Oral Disease: Herpes Labialis

What Causes Herpes Labialis?

Herpes simplex virus (HSV), after primary oral or perioral infection, remains latent in the trigeminal ganglion. HSV moves down the trigeminal nerve to produce mucocutaneous lesions if reactivated by factors such as:

Familial Adenomatous Polyposis (FAP)

What is FAP?

FAP—an autosomal dominant condition caused by mutation in the APC tumour suppressor gene on chromosome 5—is characterized by the development during the second decade of life of hundreds of adenomas in the colon and rectum. These eventually cause rectal bleeding or anaemia, or develop into cancer.

A less aggressive variant—termed attenuated FAP, is characterized by fewer colorectal adenomatous polyps (usually 10–100), a later age of denoma appearance and a lower cancer risk.

What are the Symptoms of FAP?

FAP is initially symptomless but later gastrointestinal features appear. Extraintestinal manifestations may include osteomas, dental anomalies (unerupted teeth, agenesis of one or more teeth, supernumerary teeth, dentigerous cysts and odontomas), congenital hypertrophy of retinal pigment epithelium, desmoid tumours and extracolonic cancers (thyroid, liver, bile ducts and central nervous system).

Where there are skull and mandible osteomas, dental abnormalities and fibromas on scalp, shoulders, arms and back, the term Gardner syndrome is employed.

How is FAP Diagnosed?

Clinical plus imaging and colonic polyp biopsy.

How is FAP Treated?

The intestinal polyps have a 100% risk of undergoing malignant transformation: therefore, the early identification of disease and colectomy is critical.


Reference: Scully C. 2010. Oral and Maxillofacial Disease. Vol. 4th Ed. Informa Healthcare. UK.

Dental Anasthesia: Posterior Superior Alveolar Nerve Block

The posterior superior alveolar (PSA) nerve is a branch of the maxillary division of the trigeminal nerve. It parts from the main trunk in the pterygopalatine fossa, passes inferiorly along the posterior wall of the maxilla, and enters the bone about 1 cm superior and posterior to the third molar tooth. The PSA nerve supplies the buccal gingivae, periodontium, and alveolus associated with the upper molar teeth. It provides innervation to the pulps of all the upper molar teeth with the possible exception of the mesiobuccal pulp of the first molar, which is supplied by the middle superior alveolar (MSA) nerve in approximately 50% of individuals.

Branches of the maxillary nerve

Injection for the PSA nerve block is performed in a highly vascular area, and formation of a hematoma is a recognized side effect, especially when the needle is advanced more than 15 mm. Immediate hemorrhage is controlled by pressure, but postinjection trismus may last for weeks. Antibiotic therapy should be prescribed if the hematoma is large. 

Technique: Posterior Superior Alveolar Nerve Block

1. Use a short or long needle, no less than 27 gauge.
2. Instruct the patient to open the mouth only slightly, and move the lower jaw over to side of injection.
3. Retract the lip and cheek with the thumb or first finger of left hand.
4. Insert the needle at the height of the maxillary buccal sulcus at distal aspect of second
   molar.
5. Advance the needle posteriorly, superiorly, and medially (at 45-degree angle to each plane) to a depth 15 mm.
6. Perform aspiration.
7. Inject 1.5 ml of solution slowly.
8. If bone is contacted before a depth of 1.5 ml achieved, alter the angle of approach by
   withdrawing slightly and positioning the syringe medially.

Normal orientation of needle for posterior superior alveolar nerve block. From Jastak JT, Yagiela JA, Donaldson D: Local anesthesia of the oral cavity, Philadelphia, 1995, Saunders.

Palpation of zygomatic process in posterior superior alveolar nerve block. Point of needle insertion lies within mucosal pocket posterior to palpating finger.

 

Source : Dionne RA. 2002. Management of Pain and Anxiety in the Dental Office. W.B. Saunders. Philadelphia

How Hypnosis Can Manage Pain and Anxiety in the Dental Office

Hypnosis is a formalized method of applying the techniques of attention modification, paced breathing, and muscle relaxation. It has been employed in dentistry for more than 100 years. Highly regarded courses in hypnosis for clinicians are available on a regional basis from the American Society of Clinical Hypnosis. The courses are graded from beginner to advanced. A beginner’s course will equip the clinician with skills that can be used the next day in practice. A hypnosis course is an easy way to practice talking to patients about a more comfortable way to experience dental treatment.

The process of helping a patient reach a hypnotic state is called induction, as described in the following example:

The patient should be relaxed and sitting up.

