ray source to the film
- RAD = radiation absorbed dose - the amount of energy actually absorbed in a material.
- REM = roentgen equivalent man - relates the absorbed dose in human tissue to effective biological damage.
- QF = quality factor = 1
- Fixer
- Contains - a clearing agent, an antioxidant preservative, an acidifier, a hardener (NO accelerator)
- Clearing agent - sodium or ammonium thiosulfate - dissolves and removes the undeveloped silver halide crystals from emulsion.
- Developer
- Developing agent - hydroquinone - changes the exposed silver halide crystals to black metallic silver.
- Herringbone effect - the film was placed backwards in the mouth
- Panoramic
-
- Chin tilted upward reverse occlusal plane with mand structures look narrow and max structures look wider - looks like a frown
- Chin tilted downward occlusal plane is like a V with an excessive upward curve. Severe interproximal overlapping and anterior teeth are
distorted.
- Paralleling technique
- Film is placed parallel to long axis of tooth and central ray is peroendicular
- Object-film distance is GREATER in order to keep film parallel to tooth causes image magnification and loss of definition
- Source-film distance is GREATER in order to compensate for the mage magnification. LONG CONE - greater exposure time
- Bisecting technique - film is placed along the lingual surface of the tooth. Imaginary line bisects the long axis of the tooth and the plane of the film.
Central x-ray is positioned perpendicular to the imaginary bisector.
- Image on the film may be dimensionally distorted
- DECREASED exposure time
- Use SHORT cone which results in divergent rays
- May not be able to judge alveolar bone height
- Submentovertex Projection - neck is maximally extended and the film cassette touches the top of the head. X-ray enters the head under the chin and
exits at the vertex (top of the head). Allows direct visualization of the base of the skull and clear view of ZYGOMATIC arches.
- Waters Projection - patient places face against the film with chin touching and nose 1 inch away. X-ray enters behind pts head. Best technique to see
MAX SINUS.
- Townes Projection - pt lies on back with film under head. X-ray source is from the front but rotated 30 degrees from the Frankfort plane and directed right
at the condyles. Best technique for seeing CONDYLES and RAMUS
- Lateral Cephalometric - used to evaluate the growth and development of the face.
- Filtration - the removal of parts of the x-ray spectrum using absorbing maerials in the x-ray beam.
- Inherent filtration - done by the x-ray tube or tube shield, the glass envelope of the x-ray tube, the oil cooling the tube,
- Added filtration - done by placing thin sheets of aluminum in the cone to filter the useful beam further.
- Long wavelength xrays are easily absorbed. Shorter wavelength xrays penetrate objects more readily.
- Digital radiography requires less radiation than conventional radiography because the sensor is more sensitive to x-rays so the exposure time is 50-80%
less than those for E-speed film.
- The area from which x-rays emanate is called the - focal spot - this is the area of the tungsten anode that receives the impact of the speeding electrons
and converts them into x-ray PHOTONS.
- What 3 factors influence image sharpness? The focal spot, film composition, and movement
 - Tungsten target - embedded in the ANODE at the point of electron bombardment. Tungsten is used due to its high atomic number, high melting point,
high thermal conductivity (dissipates heat), and low vapor pressure (maintains a vacuum at high temp)
- Intensifying screens - converts x-ray energy into visible light which exposes the screen film. Decreases the amount of radiation a pt receives.
- Target-film distance - determined by the PID (position-indicating device)
- Short cone = 20cm / 8 inches - exposes MORE tissue by producing a more divergent beam
- Long cone = 41cm / 18 inches - reduces the amount of exposed tissue by producing a LESS divergent beam and a sharper image.
- Osteoradionecrosis - most common factors precipitating it are pre and post irradiation extractions and periodontal disease. Caused by damage to blood
vessels.
- Hamulus - aka hamular process - a small hook like projection of bone extending from the medial pterygoid plate of the sphenoid bone. Located posterior
to the max tuberosity.
- A film will appear BROWN when it is NOT completely fixed.
- Fogged film - faulty safelight in darkroom
- Radioresistant cells - mature bone, muscle, and nerves
- Radiosensitive cells - small lymphocytes, bone marrow, reproductive cells, immature bone cells.
- When taking radiographs, the operator should stand at least 6 feet away from the pt. And 90 to 135 degree angle to the beam.
- Inverse square law - original intensity/new intensity = new distance ^2/original distance^2
- For a given beam of radiation, the intensity is inversely proportional to the square of the distance from the source of radiation.
- Ex. PID length changed from 8inch to 16 inch, so the resultant beam is as intense.
- Intensity - the total energy of the xray beam. The product of the quantity (# of photons) and the quality (energy of photons) per unit of area per
time of exposure.

ORTHODONTICS
- Space maintainer
- Very important if primary 2nd molar is lost. Must maintain space for the 2nd PM. Perm 1st molar will tip mesially and rotate into its space.
- Can be removed as soon as the permanent tooth begins to erupt through the gingiva.
- Torque - controlled root movement labiolingually or mesiodistally while the crown is held relatively stable.
- Recurring tooth rotations after ortho correction occur due to persistence of Elastic Supracrestal Gingival Fibers (mainly free gingival and transseptal fibers)
- Most often needed with Max Lateral incisors.
- Supracrestal fibers are commonly associated with relapse following ortho rotation of teeth.
- Bone formation
- Intramembranous ossification - takes place in membranes of connective tissue. Osteoprogenitor cells differentiate into osteoblasts. A collagen
matrix is formed which undergoes ossification.
- The flat bones of the skull and part of the clavicle are formed
- The maxilla and mandible are formed this way
- Endochondral ossification - how the rest of the skeleton forms. Takes place within a hyaline cartilage model. Cartilage cells are replaced by
bone cells (osteocytes replace chondrocytes), an organic matrix is laid down and calcium and phosphate are deposited.
- Forms short and long bones.
- Forms the ethmoid, sphenoid and temporal bones
- Bone growth - ONLY Appositional!!
- Growth of cartilage - can grow in two ways - Interstitial growth and Appositional Growth
- Appositional growth - recruits fresh cells, chrondroblasts, and adds to the surface of the matrix.
- Interstitial growth - occurs by the mitotic division and deposition of more matrix around chondrocytes already established in the cartilage.
- Ex - CONDYLE, nasal septum, and spheno-occipital snychondrosis.
- After age 6, the greatest increase in size of the mandible occurs distal to the first molars.
- Resorption occurs on the anterior surface of the ramus to create space for mandibular molars.
- Serial extractions
- Mainly used for arch length discrepancy - over 10mm.
- 1) Primary Canines
- 2) Primary 1st Molars
- 3) Permanent 1st Premolars - must occur before permanent canines erupt
- Maxillary arch lengthens due to bone deposition in the - tuberosity region.
- Mandibular anterior crowding occurs in normal young adults due to - late mandibular growth (NOT 3rd molars)
- 98% of 6 year old have a median diastema. 49% of 11 year olds have it too.
- If less than 2mm, it will usually close spontaneously
- If caused by an abnormal frenum - align teeth orthodontically and THEN do a frenectomy.
- Impacted teeth
- Most common - max canines
- M-D diameter of maxillary permanent teeth is 128mm. Mandibular permanent teeth is 126mm.
- Steiner's Analysis
 - SNA (sella turcia, nasion, point A) - Normal is equal to 82 degrees. Maxillary retrognathism - SNA angle LESS than 82. Greater than 82 is
maxillary prognathism.
- SNB - normal is 80 degrees. Greater than 80 is mandibular prognathism. Less than 80 is mandibular retrognathism.
- ANB - normal is 2 degrees. A class I skeletal profile has ANB of 2 degrees. Greater than 4 is Class II skeletal profile. Less than 0 is Class III
skeletal profile.
- Describes the relation of the max and mand denture bases.
- Headgear
- Components - neck strap, chin cup, face-bow, head cap.
- Force required for anchorage - 250g for 10hr/day. Force required for traction - 500g for 14-16hr/day
- Permits posterior movement of teeth in one arch without adversely disturbing the opposite arch.
- High pull - has a head cap, places a distal and upward force on maxillary teeth and the maxilla. Indications - class II, div 1 with open bite.
- Cervical pull - has a neck strap, places a distal and downward force on maxillary teeth and the maxilla. Disadvantage - can extrude maxillary
molars resulting in an open bite. Indications - class II, div 1.
- Straight pull - places force in a straight distal direction from the max molar. Indications - class II, div 1
- Reverse pull - has an EXTRAORAL component that is supported by the chin, cheeks, forehead. Indications - class III malocclusion to protract
the maxilla.
- Hyperparathyroidism - can cause PREMATURE eruption of primary teeth.
- Poor man's Cephalometric analysis - do a facial profile analysis
- Tongue thrusting does NOT lead to an open bite.
- Indirect method of bonding brackets - more complex and technique sensitive.
- Mouth breathing - causes SKELETAL open bite, "Long Face Syndrome"
- Quad Helix - a FIXED appliance, consists of 4 helices, used for posterior cross bites caused by digital sucking habit. NOT a functional appliance
- Functional Appliances
- Tissue borne
- Frankel - the ONLY tissue borne functional appliance!!! Expands the arch by padding against the pressure of the lips and cheeks on
the teeth and postures the mandible forward and down. REMOVABLE.
- Tooth borne
- Activator- advances the mandible to an edge to edge position to induce mandibular growth
- Bionator - a trimmed down version of the Activator making it more comfortable
- Herbst - can be fixed or partially removable. Mandible is postured forward to induce growth.
- Twin block - a two piece acrylic appliance that postures the mandible forward.
- The Frankfort-Horizontal plane is constructed by drawing a line connecting PORION and ORBITALE. The best representation of the natural orientation of
the skull.
- Nance appliance - has a small acrylic button that rests against palatal tissue and bands around 1st permanent molars . used when premature BIlateral
loss of max primary teeth.
- Band and loop - used after UNILATERAL loss of primary first molars. Prevents mesial migration of primary 2nd molar.
- Distal shoe - used to prevent unerupted 1st permanent molars from moving mesially with premature loss of primary 2nd molars.
- Lingual arch appliance - used when BOTH primary 1st molars are lost and permanent mand incisors are erupted. Primary 2nd molars or perm 1st molars
are banded.
- Molar uprighting - Takes about 6-12 months, Use a fixed edgewise orthodontic appliance
- Ectopic eruption - occurs when a tooth erupts in the wrong place. Most commonly seen in max 1st molars and mand incisors.
- Leeway space - refers to the space created due to the fact that the permanent canine, 1PM, and 2PM are smaller mesiodistally than the primary canine,
1st molar and 2nd molar. Accomodates the permanent canines which are larger than primary canines.
- Mand leeway space = 3-4mm, Max leeway space = 2-2.5mm
- Late mesial shift - when the permanent 1st molars move mesially into the leeway space after the primary 2nd molars are shed causing a LOSS
in arch length.
- Primate space - spacing in the anterior part of primary dentition. Caused by the GROWTH of the dental arches!!
- In the max arch, the primate space is located btwn the lateral incisors and canines
- In the mand arch, the primate space is located btwn the canines and 1st molars
- Primary molar relationships
- Mesial step - the distal surface of the lower 2nd primary molar is mesial to the distal surface of the upper 2nd primary molar. This allows 1st perm
molars to erupt into a normal occlusion.
- Flush terminal plane - aka flat plane or end to end - the distal surfaces of the max and mand 2nd primary molars are in an end-to-end
relationship. The 1st perm molars do NOT erupt immediately into normal occlusion but into Class II temporarily until late mesial shift when 1st
perm molar shift mesially.
- Distal step - where the distal surface of the mandibular primary 2nd molar is located to the distal of the distal surface of the max primary 2nd
molar. In these cases, the permanent molars erupt into a class II relationship.
- Permanent mandibular canines erupt FACIALLY to primary mandibular canines.
- Permanent teeth normally move occlusally and buccally while erupting.
- Permanent 1st PM usually erupts between 10-12 years old.
 - Conditions associated with multiple supernumerary teeth: Gardener's syndrome, Cleidocranial dysplasia, Down's syndrome, Sturge-Weber syndrome.
- A steep mandibular plane angle correlates with - a LONG anterior facial vertical dimension and an anterior open bite.
- A flat mandibular plane angle correlates with - a SHORT anterior facial vertical dimension and an anterior deep bite.
- Edgewise Appliance - used in the tx of comprehensive malocclusions of the adolescent permanent dentitions. Consists of bands on all the teeth, tubes on
the last molar and brackets on all other teeth.
- Primary growth centers of the maxilla = spheno-occipital and sphenoethmoidal junctions and nasal cartilaginous septum
- Secondary growth sites of the maxilla = frontomaxillary suture, zygomaticotemporal suture, pyramidal process of palatal bone, alveolar process
- Posterior cross bites - Should be corrected as soon as possible - at an EARLY age, even if perm 1st molars haven't erupted yet. Often corrected by
palatal expansion.
- Crowding
- When space lacking is less than 4mm, it can be obtained by stripping some interproximal enamel from anterior teeth
- When space deficiency exceeds 4mm, it indicates extraction for correction.
- Pseudo Class III - when a patient adopts a jaw position forward in order to avoid the interference of teeth.
- "Sunday Bite" - when a person postures their mandible forward in order to improve Class II esthetics. .
- Class II, Div I - a distal relationship of the buccal groove of the mandibular 1st perm molar to the MB cusp of the max 1st perm molar along with the max
laterals being in extreme labioversion (protruded).
- Class II, Div II - when the maxillary LATERALS have tipped labially and mesially (sometimes overlapping the centrals)
- Subdivisions - when the distocclusion occrs on one side of the dental arch only
- An anterior crossbite in a primary dentition usually indicated a SKELETAL growth problem.
- A retrognathic profile - when the mandible is markedly retruded. Associated with Class II malocclusion.
- Class II malocclusion is also referred to as retrognathism or overbite
- A prognathic profile - when the mandible is markedly forward of the maxilla giving a concave midfacial appearance. Indicative of a Class III malocclusion.
- Archwires - should possess high strength, low stiffness, high range, and high formability.
- Loops and helices are incorporated into archwires to increase the activation range.
- The stiffness of ortho wires is a function of the length of the wire, the diameter of the wire, and the alloy composition.
- Can be made of stainless steel
- Chromium cobalt alloys - can be softened or hardened by heat treatment.
- Titanium alloys - offers a combo of strength and springiness and reasonably good formability.
- Hawley retainer - clasps on molar teeth, outer bow with adjustment loops spanning from canine to canine, and acrylic palatal coverage
- Palatal coverage is the major source of anchorage
- Can be made for the upper or lower arch
- Cross bite
- An ANATOMIC crossbite (skeletal), as opposed to a FUNCTIONAL crossbite (from thumb sucking), usually demonstrates a SMOOTH closure
to centric.
- A FUNCTIONAL crossbite is usually caused by thumbsucking and does not demonstrate smooth closure into CO.
- Displaced teeth related to functional shifts are usually seen in posterior crossbites after prolonged thumbsucking and anterior
crossbites in mildly prognathic children.
- A corrected anterior crossbite is best retained by the normal incisor relationship that is achieved through treatment (of the overbite), NOT by
appliances.
- Tx usually starts with Maxillary Expansion
- Reverse overject is associated with Class III skeletal patterns with more than two maxillary anterior teeth in linguoversion.
- Scissor bite or bilateral lingual cross bite - results from a narrow mandible or a wide maxilla.
- Overbite - the vertical overlapping of the max anterior teeth over the mand anterior teeth.
- Overjet - the horizontal projection of the max anterior teeth beyond the mand anterior teeth.
- Moyer's Mixed Dentition Analysis - where the size of the UNerupted canines and premolars is predicted from the knowledge of the M-D size of the
mandibular INCISORS that have already erupted. (max incisors are not used due to the variability in size)
- Measure the M-D diameter of mand incisors and add them together
- Measure the space avail for mand incisors
- Subtract 1 from 2
- A NEGATIVE number indicates CROWDING in the incisor region
- Wrist-hand radiograph - best predictor of the time of pubertal growth spurt - look at ossification and development of the carpal bones of the wrist, the
metacarpals of the hands and the phalanges of the fingers.

OSHA/ BEHAVIORAL SCEINCE/ PUBLIC HEALTH

- Autoclave - minimal temp required is 250F (121C) for 15-20 minutes. Yields 15 lbs of pressure steam per square inch.
- Moist heat destroys bacteria by denaturation of high protein containing bacteria.
- Applies heat under pressure which speeds up the denaturation process
- Must do spore testing on a weekly basis to test the units
- Flash cycle - 270F (134C) at a pressure of 30psi for a minimum of 3 minutes.
- Dry heat sterilization - at temp 320F (160C) for 2 hours!! (or 340F (170C) for 1 hour)
 - Destroys microorganisms by COAGULATION of proteins
- Effective and safe for metal instruments
- Does NOT dull or corrode instruments
- Unsaturated chemical vapor sterilization - at temp 257F (132C) for 20-40 minutes. Yields 20lbs of pressure of sterilizing vapor.
- A solution of alcohol, formaldehyde, ketone, acetone, and water is used to produce the vapor.
- Temp and pressure is greater than used for autoclave.
- Does NOT rust or corrode instruments.
- Rapid Heat Transfer Sterilization - at temp 375F (191C) for 12 minutes for wrapped instruments and 6 minutes for unwrapped.
- Does not dull cutting edges, items are dry at end of cycle.
- 2% Glutaraldehyde - an ALKALIZING agent highly lethal to all microorganisms. Takes 10 HOURS.
- Disinfectants
- Alcohols - the most widely used antiseptic, used to reduce the number of microorganisms on the SKIN surface. Denatures proteins, extracts
membrane lipids, and acts as a dehydrating agent. Not an effective surface cleansing agents.
- Isopropyl alcohol 90-95% - used in hospitals
- Ethanol 70% - used to clean skin
- Iodine - most effective skin antiseptic. Acts as an oxidizing agent and combines irreversibly with proteins.
- Quaternary Ammonium Compounds - widely used for skin antiseptics. Classified as CATIONIC detergents.
- NOT sporocidal , tuberculocidal or viricidal.
- Anionic surface acting agents include detergents (synthetic) and soaps (natural).
- Intermediate level disinfectant - The marker microorganism for intermediate surface disinfection is - mycobacterium tuberculosis
- Sterilization - the killing or removal of ALL microorganisms, including bacterial spores.
- Disinfection - the killing of many, but not all microorganisms. Does not kills spores. Refers to chemicals applied to INANIMATE surfaces, not skin.
- Antiseptics - similar to disinfectants but may be applied to living tissue.
- Hand washing
- Chlorhexidine gluconate - a skin antiseptic and an antimicrobial agent.
- Triclosan - a potent wide spectrum antibacterial and antifungal agent.
- Isopropyl alcohol 60-80% - do NOT use water
- Ethylene oxide - a gas that is widely used as a sterilization agent, especially for disposable plastic ware in hospitals. Toxic to humans and flammable so
use is limited. Takes 10-16 hours!! Functions as an alkylating agent by irreversibly inactivating cellular nucleic acids (DNA) and proteins.
- Chlorine - the active component is hypochlorite (bleach). Dilution of 1:100 with water. A powerful oxidizing agent that inactivates bacteria and most
viruses by oxidizing free sulfhydryl groups.
- All reusable items that come in contact with a patient's blood, saliva, or mucous membranes must be sterilized using heat.
- Test specificity - a medical term defined as the ratio of true negative tests to the total unaffected patients tested. It is expressed as a percentage. It
measures a screening test's ability to correctly identify the absence of disease. It has few false POSITIVES. It is independent of disease prevalence in
the community.
- Test sensitivity - a medical term defined as the ratio of true positive tests to the total number of affected patients tested. It is expressed as a percentage.
It measure a screening test's ability to correctly identify the presence of a disease. A test with high sensitivity has few false NEGATIVES. It is independent
of disease prevalence in the community.
- Classical conditioning - aka pavlovian or respondent conditioning. a stimulus that leads to a response.
- Operant conditioning - the basic principle that a consequence of a behavior is in itself a stimulus that can affect future behavior. Ex. Positive and negative
reinforcement.
- Health Belief Model - suggests that individuals will act to prevent disease only when they believe that they are susceptible to it.
- Nitrous oxide - acceptable maximum exposure level allowed by OSHA is 1000ppm.
- OSHA regulates contaminated sharps - blood or saliva.
