STOMATOLOGY MEDICAL STUDENTS IV YEAR Prof. MUDr. Martina Kukletová Dentistry • Preventive dentistry • Restorative dentistry • Prosthetics • Surgery • Periodontics • Orthodontics • Pedodontics Pedodontics • Preventive dentistry • Restorative dentistry • Prosthetics • Surgery • Periodontics • Adapted to the age 0 – 18 years • Collaboration with orthodontics – diagnosis of anomalies Preventive dentistry • Methods to prevent • Dental caries • Periodontal diseases Restorative dentistry (Operative dentistry) • Caries therapy • Esthetic dentistry • Endodontics • Endodontic surgery • Materials Prosthetic dentistry • Restoration of dentition • Severely damaged teeth, missing teeth • Fixed dentures • Removable dentures • Materials • Laboratory technology Oral surgery • Surgical intervention in the mouth • Tooth extraction • Incision • Surgical extraction • Apicoectomy • Treatment of fractures, inflammations, tumors e.t.c. Periodontics • Treatment of periodontal diseases • Gingiva • Periodontal membrane • Bone • Cement • Treatment of oral mucous membrane diseases (Oral medicine) • Injuries • Local lesions (bad habits) • Infection • Immune system • Systemic diseases • Tumors Orthodontics • Treatment of anomalies • Tooth position • Intermaxillary relations DENTAL CARIES • Wide - spread disease - affecting 80-90 % of population • Multifactorial disease • Now • Infectious disease - microbial plaque FACTORS INFLUENCING CARIES DEVELOPMENT 1. Microbial plaque 2. Saliva (quantity, quality) 3. Composition of food 4. Hereditary factors 5. Orthodontic anomalies Micro-organisms No cariesNo caries No cariesNo caries SubstrateHost teeth Time Caries 1. MICROBIAL PLAQUE • Glycoproteins from saliva - pellicle, covers the tooth surface • Microbs – cocci (streptococcus mutans, lactobacilli) – short rods – aerobic, anaerobic • Intermicrobial substance • Materia alba – epithelial cells – leucocytes – remnants of food 2. SALIVA • Water 99 % • Organic substance - 0,2% – mucoids – albumins – globulins – Peptides • Enzyme – amylase – esterase – lipase – peroxidase • Lysosyme • Anorganic substances 0,5 % • Calcium – phosphate – carbonate • K, Mg – chlorides – Sulphates • Iodine • Carbon dioxide = buffer buffering the pH of saliva 3. FOOD INTAKE (DIETARY HABITS) Sugar intake - frequency, not quantity Glucose, saccharose The most dangerous - sweets sticking on the teeth, chocolate, honey Sugars - fermented by microbial plaque to organic acids then demineralization Stephen´s curve Sugars -bacteria- polysaccharides (storage of sugars) Metabolized - lack of sugars in the food 3,5 4 4,5 5 5,5 6 6,5 7 7,5 0 10 20 30 40 50 60 minutes pH critical pH The Stephan curve Sound enamel Plaque Fermentable carbohydrate Saliva Fluoride Modified diet Plaque control Carious enamel 4. HEREDITARY FACTORS No direct influence • anatomy of the teeth - shape of the crown • thickness of the enamel • mineralization of the enamel • orthodontic anomalies (crowding) LOCALIZATION OF CARIES Habitually unclean areas, susceptible sites (retention of plaque) • pits and fissures, approximal surfaces of molars and premolars • cervical parts – oral – vestibular Primary caries Secondary caries (along margins of fillings) (recurrent) Acute caries - conical shape Chronic caries - undermining the enamel CLASSIFICATION OF CARIES (BLACK – 5 CLASSES) I. class - molars, premolar, occlussal surfaces - fissures, foramina (pits) II. class - molars, premolars - approximal surfaces III. class - frontal teeth - appproximal surfaces IV. class - frontal teeth - incisal corners lost V. class - cervical region - oral, vestibular CLINICAL SYMPTOMS Incipient caries / no pain - (affecting enamel) - white spots or brown pigmentation Caries affecting dentine / no pain Soft on probing : – caries superficials – caries media Pain may be evoked by a direct irritation of the tooth by mechanical, chemical, thermal stimuli Pain disappears when irritant is removed Clinical signs - irregular, rough surface, cavitation with sharp edges (retention of food) CARIES PULPAE PROXIMA - SPREADING OF THE CARIOUS PROCESS Defense reaction of the dental pulp - tertiary dentine (irregular, irritation) Dentine tubules - irregular course , lower number Histologically - no inflammation of the dental pulp Clinically - no signs of pulpitis Pain evoked by cold, sweet ,salty , sour stimuli Pain disappers with disappearance of stimuli TREATMENT - superficial caries, - caries media Caries excavation, cavity preparation, basis, filling. - caries