Dry Socket

Definition:

      Dry socket (alveolar osteitis) is a painful dental condition that can occur after you have a permanent adult tooth extracted. Dry socket is the most common complication following tooth extractions, such as the removal of impacted wisdom teeth. If you develop dry socket, the pain usually begins three to four days after your tooth is removed.

Normally, a blood clot forms at the site of a tooth extraction. This blood clot serves as a protective layer over the underlying bone and nerve endings in the empty tooth socket. The clot also provides the foundation for the growth of new bone and for the development of soft tissue over the clot.

Dry socket occurs when the blood clot at the site of the tooth extraction has been dislodged or has dissolved before the wound has healed. Exposure of the underlying bone and nerves results in intense pain, not only in the socket but also along the nerves radiating to the side of your face.

Over-the-counter medications alone won't be enough to treat dry socket pain. Your dentist or oral surgeon can provide treatments to relieve your pain and promote healing.

Symptoms:

        Signs and symptoms of dry socket may include:

• Severe pain within a few days after a tooth extraction
• Partial or total loss of the blood clot at the tooth extraction site, which you may notice as an empty-looking (dry) socket
• Visible bone in the socket
• Pain that radiates from the socket to your ear, eye, temple or neck on the same side of your face as the extraction
• Bad breath or a foul odor coming from your mouth
• Unpleasant taste in your mouth
• Swollen lymph nodes around your jaw or neck
• Slight fever

Causes:

   The precise cause of dry socket remains the subject of study. Researchers suspect that several issues may be at play, including:

• Bacterial contamination of the socket
• Severe bone and tissue trauma at the surgical site due to a difficult extraction
• Very small fragments of roots or bone remaining in the wound after surgery

Risk factors:

      Factors that can increase your risk of developing dry socket include:

• Smoking and tobacco use. Chemicals in cigarettes or other forms of tobacco may prevent or slow healing and contaminate the wound site. The act of sucking on a cigarette may physically dislodge the blood clot prematurely.
• Oral contraceptives. High estrogen levels from oral contraceptives may disrupt normal healing processes and increase the risk of dry socket.
• Improper at-home care. Proper at-home care after a tooth extraction helps promote healing and prevent damage to the wound. Failure to follow guidelines may increase the risk of dry socket.
• Having dry socket in the past. If you've had dry socket in the past, you're more likely to develop it after another extraction.
• Tooth or gum infection. Current or previous infections around the tooth to be extracted increase the risk of dry socket.
• Use of corticosteroids. These types of medications, such as prednisone, may increase your risk of dry socket.

Treatments and drugs:

    Treatment of dry socket focuses on reducing symptoms, particularly pain. Dry socket treatment may include:

• Flushing out the socket. Your dentist or oral surgeon may flush the socket to remove any food particles or other debris that may contribute to pain or infection.
• Medicated dressings. Your dentist or oral surgeon may pack the socket with medicated dressings. This step provides relatively fast pain relief. You may need to have the dressings changed several times in the days after treatment starts. The severity of your pain and other symptoms will determine how often you need to return for dressing changes or other treatment.
• Pain medication. Talk to your doctor about which pain medications are best for your situation. You'll likely need a prescription pain medication.
• Self-care. You may be told how to flush the socket at home to promote healing and eliminate debris. To do this, you'll be given a plastic syringe with a curved tip to squirt water, salt water, or a prescription rinse into the socket. You'll be instructed to continue the rinse until the socket no longer collects any debris.

Once treatment is started, you may begin to feel some pain relief in just a few hours. Pain and other symptoms should continue to improve and will likely be gone within a few days.

Source: www.mayoclinic.org

Dry Socket

Unknown Wednesday, September 7, 2016

LOCAL ANESTHESIA

       Local anesthesia is defined as a loss of sensation in a circumscribed area of the body by a depression of excitation in nerve endings or an inhibition of the conduction process in the peripheral nerves. In clinical practice a localized loss of pain sensation is desired. Although the terms dental anesthesia and dental analgesia are used synonymously in dentistry, local analgesia is more accurate. Local anesthesia can be achieved by a number of mechanisms including mechanical trauma, anoxia, and use of neurolytic agents in addition to traditional local anesthetic drugs. However, clinically only reversible local anesthetic agents and other reversible techniques such as temperature reduction or electronic stimulation are useful to prevent pain.