- Employer must maintain a medical record for each employee whose job involves occupational exposure to blood and other potentially infectious materials.
- OPIM = other potentially infectious materials
- Center for Disease Control and Prevention recommends a minimum of 20-30 seconds of flushing of the water lines between patients.
- The FDA is responsible for regulating handpieces and their sterilization procedures.
- Hepatitis vaccine - Recombivax HB and Engerix-B.
- Waste that is capable of causing a poisonous effect is called - toxic waste.
- Hazardous waste - causes harm or injury to the environment
- Infectious waste - waste that contains strong enough pathogens in sufficient quantity to cause disease.
- OSHA bloodborne pathogens standard - a comprehensive rule that sets forth the specific requirements OSHA believes will prevent the transmission of
bloodborne diseases to employees. Requires that a written exposure control plan be reviewed annually.
- Documents that contain info concerning a hazardous chemical are called MSDs - Material Safety Data Sheets
- Capitation fee - a method of payment for dental services in which an individual or institutional provider is paid a fixed, per capita amount without regard to
the actual number or nature of services provided to each patient.
- HMO - health maintenance organization - a self contained staff model practice in which no distinction is made between the providers of
insurance and the providers of health care.
 - ADA's Principles of Ethics and Code of Professional Conduct (ADA code) - has 3 components - The Principles of Ethics, The Code of Professional
Conduct, The Advisory Opinions.
- Incidence - the number of new cases of a specific disease occurring within a population over a certain amount of time. Expressed as a rate - cases per
population / time.
- Prevalence - the proportion of persons within a population suffering from a disease at a given point in time. Expressed as a %.
- 3rd party dentistry - a system where a provider of coverage contracts to pay for some of the patient's dental tx. Ex. Insurance
- DMFT - Decayed/missing/filled teeth - an irreversible index. Applied only to permanent teeth. Scores range from 0-32. Best index used.
- DMFS - Decayed/missing/filled surfaces - Scores range from 0-160

ORAL SURGERY
- TMJ
- Myofascial Pain Dysfunction - the most COMMON cause of TMJ pain. Muscle spasm and limited jaw opening.
- Internal Derangement - when the articular disc is pulled anteriorly by the superior head of the lateral pterygoid muscle.
- With reduction - when the disc is misplaced anterior to the condyle at rest and returns to the head of the condyle during function.
Clicking and popping.
- Without reduction - when the disc is always anterior. No sound. Reduced maximum opening to less than 30mm.
- Degenerative Joint Disease aka osteoarthritis - seen in older patients. Usually asymptomatic.
- Articular disc is usually displaced anteromedially.
- Major blood supply is from Superficial temporal artery and Maxillary artery.
- Fibrous capsule is innervated by Auriculotemporal nerve (V3).
- Anterior region of the joint is innervated by Masseteric Nerve and Posterior deep temporal nerve (v3)
- A ginglymoarthroidal joint - it glides and rotates.
- Temporomandibular ligament - aka lateral ligament - runs from the articular eminence to the mandibular condyle. Provides lateral
reinforcement for the capsule. Prevents posterior and inferior displacement of the condyle. The MAIN stabilizing ligament of the TMJ. Keeps
the head of the condyle in the mandibular fossa if fractured.
- Sphenomandibular and Stylomandibular ligaments - considered accessory ligaments.
- Sphenomandibular ligament is most often damaged in IA nerve block.
- Blood pressure
- Cuff should be 80% long and 40% wide of the arm circumference.
- Cuff too small - produces falsely elevated readings
- Cuff to large - produces falsely low readings
- Glucocorticoids - retard healing by interfering with the migration of neutrophils and mononuclear phagocytes into the site of inflammation. Reduce the
digestive ability of macrophages. Inhibit the formation of granulation tissue by retarding capillary and fibroblast proliferation and collagen synthesis.
- Bone healing
- Primary intention - involves both endosteal and periosteal proliferation. Occurs when bone is incompletely fractured or fractured bone ends are
placed together. Little fibrous tissue is produced with minimal callus formation.
- Secondary intention - involves mostly endosteal proliferation. Occurs when fractured bone remains more than 1mm apart. Contains a lot of
fibrous tissue and forms a callus.
- Cranial Nerves
- CN 3, 7, 9, 10 all have parasympathetic activity.
- Trigeminal nerve - sensory and motor, NO parasymp.
- Mandibular Division - V3
- Long buccal nerve - sensory only
- Auriculotemporal - sensory only
- Lingual nerve - sensory only, anterior 2/3 of tongue
- Inferior alveolar nerve - sensory and motor, to mand teeth and skin of chin and lower lip.
- Mesencephalic nucleus - mediates proprioception ex. Muscle spindle.
- Main sensory nucleus - mediates general sensation ex. Touch
- Spinal nucleus - mediates pain and temp from head and neck
- If facial nerve is cut AFTER it exits the stylomastoid foramen, muscles of fascial expression would be affected.
- Tongue -
- Motor - hypoglossal XII
- Sensory - anterior 2/3 gets taste from chorda tympani branch from Facial nerve and sensory from lingual branch of V3. Posterior gets taste
and sensory from glossopharnygeal nerve.
- Blood supply - from the lingual artery mainly, tonsillar branch of facial artery and ascending pharyngeal artery.
- The least common site for a mandibular fracture to occur is at the coronoid process.
- The mandible deviates to the side of the injury.
- Prothrombin time (PT) - normal is less than 11 seconds
- Partial Thromboplastic time (PTT) - detects coagulation defects of the INTRINSIC system. The basic test for hemophilia. Normal is 25-36 secs.
- Platelet counts - normal is 150,000 - 450,000 per 1cu mm of blood. The minimal platelet count for oral surgery is 50,000.
- INR - the preferred lab test for assessing anticoagulant therapy in pts taking warfarin. Normal INR is 1. Target INR is 2-3 for anti-coagulant pt. NO oral
surgery should be done if INR is greater than 5.
- Inhaled general anesthetics - usually preceded by IV or IM of a short acting sedative hypnotic drug like Thiopental.
- Halothane - powerful, can be toxic to the liver
- Enflurane - less potent, more rapid onset and faster awakening. Increases intracranial pressure risking seizures so contraindicated with
seizure disorders.
- Isoflurane - not toxic to liver but can cause cardiac irregularities.
- Desflurane - may cause coughing and excitation during induction so used with IV anesthetics. Requires electrically heated vaporizer so it can
be delivered as a gas at room temp.
- Sevoflurane - does not cause coughing, so can be used without IV agents for rapid induction. Most commonly used with PEDO patients.
- Nitrous oxide - a weak anesthetic, often used with thiopental to produce surgical anesthesia. Has the FASTEST induction and recovery.
- Works on the Central Nervous System
- Maximal safe concentrations - 70% nitrous, 30% oxygen
- Anticholinergic drugs - ex. Atropine - are given post operatively to decrease the risk of bradycardia during surgery.
- Interfere with the binding of acetylcholine at its receptor.
- Inhibit secretion from all glands in the nose, mouth, pharynx. Decrease the flow of saliva and secretion from respiratory glands
- Can cause mydriasis - dilated pupils
- Increase heart rate
- Inhibitory effect on motility though the GI tract
- Contraindicated for pts with glaucoma and nursing mothers
- Dialysis - perform oral surgery the day AFTER dialysis.
- Mandibular advancement or set back- performed by mandibular ramus sagittal split osteotomy. The position of the condyle is unchanged.
- Vertical ramus osteotomy - used to set the mandible posteriorly to correct prognathism.
- Vertical body osteotomy - involves extracting mandibular teeth bilaterally along with a piece of bone to slide the mandible back to correct prognathism.
- Step osteotomy - make bilateral step shaped cuts in the body of the mandible
- A Le Fort I osteotomy is most commonly used to correct maxillary retrognathia.
- Pericoronitis - most commonly involved tooth is MAND 3rd molar. Cleanse beneath tissue flap, salt water rinse, soft diet.
- Grafts
- Alloplastic grafts - SYNTHETIC, inert, man-made synthetic materials
- Wound healing
- 1) Inflammatory stage - consists of a vascular and cellular phase. Neutrophils and lymphocytes predominate.
- 2) Proliferative stage - the fibroblastic stage where collagen and new blood vessels are formed
- 3) maturation stage - the remodeling stage where collagen fibers continue to increase tensile strength.
- IMF lasts for 3-6 weeks.
- Carotid sheath - contains carotid arteries, internal jugular vein, vagus nerve, and deep cervical lymph nodes. NOT the sympathetic trunk which lies
posterior.
- The optimum site for IV sedation for an outpatient is the median cephalic vein.
- Verrill's Sign = 50% ptosis of the eyelids (droop)
- MAC = Minimum alveolar concentration - the alveolar concentration of anesthetic at which 50% of the patients are unresponsive to a standard surgical
stimulus.
- Meyer-Overton Theory - anesthesia commences when a chemical substance reaches a certain molar concentration in the hydrophobic phase.
- Second gas effect - potent agents are administered with nitrous oxide so that the potent agent will be delivered in increased amounts to the alveoli as a
gas rushes to replace the nitrous oxide absorbed by pulmonary blood.
- Sutures - "0" is the baseline average size. Most common is 3-0 or 4-0.
- As suture diameter decreases, "0's" are added or numbers followed by "0s". Ex. 000 and 3-0 are the same size.
- As suture diameter increases, numbers are assigned.
- Resorbable sutures evoke an intense inflammatory reaction.
- Monofilament sutures - material made from a single strand. Ex. Plain and chromic gut.
- Polyfilament sutures - multiple fibers are braided or twisted. Ex. Silk, dexon, and vicryl.
- Remove in 5-7 days.
- MAO inbibitors - used for depression and Parkinson's disease. Ex. Isocarbonaxazid, Phenelzine, Tranylcypromine, and Selegiline.
- Increases endogenous concentrations of norepinephrine, dopamine and serotonin by inhibiting monoamine oxidase which breaks them down.
- Meperidine - a potent narcotic analgesic used to tx moderate to severe pain and as a cough suppressant. Most widely used narcotic. Produces slight
euphoria but no miosis.
- If meperidine is taken with MAO inhibitors - causes hyperpyrexic reactions leading to seizures or comas.
- Vertical Releasing incisions - made at LINE angle of tooth.
- Le Fort Fractures
- Le fort I - aka horizontal fracture - fracture through the maxilla just above the maxillary teeth. Results in open bite.
- Le fort II - fracture causes maxilla to separate from the facial skeleton.
 - Le fort III - horizontal fracture where entire maxilla and one or more facial bones are separated from upper face. Causes restricted mandibular
movement.
- American Society of Anesthesiologists (ASA) classifications
- ASA I - normal, healthy pt
- ASA II - mild systemic disease or significant health risk factor like smoking, alcoholism, or obesity.
- ASA III - severe disease that is not incapacitating
- ASA IV - severe systemic disease that is a constant threat to life
- ASA V - a moribund patient not expected to survive without the operation
- ASA VI - a declared brain dead patient whose organs are being removed for donor purposes.
- Sublingual gland - made up of MUCOUS cells. Innervated by Facial nerve. Blood supply is sublingual artery.
- Psychogenic reaction - caused by psychological factors rather than physical factors. Tx with
- Diazepam (valium) - 5-10mg orally
- Pentobarbital (Nembutal) - 50-100mg orally
- Secobarbital (seconal) - 50-100mg orally
- Promethazine - 25mg orally
- Dissociative anesthesia - reduces anxiety and produces a trance-like state. Primary use is in emergency situations like an injury. Pt won't remember the
procedure.
- KETAMINE - increases secretions, increases BP, muscle tone and heart rate, but not respiration. Often causes LARYNGOSPASMS.
- General anesthesia
- The medulla is the last area of the brain to be depressed. It contains the cardiac, vasomotor and respiratory centers of the brain.
- Eyes are taped shut to prevent corneal abrasion.
- Biopsy
- Use block anesthesia, but if infiltration is used, it must be 1cm away from the lesion.
- Place specimen in 10% formalin solution.
- Excisional biopsy - when entire tumor is removed. Incisional biopsy - when only a portion of the tumor is removed.
- Thrombocytopenia - less than 50,000/mm3 of platelets. Normal platelet count is 150,000 - 450,000mm3
- Chronic bronchitis - a productive cough, often with wheezing. Strongly associated with cigarettes.
- Cor pulmonale - the enlargement of the right ventricle
- Local Anesthetics
- Amide type - undergo biotransformation in the LIVER. i + caine. Ex. Lidocaine, mepivacaine
- Ester type - undergo rapid biotransformation in the BLOOD PLASMA. Ex PROCAINE, tetracaine. Allergic rxns are more common,
- Local anesthetics are most effective in tissues that have a pH of above 7 - this is why inflamed tissue is less affected since it is more acidic.
- Stop axonal conduction by blocking sodium channels. Reversibly bind to and inactivate them.
- Epinephrine calculations
- Differential blockade - sympathetic functions are lost first, then pain sensation, then temp, touch, deep pressure. Motor function is lost last.
- Small diameter fiber are affected first
- Myelinated fibers become blocked first
- A delta fibers and C fibers - small diameter, transmit pain, blocked sooner
- A alpha - motor fibers to skeletal muscle
- Can reduce salivary flow by reducing anxiety and sensitivity during the procedure
- Diabetes
- Fasting blood glucose level above 140mg/dl.
- Non-fasting glucose level greater than 200mg/dl.
- Hemophilia - inherited as a sex linked recessive trait. Prolonged PTT (partial thromboplastin time), but normal PT and bleeding time.
- Hemophilia A - a deficiency of clotting factor VIII. Most common.
- Hemophilia B - aka Christmas Disease - a deficiency in clotting factor IX.
- Von Willebrand's disease - inherited as autosomal dominant bleeding disorder. vWf binds normally binds to factor VIII and facilitates in platelet adhesion.
- Cavernous sinus thrombosis - a blood clot often caused by staph aureous due to a maxillary odontogenic infection via the venous drainage of the maxilla
due to absence of valves.
- Frenectomy
- Diamond excision and Z plasty - effective when mucosal and fibrous tissue band is NARROW. Relaxes the pull of the frenum.
- V-Y advancement - preferred when the frenal attachment has a WIDE base.
- CPR - if pulse - 1 breath every 5-6 secs or 10-12 breaths per minute. If no pulse - 15 compressions to every 2 breaths.
- Trismus - caused by spasm of MEDIAL pterygoid muscle after IA injection if injection is BELOW the mandibular foramen.
- Neuroleptic anesthesia - a combination of a narcotic analgesic and a neuroleptic agent and nitrous oxide. ONLY produces an unconscious state if nitrous
oxide is also administered. If no nitrous, then pt remains conscious. Ex. Droperidol and fentanyl
- Impacted 3rd molars - remove when root is 2/3rd formed
- Mand - most difficult - distoangular, vertical, horizontal, mesioangular
- Max - most difficult- mesioangular, horizontal, vertical, distoangular
- MESIOANGULAR impaction is most common 43%
 - Max 3rd molars are occasionally displaced into max sinus or infratemporal space
- Steroids
- Small doses 5mg prednisone/day have adrenal function suppressed in a month
- 100mg cortisol/day (20-30mg prednisone) have adrenal function suppressed in a week
- Have pt take double dose on day of surgery
- Short term therapy for 1-3 days of even high dose steroids will NOT alter adrenal cortical function.
- Suppressive doses of steroids will take a year to regain full adrenal cortical function.
- If an adrenal crisis, give IV or IM injection of hydrocortisone
- Body naturally secretes 20mg of hydrocortisone every day. 200mg when stressed
- Caldwell-Luc approach - a procedure that eliminates blind procedures and facilitates the recovery of large root tips or entire teeth that have been displaced
into the max sinus. Make an opening into the facial wall of the antrum above the max premolar roots.
- The palatal root of the max 1st molar is most often dislodged into the max sinus.
- If a root tip of a mand 3rd molar disappears while trying to retrieve it, it is most likely in the submandibular space.
- Stridor - high pitched, noisy respiration, like the blowing of wind. Caused by partial obstruction of the airway at the level of the larynx or trachea.
- Palpate the posterior aspect of the mandibular condyle externally over the posterior surface of the condyle with the mouth open (NOT through the
external auditory meatus -this can cause false joint sounds)
- Wharton's duct - aka submandibular duct - enters the floor of the mouth near the lingual frenula.
- A Class II lever is used during tooth extractions.
- Benzodiazepines - used to tx anxiety and sleep disorders. No hangovers unlike barbiturates.
- Diazepam - used for muscle spasticity in pts with cerebral palsy, IV used for status epilepticus
- Alprazolam - has selective anxiolytic effects in pts with agoraphobia
- Barbiturates - provide sedation but NO analgesia. They are CNS depressants and have anti-convulsant effects. Enhance GABA receptor binding and
prolong the opening of chloride channels.
- Ex. Thiopental - an ultra short acting barbiturate used IV to induce surgical anesthesia.
- Ex. Phenobarbital - used in long term management of seizures. LONG acting.
- Ultra short acting - thiopental, thiamylal, methohexital
- Do not use with pts with respiratory disease. Highly addictive.
- Chloral hydrate - the ONLY non-barbituate sedative -hypnotic used in dentistry. Most often used in pedo patients. A PRO-drug that is metabolized to the
active metabolite. Rapidly absorbed in 15-30 minutes and lasts 4 hours. Does NOT relieve pain. Dose- 50mg/kg up to 1g.
- Opioid analgesics
- Ex. Morphine, codeine, fentanyl, meperidine, methadone, propoxyphene, levorphenol, hydrocodone, oxycodone, and pentazocine
- Percodan = oxycodone and aspirin - STRONGEST pain medication you can prescribe and still have pt ambulatory
- Percocet = oxycodone and acetaminophen
- Naloxone - a mew opioid receptor competitive antagonist used to counter the effects of an opioid overdose
- Cushing syndrome - most common cause is pituitary adenomas. Aka hypercortisolism. Most common in females 5:1. Moon faces, buffalo hump
- Autotransplantation - most often used to transplant 3rd molar into site of unrestorable mand 1st molar.
- No oral surgery within six months of a heart attack.
- Isograft = tissue surgically transplanted from an individual of the same species who is genetically related to the recipient.
- Allograft = tissue surgically transplanted from an individual to a genetically non-identical individual of the same species.
- The most popular used implants are ROOT form endosseous implants.
- Endosseous implants - surgically inserted into jawbone.
- Root form - cylindrical in shape, can be smooth, threaded, or perforated
- Blade implants - flat in appearance, used when insufficient width of bone but adequate depth.
- Subperiosteal implants - fit on top of supporting areas in the mandible or maxilla under the mucoperiosteum.
- Transosseous implants - actually penetrate the entire jaw so they emerge on the opposite side.
- Lymph nodes
- Submental - tip of tongue, floor of mouth, mand incisors, center of lower lip
- Submandibular - front of scalp, nose, upper and lower lip, max and mand teeth, anterior 2/3 of tongue
- Blood
- Hematocrit - the volume percentage of red blood cells in whole blood. Minimum acceptable for surgery is 30%.
- Warfarin (coumadin) - interferes with vitamin K which is involves in the manufacture of prothrombin in the body. Increases PT and PTT.
- Metabolic acidosis - excessive blood acidity characterized by low levels of bicarbonate in the blood. Causes - diabetic or starvation ketoacidosis
- Respiratory acidosis - excessive blood acidity cause by a build up of carbon dioxide in the blood due to poor lung function or slow breathing.
- Metabolic alkalosis - blood is alkaline due to high levels of bicarbonate. Causes - vomiting, diuretics
- Respiratory alkalosis - blood is alkaline due to rapid or deep breathing resulting in low blood carbon dioxide levels.
- Max 1st molar - innervated by PSA and MSA nerves.
- Scopolamine - a pre-op medication used to produce amnesia and decrease salivary and respiratory secretions. It blocks the action of acetylcholine at
parasymp sites in smooth muscle, secretory glands, and the CNS. Often used to prevent motion sickness.
- Max sinus opens up into the hiatus semilunaris located in the middle meatus of the lateral nasal cavity.
- Marsupialization is the tx of choice for a recurrent ranula or for cysts close to vital structures.
 - Enucleation - the total removal of a cystic lesion - is the tx of choice for congenital cysts, mucoceles, and odontogenic cysts.
- Extraction
- Max deciduous molar - luxate palatally! Because primary molars are more palatally positioned and the palatal root is strong and less prone to
fracture.
