Main textbooks Paul Coulthard, Keith Horner, Philip Sloan, et al. Master Dentistry. Volume 1,2, Oral and Maxillofacial Surgery, Radiology, Pathology, and Oral Medicine. Churchill Livingstone 2003 Updated knowledge from library and Website.

Dental Caries

Tooth loss is common health problem. What can cause tooth loss?

Reasons of tooth loss Microbial tooth loss (dental caries, periodontitis) Non microbial tooth loss (trauma, congenital loss)

Dental caries An chronic infectious disease with progressive destruction of tooth.

Prevalence and incidence Almost everyone is affected by dental caries.

Etiology of Dental Caries Micro- organisms host & tooth sugar time no caries no caries no caries no caries 1889, Miller: chemocoparasitic theory

MAJOR FACTORS 3 necessary requirements: 1) Microorganisms — bacteria, plaque 2) sugar --- carbohydrates 3) host & tooth---saliva, tooth ( and) 4) time.

Role of bacteria There are many kinds of bacteria in normal oral cavity. Mainly the bacteria causing caries are Streptococcus Mutans (MS). Microorganisms:

Role of plaque Plaque is a biofilm on the surface of the tooth (enamel). Enamel Pulp Root canal Cememtum Apical tissue Dentin Crown Root gum Microorganisms

Role of Tooth Quality Position Structure arrangement host & tooth

Role of saliva: It plays role in remineralization on the teeth. Saliva has the buffering action and cleansing effect. host & tooth

Role of carbohydrates: the most important cause; refined carbohydrates are directly proportional with dental caries. Sugar:

MINOR FACTORS: Enamel composition Morphology of the tooth Habit of brushing teeth Immunity

Clinical classification of caries According to three basic factors : severity and rate of progression anatomical site(involving site) age patterns at which lesions predominate

Tooth anatomy Root Enamel Pulp Root canal Cememtum Apical tissue Dentin Crown gum

Acute caries Chronic caries Arrested caries Rampant caries Classification according to the developing speed

Classification according to the involving site Occlusal caries Root caries Smooth surface caries Linear enamel caries

Clinical Manifestation and Symptoms Visible pits or holes in the tooth Colour changing Soften Pain changes in tissue color, texture, and structure

AB CD A Early caries may have no symptoms B be sensitive to sweet foods or to hot and cold temperatures C very sensitive to stimulator D the acute pain

Examination Clinical observations (Visual change) Probing The explorer tip can easily damage white spot lesions

Examination Temperature test X-ray Transillumination

Diagnosis Clinical signs visual – color, texture, shape, location, cavitation, Clinical symptoms Diagnostic test--examination

Treatment Non-surgical - remineralization Surgical - restoration The different ways of treatment depend on the size and depth of the cavity, and how much structure has been lost. Calcium hydroxide pulp-capping material lining material filling material

Prevention is the most important for dental caries.

Problem for review What is the etiology of dental caries? Be familiar with the definitions of dental caries and classification. Simply describe clinical manifestation and symptoms of dental caries.

Endodontics

Etiology of Pulpitis 1-bacterial cause: caries, fracture, bacteremia, periodontal pocket caries irreversible pulpitis

pulp

2-physical cause: sever thermal change (cavity preparation), large metallic restoration

5. Other cause: internal resorption internal resorption

Possible Pulpal Diagnoses Normal Reversible pulpitis Irreversible pulpitis — acute, chronic, polyp Necrosis Previous endodontic treatment

Reversible pulpitis Clinically 1.sharp pain & respond to sudden changes in temperature 2.pain disappear as the stimuli removed last less than 20 sec 3. easily localized & unaffected by body position

Clinical Examination in reversible pulpitis Thermal: Hypersensitive with mild pain <mild Sweets: Sensitive < mild Biting Pressure: None (unless tooth is cracked)

Treatment of Reversible Pulpitis Remove irritant if present If no pulp exposure: direct restore If pulp exposure: Carious: initiate RCT Mechanical: >1 mm: initiate RCT <1 mm crown planned: initiate RCT <1 mm: direct cap or RCT If recent operative or trauma – postpone additional treatment and monitor.

Irreversible Pulpitis Reversible pulpitis are left untreated.