DESIRABLE PROPERTIES OF LOCAL ANESTHETICS:
  1. It should not be irritating to the tissue to which it is applied.
  2. It should not cause any permanent alteration of nerve structure.
  3. Its systemic toxicity should be low.
  4. It must be effective regardless of whether it is injected into the tissue or applied      locally to mucous membranes.
  5. The time of onset of anesthesia should be as short as possible.
  6. The duration of action must be long enough to permit completion of the procedure  yet not so long as to require an extended recovery.
  7. It should have potency sufficient to give complete anesthesia without the use of harmful concentrated solutions.
  8. It should be relatively free from producing allergic reactions.
  9. It should be stable in solution and readily undergo biotransformation in the body.

 MOLECULAR BASIS OF LOCAL ANESTHESIA:
     All local anesthetic agents used in dentistry work by obstructing the exchange in Na+ permeability, which is essential for the initial phases of a neuronal action potential. This mechanism prevents the development and propagation of the action potential by preventing the wave of depolarization. 

FAILURE OF ANESTHESIA: 
     Failure of local anesthetics to achieve profound analgesia may be related to:  
1. inaccurate anatomic placement of local anesthetic solution
2. placing too little solution 
3. allowing insufficient time for it to diffuse and take effect 
4. injecting into inflamed or infected tissues
5. using an outdated or improperly stored anesthetic solution.
   It is recommended that a local anesthetic not be injected in infected tissue because of the risk of spreading the infection and the increased probability of achieving less than effective anesthetic results owing to the low pH within the infected tissue maintaining the ionized, nonlipid-soluble state to the anesthetic.

COMPLICATIONS OF LOCAL ANESTHETICS
    Complications of local anesthetic administration include both local effects and systemic effects.7 Local complications include: 
1. Spread of infection: occasionally infection may be spread into the tissues by the needle passing through a contaminated tissue or by the needle being contaminated before use. 
2. Hematoma: damage of a blood vessel by the tip of a needle may lead to bleeding into the tissues, resulting in the formation of a hematoma. Significant bleeding may produce swelling, act as an irritant to the tissues, and cause pain and trismus. Theoretically, the localized collection of blood becomes an ideal culture medium for bacteria, although infection of a hematoma is unusual. 
3. Nerve damage: rarely, during an injection the needle may pierce a nerve bundle during placement, producing an immediate electric shock sensation to the patient. It is usually followed by a partial sensory deficit, but subsequently a complete return to normal sensation usually follows. 
4. Blockade of the facial nerve: if the injection is given in close proximity to the facial nerve, a motor blockade causing temporary paralysis of the muscles of facial expression may occur. The effect may last for 1- 2 hours. In such circumstances, the desired branch of the trigeminal nerve will not be anesthetized, and a subsequent injection will be required at the correct anatomic location to achieve the desired effect. 

Systemic complications include: 
1. Regional or systemic infection: the spread of infection within the perioral tissues can be potentially spread through planes of the head and neck by passage of a needle through an infected area.
 2. Endocarditis risk: injections such as the intraligamentary injection can force bacteria into the systemic circulation and cause bacterial endocarditis. 
3. Cardiovascular disease: patients with ischemic heart disease (angina pectoris, previous myocardial infarction) or who have had previous cardiac surgery or circulatory dysfunction such as cardiac failure, show higher plasma levels of lidocaine when compared with healthy subjects given the same dose. Therefore it is recommended that the maximum safe dose be halved in such patients.8 Low plasma potassium levels and acidosis also potentiate adverse effects of local anesthetics on the myocardium.7
 4. Liver disease: patients with reduced hepatic function may exhibit an abnormally decreased rate of metabolism of amide local anesthetics, resulting in potentially toxic blood levels. Dosage levels must therefore be reduced for these patients.
 5. Pseudocholinesterase deficiency: local anesthetics of the ester type (eg, procaine) should be avoided in patients who have this rare familial enzyme defect as metabolism of these drugs is impaired. Ester-type local anesthetics are no longer routinely used for dental procedures.

References

Bahl, R. ( 2003). Local Anesthesia in Dentistr. Anesth Prog, 139, 140, 141, 142.

Malamed, S. F. (2004). HANDBOOK OF LOCAL ANESTHESIA. Elsevier’s Health Sciences Rights Department.

LOCAL ANESTHESIA

Unknown Wednesday, August 31, 2016

DENTAL HEALTH AND VENEERS

     Dental veneers (sometimes called porcelain veneers or dental porcelain laminates) are wafer-thin, custom-made shells of tooth-colored materials designed to cover the front surface of teeth to improve your appearance. These shells are bonded to the front of the teeth changing their color, shape, size, or length.

Dental veneers can be made from porcelain or from resin composite materials. Porcelain veneers resist stains better than resin veneers and better mimic the light reflecting properties of natural teeth. Resin veneers are thinner and require removal of less of the tooth surface before placement. You will need to discuss the best choice of veneer material for you with your dentist.