- Max permanent molars - luxate buccally.
- Highest incidence of fractures occurs in - young males 15-24. Due to trauma.
- Bacterial endocarditis - prosthetic heart valves, pulmonary shunts or conduits, prior BE,
- Amoxicillin 2g, 1hr prior to procedure (4 500mg tablets)
- Clindamycin 600mg, 1 hr prior to procedure if allergic to penicillin NOT erythromycin
- Children - amoxicillin 50mg/kg or clindamycin 20mg/kg
- Lingual artery - arises from the ECA at the hyoid bone and does NOT accompany the course of the lingual nerve.
- Acetaminophen - has anti-pyretic effects but NO anti-inflammatory effect. A weak COX inhibitor.
- Pterygomandibular raphe - insertion point for superior pharyngeal constrictor and buccinators muscles.
- Buccinators muscle is pierced by needle in IA block.
- Congestive heart failure - results from impaired pumping ability by the heart. A ventricular ejection fraction below 50% indicates CHF. Usually LEFT
ventricle fails first.
- ACE inhibitors - captopril, lisinopril - dialate blood vessels and reduce the hearts workload
- Beta blockers - carvedilol, bisoprolol, metoprolol, atenolol - reduce arrhythmias and improve mechanical efficiency of the heart
- Inotropes - digoxin - increase the strength of cardiac contractions
- Diurectics - lasix, aldactone, zaroxolyn - eliminates water and sodium through kidneys and reduces edema and shortness of breath
- Atelectasis - when mucous or a foreign object obstructs airflow in a mainstem bronchus causing collapse of the affected lung tissue into an airless state.
- Pneumothorax - when air leaks into the pleural space causing the lung to recoil from the chest wall.
- Osteomyelitis - most often caused by STAPH AUREUS. Due to reduced blood supply. Most common in mandible since dense cortical bone causes less
blood.
- An inflammatory process within medullary (trabecular) bone that involves the marrow spaces.
- Suppurative - can be acute, chronic, or infantile
- Non-supurative - can be chronic sclerosing, Garre's osteomyelitis, or actinomycotic osteomyelitis.
- Contradictions to tooth extractions - cellulitis, acute pericornitis, irradiated jaws, ANUG, uncontrolled diabetes
- Masticator space - consists of the masseteric, pterygomandibular, and temporal spaces. Bounded by muscles and fascia of mastication. Infections of
zygomatic and temporal bones and abscesses of mand molar teeth may pass to the masticator space.
- Propylene glycol in IV valium can cause phlebitis - irritation or inflammation of a vein.
- Parotid gland - purely serous (same as von Ebner's glands)
- Most common mid face fracture - zygomaxillary complex - 40%
- Geudel's Stages of Anesthesia
- Stage I - amnesia and analgesia - administration of anesthesia and loss of consciousness. Reflexes are still present.
- Stage II - delirium and excitement - loss of consciousness and onset of total anesthesia. WORST stage.
- Stage III - surgical anesthesia - regular pattern of breathing, respiratory and CV failure begins
- Stage IV - premortum - signals danger, low BP, pupils dialated, skin is cold
- Most common developmental cyst is - nasopalatine duct cyst - a heart shaped radiolucency on midline.
- Most accurate way of taking body temp - rectally

ORAL PATHOLOGY
- Hepatitis - the presence of surface antigen in pts serum indicates the pt is infectious for hepatitis (carrier state). Hepatitis is very HEAT resistant - more
than HIV.
- Hep A - transmitted enterically - fecal/oral route. An RNA enterovirus. Initial symptoms appear after an incubation period of 3-6 weeks.
Increase in serum level of transaminases due to liver damage. Recovery occurs in 4 months.
- Hep B - double stranded DNA, transmitted by parental and sexual contact - sex and IV abuse - blood, breast milk, amniotic fluid. LONG
incubation period of 6-8 weeks
- Hep C - high incidence of CHRONIC disease, cirrhosis and hepatocellular carcinoma. MOST common reason for liver transplants
- Hep D - found ONLY in pts with acute or chronic Hep B!!! makes Hep B infection more severe.
- Hep E - transmitted enterically. Similar to Hep A.
- Neurilemoma (aka Schwannoma) - a well demarcated, benign lesion consisting of fibroblastic proliferation of the nerve shealth cells (Schwann cells).
Most frequently located on the TONGUE.
- Traumatic neuroma - caused by trauma to peripheral nerve. Most common site is MENTAL foramen.
- Neurofibroma - 2 forms
- Solitary neurofibroma - asymp, occurs on tongue buccal mucosa and vestibule.
- Parts of the syndrome of Neurofibromatosis - aka von Recklinghausen's Disease - autosomal dominant inherited, multiple neurofibromas on
skin, and 6 or more caf au lait spots
- Palisaded encapsulated neuroma - sessile, smooth nodule under 1cm in diameter. Most common seen on nose and cheek.
- Nasopalatine duct cyst - aka incisive canal cyst - MOST COMMON maxilla cyst, MOST COMMON non-odontogenic cyst. seen as a marked swelling of
palatine papilla. Distal to roots of central incisors. Teeth test VITAL.
- Globulomaxillary cyst - appears between roots of lateral incisor and canine. PEAR shaped. Can cause roots of teeth to diverge.
- Median palatal cyst - situated in midline of hard palate posterior to premaxilla. Painless.
- Lateral periodontal cyst - 95% seen in MAND cuspid area, assoc with VITAL tooth, TEAR DROP shaped.
- White sponge nevs - asympt, white, folded and spongy, HERDITARY as autosomal dominant, most commonly bilaterally on buccal mucosa. Has an
eosinophilic condensation in the perinuclear region of cells in the superficial layers of the epithelium. No tx.
- Hairy tongue - hypertrophy of FILLIFORM papillae
- Tongue papillae
- Fillliform - MOST NUMEROUS, NO TASTE BUDS, highly keratinized
- Fungiform - flat, mushroom shaped, found at tips of tongue and lateral margins
- Circumvallate - LARGEST, circular in shape, located in back of tongue. Associated with VON EBNERS glands. LEAST numerous.
- Foliate - found on lateral margins
- Taste buds are present on fungiform, circumvallate and foliate papillae only.
- Osteosarcomas - aka osteogenic sarcomas - cause SWELLING and localized PAIN, MOST COMMON malignant neoplasm in bone. Males 30-40. Early
radiographic feature - symmetrically widened PDL around one or more teeth
- Karposi's sarcoma - cancer of the lining of blood vessels
- AIDS - caused by RNA retrovirus
- Lymphoepithelioma - swelling on lymph node is most common symptom, seen in East Asian young adults, show metastasis at EARLY stage to cervical
lymph nodes.
- Multiple myeloma - multiple "punched out" radiolucencies in involved bone, a primary MALIGNANT neoplasm of bone characterized by progressive
destruction of the marrow with replacement by neoplastic PLASMA cells. Men 40-70s. Common early symptom in pain in lumbar or thoracic region.
Jaws are a rare primary site but become involved 70% of the time - seen in molar-ramus area. Lab findings - hypergammaglobulinemia of IgG, Bence
Jones proteinuria. Poor prognosis.
- Traumatic bone cyst - aka Simple Bone cyst - NOT a true cyst. PSEUDOcyst. often seen in young people, usually seen in MANDIBLE between cuspid
and ramus. Teeth are VITAL. May contain blood, fluid or be empty. SCALLOPS around roots.
- Dentigerous cyst - contain crown of UNERUPTED tooth or odontoma, arises from remnants of REDUCED ENAMEL EPITHELIUM. 2nd most common
odontogenic cyst.
- Primordial cyst - aka Follicular cyst - contains NO calcified structures. Lined with stratified squamous epithelium. Found in the place of a tooth. Arises
from epithelium of enamel organ
- Aneurysmal Bone Cyst - an uncommon expansile osteolytic lesion of bone consisting of a proliferation of vascular tissue that forms a lining around blood
filled cystic lesions. Seen in TEENS, can be tender, NOT common in jaws, PSEUDOcyst - not a true cyst since no epithelial lining. Appears similar to
CGCG. Honey comb or soap bubble. Teeth are moved, filled with blood, fibroblasts, macrophages, and multinucleated giant cells.
- Residual cyst - when a tooth associated with a radicular cyst is extracted but the cyst remains and persists.
- Gingival cyst - rare, usually seen in canine and bicuspid areas of MANDIBLE
- Fissural cysts - aka developmental cysts - NON-DENTAL in origin, include nasoalveolar, median palatal and nasopalatine cysts.
- Odontogenic Keratocyst - ages 10-30, associated with IMPACTED teeth, RECURS, 50% seen in MAND 3RD MOLAR area
- Benign cementoblastoma - usually occurs in MAND 1st PM to molar region, comes from the PDL!!, males under 35, VITAL tooth
- Gigantiform cementoma - derived from PDL, seen in AA females
- What is the most common osseous malignancy? Osteosarcomas.
- Periapical cemental dysplasia -aka cementoma - seen in middle aged AA females, MAND incisor region, derived from PDL, opacities are BONE not
cementum, teeth are VITAL, seen in middle aged AA women, NO tx.
- 3 stages - osteolytic cementoblastic mature stage
- Cementifying fibroma - derived from PDL, painless swelling in mandible
- Pindborg tumor aka Calcifying Epithelial Odonotgenic Tumor - most common in mand molar area, derived from REE, seen in middle age, painless swelling
- Adenomatoid Odontogenic Tumor - aka adenoameloblastoma - seen in TEENS, in anterior maxilla
- Squamous Odontogenic Tumor - derived from Rests of Malassez, ectodermal in origin
- Ameloblastic Fibroma - most common over UNerupted molars in young pts, OFTEN mistaken for ameloblastoma - except
- Compound odontoma - looks like a TOOTH, most common in max incisor/cuspid area,
- Complex odontoma - conglomerate masses of dental tissues - enamel, dentin, cementum, disorganized
- Dilatin - an anticonvulsant drug used to control epileptic seizures, causes fibrous hyperplasia of gingiva
- Addison's Disease - aka chronic adrenocortical insufficiency - results from hypofunction of the adrenal cortex, causes bronzing of entire skin. Causes
diffuse pigmentation of oral mucosa. Skin pigmentation disappears following therapy but oral pigmentation persists!! Pts may not be able to tolerate
stress. Clinical symptoms don't appear until 90% of adrenal cortex is destroyed.
- Albright Syndrome - aka McCune Albright syndrome - a severe form of polyostatic fibrous dysplasia involving ALL bones, CAF au lait spots, endocrine
dysfunction, precocious puberty in girls. Increased incidence in osteosarcomas.
- Peutz- Jeghers Syndrome - aka Hereditary Intestinal Polyposis Syndrome - INHERITED, causes multiple intestinal polyps and intraoral melanin
pigmentations often seen on LOWER lip. The polyps in the colon may undergo malignant change.
- Cushings syndrome - a hormonal disorder caused by prolonged exposure to high levels of CORTISOL, causes upper body obesity, moon face, buffalo
hump, thin arms and legs
- Nevus
- Intradermal nevus - MOSTCOMMON skin lesion, aka common mole, nevus cells lie exclusively in dermis.
- Junctional nevus - nevus cells located at interface between epithelium and lamina propria, flat, considered premalignant and can become
malignant melanomas
- Compound nevus - nevus cells located at interface between epithelium and lamina propria and also deep in dermis, raised and solid
- Blue nevus - congenital, color caused by deep cutaneous or subcutareous deposits of melanin
- Intramucosal nevus - MOST COMMON intraoral nevus, But intraoral nevi are generally uncommon. Often seen on HARD PALATE, nevus cells
are located in connective tissue or lamina propria of oral mucosa.
- Congenital nevi - aka birthmarks - usually large, greater than 10mm, 15% occur on skin of head and neck, have higher incidence of malignant
transformation.
- Median Rhomboid Glossitis - caused by chronic Candida albicans infection. Devoid of FILLIFORM papillae.
- Burning mouth syndrome - most common in POST menopausal women, feels like front of mouth was scalded but clinically normal.
- Osler-Weber-Rendu Syndrome - aka Hereditary Hemorrhagic Telangiectasia - autosomal dominant disorder, causes telangiectasias on face, neck,
mucosas, recurrent EPISTAXIS, and positive family hx of the disorder
- Encephalotrigeminal Angiomatosis - aka Sturge Weber Disease - congenital disease, PORT WINE STAIN distributed over trigeminal nerve, UNILATERAL
- Juvenile nasopharyngeal angiofibroma - rare, benign polyp neoplasm seen in TEEN MALES, causes a mass in nasopharynx causing nose bleeds.
RECURS.
- Pyogenic granuloma - arises from minor trauma to tissues, appears as a soft, pedunculated growth with a smooth red surface, caused by hyperplastic
granulation tissue. Often called PREGNANCY tumor.
- Peripheral Giant Cell Granuloma - always occurs on alveolar mucosa or gingiva, a reactive lesion to calculus, poor dental restorations, perio disease.
70% are seen in ANTERIOR of jaw. Pedunculated, broad based growth with smooth, red/blue color. Seen in pts OVER 20 (CGCG is seen is pts under
20). More common in FEMALES. Resembles a fibroma or pyogenic granuloma clinically.
- Hemangioma - common tumor caused by proliferation of blood vessels. More common in FEMALES. Present at birth or early in life. Do NOT do
incisional biopsy!!
- 3 types
- Capillary, Cavernous, and Hemangioendothelioma
- Nutritional factors, especially the amount of protein a pt is consuming, affects wound healing.
- The fixative of choice to preserve biopsy specimens is 10% buffered FORMALIN.
- Excisional biopsy - entire lesion is removed
- Incisional biopsy - only a portion of the lesion is removed, used when lesion is too large to excise without a diagnosis.
- Ludwig's Angina - a severe and spreading infection that involves the submandibular, submental, and sublingual spaces BILATERALLY. Often results from
odontogenic infection. RAPID onset. Most serios complication is edema of the glottis.
- Erythrocyte Sedimentation Rate (ESR) - a non-specific screening test that monitors the progression of disease by measure the rate at which RBCs settle
out in a tube of unclotted blood. mm per hour. Elevated rates indicate inflammation.
- Estimated toxic dose for fluoride ingestion is - 5-10mg/kg. Death can result from 2g of fluoride in an adult and 16mg/kg in kids. Symptoms - convulsions,
hypotension
- Sodium carboxymethylcellulose - a saliva substitute that increases the viscosity of saliva. Used to treat xerostomia.
- Malignant melanoma - only account for 4% of all skin cancers, but the GREATEST number of skin cancer related deaths.
- Basal cell carcinoma - metastasis is RARE, local invasion destroys underlying skin and tissue. Caused by sun or x-rays.
- Eryhtroblastosis fetalsi - occurs when fetus has Rh-positive blood and mother has Rh-negative blood. Most common form is ABO incombatability.
- Leukemia - a form of cancer that begin in the blood forming cells of the BONE MARROW. Leukocytes are damaged or remain in immature form and
multiply excessively. Results in decreased number of normal leukocytes, RBCs and platelets.
- Which form is most common in children? ALL - Acute Lymphocytic leukemia - peak age is 4 years old. MOST responsive to therapy.
- Acute leukemia - a malignant proliferation of WBC precursors (blasts) in BONE MARROW and lymph tissue. IMMATURE forms of WBCs are
found. Causes ANEMA resulting in fatigue, absence of functioning granulocytes causing infections, and thrombocytopenia. Spleen and liver
are enlarged and lymph nodes are enlarged. High ESR.
- Acute Myeloid Leukemia - MOST MALIGNANT form of leukemia where hematopoietic precursors of the bone marrow are arrested in early
stage of development. Greater than 300% of blasts are in the blood or bone marrow contain AUER RODS in their cytoplasm.
- Acute Lymphocytic Leukemia - in 75% of cases, the lymphocytes are neither B or T cells but NULL CELLS. Untreated pts die in 6 months, but
with intensive chemo and bone marrow transplants they can live up to 5 years. Death due to hemorrhage or bacterial infection.
- Chronic leukemia - characterized by proliferations of lymphoid or hematopoietic cells that are more mature than those of acute leukemias.
Have a slower onset and progression. And a longer less devastating course. Cause massive splenomegaly, lymph node involvement,
petechiae and ecchymoses. Lab findings show leukocytosis above 100,000 per cu. Mm with mature forms of granulocytes and lymphocytes
predominating.
- Chronic myeloid leukemia - 90% associated with PHILADELPHIA chromosome and low levels of leukocyte alkaline phosphatase. Survival is
only 4 years with death due to hemorrhage or infection.
- Chronic lymphocytic leukemia - older patients can survive years with NO tx. LEAST MALIGNANT type.
- Stem Cell Leukemia - abnormal cells that are poorly differentiated but are considered to be precursors of lymphoblasts, myeloblasts, or
monoblasts but the cells are too immature to classify.
 - Aleukemic leukemia - leukemic cells present in the bone marrow but the circulating white blood cells are neighter immature nor increased in
number.
- Subleukemic leukemia - leukemic cells appear in the blood but there is no sig increase in the number of white blood cells.
- A leukemoid reaction - a marked increase in the number of circulating granulocytes.
- Lymphangioma - most commonly seen on TONGUE, they are benign hamartomas of lymphatic channels. Do NOT become malignant. Some regress
spontaneously during childhood.
- Lymphangioma simplex - aka capillary lymphangioma -
- Cavernous lymphangioma -
- Cystic lymphangioma - aka cystic hygroma - huge macroscopic lymphatic spaces
- Scleroderma - a systemic disease that affect many organ systems. Causes inflammation and progressive tissue fibrosis and occlusion of
microvasculature by excessive production of types I and II COLLAGEN. Shows abnormally WIDE PDL that is uniform in width. Resorption of the angle of
the ramus.
- Congenital epulis of newborn - composed of cells identical to a granular cell myoblastoma (aka granular cell tumor). Contains granular cells. Seen in
anterior maxilla and is 10 times more likely to occur in females.
- Granular cell myoblastoma - aka granular cell tumor - most common on TONGUE. Contains granular cells and pseudoepitheliomatous hyperplasia.
- Osteoporosis - aka Albers-Schoeberg Disease or Marble Bone Disease - most common type of bone disease, usually caused by drop in estrogen during
menopause.
- Osteomyelitis - an acute pyogenic infection of bone, caused by S. AUREUS. Affects LONG bones in children. Affects vertebrae and pelvis in adults. Bone
gets infected and produces pus resulting in an abscess which deprives the bone of oxygen.
- Condesing osteitis - aka chronic focal sclerosing osteomyelitis - an unusual reaction of bone to infection. A well circumscribed radioopaque mass of
sclerotic bone surrounding the apex of a tooth. Most commonly seen with mand 1st molar, associated with long standing periapical infection.
- Cleft lips - results when the medial nasal process fails to fuse with the lateral portions of the maxillary process. 1st branchial arch!! Fusion occurs during
the 6th-7th week. Most common on LEFT.
- Cleft palate - occurs in 8th-10th week.
- Osteogenesis imperfect - caused due to a genetic defect that causes imperfectly formed or inadequate amount of COLLAGEN. Results in weak bones
that FRACTURE easily. Pale blue sclera. Teeth - obliterated pulps, narrow and short roots, deciduous teeth are more severely affected.
- Associated with Type I Dentinogenesis Imperfecta.
- Hypophosphatasia - a genetic metabolic disorder of bone mineralization cause by a deficiency in ALKALINE phosphatase which is essential in calcification
of bone tissue. Can cause blue sclera, premature loss of teeth, large pulp chambers and canals.
- Paget's disease - pts have HIGH levels of alkaline phosphatase
- Acromegaly - a hormonal disorder that results when the pituitary gland produces excess growth hormone. 90% have a benign tumor of the pituitary gland
called an adenoma. AFTER adolescence (Gigantisism occurs BEFORE adolescence).
- Hyperthyroidism - too much thyroxin in the body which stimulates cell metabolism.
- Most severe form is Graves Disease - most severe and most common. Causes a GOITER and exophthalmos.
- Plummer's Disease - aka toxic nodular goiter - nodules or lumps in the thyroid that become overactive.
- Osteomalacia - related to Vit D abnormalities, softening of bones due to Vit D deficiency. Osteoid tissue fails to calcify.
- Cerebral Palsy - insult or anomaly in brain's motor control centers.
- Down Syndrome - congenital defect caused by chromosomal trisomy 21.