Symptoms of Irreversible Pulpitis Thermal: Hypersensitive-moderate to severe Sweets: Moderately to severely sensitive Biting Pressure: Usually sensitive in later stages (periapical symptom) spontaneous pain: Moderate to severe

Diagnosis Irreversible Pulpitis Hypersensitive to hot or cold that is prolonged. A history of spontaneous pain. Vital or partially vital pulp.

may occur as a sequel of focal reversible pulpitis or occur due to acute exacerbation of chronic pulpitis. clinically 1- big cavity or margin of a restoration 2- sleep pain 3- spontaneous pain 4- pain lasts 5- difficult to localized Acute pulpitis:

a result of acute pulpitis, or develops as chronic one. Clinically 1-spontaneous dull, itching pain 2-increased pain threshold (need strong stimuli) due to degeneration of the nerve fibers 3- the pain lasts for about 2 h. Chronic pulpitis

Chronic hyperplastic pulpitis(polyp) Clinically: 1- polyp 2- occurs in a tooth with large carious lesion 3- not sensitivity 4- bleed easily 5- may confused with hypertrophic gingival polyp

Treatment of Irreversible Pulpitis Root canal treatment or extraction

Necrotic Pulp Pulp continued degeneration. no reparative potential. Commonly have apical radiolucent lesion.

Maxillary first molar with large amalgam restoration and periapical radiolucencies around all three roots. The tooth was unresponsive to electrical and thermal testing.

Symptoms of Necrotic Pulp Thermal: No response Sweets: No response Biting Pressure: Usually moderate to severe pain (not symptom of necrotic pulp, but rather periapical inflammation) Moderate to severe spontaneous pain

Diagnosis of Necrotic Pulp Distinguishing features: No response to cold. No response to EPT. Caveats Decreased sensitivity Periapical radiolucency is strong but not conclusive evidence that pulp is necrotic.

Necrotic Pulp (additional considerations) Antibiotic coverage Pain Management Occlusal Reduction

Root Canal Treatment The procedure involves removing inflamed or damaged tissue from inside a tooth and cleaning, filling and sealing the remaining space, to prevent re- infection.

Pre-operative film

Access and Working length

Completed RCT

case

Points you must know: What is root canal treatment? Simply describe the clinical manifestation of pulpitis.

The oral manifestation of HIV Infection

human immuno-deficiency virus (HIV) retroviruses acquired immune deficiency syndrome, （ AIDS ）

Oral manifestations are often the first clinical feature of HIV infection. The first AIDS case, worldwide ： 1981, AIDS China ： 1985, AIDS, Beijing,Argentina Shanghai ： 1987, AIDS Hangzhou: 1985, AIDS--hemophila 2009, 1272/236 (HIV/AIDS) Epidemiology

Oral Manifestations observed in HIV Fungal Neoplastic Viral Bacterial Other

Fungal Manifestations ----candidiasis Can manifest in 4 different ways Pseudomembraneous candidiasis Erythematous candidiasis Hyperplastic candidiasis Angular chilitis

Pseudomembraneous Candidiasis

Erythematous Candidiasis

Hyperplastic Candidiasis

Angular chilitis

Neoplastic Oral Manifestations There are two types of neoplasms associated with oral manifestations in HIV individuals Kaposi ’ s Sarcoma (KS) Non-Hodgkin ’ s Lymphoma

Kaposi ’ s Sarcoma

Non-Hodgkin ’ s Lymphoma

Viral Manifestations Herpes Simplex Virus (HSV) lesions Herpes Zoster Hairy leukoplakia Cytomegalovirus (CMV) ulcers Human Papillomavirus (HPV) lesions

Leukoplakia

Herpes Simplex Virus (HSV) lesions

Cytomegalovirus (CMV) ulcers Combination of HSV and CMV

HPV

Bacterial Manifestations Linear Gingival Erythema Necrotizing Ulcerative Periodontitis Tuberculosis

Linear Gingival Erythema (red-band gingivitis)

Necrotizing Ulcerative Periodontitis

Necrotizing Ulcerative

Tuberculosis Oral lesions in people with tuberculosis are seen rarely. They have been reported as ulcers on the tongue secondary to pulmonary tuberculosis.

Other Oral Manifestations Aphthous Ulcerations (canker sores) Minor Major Salivary Gland Disease Xerostomia

Aphthous Ulcerations minor major

Salivary Gland Disease

Xerostomia

Conclusions Lesions or other manifestations in the mouth may be the initial indicator of a persons HIV status or it may indicate a further decrease or worsening of an infected individuals immune system.

You must know: What is the main oral manifestation of HIV infection? List the four categories of oral manifestations that may present in HIV Be familiar with fungal oral manifestation that may present in HIV infected individuals