Dentist: Please make yourself comfortable. You must be comfortable to get relaxed.
Do you feel comfortable now?

Patient: Yes.

Dentist: Now raise your arms over your head and then just let them drop into your lap. Good. You may have felt a moment of relaxation when you did that. Your whole body relaxed briefly. Please try it again. You may begin to sense that when you relax that your limbs get heavy. This heaviness is part of relaxation. Now try breathing slowly.
Take a deep breath, hold your breath as you are comfortable, and let it out slowly. Each time you breathe in and out, you will get more and more relaxed. You may want to close your eyes.

The dentist can count while giving breathing and suggestions for relaxation as follows:

Dentist: I would like you to tighten your arm and hand muscles; make them stiff out in front of you. Now as I count, I want you to imagine first tightening and then loosening the muscles. One, feel the muscles of your hands tighten and your arms stiffen. Two, make them really tight. Three, now begin to loosen them a little. Take a deep breath and let it out slowly. Four, imagine your muscles getting heavy and much looser. Take another breath. Five, your arms may not feel so heavy that they begin to fall into your lap.

Once a patient becomes comfortable, the dental work can be started. The dentist should alert the patient about an upcoming noise, bump, or other action. Throughout the procedure the dentist can continue to encourage the patient to maintain the relaxed quiet state.

Often, hypnosis sessions end by the clinician giving the patient posthypnotic suggestions, which usually take the form of praising the patient for doing well and suggesting that the feeling of calm and painlessness of the session will continue in the period after treatment. The patient should be told that practice at home improves the effectiveness of hypnosis.

Source: Dionne RA. 2002. Management of Pain and Anxiety In The Dental Office. W.B. Saunders. Philadelphia

Hypodontia

Hypodontia (oligodontia), the congenital absence of teeth, represented by the loss of one or two teeth with no apparent associated abnormalities is not uncommon. The most common teeth to be missing are the last in each series. Most surveys, however, show that one or more third molars are missing in approximately one-quarter of the population. A study carried out in an English population and excluding the third molars has shown that the teeth most likely to be missing are the lower second premolars (40.9%) followed by the upper lateral incisors (23.5%) and by the upper second premolars (20.9 %).

The pattern of missing teeth does, however, vary from population to population. A common finding in hypodontia is the presence of small and conically shaped teeth replacing normal units of the dentition . Hypodontia in the primary dentition is a relatively rare occurrence.

The congenital absence of teeth associated with abnormalities of the bone or ectodermal appendages is relatively rare. The dysplasia involved may be attributed to ectodermally derived structures or to more complex syndromes in which there are both dermal and bony abnormalities.

Hairy Tongue

Hairy tongue (lingua villosa) is a commonly observed condition of defective desquamation of the filiform papillae that results from a variety of precipitating factors. In hairy tongue the lesion does not consist simply of a coating on the surface of the tongue but represents an elongation of the filiform papillae, often to many times their original length. With this elongation the papillae often take on a dark colour, black or brown being common. The mechanism for the formation of these coloured hairy tongues is quite unknown, there apparently being many initiating factors. For instance, hairy tongue frequently follows a course of antibiotic therapy and may resolve quite rapidly on completion of treatment. Other hairy tongues apparently appear completely spontaneously and no cause is ever found for them. Equally doubtful is the source of the pigment involved. It is usual to relate this to pigment-producing organisms entrapped within the papillae but, in fact, no such organisms have ever been demonstrated. In the past, the presence of hairy tongue was often ascribed to candidal infection but, again, it has never been shown that there is any true association between candidosis and the production of the elongated papillae.

Treatment of hairy tongue is remarkably difficult. Those cases associated with antibiotic therapy frequently, but not invariably, resolve when the medication is finished. The use of effervescent and mucus-solvent mouthwashes may be helpful in reducing secondary irritation and thereby producing suitable conditions for the resolution of the abnormality but, again, the results are variable. The authors have used chemical cauterization, with trichloracetic acid, to treat hairy tongue, but only small areas can be managed at a time, because of discomfort afterwards. Long-term results of this chemical counterization were disappointing. "Sucking a dry peach stone" has been advocated for the management of hairy tongue but this approach does seem to be potentially hazardous! Some patients with this condition use tongue scrapers or brush their tongue vigorously but these measures are rarely effective. 

 
Source :
Field A. 2003. Tyldesley's Oral Medicine. Vol. 5th Ed. Oxford University Press. UK
http://emedicine.medscape.com/article/1075886-overview 
http://www.youtube.com/watch?v=S1lyFPUIkfE