- Myasthenia Gravis - an autoimmune disorder where antibodies form against Acetylcholine Nictotinic postsynaptic receptors at the myoneural junction.
Muscles fatigue. Causes xerostomia since salivary glands don't get stimulated.
- Multiple sclerosis - attacks the CNS (brain and spinal cord), thought to be an autoimmune response that attacks CNS tissues. More common in WOMEN.
Often seen with Bell's Palsy and Trigeminal Neuralgia.
- Myofascial pain-dysfunction syndrome (MPDS) - main cause is muscle spasm due to fatigue. The muscle most apt to cause tenderness is LATERAL
pterygoid.
- Squamous cell carcinoma - most common type of oral cancer and 90% of all malignant neoplasms in the oral cavity. Most common site is LOWER LIP.
Tobacco use including smokeless is the primary risk factor.
- Central Ossifying Fibroma - seen in young females. Posterior mandible in 90% of cases.
- Condylar hyperplasia - progressive, UNIlateral overgrowth of the mandible, chin deviates toward UN-affected side.
- Condylar agenesis - absence of ALL or portions of coronoid process, condyle and ramus
- Central Giant Cell Granuloma - a non-neoplastic process, can behave aggressively and expansile, destroys bone and displaces teeth. 0ver 70% occurs in
mandible anterior to 1st molar. Occurs EXCLUSIVELY within jaw bones. Occurs due to trauma or a tooth extraction. Seen in young pts under 30. Twice
as more common in FEMALES. Appears similar to ameloblastoma or odontogenic keratocyst. Histologically contains multinucleated giant cells.
- Actinomycosis - SULFUR granules, a subacute bacterial infection caused by Actinomyces israelii. Can cause LUMPY JAW due to abscesses. Tx is long
term penicillin.
- Histoplasmosis - a chronic lung infection caused by inhaling spores of Histoplasma capsulatum. Causes chronic non-healing ulcer. Tx with Amphotericin
B, itraconazole or ketoconazole.
- Mikulicz's Disease - aka Benign Lymphoepithelial Lesion - an autoimmune process that is a clinical variant of Sjogren's Syndrome. Parotid gland and
submandibular gland is enlarged.
- Hyperparathyroidism - a metabolic disorder resulting in too much Calcium released from bones. Often results in FRACTURE as first symptom. Can result
in malocclusion due to shifting of teeth. Loss of lamina propria or well defined cystic radiolucencies. Multinucleated giant cells are found.
- Hypoparathyroidism - LOWERS blood Calcium and RAISES phosphate levels.
- Hypocalcemia - results from low parathyroid hormone levels. Clinical manifests as TETANY. Positive CHVOSTEK'S sign - twitching of facial muscles
when facial nerve near parotid gland is tapped.
- Histiocytosis X - a generic name for a group of disorders that cause an increase in HISTIOCYTES - including monocytes, macrophages, dendritic cells.
- Letterer-Siwe Disease - acute disseminated form - aggressive, seen in infants and young children, widespread on skin and mucosa.
- Hand-Schuller-Christian Disease - chronic disseminated - characteristic traid of exophthalamos, diabetes insipidus, and lytic skull lesions
- Eosinophillic Granuloma - focal chronic - solitary localized bone destruction, looks like periodontal disease or apical lesions. The most
BENIGN form. Complications can affect lungs resulting in pneumothorax.
- Pemphigus Vulgaris - blistering of skin caused by igG antibodies binding to SUPRA BASILAR cells.
- Acantholysis - intercellular edema and loss of intercellular bridges with loss of cohesiveness.
- TZANK cells - clumps of cells floating free in the vesicle space
- Trigeminal neuralgia - aka douloureux - a pain syndrome characterized by pain accompanied by a brief facial spasm or tic. Pain follows UNIlateral
SENSORY distribution of CN V. Feels like sudden stabbing pains with duration of under 2 minutes. Pain is provoked by TRIGGER zones. Tx is
CARBAMAZEPINE - an analgesic and anticonvulsant.
- Mumps - paramyxovirus acquired by respiratory droplets, 90% of cases occur before age 14. Can cause sterility in men due to orchitis. Elevated serum
amylase. LIVE attenuated vaccine.
- Syphilis - Hutchinson's incisors, infection with spirochete Treponema Pallidum. Most infectious stage is the SECONDARY Stage.
- Primary = chancre, NON-painful
- Secondary = HIGHLY infectious, occurs 6 weeks after non-tx of primary syphilis, mucous patches, condyloma lata (elevated plaques)
- Tertiary = gumma ( a focal, nodular mass), seen on palate and tongue, bacteria can damage eyes, heart, and CNS!! Neurosyphilis =
headache,
- Frey's syndrome - aka auriculotemporal syndrome - caused by damage to auriculotemporal nerve and subsequent reinnervation of the sweat glands by
parasympathetic salivary fibers. Often results in gustatory swelling - flushing and sweating on involved side of face during eating.
- Postherpetic neuralgia - persistent burning, itching along cuteanous nerve following herpes zoster attack.
- Acinic Cell carcinoma - derived from serous acinar cells found exclusively in PAROTID gland. Rare tumor.
- Adenocarcinoma -found in minor salivary glands of nose and paranasal sinuses.
- Fibrous dysplasia - radioopaque, non-circumscribed, GROUND GLASS appearance, asymptomatic regional alteration of bone replaced by fibrous tissue.
Can transform into malignant osteosarcomas.
- Monostotic - MOST COMMON form 80%, affects ONE bone (usually ribs or femur), Maxilla is often affected
- Polystotic - affects multiple bones- often long bones, face, clavicles, and pelvis, seen in children, mainly females,
- Albright's syndrome - aka McCune Albright syndrome - most severe form of polystotic fibrous dysplasia. Caf au lait spots on skin, endocrine
abnormalities causing precocious sexual development in females. Can result in pathologic bone fractures.
- Jaffe Syndrome
- Tzank smear - done to detect HERPES viruses.
- Epstein Barr virus - causes infectious mononucleosis, and has been associated with the development of 2 forms of cancer - Burkitt's Lymphoma and
Nasopharyngeal carcinoma. The virus infects B lymphocytes. Causes the production of IgM heterophile antibodies that can be detected with The
Heterophile Test which is highly diagnostic.
- Rubella - causes German measles, causes flat pink spots on face and other body parts
- Paramyxoviruses - cause measles (rubeola) and mumps. Measles = Koplik's spots in oral cavity.
- Agranulocytosis - a severe reduction in circulating granulocytes, usually neutrophils. More than half the cases are caused by INGESTION of a drug -
antimetabolic, antibiotic,and cytotoxic drugs.. Usually causes ulcers in the mouth.
- Cyclic neutropenia - a form of agranulocytosis - pts exhibit severe gingivitis but NO ulcerations
- Polycythemia vera - condition of TOO many RBCs. Blood becomes too thick to pass in small blood vessels causing clotting and strokes. Gingiva appears
very red and swollen, petechiae and ecchymosis.
- Primary polycythemia - excess erythrocytes are produced due to a tumor. SPLENOMEGALY occurs due to vascular congestion in 75% of pts.
- Secondary polycythemia - increased # of erythrocytes due to chronic tissue hypoxia or high altitude, or erythropoietin secretion.
- Achondroplasia - most common type of dwarfism. Upper arms and thighs are shorter than forearms and lower legs. Head is large, prominent forehead
and saddle-like nose, prognathic mandible. NORMAL torso, but short arms and legs. Overcrowding of teeth, ear infections.
- Ewing Sarcoma - MOTH EATEN radiolucencies of medulla and erosion of cortex with expansion. A malignant neoplasm of bone. Seen in pts 10-20.
PAIN and swelling of involved bone.
- MEN - a group of genetically distinct familial diseases involving adenomatous hyperplasia and malignant tumor formation in several ENDOCRINE glands
- MEN III - multiple endocrine neoplasia syndrome - an autosomal dominant condition characterized by multiple mucosal neuromas in the oral
cavity, endocrine neoplasms (pheochromocytomas of the adrenal medulla and medullary carcinoma of the thyroid gland), and Marfan's
features.
- Paget's Disease - aka Osteitis Deformans - chronic bone disorder where bones become enlarged and deformed - dense but fragile. Seen in pts OLDER
pts. Dentures stop fitting. Develops slowly. COTTON WOOL appearance, hypercementosis, and loss of lamina dura. Labs - INCREASE serum
ALKALINE phosphatase but normal serum phosphate and calcium. Risk of osteosarcomas.
- Cystic fibrosis - a congenital metabolic disorder causing exocrine glands to produce abnormal secretions - thick, viscous mucous. Tend to be mouth
breathers, enlarged salivary glands, intrinsic teeth staining due to tetracycline used. REDUCED caries rate.
- TNM -
 - T = size. T1 (less than 2cm diameter), T2 (4cm in diameter), T3 (greater than 4cm diameter)
- N = lymph node involvement. NO - not palpable and no metastasis. N1 - unilateral palpation and not fixed but metastasis is suspected. N2 -
Bilateral lymph nodes, not fixed but metastasis is suspected. N3 - bilateral lymph nodes, FIXED and metastasis is suspected
- M = distant metastasis. MO - no metastasis. M1 - clinical or radiographic evidence of distant metastasis other than regional lymph nodes. \
- Sjogren's Syndrome - an autoimmune chronic inflammatory disorder characterized by infiltration of exocrine glands (salivary and lacrimal) with
lymphocytes and plasma cells. Causes xerostomia, keratoconjuctiva sicca (dry eyes), and rheumatoid arthritis. Tx - symptomatic.
- Histologicaly identical to Benign lymphoepithelial lesion in a salivary gland.
- Stomatitis nicotina - NOT considered to be pre-malignant. Just stop smoking.
- Erythema multiforme - an acute self-limited eruption characterized by a distinctive clinical eruption of an iris or target lesion - BULLSEYE (central lesion
surrounded by concentric rings of pallor and redness over the dorsal aspects of hands and forearms.
- EM Major - aka Stevens-Johnson Syndrome - an SEVERE acute form that involves the skin and mucous membrane. Large bullae. Positive
Nikolsky sign. Dark red crusted lesions on lips and eyes. Classic triad - eye lesions, genital lesions, and stomatitis. BLINDNESS can occur
due to secondary infection. Tx is just supportive and symptomatic.
- Chronic EM minor - mildest form, small lesions, aphthous ulcers.
- Developmental (Fissural) Cysts - nasopalatine duct cyst, nasolabial cyst, median palatal cyst, median alveolar cyst.
- Nasolabial cyst - aka nasoalveolar cyst - is EXTRAOSSEOUS and typically found within soft tissue of upper lip.
- Nasopalatine cyst - most common, heart shaped
- Congenital Cysts
- Thyroglossal duct cyst - found in midline, symptom is hemorrhage into the mouth due to rupture of overlying veins
- Branchiogenic cyst - arises from persistence of 2nd branchial arch cleft. Located along anterior border of SCM.
- Dermoid cyst - contains hair, sebaceous and sweat glands, and even tooth structures! Most common on floor of mouth.
- Metastatic tumors - may be asymptomatic, mandibular molar region is affected most frequently. Rarely seen in max or mand, BUT a tumor of the jaws
may be the FIRST evidence of dissemination of a known tumor from its primary site - usually BREAST, kidney, lung, colon, prostate, thyroid. NOT the
brain.
- Most COMMON malignancy affecting skeletal bones is metastatic carcinomas.
- Adenoid cystic carcinoma - MOST COMMON malignant tumor of MINOR salivary glands. Often seen with facial nerve paralysis. Slow growing but often
infiltrates NERVES. Seldom metastasizes.
- Mucoepidermoid carcinoma - MOST COMMON malignant salivary gland neoplasm. Mainly seen in the PAROTID gland.
- Warthin's tumor aka Papillary Cystadenomalymphomatosum- a slow growing cystic tumor that almost always occurs in older men. Exclusively PAROTID
neoplasm. NON-tender. Seen at angle or ramus of mandible.
- Oncocytomas - benign salivary tumors, very rare 1%, usually found in parotid gland of older pts. Abundant MITOCHONDRIA.
- Sialoscintigraphy - a simple, non-invasive procedure that can separate benign tumors from malignant tumors.
- Choristoma - a mass of histologically NORMAL tissue that presents in an ABNORMAL location.
- Hamartoma - a developmental defect characterized by an overgrowth of tissues NORMAL to the organ in which it arises.
- Teratoma - a NEOPLASM composed of multiple tissues FOREIGN to the organ in which it arises. Can be benign or malignant.
- Anaplastic - a malignant neoplasm composed of Undifferentiated cells. This is a HALLMARK of malignant transformation.
- Pleomorphism - cellular variation in size and shape
- Verrucous Carcinoma - aka Sniff Dipper's Cancer - a distinct, diffuse, papillary, superficial, non-metastazing form of SCC. Rarely metastasizes.
- Nevoid Basal Cell Carcinoma -aka Gorlin and Goltz Syndrome - autosomal dominant. characterized by multiple odontogenic keratocysts.
- Geographic tongue - desquamation of FILLIFORM papillae.
- Melkersson-Rosenthal Syndrome - appear with fissured tongu, cheilitis granulomatosum, and facial nerve paralysis.
- Pernicious anemia - can manifest orally as GLOSSITIS. A MEGAblastic anemia caused by lack of secretion of INTRINSIC factor in normal gastric juice -
as a result B12 is not absorbed which is needed for the maturation of erythrocytes. A Schilling 24-hr urine test is done to eval if B12 is being absorbed.
- Thalassemia major and minor - HEMOLYTIC anemias that result from a genetic defect. LOW levels of erythrocytes and abnormal hemoglobin. Pts exhibit
anemic PALLOR. Anterior teeth flare with malocclusion.
- Odontogenic Keratocyst - derived from the DENTAL LAMINA. 70-80% occur in mandible. If multiple,eval for Gorlin Syndrome. Great tendency to
RECUR!
- Odontogenic myxoma - Arises from follicular connective tissue resembling pulp tissue. An aggressive tumor, recurrence is common.
- Ameloblastoma - consists entirely of odontogenic epithelium. MOST AGGRESSIVE odontogenic tumor. MOST COMMON epithelial odontogenic tumor.
- Solid (multicystic or polycystic) - most aggressive kind and requires surgical excision.
- Gardner's Syndrome - a rare autosomal dominant disease characterized by GI polyps, multiple osteomas, and soft tissue tumors. Inevitable outcome is
COLON CANCER due to adenocarcinoma by the 4th decade. Multiple impacted and supernumerary teeth.
- Osteomas have a COTTON WOOL appearance. Most often seen at angle of mandible
- Burkitt's Lymphoma - associated with EBV, a high grade NON-Hodgkin's lymphoma. FIRST cancer associated with VIRAL etiology. Bone appears MOTH
EATEN.
- African form - manifests as a large osteolytic lesion in the jaw, seen in very young children - 3yo, often involves jaws
- Non-african form - manifests as an abdominal mass, seen in older children - 11yo,
- Ectodermal dysplasia - a hereditary condition characterized by abnormal development of skin, hair, nails, teeth, and sweat glands. All structures derived
from ectoderm. More common in males. CONICAL TEETH - need dentures.
- Cleidocranial dysplasia - an inherited disorder of bony development characterized by absence of collar bones, protruded jaw, wide nasal bridge,
RETAINED primary teeth. Supernumerary teeth and unerupted teeth.
- Pierre Robin syndrome - an inherited disorder that presents as micrognathia and retrognathia of the mandible, glossoptosis (posterior displacement of
tongue), and cleft palate. Often seen with respiratory problems.
- Peutz-Jeghers - a genetic condition marked by hyperpigmentation and freckling of lips, hands, face, and benign polyps called hamartomas in SMALL
intestine.
- Cherubism - a familial disease where the maxilla expands and the orbits look upward, lesions are characterized by multinucleated giant cells. Seen
mostly in male children around 5yo. Often seen with delayed eruption. Multilocular radiolucencies of the mandible. Similar to CGCG but with perivascular
collagen cuffing.
- Lesions containing multinucleated giant cells - CGCG, hyperparathyroidism, and anuerysmal bone cysts.
- Bell's Palsy - damage to facial nerve. Most commonly seen in pregnant women and people with diabetes or a URI. Unilateral paralysis of all facial
muscles - loss of forehead wrinkles, drooping eyebrow, sagging lip. Subsides in 2-3 weeks.
- Sialoliths - mostly found in Submandibular (wharton's) duct. Calcium and phosphate salts around a nidus or mucous or bacteria. Pain intensifies at
mealtimes. Radiographically seen best with a mandibular occlusal view.
- Ranula - a TRUE retention cyst, fluctuant and painless
- Mucocele - NOT a true cyst (not lined by epithelium), it is mucin surrounded by granulation tissue.
- Herpes
- Corticosteroids are contraindicated in pts with herpes simplex infections.
- Lipschultz bodies - the nuclei of epithelial cells are often multiple with margination of the chromatin around the intra-nuclear inclusions.
- Tzank smear - a scrapping taken from an unroofed vesicle to diagnose herpes.
- Mucormycosis - an aggressive, opportunistic infection with a high affinity for afflicting individuals with DIABETES due to the decreased ability of
neutrophils to phagocytize and adhere to endothelial walls. Tx with Amphotericin B.
- Herpangina - Group A coxsackie virus. Localized to the posterior soft palate and nasopharynx. Clears up in 1 week.
- Thrombocytopenic purpura - aka Werlhof's disease - a bleeding disorder characterized by a deficiency in the NUMBER of platelets.
- Thrombotic thrombocytopenic purpura - a severe and often FATAL disease caused by LOW platelet count in the blood due to consumption of platelets by
thrombosis in the terminal arterioles and capillaries.
- One of the most common inherited disorders among African Americans is - sickle cell anemia - RBCs are crescent shaped, abnormal hemoglobin S due
to genetic defect - mutation of thymine for ADENINE. More common in females and seen before age 30. LARGE marrow spaces due to loss of
trabeculae. Lamina dura and teeth are unaffected. Reduced lifespan of RBCs from 120 days to 20 days.
- Aplastic anemia - etiology is unknown, thought to be chemicals or radiation exposure, bone marrow does not produce enough
RBCs. FATAL!!! The MOST serious and life threatening blood dyscasia associated with drug toxicity.
- Plummer-Vinson syndrome - causes iron deficiency anemia, along with atrophic changes to oral and esophageal mucosa, koilonychias (spoon-shaped
fingernails) and dysphagia due to esophageal stricture. Often causes carcinoma of the oral mucous membranes.
- Dentin dysplasia - a hereditary defect in dentin formation where coronal dentin and tooth color is normal. Root dentin is abnormal with a gnarled pattern
and associated with SHORT AND TAPERERD ROOTS.
- Type I - RADICULAR dysplasia - more common, normal crowns, obliterated pulp cavities, SHORT ROOTS, PARLs
- Type II - CORONAL dysplasia - semi-transparent opalescent PRIMARY teeth but normal permanent teeth. Obliterated pulp chambers, pulp
stones.
- Amelogenesis imperfecta - a hereditary ectodermal defect, only affects enamel not dentin, pulp, or cementum. Affects primary and permanent teeth
- Type I - Hypoplastic - enamel is NOT FULLY FORMED to full thickness. Results from defective formation of the enamel matrix.
- Type II - hypocalcified - QUANTITY of enamel is NORMAL but enamel is SOFT and can be removed during prophy. Results from
defective mineralization of enamel matrix.
- Type III - hypomaturation - enamel can be pierced by an explorer tip and chipped away. Results from IMMATURE crystallites.
- Internal resorption - resorption of the dentin of the pulpal walls. RCT has high success rate.
- External resorption - invasion of the cervical region of the root by fibrovascular tissue which progressively resorbs dentin, enamel, and cementum. RCT is
no help/
- Abfraction - cervical erosive lesions caused by tensile and compressive forces during tooth flexure.
- Most commonly ankylosed tooth is the primary 2nd molar.
- Hypercementosis - the excessive deposition of SECONDARY cementum on the roots. Most frequently seen on PREMOLARS. Commonly seen with
PAGET'S disease.
- Dentinogenesis Imperfecta - an inherited disorder of dentin, autosomal dominant. Teeth have an amber, grey or purple opalescence or translucency.
Abnormal constriction at cemento-enamel junction. Pulp chamber is often obliterated.
- Type I - dentin abnormality associated with OSTEOGENESIS imperfecta
- Type II - MOST COMMON, has NO bone involvement
- Type III - Brandywine Type - only dentin involvement but also multiple pulp exposure in primary dentition.