What Types of Problems Do Dental Veneers Fix?

• Teeth that are discolored -- either because of root canal treatment; stains from tetracycline or other drugs, excessive fluoride or other causes; or the presence of large resin fillings that have discolored the tooth
• Teeth that are worn down
• Teeth that are chipped or broken
• Teeth that are misaligned, uneven, or irregularly shaped (for example, have craters or bulges in them)
• Teeth with gaps between them (to close the space between these teeth)

What Are the Advantages of Dental Veneers?

     Veneers offer the following advantages:

• They provide a natural tooth appearance.
• Gum tissue tolerates porcelain well.
• Porcelain veneers are stain resistant.
• The color of a porcelain veneer can be selected such that it makes dark teeth appear whiter.
• Veneers offer a conservative approach to changing a tooth's color and shape; veneers generally don't require the extensive shaping prior to the procedure that crowns do, yet offer a stronger, more aesthetic alternative.

What Are the Disadvantages of Dental Veneers?

The downside to dental veneers include:

• The process is not reversible.
• Veneers are more costly than composite resin bonding.
• Veneers are usually not repairable should they chip or crack.
• Because enamel has been removed, your tooth may become more sensitive to hot and cold foods and beverages.
• Veneers may not exactly match the color of your other teeth. Also, the veneer's color cannot be altered once in place. If you plan on whitening your teeth, you need to do so before getting veneers.
• Though not likely, veneers can dislodge and fall off. To minimize the chance of this occurring, do not bite your nails; chew on pencils, ice, or other hard objects; or otherwise put excessive pressure on your teeth.
• Teeth with veneers can still experience decay, possibly necessitating full coverage of the tooth with a crown.
• Veneers are not a good choice for individuals with unhealthy teeth (for example, those with decay or active gum disease), weakened teeth (as a result of decay, fracture, large dental fillings), or for those who have an inadequate amount of existing enamel on the tooth surface.
• Individuals who clench and grind their teeth are poor candidates for porcelain veneers, as these activities can cause the veneers to crack or chip.

How Long Do Dental Veneers Last?

   Veneers generally last between 5 and 10 years. After this time, the veneers would need to be replaced.

Do Dental Veneers Require Special Care?

Dental veneers do not require any special care. Continue to follow good oral hygiene practices, including brushing, flossing, and rinsing with an antiseptic mouthwash as you normally would.

How Much Do Veneers Cost?

Costs of veneers vary depending on what part of the country you live in and on the extent of your procedure. Generally, veneers range in cost from $500 to $1,300 per tooth. The cost of veneers is not generally covered by insurance. To be certain, check with your specific dental insurance company.

Source: American Dental Association (ADA)

DENTAL HEALTH AND VENEERS

Unknown Tuesday, August 30, 2016

OPEN BITE

Definition

Anterior openbite is generally defined as a condition where the upper incisor crowns fail to overlap the lower incisor crowns when the mandible is brought into full occlusion (Mizrahi 1978, Moyers 1975, Shapiro 2002, Beckman 1998). Hence an openbite could range from a mild case of ‘edge- to-edge’ incisor relationship to a severe skeletal openbite with only the molars in contact.

Simple openbites are usually confined to the teeth and alveolar process whereas complex openbites are based primarily on vertical skeletal dysplasias.

Openbite will occur during transition from primary to permanent dentition, and is considered to be a transient stage of normal dento-alveolar growth and development.

Incidence

Most openbites will resolve during the mixed dentition without treatment; however complex openbites that extend distal to the incisors and persist beyond the mixed dentition phase are more problematic. True anterior openbite in the British population varies from 0.4% to 3% at age 10 years, maintaining an incidence of 2% by 15 years of age (Haynes 1972, Robert and Goose 1979, Todd 1973). Wide racial variation occurs, with 16.3% of African-Americans having openbite at age 11 years (Cooke 1980). Kelly and Harvey
in 1977 stated that 3.5% of Caucasian and 16.3% of African Americans have an openbite. Thirty percent of adult Class III cases have an anterior openbite (Ellis and McNamara 1984), with others suggesting that most openbites are skeletal (Subtelny and Sakuda 1964).

A relatively high 32.3% of children in special needs schools were found to have an anterior openbite malocclusion (Gershater 1972).

Aetiology

Broadly speaking, anterior openbite, like any other malo- cclusion, can be either hereditary or environmental in origin, with aetiological factors acting pre- or post-natally on the tissues of the oro-facial region. Anterior openbites are usually multi-factorial in origin, determined by a combination of many factors operating within the inherent pre- determined growth potential of each particular patient.