- Anodontia - congenital absence of ALL teeth
- Oligodontia - refers to the congenital absence of 6 or more teeth, but not all
- Hypodontia - refers to the absence of only a few teeth
- Diphyodontia - having 2 successive sets of teeth ex. Humans
- Hypsodontia - having high crowns. Seen with diets of abrasive foods.
 - A papilloma is a benign epithelial neoplasm. A fibroma is a benign neoplasm of connective tissue origin
- Inflammatory fibrous hyperplasia - aka epulis fissuration - seen on maxillary in area of denture borders. Caused by ill-fitting dentures. Surgical excision
and remake denture.
- Inflammatory papillary hyperplasia - aka palatal papillomatosis - seen on hard palate, caused by poor oral hygiene under denture. Surgical excision and
remake denture.
- Verruciform xanthoma - a papilloma look alike lesion. Seen in middle aged and older females. Cause is unknown.
- Melanoma
- Superficial spreading - MOST COMMON type
- Nodular - POOREST prognosis
- Lentigo maligna - usually seen in elderly
- Acral lentiginous - LEAST COMMON, seen on palms, soles, or under nails, more common in African Americans.

PROSTHODONTICS
- Electrosurgery - do NOT use with pts that have pacemakers! Excellent for hemostasis. Too low a current can cause tissue drag.
- TMJ - a ginglymoarthroidal joint meaning that it glides and rotates.
- Upper compartment of TMJ - between mandibular fossa and articular disk. ONLY SLIDING movements or translation motion occurs here
- Lower compartment of TMJ - between condyle and articular disk, ONLY hinge type or rotary motion occurs here.
- A high palatal vault or a constricted palate can cause whistling sounds.
- 5 factors that govern the establishment or balanced articulation
- Inclination of condylar guidance (dictated by pts anatomy)
- Inclination of incisal guidance
- Inclination of occlusal plane
- Convexity of compensating curve
- Angle and height of the cusps
- Cast chromium cobalt for RPD framework - low density and weight, high modulus of elasticity (very stiff), low cost, resistant to corrosion
- Chromium - resists tarnish and corrosion
- Cobalt - contributes strength and rigidity
- Nickel - increases ductility
- Alginate
- Diatomaceous earth - the main component 50%, acts as a filler
- Gypsum products - all come from the mineral gypsum which is the dehydrate form of CALCIUM SULFATE. When heated, water is lost and gypsum is
converted to the HEMI-hydrate form of calcium sulfate (a powder). When water is added, the hemihydrates is converted back to the DI-hydrate form of
calcium sulfate.
- Type II - Dental plaster - produced by heating gypsum in an open vessel at 150-160C. Produces particles that are porous and irregularly
shaped. The WEAKEST gypsum product. BETA-hemihydrate
- Type III - Dental stone - produced by heating gypsum under STEAM pressure in an autoclave at 120-150C. Produces particles that are
UNIformly shaped and less porous. ALPHA- hemihydrate
- Type IV - Die stone - produced by BOILING gypsum in a 30% aqueous solution of Calcium Chloride and Magnesium Chloride. A HIGH
strength die stone - the LEAST porous and STRONGEST.
- Elastic impression materials
- Aqueous hydrocolloids
- Agar (reversible)
- Alginate (irreversible)
- Non-aqueous hydrocolloids
- Polysulfides
- Silicones
- Condensation - involves ionic species and produces water as a by-product.
- Addition - ex. PVS - involves adding Carbon units on each side of the C=C double bond. NO IONIC forms are involved
- Polyethers
- All elastomeric impression materials - contract slightly during curing
- Elastomers - impression materials that have elastic or rubber-like qualities
- Non-elastic impression materials - plaster, compound, waxes, ZOE
- Polyvinylsiloxane impression material - aka ADDITION silicones - most widely used and most accurate. LESS polymerization shrinkage, low distortion,
high tear strength, NO biproducts during the reaction.
- SULFUR in powdered latex gloves retards the setting
- Polysulfides - aka rubber base - polymerizes in an exothermic reaction. Excellent flow properties and a high flexibility and tear strength. STRONGEST
resistance to tearing. Low resistance to deformation. Requires a use of custom tray. LONG setting time 8-12 minutes. Sets by S-S cross linking
- Base - the white paste, contains a low molecular weight polysulfide polymer called MERCAPTAN and titanium oxide.
- Accelerator - the brown paste, contains LEAD DIOXIDE.
- Custom trays are important since elastomers are more accurate in UNIFORM, thin layers of 2-4mm thick.
- Alginate -
- The setting reaction is a "Double decomposition" reaction between potassium alginate and calcium sulfate.
- Both over and under mixing can reduce the strength of the impression.
- 0.25 inch (3mm) of alginate should remain over all critical structures between the impression tray and the tissue.
- Sodium phosphate - serves as a retarder of the setting reaction. Once all of it reacts, the sodium alginate reacts with Ca2+ ions to form
calcium alginate.
- Agar impression material - REVERSIBLE hydrocolloid where the materials physical state can be changed from a GEL to a SOL by the application of heat,,
VERY high accuracy. Hydrophillic. Dimensionally unstable so must be poured immediately and only used one. Use is limited by the need for special
equipment. Setting does NOT involve a chemical reaction.
- Non-aqueous elastic impression materials
- Cost - alginate (cheapest) < agar and polysulfide < condensation silicones < addition silicones < polyethers (most expensive)
- Dimensional stability - addition silicone (most stable) > polyether > polysulfide > condensation silicone > hydrocolloid
- Wettability - hydrocolloids (best) > polyeither > hydrophilic addition silicones > polysulfides > hydrophobic addition silicones and condensation
silicones
- Castability - hydrocolloics (best) > hydrophilic addition silicone> polyether > polysulfide > hydrophobic addition silicone = condensation silicone
- Stiffness - polyether (most) > addition silicone > condensation silicone > polysulfide = hydrocolloids (least stiff)
- Tear strength - polysulfide (greatest) > addition silicone > polyether > condensation silicone > hydrocolloids (least tear strength)
- ZOE impression paste - an INELASTIC impression material. Sets into a hard, brittle mass. Setting time can be accelerated by adding a little water to the
mix and retarded by adding oils to the mix.
- Calcium chloride - functions as an accelerator of the setting time
- Oil of cloves - contains 75-80% eugenol.
- Rosin - facilitates the speed of the reaction which results in a smoother, more homogenous product.
- Silicones - aka condensation silicones - record surface detail well and have excellent elastic properties but a LOW tear strength. LESS expansive than
PVS and polyethers. Must pour up immediately!! Within 30 minutes. POOR dimensional stability - because the setting reaction is a condensation
reaction that occurs by eliminating an ether or methyl alcohol.
- Polyether impression material - working and setting times are shorter than for polysulfides but similar to PVS. EXCELLENT Dimensional stablIity when
DRY so more than one cast can be poured up. MOST RIGID compared to other materials so it tears easily and can be difficult to remove from mouth. Set
VERY quickly - forms a rubber by a cationic polymerization process. Truly hydroPHILIC.
- Investment Materials
- Gypsum bonded - binder is gypsum. Used when casting conventional gold alloys
- Phosphate bonded - binder is a metallic oxide and a phosphate. Used when casting base metal alloys for metal-ceramic crowns.
- Silica bonded - binder is a silica gel. Used when casting base metal alloys for partial denture frameworks.
- You add stone to water when mixing to result in better powder mixing and reduced chance for air bubbles.
- When a high proportion of water is used in mixing up stone, the powder particles are farther apart. This results in LESS expansion with a retarded setting
time and a weaker producr.
- Color
- Chroma - the saturation or strength of a color
- Value - the relative amount of lightness or darkness in a color - the MOST IMPORTANT factor in shade selection
- Hue - the color tone (blue, yellow, red)
- The shade of a ceramic crown should be matched by - 1) Value 2) chroma 3) hue
- Metamerism - when teeth appear to be one color under one type of light but appear different under another light source.
- Strain hardening or work hardening - hardening (or deformation) of a metal at room temperature.
- Compensating curve - the anteroposterior curvature in the median plane and the mediolateral curvature in the frontal plane in the alignment of the
occluding surfaces and the incisal edges of artificial teeth that are used to develop balanced occlusion.
- Centric relation - aka Retruded Contact Position - a bone to bone relationship. It is a LIGAMENT guided position.
- Primary centric holding cusps are the max lingual cusps. Secondary centric holding cusps are the mandibular buccal cusps.
- Grind secondary centric holding cusps only if there is a balancing side interference.
- Camper's line (plane) - the line running from the inferior border of the ALA of the nose to the superior border of the TRAGUS of the ear. The occlusal
plane is parallel to the Camper's line and the interpupillary line when setting denture teeth.
- Group function - aka unilateral balanced occlusion - all posterior teeth on a side contact EVENLY as the jaw is moved toward that side. All teeth on the
non-working side are FREE of any contact.
- Posselt's envelope of mandibular motion - shows a SAGITTAL section.
- Tooth contacts are of longer duration in swallowing than in chewing.
- Kennedy Classification
- Class I - bilateral distal extension
- Class II - unilateral distal extension
- Class III - unilateral endentulous spaces bound by teeth - tooth borne
- Class IV - anterior distal extension crossing the midline (missing canines)
- Modifications - added for additional edentulous areas.
- Wrought wire clasps - must have an ELONGATION percentage of MORE THAN 6% to allow the clasp to bend without microstructure changes that could
compromise its physical properties. The elongation is the most important mechanical property involved.
- The strength, hardness and tensile strength is 25% GREATER than the cast alloy from which it is fabricated. - tougher than cast clasps
- Indirect retainer - refers to RESTS, located as far anterior as possible to prevent vertical dislodgement of the distal extension base of an RPD. Not
necessary on tooth-borne RPDs.
- Immediate dentures
- A reline or rebase is required in 8-12 months.
- Two step schedule for immediate dentures - 1) Extract all posterior teeth EXCEPT a max PM1 and its opposing tooth to retain a posterior stop
for VDO. 2) fabricate denture after healing. Extract anterior teeth at time of denture insertion.
- The most frequent cause of porosities in a denture is - insufficient pressure on the flask during processing. Should be 20-30 psi. if insufficient, the
porosities occur in the thickest part of the denture.
- Denture overextension -
- An overextended DISTOBUCCAL corner of a mandibular denture will push against the MASSETER during function.
- Masseter originates from the zygomatic process of the maxilla and inserts at the angle and lower lateral side of the ramus of the
mandible.
- Denture displaced when smiling = over extended buccal notch and buccal flange
- Denture displaced when yawning or opening wide = over extended distobuccal flange hitting the coronoid process
- Tingling or numbness at corner of mouth or lower lip = excessive pressure from lower buccal flange on mental foramen.
- Posterior Palatal Seal - .5mm deep near the midline and 1.5mm deep 3mm outside of the midline. Extends up to the medial boundary of the
pterygomaxillary notches.
- 4 types of casting alloys
- Type I - weakest, has the greatest elongation, used for INLAYS
- Type IV - the strongest, has the least elongation, used for high stress bridges and partial denture frameworks
- High-gold noble alloys - 98% gold, platinum and palladium.
- Nobel alloys like gold, platinum, and palladium do NOT oxidize on casting.
- Palladium-Silver alloys - 50-60% palladium and 30-40% silver - Silver is NOT a noble metal so it oxidizes on casting.
- Nickel-chromium alloys - 70-80% nickel and 15% chromium. Readily oxidize which can cause PFM interface problems.
- Base metal dental casting alloys - alloys with less than 25% noble elements. Much STRONGER and has a LOWER density. MUCH higher melting temp.
Nickel is responsible for the ductility of the alloy. Chromium produces a passivating film for corrosion resistance. Cobalt increases the rigidity of the alloy.
- Porcelain adheres to metal primarily by a CHEMICAL bond.
- Ante's Law - the root surface area of the abutment teeth supported by bone must equal or surpass the root surface area of the teeth being replaced by
pontics in a bridge.
- Soldering - The strength of a solder joint is proportional to its SURFACE AREA. The solder must melt at at least 150F below the fusion temp of the metals
being soldered. Flux is used to dissolve surface impurities and protect the surface from oxidation while heating.
- POTASSIUM FLUORIDE is commonly added to flux to dissolve the passivating film that may prevent wetting of the metal with the solder.
- An antiflux is used to outline the area to be soldered in order to restrict the flow of solder - most commonly used is a soft graphite pencil
- Quenching - when a metal is rapidly cooled from an elevated temperature to room temp or below. Done to rapidly terminate a process that only occurs at
elevated temperatures.
- Annealing - the controlled cooling of a material to increase ductility and strength. It involves first heating a material for a given time and then slow cooling.
- Fritting - a process of manufacturing low and medium fusing porcelains. It involves raw constituents of porcelain to be fused, quenched, and ground back
to an extremely fine powder. The frit can then be added over by other metallic substances to produce color in porcelain.
- Clasp Assembly - in an RPD, the retentive clasp arm and a reciprocal or stabilizing clasp arm, plus any minor connectors or rests.
- Reciprocal bracing is usually on the lingual and retentive portion of the clasp assembly is on the buccal.
- Stressbreakers - effectively dissipate vertical forces to terminal abutments. However, this occurs at the expense of the residual ridge where the thrust of
the functional stress is directed.
- Precision attachment restorations - a pre-constructed attachment with male and female portions that fit together in a precise fashion with little tolerance.
provide retention without an unslightly display of metal. The functional load is dispersed down the long axis of the abutments by virtue of the low central
loading at the base of the attachments. These restorations permits patient access to all areas of the tissue when the dentures are not in place. CANNOT
be used in distal extension RPDs without a stressbreaker!!!
- Semiprecision attachment - cast into the crown and the RPD. The female and male parts fit together with much more tolerance than the precision
attachment resulting in less retention.
- Dental surveyor - an instrument used to determine the relative parallelism of oral anatomy.
- Ceramics
- In-Ceram Zirconia - has a higher flexural strength than most other porcelains.
- A Seven-eighths crown is a crown whose vertical distobuccal margin is positioned slightly mesial to the middle of the buccal surface.
- Sintering - done when processing ceramics to increase its DENSITY. Changes the porcelain from a powder to a solid.
- Ceramic restorations are severely damaged by acidulated fluoride.
- Gelation - the term given to the setting process of a hydrocolloid material - changing from a sol to a gel.
- Hysteresis - refers to a material's characteristic of having a melting temp different from its gelling temp.
- Methylmethacrylate (MMA) - most common polymer used in dentistry.
- Acrylic resin
- The powder is the polymer. The liquid is the monomer (ex. Methylmethacrylate)
- A patient wearing a complete max denture who complains of a burning sensation in the palatal area indicates too much pressure exerted by the denture
on the incisive foramen. If burning occurs in the mand anterior area, too much pressure is exerted on the mental foramen.
- Overdenture - the most important benefit is the preservation of the alveolar ridge thanks to retained roots.
- The primary indicator of the accuracy of border molding is the stability and lack of displacement of the tray in the mouth.
- Modeling compound has a relatively LOW thermal conductivity.
- Primary support area of max denture - residual ridges. Secondary support area of max denture are - palatal rugae.
- Anterior guidance - aka anterior coupling - a tightly overlapping relationship of the opposing max and mand incisors and canines which produces
disclusion of the posterior teeth when the mandible protrudes or moves from side to side. It is the result of horizontal and vertical overlap of the incisors.
- Bennett Movement - aka Lateral shift or Immediate shift - Refers to the WORKING side condyle ONLY. In the early stages of lateral movements, the
condyle rotates with a slight lateral shift in the direction of the movement.
- In a lateral movement, the NON-working side condyle moves downward, forward, and medially. The WORKING side moves laterally.
- Guiding cusps = balancing = non-supporting cusps - they do not occlude or fit into fossae or marginal ridge areas of the opposing arch. Max buccal and
mand lingual.
- Prolonged sensitivity to heat, cold and pressure after cementation of a crown or a fixed bridge is usually related to occlusal trauma.
- Pontics
- Sanitary pontic - leaves a space between the pontic and the ridge. Most common if esthetics are NOT an issue. Convex in all areas.
- Saddle pontic - looks the most like a tooth. Covers the ridge labiolingually with a large, concave contact. Impossible to clean so should not be
used.
- Modified ridge lap pontic - gives the illusion of looking like a tooth but possesses ALL convex surfaces for ease of cleaning. Good for esthetics.
- Conical pontic - rounded and conical. Good for thin mandibular ridges in non-esthetic zones.
- Ovate pontic - a sanitary substitute for the saddle pontic. Set in the concavity of the ridge to give the appearance that it is growing like a tooth.
- Cement
- Ceramic crowns are bonded with composite resin!!! Provides the strongest bond.
- Zinc phosphate cement - has a good compressive strength, BUT HIGH pH! Apply 2 layers of varnish to protect the pulp.
- Zinc polycarboxylate - adheres to calcified dental tissue and is more biologically compatible than zinc phosphate.
- Sprue pin - the diameter should be equal or greater than the thickest portion of the pattern. 10 gauge sprue pin is used on most patterns. 12 gauge pin is
used on small premolars.
- For optimum perio health, restoration finish lines should be - supragingival whenever possible to allow for hygienic cleaning.
- The path of insertion for an anterior crown should be - be parallel to the incisal -2/3 of the labial surface rather than the long axis of the tooth. (or else
an unnecessary amount of gold with show esthetically)
- Posterior fixed bridge - the pontic should contact in CO and maybe in working-side movement. But should NOT be in contact in NON-WORKING side
movement.
- The protrusive condylar path inclination influences the mesial inclines of the mandibular cusps and the distal inclines of the maxillary cusps.
- Arcon articulator - has the condylar elements on the lower member of the articulatory and the condylar path elements on the upper member. The ANGLE
between the condylar inclination and the occlusal plane is FIXED. Used for diagnostic study casts.
- Non arcon articulator - has the condylar elements on the upper member of the articulator. More popular for denture fabrication.
- Packing cord
- Alum - aka aluminum potassium chloride - use if pt has hypertension or hyperthyroidism
- Zinc chloride - it is caustic and causes delayed healing by causing necrosis of the sulcular epithelium and connective tissue. Should NOT be
used in impregnated cord.
- Hamulus - a small hook-like projection of bone that extends from the medial pterygoid plate of the sphenoid bone. Serves as the superior attachment of
the pterygomandibular raphe.
- Epulis fissuratum = inflammatory fibrous hyperplasia - results from overextension of denture flanges. Occurs in vestibular mucosa where the denture
flange contacts the tissue. Painless folds of fibrous tissue surround the flange.
- Paget's Disease - aka osteitis deformans - excessive breakdown of bone followed by abnormal bone formation. New bone is enlarged but weakened with
heavy calcifications. Pt complain dentures are feeling tight
- Bilateral balanced occlusion - dictates that a maximum number of teeth should contact during mandibular excursive movements.
- Unilateral balanced occlusion - aka group function - calls for all teeth on the working side to be in contact during a lateral excursion.
- Mutually protected occlusion - aka canine guidance - when anterior teeth protect posterior teeth in all mandibular excursions. The most widely accepted
arrangement of occlusion.
- Mastication:
- Open - lateral pterygoid, anterior belly of digastrics, and omohyoid
- Close - masseter, medial pterygoid, anterior fibers of temporalis
- Protrude - lateral pterygoids together
- Retract - posterior fibers of temporalis
- Porcelain
- Rust at temps over 2000F
- In an all ceramic crown, the core material is a high strength sintered ceramic.
 - Opaque porcelain - the first layer. It effectively covers the metallic sheen of the underlying casting. Creates a CHEMICAL bond to the metal
alloy.
- Body porcelain - makes up the bulk of the restoration, provides most of the color or shade.
- Glazed porcelain - nonporous, resists abrasion, possesses esthetic ability and is well tolerated by the gingiva. The LEAST irritating to gingival
tissues.
- 20% shrinkage occurs during firing of the porcelain.
- Low fusing porcelain - usually used for the manufacture of PFMs
- High fusing porcelain - used for denture teeth
- Medium fusing porcelain - used for all ceramic and porcelain jacket crowns
- COMPRESSIVE strength (350-550 MPa) is greater than its tensile or shear strengths.
- A mixture of FELDSPAR and QUARTZ.
- Kaolin - a clay, is a sticky material that binds the particles together when the porcelain is unfired. Household porcelain has more of this.
- Aluminous porcelain uses alumina instead of quartz as a strengthener. It is stronger.
- Degassing - the process by which a casting is heated in a porcelain furnace to a temp of 980C to BURN OFF any remaining impurities prior to
adding porcelain. If temp is too low, an oxide layer forms and decreases the bond of the porcelain.
- Pickling - the process of removing surface oxides from a casting prior to polishing. The solution is acidic an reduce the surface oxides.
- Crystalline reinforced glass - a glass in which a crystalline substance such as leucite is dispersed. It imparts strength to the ceramic. Ex. IPS
Empress
- Alumina - used to reinforce glass.
- Major connectors
- Anterior-palatal strap - 6-8mm wide, to provide strength with minimum tissue exposure, the MOST RIGID major connector. Should cross the
midline at right angles.
- Palatal horseshoe shaped - used when a large torus
- Single palatal bars - not often used since they lack rigidity. Use is limited to toothborne restorations for bilateral short span edentulous areas.
The wide, thin bar is MORE RIGID with less bulk compared to a narrow bar.
- Mandibular lingual bar - requires an minimum of 7MM of vertical height between the gingival margin and the floor of the mouth. The upper
border is a minimum of 3mm below the gingival margins and at least 4mm wide.
- Retainers
- Extracoronal retainers - aka Clasps - the most common type. 2 types - suprabulge and infrabulge
- Suprabulge retainers - the clasp originates ABOVE the height of contour and angle downward until the tip engages the undercut.
- Infrabulge retainers - clasp originates BELOW the survey line.
- Intracoronal retainers - attachments build into the contour of a crown to produce mechanical and frictional retention. Give optimal esthetics.
NOT used when an RPD is a distal extension since more functional motion is necessary without torquing the abutment tooth.

PHARMACOLOGY
- Efficacy - aka Intrinsic ability or Ceiling effect - the ability of a drug to produce a desired therapeutic effect regardless of dosage. Drugs that have the
greatest maximum effect have the highest efficacy.
- Potency - the relative concentration of two or more drugs that produce the same effect. Determined by the affinity of the receptor for the drug. It is a
comparative term used to compare drugs.
- EC50 = the dose that causes 50% of the maximal effect. The SMALLER the EC50, the more potent the drug.
- An additive effect - when two drugs have similar effects and are administered in combination resulting in a response that is the sum of the individual
actions of each drug alone. The response is NO greater than that which would be expected if the drugs were given one at a time. They are not enhanced
by being used in combination.
- A synergistic effect - occurs when the combination of two drugs having similar pharmacological effects is GREATER than the sum of the individual actions.
- Ex. Alcohol is synergistic with Valium, narcotics, and barbiturates.
- Bioavailability - the measurement of the rate and amount of therapeutically active drug that reaches the systemic circulation. Affected by the dissolution of
a drug in the GI tract and destruction in the liver. IV injections provide 100% bioavailability!!
- Cumulative action - when a drug is administered repeatedly, a higher concentration of the drug than desired may be achieved. resulting in excessive
accumulation.
- Idiosyncrasy - a response to a drug that is unusual or abnormal or one that grossly deviates from the routine reaction
- Nervous system
- Cholinergic neurons - secrete Acetycholine
- PRE-ganglionic neurons in BOTH the symp and parasymp are cholingeric
- POST-ganglion neurons in the parasym are cholinergic
- POST ganglion neurons in the symp that innervate SWEAT glands are adrenergic.
- Adrenergic neurons - secrete NE
- POST-ganglion neurons in the symp are adrenergic EXCEPT those that innervate SWEAT glands
- Cholinergic Receptors - CONSTRICT pupils (miosis), slows the heart, stimulates smooth muscles of bronchi, GI tract, gallbladder, bile duct, and bladder,
stimulates sweat, salivary, tear, and bronchial glands.
- Muscarinic - located in autonomic effector cells in the heart, vascular endothelium, smooth muscle and exocrine glands.
 - Nicotinic receptors - two kinds - at neuromuscular junction and autonomic ganglia.
- Nicotinic Receptor Antagonists - divided into ganglion-blocking drugs and neuromuscular blocking drugs.
- Ganglionic blockers - very potent but seldom used because side effects include parasympathetic blockade = pronounced xerostomia,
constipation, blurred vision, postural hypotension.
- Ex. Mecamylamine and Trimethaphan - used to tx severe or malignant hypertension and emergency hypertensive crisises. Cause
a RAPID fall in blood pressure.
- Neuromuscular blockers - produce complete skeletal muscle relaxation and facilitate endotracheal intubation. Used as an adjunct to surgical
anesthesia. Major danger is TOO much paralysis causing respiratory failure.
- Depolarizing - NON-competitive, depolarizes and desensitizes the neuromuscular end plate so it can't be stimulated again.
- Ex. Succinylcholine - protype - Caution in pts with low levels of pseudocholinesterase which breaks down
succinylcholine because it can cause respiratory failure.
- Non-depolarizing - Competitive with acetylcholine at nicotinic receptors. Prevent acetylcholine from stimulating motor nerves
causing muscle paralysis.
- Ex. Tubocurare (prototype), mivacurium, vecuronium, doxacurium, pancuronium, atracurium.
- Neostigmine and pyridostigmine - cholinesterase inhibitors. Reverse the blockage of these drugs.
- Cholinergic Agonists
- Cholinesterase inhibitors - inhibits the break down of Acetylcholine in the body resulting in a cholinergic effect. INDIRECT acting
cholinomimetic agents.
- Ex. Neostigmine, Physostigmine, Edrophonium, Pyridostigmine
- Edrophonium - an INDIRECT acting cholinomimetic. Often used to diagnose myasthenia gravis due to its rapid onset and distinguish
it from a cholinergic crisis.
- Pralodoxime - a cholinesterase REACTIVATOR. Used as an antidote to reverse muscle paralysis resulting from organophophate
anticholinesterase pesticide poinsoning
- Cholingergic alkaloids - Ex. Pilocarpine -Directly stimulates cholinergric receptors. Used to stimulate salivary flow in pts with xerostomia due to
radiation therapy. Also used to tx open angle glaucoma.
- Ex. Cevimeline - used to tx Sjogren's Syndrome pts
- Choline Esters - cause a fall in BP due to generalized vasodilation, flushing of the skin, and slowing of heart rate. Topical application causes
miosis of the eye.
- Ex. Methacholine, Bethanechol, Carbachol
- Receptors - alpha receptors are mostly excitatory causing vasoconstriction and contractions, Beta receptors are mostly inhibitory causing vasodilation and
relaxation of respiratory smooth muscle.
- The heart is mainly B1 receptors.
- A1 - found in arterioles in skin, mucosa, viscera, kidney and veins. Cause constriction.
- A2 - found in presynaptic nerve endings inhibit NE release. Found in postsynaptic CNS decrease sympathetic tone
- B1 - most common receptor in the heart increase the heart rate and increase the force of contraction
- B2 - found in arterioles cause dilation. Found in bronchial and smooth uterine muscle cause relaxation.
- Adrenergic Agonists aka Sympathomimetic agents
- Divided into A1, A2, B1, B2.
- Direct acting - act directly on Alpha and beta receptors Ex. Epinephrine!!
- Indirect acting - cause the release of stored NE at the postganglionic nerve endings to produce their effects.
- Used to control superficial hemorrhage - A1 agonists, vasoconstrictors. Ex. Epinephrine
- Allergic shock - A1 adrenergic agonists - vasoconstrictors, Ex. Epinephrine. B2 adrenergic agonists - relaxes bronchial smooth muscle and
dilates airway.
- Nasal decongestant - A1 - adrenergic agonists - vasoconstrictors. Ex. Phenylephrine.
- Bronchial relaxation and airway dilation - for asthma attack - B2 adrenergic agonists. - cause bronchodillation
- Ex albuterol, epinephrine, salmetrol, metaproterenol
- Cardiac stimulation - B1 adrenergic agonists. Ex. Isoproterenol
- Epinephrine - stimulates BOTH Alpha1,2 and Beta1,2 receptors. Constricts arterioles, relaxes bronchial smooth muscle, decreases blood volume to
nasal tissue, causes a hypertensive response, actions are opposite of histamine. Used to alleviate an acute asthma attack, to tx anaphylactic response, to
prolong the activity of LA, to restore cardiac activity in cardiac arrest.
- A1 receptor - cause vasoconstriction and reverse hypotension
- B2 receptor- dilate the bronchial tubules
- B1 - stimulate cardiac muscles and increase cardiac output
- Norepinephrine - stimulates ALPHA receptors ONLY
- Epinephrine reversal - seen in pts receiving ALPHA blockers - since epinephrine stimulates BOTH alpha and beta receptors, these patients only have beta
receptors stimulated causing a FALL in BP. (alpha receptors increase BP, beta receptors decrease BP)
- Sympatholytic - aka anti-adrenergic drugs - a drug that acts in a way OPPOSITE to the sympathetic nervous system. Used to treat HYPERTENSION.
- Beta adrenergic blockers - most common side effects are weakness and drowsiness
- Non- Selective
- Propranolol - non-selective - blocks both B1 and B2 receptors
 - Timolol - non-selective - blocks both B1 and B2 receptors
- Nadolol - non-selective - blocks both B1 and B2 receptors
- Selective - safer to use with pts with a hx of asthma or bronchitis. At HIGH doses, they are no longer selective for B1 - they also will
block B2 receptors and affect smooth muscle
- Metoprolol - blocks B1 receptors ONLY - similar to Atenolol, has a long duration of action due to a long half life, Used to
tx HTN, angina.
- Atenolol - blocks B1 receptors ONLY - similar to metoprolol - has a low lipid solubility so it is renally eliminated and
minimally metabolized.
- Low lipid solubility means it has less potential for causing CNS side effects compared to lipid soluble beta
blockers.
- Acebutolol - B1 selective blocker ONLY - used to tx HTN and control ventricular arrhythmias. Low lipid solubility. Has
mild intrinsic sympathomimetic activity - meaning it is a partial agonist at B2 receptors.
- Alpha adrenergic blockers - act on blood vessels and cause them to relax. Commonly used to reduce high BP and to treat enlarged prostate.
Side effects - can cause HYPOtension.
- Selective alpha antagonists - used to tx HTN, can cause orthostatic hypotension
- Tolazoline - blocks A2 receptors - used to tx persistent pulmonary HTN of the newborn
- Prazosin - blocks A1 receptors, rarely used
- Doxazosin - blocks A1 - most commonly used to tx HTN since it has a long duration of action.
- Terazosin - blocks A1 - used to tx benign prostate hypertrophy
- Non-selective alpha antagonists - used for pre-surgical management of pheochromocytoma. NOT used to tx cardiac conditions
because blocking both receptors can cause tachycardia.
- Phentolamine - blocks BOTH A1 and A2 receptors
- Phenoxybenzamine - blocks both A1 and A2 receptors
- Centrally acting agents - inhibit adrenergic nerve transmission through actions within CNS
- Clonidine, guanfacine, guanabenz, methyldopa
- Neuronal depleting agents - deplete catecholamine (NE) and serotonin stores from adrenergic terminals and in the brain
- Reserpine and guanethidine
- Modafinil - used to improve wakefulness during daytime sleepiness. A CNS stimulant. Used for narcolepsy, sleep disorders, unlabeled use to treat
ADHD.
- Monoclonal antibodies -
- Adalimumab - a recombinant monoclonal antibody that binds to TNF-alpha receptor sites. Used to treat rheumatoid arthritis.
- Alefacept - a monoclonal antibody used to treat moderate to severe plaque psoriasis.
- Infliximab - a monoclonal antibody used to treat ankylosing spondylitis, Crohn's disease, and rheumatoid arthritis. Binds to TNF-alpha receptor
sites.
- Trastuzumab - a monoclonal antibody which binds to the extracellular domain of the human epidermal growth factor receptor 2 (HER-2). Used
to treat pts with metastatic breast cancer whose tumor overexpress the HER-2 protein and are not receiving chemo.
- Immunosuppressants
- Pimecrolimus - used to tx mild to moderate atopic dermatitis.
- Sirolimus - used for prophylaxis of organ rejection in pts receiving renal implants.
- Tacrolimus - used to tx moderate to severe atopic dermatitis in pts not receiving conventional therapy.
- Granisetron and Ondansetron - selective 5HT3 receptor antagonists used to treat emesis caused by cancer chemotherapy.
- 5HT3 is a serotonin receptor that when activated during chemo for cancer, causes emesis (nausea and vomiting). These drugs prevent emesis
and nausea and vomiting associated with radiation therapy. (5-Hydrotryptamine typ3 3 receptor)
- Barbituates
- Depress neuronal activity by increasing membrane ion conductance, reducing glutamate induced depolarizations and potentiating the inhibitory
effects of GABA.
- Have a steeper dose-response relationship than benzodiazepines.
- Metabolized in the LIVER
- DO NOT possess analgesic properties.
- May precipitate acute porphyria in susceptible patients.
- DECREASE the half lives of drugs metabolized by the liver because they induce the formation of the liver microsomal enzymes that metabolize
drugs. Causes an increase clearance and decreases the effectiveness of these drugs.
- Cause of death from overdose is from respiratory failure.
- Ultra short acting -5-20 minutes, IV, used for the induction of general anesthesia, metabolized in liver, the MOST LIPID SOLUBLE
- EX - thiopental and methohexital
- The brief duration of general anesthetic action of an ultra-short acting barbiturate is due to the rapid rate of redistribution from the
brain to peripheral tissues. They maintain anesthesia only while in the brain. Because of their high lipid solubility, they rapidly leave
the brain for other tissues so the pt wakes up.
- Short-acting - 1-3 hrs, can be used orally for their hypnotic and calming effect. Often used before dental appt to reduce anxiety.
- Ex. Secobarbital and pentobarbital
 - Intermediate acting - 3-6 hrs, can be prescribed to relieve anxiety before a dental appt. used for day time sedation and to tx insomnia.
- Ex. Amobarbital and Butabarbital
- Long acting barbiturates - 6-10hrs, used for daytime sedation and tx of epilepsy, the LEAST lipid soluble.
- EX. Phenobarbitol, Mephobarbital, and Primidone
- Benzodiazepines - aka tranquilizers. Used to alleviate anxiety, induce sleep, and via IV to cause conscious sedation for outpatient surgery. Depress the
LIMBIC system and reticular formation by potentiating GABA neurotransmitter. Preferred over barbiturates since it has less addiction potential and
produces less profound CNS potential. Do NOT use if pt has acute narrow angle glaucoma and psychoses. Does NOT cause respiratory depression.
- Diazepam (valium) - tx of anxiety, tension, muscle spasm, and as an anticonvulsant. Agent of choice to reverse STATUS EPILEPTICUS
induced by a local anesthesia overdose. Can be locally irritating to tissue so use large veins if given via IV to avoid thrombophlebitis. Most
common side effect is drowsiness.
- Ex. Chlordiazepoxide, alprazolam, lorazepam,
- Tx insomnia - flurazepam, triazolam, temazepam
- Midazolam (Versed) - comes as a liquid for pre-op sedation in children and as an injectable for IV conscious sedation.
- Triazolam - a pre-op sedative used in dentistry. Metabolized by liver by the P-450 isoform CYP 3A4 enzyme.
- If a drug inhibits the action of CYP 3A4, it would increase the serum levels of triazolam.
- Ex. ANTIFUNGAL (itraconazole, ketoconazole, fluconazole, miconazole, etc) inhibit the CYP 3A4 isoform!!
- Flumazenil - a benzodiazepine ANTAGONIST - used to reverse the residual effects of benzos after an OVERDOSE.
- Buspirone - an orally administered anxiolytic (an anti-anxiety agent) that is structurally and pharmacologically distinct from benzos and barbiturates. Does
NOT possess anti-convulsant or muscle relaxant properties. Does NOT impair psychomotor function. Does NOT cause sedation or physical dependence.
Very slow onset of action (up to 2 weeks). Works by diminishing serotonergic activity.
- NSAIDS - anti-inflammatory effects. Inactivate the enzyme prostaglandin endoperoxide synthase (Cyclooxygenase) in the arachidonic acid cascade
reducing prostaglandin synthesis.
- Propionic acid derivatives - ibuprofen, fenoprofen, ketoprofen, naproxen, piroxicam, flurbiprofen, nabumetone
- Acetic acid derivatives - indomehtacin, sulindac, tolmetin
- Fenamic acid derivatives = meclofenamate, mefenamic acid
- NON-selective NSAIDs - Ex. Ibuprofen, Naproxen and Flurbiprofen - inhibits both COX1- and COX-2. Enhances the anti-coagulant effects of
Warfarin. Can cause GI ULCERS.
- Cox-1 - produces prostaglandins in the GI tract. Help protect the formation of GI ulcers.
- Cox -2 - produce prostaglandins are sites of surgery, infection, and inflammation.
- Ibuprofen - inhibits the production of prostaglandins in peripheral tissues which reduces the inflammatory response at sites of
surgery, infections, or injury. This reduces perceived pain. Inhibits platelet aggregation (reversible so platelets are normal once
drug leaves the system) so should NOT be used by pts on Coumadin!!
- Ex. Advil, Nuprin, and Medipren
- Motrin - contains 400mg of ibuprofen or higher and requires Rx.
- Aspirin - a Salicylate. inactivates Cyclooxygenase which synthesizes prostaglandins. Analgesic, antipyretic, and anti-inflammatory.
IRREVERSIBLE platelet inhibitor so it reduces blood clotting and can cause prolonged bleeding until new platelets are formed -
potentiates the anticoagulant effects of Warfarin.
- Overdose causes Salicylism - causes tinnitus, vertigo, nausea, sweating, vomiting.
- Reyes Syndrome
- Cox-2 Selective inhibitors - Ex. Celecoxib - does NOT affect platelet function. Great for pts taking Warfarin or aspirin. Used to tx rheumatoid
and osteoarthritis, dysmenorrhea. No risk of GI ulcers.
- Acetaminophen - analgesic and antipyretic effect. Does NOT reduce inflammation!!! Affects CENTRAL prostaglandin synthasis - it is a weak
inhibitor of prostaglandin production in peripheral tissues. NO effects on platelets or the coagulation pathway - good drug to give to pts on anti-
coagulants. Can cause hepatic necrosis in large doses.
- Codeine and Hydrocodone - narcotic analgesics effectively reduce pain but do NOT reduce inflammation. Work within the brain to block
ascending pain impulses traveling to the brain from the periphery.
- Antipsychotic Agents - improve mood and behavior and have neuroleptic effects (emotional quieting and development of EXTRAPYRAMIDAL symptoms
due to the effect on the basal ganglia.
- Neuroluptic agents - major tranquillizers, used in acute manic episodes.
- **** Phenothiazines - most COMMONLY used. Blocks dopaminergic sites in the brain. Causes sedation, ANTI-EMETIC activity, potentiates
effects of narcotics.
- Ex. Chlorpromazine and Thioridazine
- Ex. Chlorprimazine, Promazine, Thiordazine, Fluphenazine, Mesoridazine, Triflupromazine, Acetophenazine, Trifluoperazine
- Tardive Dyskinesia - an EXTRApyramidal disease - an IRREVERSIBLE side effect resulting from long term phenothiazine therapy.
Causes involuntary, repetitious movements of the face, limbs, and trunk.
- Butyrophenones -
- Haloperidol and droperidol - highly effective antipsychotic drugs used to tx schizophrenia. Also used to tx Tourette's Syndrome. A
potent dopamine antagonist.
- Thioxanthenes -
- Chlorprothixene and thiothixene - less potent group of antipsychotics. Used to tx schizophrenia.
 - Diverse heterocyclic antipsychotics - treat schizophrenia and have proven to be more effective and less toxic than older drugs. NEW - not only
antagonized dopamine, but also antagonize serotonin in the brain.
- Ex. Molindone, clozapine, loxapine, olanzapine, risperidone, and quetiapine.
- Extrapyramidal syndrome (EPS) = muscle spasms of the oral-facial region. Results from the blockade of dopamine receptors in the basal
ganglia.
- Anti-depressants
- Tricyclic antidepressants - the drugs of choice to treat UNIpolar depression. Inhibit neuronal reuptake of norepinephrine and serotonin in the
brain. Ex. Elavil - induce significant xerostomia. CAUTION with HTN meds - they increase NE levels in tissues and can increase BP.