Aetiological factors include:

1) Heredity
2) Environmental Factors –
a) Thumb, finger or foreign body sucking
b) Abnormal tongue function
c) Trauma or pathology to one or both condyles
d) Neurologic disturbances Iatrogenic factors, e.g. extruding molars during treatment
e) Airway pathology. An oral breathing pattern is generally considered to be an aetiological factor

Classification and Diagnosis

In describing a skeletal openbite, Schendel et al (1976) coined the term “long face syndrome” in which there is excessive height of the maxilla and a relatively large mandibular plane angle. Proffit characterised patients with skeletal openbite and an increased total face height manifested entirely in the lower facial third as having “long face syndrome”. Due to dental compensation, patients with increased lower facial height may not necessarily have an anterior openbite.

Clinical Presentation

There is great variation in the dental and skeletal morphology in patients with openbites (Cangialosi 1984)

Skeletal Open bite

Extra-oral features of patients with a skeletal openbite often include a long face, lip incompetence, an anterior openbite, steep mandibular plane angle, marked antegonial notching, increased anterior facial height and decreased posterior facial height. These cases may also present with a Class II malocclusion and mandibular deficiency due to posterior and downward rotation of the mandible. Intra-oral features include dental crowding with upright lower incisors, maxillary constriction with buccal segment crossbites, occlusion confined to molar contact and gingival hypertrophy in the anterior segments due to mouth breathing.

Dental Openbite

These patients generally exhibit normal facial features with only intra-oral abnormalities related to the aetiology, eg. Thumb sucking, tongue function/posture. The openbite is generally confined to the incisor region and maybe asymmetric. In cases of digit sucking the maxillary arch may also be narrow with proclination of the upper incisors and retroclination of the lower incisors. In patients with a forward tongue posture proclination and spacing of the upper and lower incisors is often seen.

Treatment Options

1. No active treatment

Clinicians may wait for self correction, particularly during the mixed dentition where skeletal growth appears normal and where no obvious habits are present. About 40-80% of mixed dentition openbites will self-correct in the teenage years (Kantowicz and Korhaus 1929, Anderson 1963, Worms 1971).

2. Habit control

Passive management can include education, motivation and passive appliance treatment such as tongue cribs (Fig. 3) or tongue spurs.

3. Growth modification and active orthodontic treatment

The aim of active treatment is often a combination of impeding posterior tooth eruption, reducing/redirecting vertical growth and extrusion of the anterior teeth. Appliances such as bite blocks, high pull headgear, chin cups and appliances employing magnets have been used. Fixed appliances must be managed carefully to avoid iatrogenic molar extrusion. Segmental arch wire techniques can be used for differential vertical control. More recently, mini- screws and skeletal anchorage plates (Fig. 4) have been used for molar intrusion.

Unfortunately, relapse is usually a major concern in the treatment of anterior openbites. For example Lopez- Gavito (1985) in a sample of 41 patients with an original openbite of 3mm or more reported, 10 years post retention, 36% relapse of openbites. No single parameter of dentofacial form was reliable in predicting stability.

It should be stressed that relapse following conventional orthodontic therapy of skeletal openbites can be considerable. This highlights the need for accurate diagnosis, prudent treatment planning and adequate explanation to patients in such cases.

4. Surgical Management

Surgical treatment is generally undertaken after active growth is complete to minimise relapse. This may involve measures as simple as extraction of posterior teeth, however in more severe cases posterior impaction of the maxilla is indicated. Maxillary impaction allows forward and upward rotation of the mandible, thereby decreasing the lower anterior facial height and providing closure of the anterior openbite. Other surgical movements of the maxilla and/or mandible can also be planned as required as part of the surgical treatment plan. A common surgical combination is a LeFort I osteotomy of the maxilla with a bilateral sagittal split osteotomy (BSSO) of the mandible.

Hoppenreijs et al (1996), in a study of 6 year post operative results, found 20% relapse in 267 patients treated using LeFort I intrusion with or without BSSO. McCance et al (1992), in a study of 1 year post operative results of surgically corrected Class II and III openbite cases using LeFort I and BSSO procedures, reported stable results in Class II cases and a 23% relapse in Class III cases.

Openbite patients can often be the most challenging cases to manage effectively. The importance of appropriate diagnosis and treatment planning cannot be over-emphasised if a pleasing, stable and acceptable long term result is to be achieved. It is also important that the clinician understand dento-facial growth and development in addition to the effects of the appliances and mechanics that are to be employed to avoid unwanted iatrogenic side-effects.