- Ex Amitriptyline, Doxepin, Imipramine
- Most widely used tricyclic antidepressant is Amitriptyline (Elavil) - displays the greatest anti-cholinergic effects (dry mouth)
- Serotonin and NE reuptake inhibitors - Ex. Effexor - induce significant xerostomia. CAUTION with HTN meds - they increase NE levels in
tissues and can increase BP.
- Ex. Venlafaxine, Norptriptyline, Desipramine
- Selective serotonin reuptake inhibitors - have revolutionized the tx of depression. Can also tx panic attacks. High specificity for blocking only
the reuptake of serotonin. Ex. Prozac - have no secondary anti-cholinergic effects so they do NOT cause xerostomia. No effect on BP.
- Ex. Citalopram, Escitalopram, Fluoxetine, Paroxetine, Sertraline
- Fluoxetine (Prozac) - prototype. Has the longest half life.
- 2nd generation - Ex. Buproprion, Trazodone, Nefazodone, Mirtazapine
- MAO inhibitors
- Ex. Phenelzine, Tranycypromine, Isocarboxazide
- Chemotherapy
- 8 classes of drugs
- Alkylating agents - alkylate DNA so it cannot replicate. Form COVALENT alkyl bonds to nucleic acids. Most commonly bind to
guanine. Used to tx chronic leukemias, lymphomas, myelomas, and breast and ovarian cancers.
- Ex. Cisplatin, Cyclophosphamide
- Cisplatin - side effects cause nausea and vomiting, hair loss, xerostomia, mucositis.
- Ex. Mechlorethamine, Cyclophosphamide, Chlorambucil, Melphalan, Carmustine, Lomustine, Semustine, Busulfan
- Anthracyclines - destroy DNA so the cell cannot replicate. Ex. Daunorubicin and Doxorubicin
- Antibiotics - specifically used to tx cancer, not bacteria. Ex. Dactinomycin
- Antimetabolites - interfere with selected biochemical reactions necessary for cell growth. A cell cycle specific drugs acting primarily
in the S phase of the cell cycle = DNA synthesis. Interfere with biosynthesis of purine and pyrimidine bases.
- Ex. 5-Fluorouracil, 6-Mercaptopurine, and Methotrexate
- Ex. Methotrexate, Fluorouracil, Floxuridine, Mercaptopurine, Thioguanine
- Methotrexate - causes ulceration of oral tissues.
- Antimicrotubular - affects microtubule assembly in cells to inhibit cell mitosis. Ex. Paclitaxel
- Antiestrogen - block tumors that are stimulated by estrogen. Ex. Tamoxifen
- Vinca alkaloids - mitotic spindle poisons. Ex. Vinblastine and Vincristine
- Gonadotropin hormone releasing antigen - inhibit gonadotropin secretion . Ex. Leuprolide.
- Mucositis is a common reaction to cancer chemo. Mucosa begins to desquamate and develop ulcerations.
- Alopecia - hair loss occurs 1-2 weeks after tx.
- Aromastase inhibitors -
- Exemestane - an irreversible, steroidal aromatase inhibitor. Prevent the concersion of androgens to estrogens by tying up the
enzyme aromatase. Lowers circulating esterogens - helpful in breast cancers where growth is estrogen dependent.
- Letrozole - first line treatment of horomone receptor positive or metastatic breast cancer in post menopausal women.
- Corticosteroids
- Used to tx - asthma, arthritis, allergies, aphthous stomatitis, lupus, and TMJ pain, Addison's Disease
- Contraindications - latent infections, AIDS, herpes, gastric ulcers, CHF
- Long term effects - abdominal edema, peptic ulcers, osteoporosis, muscle weakness
- Nasal and inhaled corticosteroids do NOT achieve significant blood levels.
- Glucocorticoids - Used as anti-inflammatory agents. Affect carbohydrate, lipid and protein metabolism. ENHANCE gluconeogenesis through
the breakdown of endogenous proteins which are converted to glucose.
- Aerosols - Triamcinolone, Beclomethasone, Fluticasone, and Budesonide - used for chronic asthma and bronchial disease.
- Nasal sprays - Triamcinolone, Fluticasone, Budesonide
- Mineralocorticoids - regulate sodium and potassium metabolism by INCREASING sodium retention and potassium depletion which can lead to
edema and hypertension.
- Opiates - aka narcotic analgesics. Raise the pain threshold to increase pain tolerance. Used to relieve moderate to severe pain, as pre-anesthesia
medications, as analgesic adjuncts during anesthesia, as antitussives, and antidiarrheals. Cause drowsiness and sleep as a side effect. Most serious
side effect is respiratory depression. Produce drug dependence. Do NOT cause peptic ulcers. Do NOT affect blood clotting or affect pts taking Warfarin.
- Opium alkaloids
- Codeine
 - Morphine - NOT used in dentistry due to high addictive liability.
- Synthetic derivatives
- Meperidine = Demerol - an IV supplement during conscious sedation. LESS potent than morphine. Also used as an oral medication
after dental surgery. The ONLY narcotic agent that does NOT cause miosis.
- Hydrocodone = Vicodin
- Oxycodone = Oxycontin - side effects include nausea and constipation.
- Fentanyl - a potent narcotic analgesic used primarily as an IV supplement during conscioius sedation or general anesthesia. 80-100
times MORE POTENT than morphine. Can be administered as a lollipop or skin patch.
- Pentazocine - chemically related to morphine. Has weak analgesic properties.
- Hydrocodone with Acetaminophen = Vicodin, Lorcet, Lortab
- Hydrocodone with ibuprofen = Vicoprofen
- Oxycodone with acetaminophen = Percocet, Roxicet, or Tylox
- Oxycodone with ibuprofen = Combunox
- Codeine with Acetaminophen = Tylenol #3
- Opioid antagonists = Naloxone - used in opioid overdoses. Also - Nalmefene and Naltrexone.
- Endogenous opioids - produce morphine like effects
- Beta-endorphins - bind to opioid receptors in the brain and have potent analgesic activity
- Enkephalins - bind to opioid receptors in the brain. More widely distributed than beta-endorphins. Plays a role in pain, movement, mood, and
behavior.
- Dynorphins - the MOST powerful of the endogenous opioids. Found in the CNS and PNS.
- Opioid receptors
- Mu = prototype opoid agonist is morphine.
- Delta = enkephalins bind here
- Kappa = dynorphins bind here
- Interferons - act to induce gene transcription, inhibit cellular growth and alter the state of cell differentiation. Used to tx hairy cell leukoplakia, chronic Hep
B, recurring genital warts, and tx of multiple sclerosis.
- Anti-hypertensive agents - lower BP by reducing the total peripheral resistance and reducing cardiac output through a variety of mechanisms.
- Diuretics - inhibit sodium reabsorption in renal tubular cells within the kidney to cause excess sodium and urinary excretion resulting in reduced
blood volume
- Thiazides - inhibit sodium reabsorption in the renal tubules causing excretion of sodium and water. Ex. Hycdochlorothiazide
- Loop diurectics - inhibits the reabsorption of sodium and chloride in the ascending loop of henle. Ex. Furosemide (Lasix)
- Potassium-sparing diuretics - conserve potassium so none is lost. Result in increased sodium and decreased potassium
concentrations at the end of the distal convoluted tubules. Most important toxic effect is hyperkalemia.
- Ex. Spironolactone and Triamterene - competes with aldosterone receptors sites in renal tubule causing increased
secretion of sodium, chloride and water but no effect on potassium.
- Spironolactone - a pharmacologic antagonist of aldosterone in the collecting tubules.
- Beta adrenergic receptor blockers - reduce the volume of cardiac output into the circulation resulting in reduced peripheral pressure
- Cardioselective beta blockers- B1 receptor in heart muscle is blocked - Ex. Atenolol and Metoprolol
- Non-cardioselective beta blockers - Ex. Nadolol, and Propranolol
- ACE inhibitors - inhibit the conversion of inactive Angiotensin I to Angiotensin II (the vasoconstrictor). Results in peripheral vasodilation and
increases urinary volume excretion.
- Ex. Lisinopril, Ramipril, Captopril and enalapril
- Calcium channel blockers - inhibit calcium entry into vascular smooth muscle causing vasodilation of coronary and peripheral blood vessels.
- Ex . Amlodipine, Diltiazem, Nifidepine
- Tolazoline - a parental antihypertensive agent. Causes direct peripheral vasodilation by CENTRALLY stimulating A2
- Methyldopa - most effective when combined with a diuretic. Produces a false transmitter which replaces NE in vesicular storage sites. Used to
tx HTN in pts with renal damage.
- Clonidine - used in combination with Thiazide diurectics and hydralazine. An A2 selective agonist - it relaxes blood vessels and lowers BP.
- Guanfacine and Guanabenz - stimulate A2 adrenergic receptors reducing peripheral vascular resistance.
- Angiotensin II blockers - prevents angiotensin II from constricting the blood vessels which raise BP. Angiotensin II also stimulates the release of
aldosterone which promotes sodium and water retension.
- Ex. Losartan, Valsartan, Candesartan, Irbesartan
- Direct vasodilators - act on smooth muscle of arterioles resulting in a decrease in peripheral resistance and blood pressure.
- Minoxidil - very effective so it is reserved for extreme hypertension
- Nitroprusside and diazoxide - parental vasodilators used in hypertensive emergencies.
- Nitroglycerin
- Angina pectoralis - pain in the heart and chest during the occlusion of coronary arteries. Triggered by physical exertion, increased BP and
vasoconstriction.
- Nitroglycerin - a coronary artery vasodilator. Relaxes blood vessels to increase blood flow so more oxygen can get to the heart. Effective
sublingually in 2-4 minutes.
 - Nifedipine and diltiazem - calcium channel blockers used to prevent angina attacks.
- Propranolol and atenolol - beta blockers used to decrease the work load of the heart so less oxygen is required.
- Cholesterol
- HMG-CoA Reductase Inhibitors - aka Statins - lowers blood cholesterol by inhibiting a key enzyme in cholesterol synthesis pathway in the liver.
- These drugs can increase the breakdown of skeletal muscle causing the release of muscle protein. This protein can overload the
kidneys causing renal failure. CAUTION - Erythromycin enhances this side affect!!!
- Ex. Atorvastatin (Lipitor), Simvastatin, Fluvastatin, Lovastatin, Pravastatin, Rosuvastatin
- Anti-coagulants
- Used to prevent CAD, angina pectoris, myocardial infarction, and strokes. NOT hypertension.
- The MOST valuable test used to evaluate the patient as a surgical risk - PT (Prothrombin Time)
- INR - international normalized ratio - 1 = normal prothrombin time of 12 sec. Values greater than 1 = there is an anticoagulant effect.
- The higher the INR value, he greater the anticoagulant effect. Values between 1-1.5 are considered safe for surgery (12-18 sec)
- Other drugs that increase pts bleeding time - aspirin, NSAIDS, Clopidogrel (Plavix), Ticlopidine, Coumadin and Heparin
- Heparin - inactivates THROMBIN and prevents the conversion of fibrinogen to fibrin. Enhances ANTITHROMBIN III which impairs Factor Xa
inactivating thrombin.
- Ex. Enoxaparin, Dalteparin, Tinzaparin - low molecular weight heparin type anticoagulants.
- Contains within mast cells and basophils. Neutralizes tissue thromboplastin and also block thromboplastin generation.
- Warfarin (Coumadin) - interferes with the hepatic synthesis of VITAMIN K dependent coagulation factors like factors II, VII, IX, and X resulting
in the inability of the coagulation pathway to produce THROMBIN. Prolong blood clotting times.
- Vitamin K - a FAT soluble vitamin involved in the synthesis of factors II, VII, IX, X, and prothrombin in the liver. enhances blood
clotting!
- Aspirin - inhibits blood clotting by inhibiting PLATELET aggregation in an IRREVERSIBLE way. Does NOT affect the coagulation pathway, but
prevents clotting by inhibiting the fibrin clot from forming. Takes 5-7 days for normal clotting to resume.
- Clopidogrel (Plavix) - inhibits platelet aggregation in an IRREVERSIBLE manner similar to aspirin. But does not cause gastric ulcers like
asprin.
- Glycoprotein IIb/IIa inhibitor type of antiplatelet agents - REVERSIBLE anti-platelet agents. Used to prevent acute cardiac ischemic
complications. Administered via IV. Ex. Abciximab, Eptifibatide, Tirofiban.
- Thrombin-inhibitor type anticoagulants - administered via IV to prevent post-op deep vein thrombosis after hip surgery. Directly inhibits
thrombin.
- Ex. Lepirudin, Argatroban, Danaparoid
- Antisialagogues - classified as anticholinergics. They block postganglionic cholinergic fibers. Reduce spasms of smooth muscle in the bladder, bronchi,
and intestines. Relax the iris sphincter = mydriasis, decrease gastric, bronchial, and salivary secretions, decrease perspiration.
- Ex. Atropine Sulfate, Glycopyrrolate, Belladonna derivatives, Propantheline bromide
- Contraindications - glaucoma, CV problems, asthma
- Anti-muscarinic agents - no intrinisic activity - they simply bind to the receptor site and prevent Acetylcholine from binding. Often used to prevent motion
sickness. To cure traveler's diarrhea.
- Ex. Atropine, Scopolamine, Glycopyrolate, Propantheline
- Cholingeric drugs - induce the formation of saliva. Stimulate acetylcholine cholinergic receptors. Cause miosis (papillary constriction), excessive
sweating, increased GI motility, bradycardia.
- Direct acting - methacholine, carbachol, bethanecol, pilocarpine
- Indirect acting - neostigmine, physostigmine, edrophonium, pydridostigmine
- Monoamine Oxidase Inhibitors - used to treat depression. Antagonize MAO which is responsible for the degradation of the naturally occurring
monoamines - epinephrine, norepinephrine, dopamine, and serotonin. An increase in MAO in the brain helps depression.
- Ex. Isocarboxazid, Tranylcycpromine, Phenelzine
- Do NOT give EPINEPHRINE to patients taking MAO inhibitors!!!!
- Interact with MANY drugs! - meperidine, epinephrine, and ephedrine.
- Foods that contain TYRAMINE are prohibited if taking this drug
- Antihistamines - histamine is preformed and stored in cytoplasmic granules of tissue mast cells and blood basophils. It is released in response to IgE
allergic reactions. Can both stimulate and depress the CNS.
- H1 blockers - involved in ALLERGIC reactions. Do NOT prevent the release of histamine but rather compete with free histamine from binding.
Block vasodilation, block constriction of bronchi, block capillary permeability.
- First generation - Ex. Diphenhydramine (Benedryl), - have a BROAD spectrum of action. Can cause drowsiness.
- Second generation - Ex. Chlorpherniramine, Loratidine (Claritin), Desloratidine (Clarinex), Fexofenadine (Allegra) - cause less
sedation and drowsiness than first generation agents.
- H2 blockers - involved in GASTRIC secretions. Mainly used to treat DUODENAL ulcers. REVERSIBLE competitive agonists of H2 receptors.
- Ex. Cimetidine (Tagamet), Femotidine (Pepcid)
- Rantidine - used to treat GERD by competing with histamine in the GI tract.
- Hepatic drug metabolism -
- Microsomal enzyme inhibition - ex. P450 micrsomal drug metabolizing system -
- Routes of Drug Administration
 - Subcutaneous administration of a drug - 15 minutes
- Oral route - takes 30 minutes
- Intramuscular - takes 5 minutes since blood flow through muscles is rapid
- Inhalation - gains access to general circulation within 5 minutes
- Topical ointments or creams - not intended for systemic drug administration
- Patch - releases drugs over 12-24 hours
- Local Anesthetics - decreases sodium uptake through sodium channels of the axon resulting in decreasing the nerve excitability below a critical level so
impulses can't propagate along the axon. NO effects on potassium.
- Amides - metabolized in the LIVER by the hepatic microsomal enzyme system (caution for pts with liver disease!)
- Ex. Lidocaine, Mepivacaine, Prilocaine, Bupivacaine, Articaine
- Bupivacaine - has the LONGEST duration of action - 5-7 hrs for an IA block!
- Articaine - aka Septocaine - 4% solution. An amide but chemically unique because it has an ester group attached to it - this allows it
to be metabolized by plasma cholinesterase. The ONLY amide-type LA metabolized in the BLOODSTREAM rather than the liver.
- Max dose recommended - 7mg/kg.
- Prilocaine - used for nerve blocks, epidural and regional anesthesia. Longer acting than lidocaine. When metabolized, it produces
methemoglobin - a less effective kind of hemoglobin. Do NOT use in pts with LIVER disease.
- For lidocaine, a dosage of 4.4mg/kg should NOT be exceeded. Max dose 300mg (15ml)
- 2% = 20mg/ml x 1.8ml/carpule = 36mg/1carpule
- Esters - metabolized in PLASMA by plasma cholinesterase. Mainly used as topical anesthetics, NOT injectable due to high incidence of allergy
to PABA.
- Ex. Benzocaine, tetracaine, dibucaine. Procaine = novocaine. Cocaine is an ester!!!
- The BISULFATES are what might cause an allergic reaction.
- Allergic reactions are more common in Ester-type LA.
- Overdose - causes restlessness, tremors, seizures followed by CNS depression, bradycardia, slowed respiration.
- SMALL UN-myelinated nerve fibers which conduct pain and temp are affected first.
- They are fat soluble drugs that are converted to their water-soluble hydrochloride salts for injections.
- ONLY NON-IONIZED (where the free base is readily avail) form can readily penetrate tissue membranes. Once injected, the pH of
the tissue favor the non-ionized form BUT if there is an infection and the tissue is more acidic, there is a reduction in the non-ionized
form.
- Glaucoma - an increase in intraocular pressure. Caused by poor drainage of the aqueous humor and can cause blindness.
- Pilocarpine - eye drops cause papillary constriction allowing drainage of the aqueous humor to reduce pressure
- Latanoprost - a prostaglandin analog. Eye drops reduce intraocular pressure by increasing the outflow of the aqueous humor.
- Betaxolol - a beta blocker, eye drops reduce intraocular pressure by reducing the production of aqueous humor
- Bimatoprost - same action as latanoprost
- Xerostomia - caused by many drugs
- Tricyclic Antidepressants - Ex. Amitriptyline
- Anti-histamines - Ex. Diphenhydramine (benedryl)
- Anti-cholinergics - Ex. Atropine
- Benzodiazepines - Ex. Diazepam
- Rheumatoid Arthritis - a chronic inflammatory disease of joints that results in joint pain, swelling, and destruction. Characterized by chronic inflammation
of the synovium which lines the joints. Prostaglandin, leukotrienes, accumulate and destroy the synovial lining. These drugs, except gold, can be used to
treat Osteoarthritis too.
- DMARDS = disease modifying anti-rheumatic drugs
- Ex. Prednisone, Gold injections (decrease prostaglandin production), Methotrexate.
- Ex. Nabumetone and Piroxicam - NSAIDS that inhibit prostaglandin synthesis
- Ex. Etanercept - used when DMARDs are not adequate. Binds to TNF to decrease the inflammatory process.
- Ex. Infliximab - used to tx Crohn's disease and rheumatoid arthritis. Binds to TNF alpha.
- Proton Pump Inhibitors - GI drugs that reduce the formation of stomach acid by inhibiting the proton pump of stomach parietal cells.
- Ex. Omeprazole and Lansoprazole
- H2 receptor blockers - Histamine normally stimulates the gastric parietal cells to produce HCl.
- Ex. Ranitidine, Cimetidine and Famotidine
- Allergic reaction
- Immediate - onset reactions like anaphylaxis which occur within 30 minutes and are IgE mediated.
- Accelerated - reactions that occur 30 min to 48 hrs later. Usually not life threatening - urticaria, wheezing, pruritus.
- Delayed - take longer than 2 days to develop. 80-90% of all penicillin reactions are this type - skin rash.
- Asthma -
- Fluticasone - an inhalation corticosteroid used to decrease inflammation in the airway. Enhances the bronchiodilating effects of B2 agonists.
Side effects - can cause fungal infections of mouth and throat.
- Also - Triamcinolone, Beclomethasone, Budesonide
- Anti-epileptic drugs
 - *** Phenytoin (Dilantin) - causes Na channel blockade. Used to treat tonic-clonic grand mal seizures. Can cause severe gingival hyperplasia.
- Gabapentin - used to tx partial seizures
- Carbamazepine - used as prophylaxis for partial seizures. Also treats tonic-clonic grand mal seizures and TRIGEMINAL NEURALGIA.
- Diazepam - tx for status epilepticus and in emergency tx of seizures.
- Valproic acid - tx for pts with complex partial seizures and pts with multiple seizure types. Can cause liver failure and blood dyscrasia.
- Ethosuximide - effective in tx of absence seizures by causing a Calcium Channel blockade.
- Bipolar disorder - Ex. Lithium - used to tx the manic phase.
- Amphetamines - sypathomimetic amines that have a stimulating effect on BOTH the CNS and PNS. Pass readily into the CNS and cause a rapid release
of NE in the brain. Increase systolic and diastolic BP, act as weak bronchodilators and respiratory stimulants. High potential for abuse.
- Tx - ADHD, Narcolepsy, Weight loss
- Ex. Dextroamphetamine (Adderol)
- Anti-arrhythmics - uses the Vaughan-Williams classification system to classify them.
- Group 1 = block sodium channels. Further classified on the basis of their effects on ACTION POTENTIAL
- Group 1A - PROLONG the action potential. Ex. Quinidine, procainamide, amiodarone, disopyramide.
- *** Quinidine (prototype) - treats atrial fibrillation and supraventricular tachycardia. Not effective with life-threatening
ventricular fibrillaiton
- Procainaminde -used to tx atrial fibrillation, atrial flutter. Derived from the ester local anesthetic procaine.
- Group 1B - SHORTEN the action potential. Ex. Lidocaine, mexiletine, and tocainide.
- Lidocaine - used via IV to treat ventricular arrhythmias. Acts on fibrillating ventricles to decrease the cardiac excitability
but spares the atria
- Group 1C - have NO effect on action potential duration. Ex. Flecainide.
- Group 2 - beta blockers Ex. Propranolol and esmolol.
- Group 3 - potassium channel blockers Ex. Amiodarone
- Ex. Amiodarone - the most potent and broad spectrum anti-arrhythmic. Blocks sodium, calcium, and potassium receptors AND beta
receptors. Suppresses both supraventricular and ventricular arrhythmias.
- Group 4 - Calcium channel blockers (also used to tx angina)
- Verapamil (prototype) - inhibits the entry of calcium through the slow channels of the calcium dependent tissues of the myocardium
in the SA and AV nodes. Drug of choice for paroxysmal supraventricular tachycardia stemming from the AV node.
- Diltiazem, Nifedipine
- General Anesthesia
- Four stages
- Amnesia/analgesia
- Delirium - los of eyelid reflex, purposeless movement, dilated pupils, reflex vomiting, tachycardia, hypertension - BAD!
- Surgical
- Medullary paralysis - cessation of respiration resulting in death - BAD
- Inhalation agents - Desfluorane, sevofluorance, Halothane, isoflurane, enflurane - effective at 3-5% conc.
- IV agents
- Barbiturates - Thiopental, Methohexital, Ketamine
- Benzodiazepines - Diazepam, Midazolam, Iorazepam
- Neuroleptic opiods - combine fentanyl and droperido.
- Nitrous Oxide - Produces sedation and mild analgesia. a gas at room temp and pressure. Can NOT produce general anesthesia except at concentrations
greater than 80%. Not flammable. Must be given with a minimum of 20% oxygen.
- Nitrous oxide = blue. Oxygen = green
- Glucocorticoids - steroid hormones produced by the adrenal cortex. Side effects - can cause peptic ulcers!
- Glucocorticoids - affect arachidonic acid metabolism by inducing the synthesis of a protein that inhibits the productin of phospholipase A2
resulting in a decrease in production of prostaglandins and leukotrienes.
- Ex. Cortisol, prednisone, dexamethasone, triamcinolone
- Mineralocorticoids - secreted from zona glomerulosa in the adrenal cortex. Regulate sodium and potassium reabsorption in the kidney and
increases BP (a decrease in sodium concentration causes juxtaglomerular cells on the kidney to secrete rennin which converts
angiotensinogen to angiotensin I. Angiotensin II stimulates the release of aldosterone.
- Ex. Aldosterone, deoxycorticosterone, fludrocortisones
- Colony Stimulating factors - stimulate the production of neutrophils and erythroid progenitor cells in the hematopoietic process
- Darbepoetin alpha - induces erythropoeisis by stimulating the division and differentiation of erythroid progenitor cells. Used to tx anemia
associated with chronic renal failure
- Pegfilgastrim and sargramostin - stimulates the production, maturation, and activation of neutrophils. Used to decrease the incidence of
infection in pts with nonmyeloid malignancies or after bone marrow transplants.
- Urinary elimination of drugs is controlled by - glomular filtration, tubular reabsorption and active transport.
- Anti-malarials- Mefloquine, Chloroquine, Quinine, Halofantrine, Combo of atovaquone and proguanil, combo of sulfadoxine and pyrimethamine
- Bisphosphonate drugs - used to treat and manage osteoporosis and prevent hypercalcemia. BRONJ!
- Ex. Zolendronic acid, Palmidronate, Alendronate (Fosamax)
- Controlled Substance Act of 1970 - Schedule of Drugs - must have DEA number.
- Schedule I - not considered legitimate for medical use. Cannot be prescribed. Ex. LSD, heroin, marijuana.
- Schedule II - strong potential for abuse and addiction but have legitimate medical use. Cannot be called in to the pharmacy over the phone.
Cannot prescribe refills - a new Rx must be written. Ex. Amphetamines, Morphine, Cocain, Oxycodone, Codeine
- Schedule III - less potential for abuse or addiction. Ex. Tylenol #3, Vicodin (combo with codeine or hydrocodone)
- Schedule IV - Benzodiazepines, chloral hydrate
- Beta-lactam Antibiotics - include cephalosporins, penicillins, monobactams, and carbapenems
- Beta-lactamases -enzymes produced and secreted by bacteria as a defense against antibiotics..
- Ex. Cephalosporinease and penicillinase
- Methicillin renders the antibiotics stable in the presence of these enzymes
- By combining CLAVULANIC ACID with penicillin - the beta lactamase enzyme is permenantly inhibited by the acid.
- AUGMENTIN - combines amoxicillin and clavulanate potassium.
- Probenecid - often co-administered with antibiotics to delay the renal clearance of it to elevate and prolong the serum concentration of the
antibiotic when high tissue concs are necessary. Also used to tx gout.,
- Imipenem -a beta lactam antibiotic derived from thienamycin. The first CARBAPENEM antibiotic.
- Aztreonam - a parental synthetic beta lactam antibiotic. Limited to gram negative rods. Has no gram positive or anerobic activity.
- Penicillins - contain a beta-lactam ring structure joined to a thiazolide ring. BACTERIOCIDAL - inhibit cell wall synthesis
- Penicillin G - prototype penicillin,
- Penicillin VK - preferred for oral infections because it is more acid stable. Associated with the highest incidence of ALLERGY! Can
be prescribed to pregnant women. Very LIMITED spectrum of action - gram positives and anaerobes.
- Which penicillin has the widest spectrum of antibacterial activity? Carbenicillin
- Aminopenicillins - Ex. Ampicillin and Amoxicillin - characterized by the amino substitution of pencillin G.Inhibit CELL WALL
synthesis. Used to tx URI and UTI. NOT stable to beta-lactamases. Very effective against GRAM -.
- Amoxicillin - has an EXTENDED spectrum of action - higher oral absorption, high serum levels, long half life than
ampicillin.
- Bacampicillin - used to tx upper and lower respiratory infections, UTI. Better absorption than ampicillin and decreased GI
side effects.
- In large doses, it inhibits the renal tubular secretion of METHOTREXATE
- Methicillin - used to tx SEVERE penicillinase producing staphylococcal infections. Given IV.
- MRSA - methicillin resistant streptococcus aureus - resistant to all penicillinase resistant penicillins and cephalosporins.
Tx with Vancomycin.
- Degraded by stomach acid so MUST be given parentally - methicillin, penicillin G, and carbenicillin
- Acid stable - penicillin VK, Amoxicillin, Ampicillin, Nafcillin, Oxacillin, Cloxacillin, Dicloxacillin
- Extended spectrum - aminopenicillins
- Broad spectrum - carbenicillin, piperacillin, ticarcillin. They have the WIDEST spectrum of all penicillins
- Penicillinase-resistant - methicillin, nafcillin, oxacillin, cloxacillin, dicloxacillin - they have a protected beta-lactam ring.
- Cephalosporins - BROAD spectrum antibiotics. BACTERIOCIDAL. Affect the bacterial CELL WALL during cell division. Four generations -
gets broader action against gram + and decreased activity against gram -. 10% of those allergic to penicillin are also allergic to cephalosporins.
- 1st generation - cephalexin, cephradine, cefadroxil, cefazolin
- 2nd generation - cefaclor, cefuroxime, cefoxitin
- 3rd generation - cefixime, cefoperazone
- 4th generation - cefepime
- Macrolide antibiotics -prototyle is Erythromycin. Ex. Azithromycin, Clindamycin, clarithromycin - BACTERIOSTATIC - Inhibits PROTEIN SYNTHESIS by
binding to 50S subunit of bacterial ribosome.
- Intrinsic activity against H. influenza.
- Erythromycin - know to cause adverse GI effects. Usually enteric coated because stomach acid destroys them.
- Clindamycin - can cause severe diarrhea and pseudomembranous colitis due to overgrowth of Clostridium difficile. Active against gram +,
many anaerobic organisms, including Bacteroides fragilis. Can be given to pts allergic to penicillin since there is no cross allergenicity.
- Tetracyclines - inhibit PROTEIN synthesis by binding to 30S subunit of bacterial ribosome. BROAD spectrum. BACTERIOSTATIC. Useful in tx of acne,
periodontitis associated with Actinobacillus actinomycetemcomitans = ANUG!!, rickets. Absorption in GI tract is inhibited by divalent and trivalent cations
liked Ca2+, Mg2+, Fe2+, and Al3+ - they chelate the drug preventing absorption. Do not take with dairy, iron, or magnesium!!! Side effects - yeast
infections!!, Associated with photosensitivity causing red rashes.
- Aminoglycosides - BACTERIOCIDAL, have BROAD spectrum, used mainly to treat AEROBIC gram - infections. Bind IRREVERSIBLY to 30S subunit of
ribosome inhibiting PROTEIN synthesis. Severe side effects - OTOTOXICITY and NEPHROtoxicity. Administered by IM or IV since poorly absorbed
orally.
- Gentamicin - Amikacin, Tobramycin, Netilmicin,
- Streptomycin - was once used to tx tuberculosis.
- Chloramphenicol - a BROAD spectrum, major side effects - can cause APLASTIC ANEMIA, bone marrow suppression, and Gray syndrome.
- Sulfonamides - structurally similar to PABA which is used by bacteria to synthesis folic acid. Inhibits PABA which inhibits cell growth. BACTERIOSTATIC.
Not used to tx dental infections. Used to treat UTI.
- Metronidazole- NOT a true antibiotic since it is not found in natural organisms - it is a SYNTHETIC substance produced in the chemical laboratory.
- Agents affecting cell wall - penicillins, cephalosporins, bacitracin, vancomycin, cycloserine, azteronam, imipenem
- Agents interfereing with protein synthesis - tetracycline, aminoglycosides, chloramphenicol, erythromycin, lincomycin, clindamycin, azithromycin,
clarithromycin
- Agents interfering with bacterial metabolic pathways - sulfonamides
- Agents affecting bacterial DNA - metronidazole (flagyl), trimethoprim, fluoroquinolones (ciprofloxacin)
- Bacteriostatic abx - tetracyclines, clindamycin
- Antibiotic prophylaxis
- For pts with total joint replacement -
- Amoxicillin - penicillin family. 2g 1hr prior. Tx of choice to prevent bacterial endocarditis
- Clindamycin - 600mg 1hr prior.
- Cephalexin - 1st generation cephalosporin. 2g 1hr prior.
- Cephradine - 1st generation cephalosporin. 2g 1hr prior
- HIV
- Nucleoside reverse transcriptase inhibitors - nucleosides which inhibit the viral enzyme known as reverse transcriptase. Inhibits the HIV viral
RNA from being made into a DNA segment.so the genome can't be copied.
- Ex. Stavudine, Didanosine, Zalcitabine
- Protease inhibitors - suppress viral replication by inhibiting protease, the enzyme responsible for cleaving viral precursor peptides into infective
virions.
- Ex. Indinavir, Nelfinavir, Ritonavir, Saquinivir
- Non-nucleoside reverse transcriptase inhibitors - inhibit the catalytic reaction of reverse transcriptasr that is independent of nucleoside binding.
- Ex. Delavirdine, Adefovir, Nevirapine
- Anti-fungal
- Ex.Amphotericin- B- given IV or orally to treat SEVERE systemic fungal infections. Associated with kidney toxicity.
- Ketoconazole - avail as a cream or tablet
- Fluconazole - tablets ONLY, used to tx oral and esophageal candidiasis
- Nystatin - avail as oral suspension or a cream. Drug of choice for candidiasis
- Clotrimazole - ONLY avail as a troche.
- Drugs that cause orthostatic hypotension - antihypertensives (guanethidine), phenothiazines (chlorpromazine,thioridane), tricyclic antidepressants
(doxepin, amitriptyline, imipramine), narcotics (meperidine), antiparkinsons drug (Levodopa)
- Herpes labialiis - pencyclovir, acyclovir cream or tablets,
- Penciclovir - a cream indicated for recurrent herpes labialis. Not avail for systemic dosing. Inhibits viral action by selectively inhibiting herpes
viral DNA synthesis.
- Antiprotozoal Agents
- Nitazoxanide - tx diarrhea caused by giardia. Interferes with electron transfer reaction essential for protozoa anaerobic metabolism.
- Atovaquone - tx pneumocystitis carinii pneumonia (PCP)
- Eflornithine - tx of trypanosmoma brucei (sleeping sickness). Also used to remove unwanted hair from face.
- Furazolidone - tx diarrhea caused by giardia and vibrio cholera
- Metronidazole (flagyl) - synthetic antibiotic effective against trichomonas vaginalis and anaerobic bacterial infections.
- Tuberculosis - bacterial infection caused by mycobacterium tuberculosis. Combination of drugs are always used.
- Isoniazid, Rifampin, pryrazonamide, and ethambutol - often given in a four drug regimin
- Amyl nitrite - a vasodilator administered by inhalation ONLY. Used in emergency treatment of cyanide poisoning because it oxidizes hemoglobin to
methemoglobin which binds cyanide tightly keeping it in the peripheral circulation so it can't access tissues.
- CNS stimulatants -
- Analeptics = a CNS stimulant which has the ability to overcome drug induced respiratory depression and hypnosis. NOT for overdose of CNS
depressants!
- Ex. Pentylenetetrazol, nikethamide, doxapram, picrotoxin, strychnine.
- Xanthines - Ex. caffeine, theophylline and theobromine. Caffeine is the ONLY OTC stimulant.
- Theophylline - used to tx asthma by stimulating respiratory centers of the medulla and causing bronchial dilation.
- Sympathomimetic amines - Ex. Amphetamines. POTENT CNS stimulants used to treat narcolepsy, obesity, and ADD.
- Ex. Methylphenidate, phenmetrazine
- Cardiac Glycosides - aka Digitalis. Tx SUPRAventricular arrhythmias, cardiogenic shock, and congestic heart failure. Help the heart beat more strongly
(a positive inotropic effect) and more efficiently. INCREASES the refractory period of cardiac muscle. Inhibit the Na-K-ATPase membrane pump which
results in an increased calcium ion influx into the cell causing stronger muscle contractions.
- Ex - Digoxin - the most versatile and widely used. A positive inotrope which is independent of normal sinus rhythm and adrenergic stimulation.
- Rx
- Superscription - pts names, address, age, date
- Inscription - name of drug and strength (ex. Amoxicillin 500mg tablets)
- Subscription - directions to pharmacist (ex. Disp - 4 tabs
- Transcription - directions to pt (ex. Sig - take 4 tabs 1 hr prior to dental appt)
 - Signature
- Anti-diabetics - used to treat NON-insulin dependent diabetes II that's can't be controlled by diet alone.
- Glyburide and chloropropamide - stimulates insulin release from the pancreas. Reduces glucose output from the liver by increasing insulin
sensitivity at peripheral targets.
- Metformine and pioglitazone - increase insulin sensitivity at peripheral targets
- Toblutamide - a sulfonylurea which stimulates the synthesis and release of insulin from the pancreas. Als increases the sensitivity of insulin
receptors and improves the peripheral utilization of insulin.
- Insulin -
- Short acting - 8-12 hours
- Intermediate acting - 18-24 hr.
- Insulin zinc suspension - aka lente insulin - an INTERMEDIATE acting insulin with a duration of over 24 hours after a single
injection.
- Isophane insulin suspension
- Long acting - more than 36 hour, Ex. Protamine zinc insulin and Ultralente insulin
- Ex. Humulin 70/30 = brand name for 70% isophane insulin suspension and 30% regular insulin injection. FAST onset, LONG duration.
Regular insulin provides the fast onset. The suspension provides long duraction.
- Disulfiram (antabuse) - used to treat alcohol abuse. It is an antioxidant that interferes with the hepatic oxidation of the acetaldehyde metabolized from
alcohol. It inhibits aldehyde dehydrogenase resulting in large amounts of acetaldehyde in the body.
- Antacids - decrease the concentration and total load of gastric acid.
- Aluminum salts - Ex. Aluminum hydroxide - the MOST POTENT of all, but has less neutralizing capacity.
- Sodium bicarbonate - ex. Alka seltzer
- Calcium carbonate - ex. Amitone, tums
- Magnesium and aluminum products - Maalox and Mylanta
- Gout
- Colchicine - drug of choice. Reduces the inflammation during acute attacks. Impairs leukocytic migration to inflamed areas and disrupts urate
deposition and subsequent inflammatory response.
- Indomethacin - NSAID that is commonly used
- Spasmolytic drugs - skeletal muscle relaxants - relieve muscle spasms without paralysis. Act in the CNS or skeletal muscle cell rather than at the
neuromuscular plate. Used in chronic CNS diseases like multiple sclerosis, cerebral palsy, and Cerebrovascular accidents.
- Chronic muscle spasms
- Baclofen - a derivative of GABA. Reduces spams in the spinal cord. Used to tx multiple sclerosis.
- Carisoprodol - used to tx muscle spasms associated with acute temporomandibular joint pain.
- Acute muscle spasms
- Cyclobenzaprine - relieves muscle spasms through a central action, possibly at the brain stem level. Used to relieve acute, painful
musculoskeletal conditions. NOT effective for muscle spasms caused by cerebral or spinal cord diseases.
- Methocarbamol - centrally acting muscle relaxant used to relieve acute, painful musculoskeletal conditions and tetanus.
- Quinine - widely used to relieve nocturnal leg cramps.
- Parkinson's Disease - a slow, progressing, degenerative disorder of the nervous system. Tremors, sluggish initiation of movements, muscle rigidity.
Nerve cells in the basal ganglia degenerate resulting in lower production of DOPAMINE.
- *** Carbidopa - used to treat Parkinson's disease. MUST be used in combination with LEVODOPA. Levodopa replenishes the brains supply of
dopamine. Carbidopa inhibits the peripheral decarboxylation of levodopa so more can reach the brain.
- Bromocriptine or pergolide - dopamine agonists given in addition to levodopa to enhance its action.
- Selegiline - a selective MAO inhibitor which usually demainates dopamine in the brain.
- Amandtadine - potentiates dopaminergic responses.
- ADHD
- Methyphenidate (Ritalin) - a mild CNS stimulant. Increases attention span, reduces hyperactivity, and improves behavior.
- Ex. Focalin, Concerta, Adderall, Strattera, Metadate CR
- Strattera - the brand name for atomoxetine, the first NON-stimulant approved for treating ADHD.
- Anti-diarrhea
- Loperamide - aka Imodium - acts on intestinal muscles to inhibit peristalsis. A member of the OPIOID family, but does not penetrate the CNS
like codeine so it can be sold OTC. No evidence of dependence.
- Diphenoxylate and atropine - lomotil - inhibits excessive GI motility. Requires a Rx.
- Oral contraceptives - block ovulating by inhibiting FSH and LH.
Most drugs travel through the blood stream by binding to albumin protein, which is abundant in plasma. The unbound portion is free to leave the blood to be taken up
in tissues where the drug elicits its effect.