Originally published on Australian Society of Orthodontists (ASO)

OPEN BITE

Unknown Tuesday, January 12, 2016

FACIAL TRAUMA

FACIAL TRAUMA

The dental specialist performs the proper treatment of facial injuries. These professionals must be well versed in emergency care, acute treatment and long term reconstruction and rehabilitation not just for physical reasons but emotional as well. Oral and Maxillofacial Surgeons are trained, skilled and uniquely qualified to manage and treat Facial Trauma. Injuries to the face, by their very nature, impart a high degree of emotional, as well as physical trauma to patients. The science and art of treating these injuries requires special training involving a “hands on” experience and an understanding of how the treatment provided will influence the patient’s long term function and appearance.

Dr. Lee meets and exceeds these modern standards. He is trained, skilled and uniquely qualified to manage and treat facial trauma. He is on staff at local hospitals and deliver emergency room coverage for facial injuries, which include the following conditions:

• Facial lacerations
• Intra oral lacerations
• Avulsed (knocked out) teeth
• Fractured facial bones (cheek, nose or eye socket)
• Fractured jaws (upper and lower jaw)

THE NATURE OF MAXILLOFACIAL TRAUMA

There are a number of possible causes of facial trauma such as motor vehicle accidents, accidental falls, sports injuries, interpersonal violence and work related injuries. Types of facial injuries can range from injuries of teeth to extremely severe injuries of the skin and bones of the face. Typically, facial injuries are classified as either soft tissue injuries (skin and gums), bone injuries (fractures), or injuries to special regions (such as the eyes, facial nerves or the salivary glands).

SOFT TISSUE INJURIES OF THE MAXILLOFACIAL REGION

When soft tissue injuries such as lacerations occur on the face, they are repaired by suturing. In addition to the obvious concern of providing a repair that yields the best cosmetic result possible, care is taken to inspect for and treat injuries to structures such as facial nerves, salivary glands and salivary ducts (or outflow channels). Dr. Lee is a well-trained oral and maxillofacial surgeon and is proficient at diagnosing and treating all types of facial lacerations.

BONE INJURIES OF THE MAXILLOFACIAL REGION

Fractures of the bones of the face are treated in a manner similar to the fractures in other parts of the body. The specific form of treatment is determined by various factors, which include the location of the fracture, the severity of the fracture, the age and general health of the patient. When an arm or a leg is fractured, a cast is often applied to stabilize the bone to allow for proper healing. Since a cast cannot be placed on the face, other means have been developed to stabilize facial fractures.

One of these options involves wiring the jaws together for certain fractures of the upper and/or lower jaw. Certain other types of fractures of the jaw are best treated and stabilized by the surgical placement of small plates and screws at the involved site. This technique of treatment can often allow for healing and obviates the necessity of having the jaws wired together. This technique is called “rigid fixation” of a fracture. The relatively recent development and use of rigid fixation has profoundly improved the recovery period for many patients, allowing them to return to normal function more quickly.

The treatment of facial fractures should be accomplished in a thorough and predictable manner. More importantly, the patient’s facial appearance should be minimally affected. An attempt at accessing the facial bones through the fewest incisions necessary is always made. At the same time, the incisions that become necessary, are designed to be small and, whenever possible, are placed so that the resultant scar is hidden.

INJURIES TO THE TEETH AND SURROUNDING DENTAL STRUCTURES

Isolated injuries to teeth are quite common and may require the expertise of various dental specialists. Oral surgeons usually are involved in treating fractures in the supporting bone or in replanting teeth that have been displaced or knocked out. These types of injuries are treated by one of a number of forms of splinting (stabilizing by wiring or bonding teeth together). If a tooth is knocked out, it should be placed in salt water or milk. The sooner the tooth is re-inserted into the dental socket, the better chance it will survive. Therefore, the patient should see a dentist or oral surgeon as soon as possible. Never attempt to wipe the tooth off, since remnants of the ligament that hold the tooth in the jaw are attached and are vital to the success of replanting the tooth. Other dental specialists may be called upon such as endodontists, who may be asked to perform root canal therapy, and/or restorative dentists who may need to repair or rebuild fractured teeth. In the event that injured teeth cannot be saved or repaired, dental implants are often now utilized as replacements for missing teeth.

The proper treatment of facial injuries is now the realm of specialists who are well versed in emergency care, acute treatment, long term reconstruction and rehabilitation of the patient.

Source: Oyster Point Oral and Facial Surgery

FACIAL TRAUMA

Unknown Sunday, January 10, 2016