p.p. \ indirect pulp capping (no exposure of the dental pulp) direct pulp capping (exposure of the dental pulp) MATERIALS USED FOR THE TREATMENT OF THE DENTAL CARIES - carious structures must be caefully removed (undermined enamel, soft dentine, soft cement) - cavity must be shaped to provide good - retention of the filling - resistence of the filling (to withstand masticatory forces) - resistance of the tooth (not to fracture , to be resistent enough) All caries susceptble sites must be involved in the cavity (fissure system) occlusal outline pulpal floor of the occlusal box gingival floor of the approximal box Fissure sealing blockades the entrance to the underlying fissure Preventive resin restoration C = composite resin G = glass iomer cement S = sealant C S S C G MATERIALS USED FOR THE TREATMENT OF THE DENTAL CARIES Materials – permanent – temporary Insulating base (to protect dental pulp against irritation) – zincoxyd phosphate cement – carboxyl cement – zincoxy- eugenol cement DISEASES OF THE DENTAL PULP Causes: – infection – chemical – physical irritation – combined – mechanical DISEASES OF THE DENTAL PULP Bacterial infection – caries - dentine tubuli - dental pulp – foramen apicale - less frequently (deep periodontal pocket) – hematogenic way – chemical irritation - filling materials without bases (composite resins, glass ionomers) – dental pulp involvement Acute trauma Chronic traumatic irritation DISEASES OF THE DENTAL PULP Inflammation - pulpitis Hyperemia - reversible state Pain (short, well localized) - cold, hot, sweet, biting disapppears when the cause of irritation is removed Treatment – caries removal – indirect dental pulp capping Ca(OH)2 application – temporary filling Permanent filling - 6-8 weeks later Extent of chronic inflammation in the pulp of deep carious lesions (left), in partial chronic pulpitis (centre) and in total chronic pulpitis DISEASES OF THE DENTAL PULP Acute serous (partial,total) suppurative (partial, total) Chronic open, closed open - ulcerative, hyperplastic (polyp) closed - internal resorption (pink spot), retrograde Pulpitis Acute Chronic DISEASES OF THE DENTAL PULP CLINICAL SYMPTOMS Serous pulpitis – pain starts spontaneously (on its own accord) in the evening, in the night – sharp, throbbing – intensity reaches crescendo and diminishes – cold stimuli increase the pain – hot stimuli calm the pain Suppurative pulpitis – symptoms similar, more pronounced – cold stimuli ease the pain – hot stimuli increase the pain – in severe case - the raise of temperature DISEASES OF THE DENTAL PULP Exstirpation - removal of the entire dental pulp Vital under local anaesthesia Mortal devitalizer (paraformaldehyde) previously:arsenic, arsenum metallicum crudum (cobalt) Root canal filling Filling (inlay crown) DISEASES OF THE DENTAL PULP PERIODONTITIS Inflammatory changes - transfer from the root canal into the apical periodontium. infection - untreated caries Less frequently - trauma, chemical agents oral cavity S V T sublingual submandibular skin This coronal section shows the directions that may be taken by pus from an apical abscess. DISEASES OF THE DENTAL PULP ACUTE PERIODONTITIS Extent of inflammatory changes - 4 phases – periodontal phase - surrounding of the apex – intraosseal phase - serous exsudation, pus formation in the bone – subperiosteal phase inflammatory changes reach the periosteum – submucous phase - inflammatory exudate cortical plate + periosteum perforated a- penetrates into soft tissues - abscess b- spreading without abscess formation - phlegmone (cellulitis) DISEASES OF THE DENTAL PULP CLINICAL FEATURES Tenderness of the affected tooth, throbbing pain, pain on pressing, biting, percussion, touch. Sensitivity in the periapical region, infiltration of submucose, swelling, redness, fluctuation. Pain is increased by hot stimuli, no response to cold, the affected tooth can be localized. Lymphadenopathy, fever, headache, chills, malaise The most sever pain - subperiosteal abscess Submucous phase (fistula - vestibule channalizing through soft tissue)= relief DISEASES OF THE DENTAL PULP TREATMENT Drainage and elimination of the focus of infection Periapical phase: tooth trepanation Intraosseal phase: tooth trepanation bone trepanation + ATB Subperiosteal phase: tooth trepanation incision + ATB Submucous phase: tooth trepanation incision + ATB If the treatment is successfull - root canal treatment and filling No hope = extraction (apicoectomy) DISEASES OF THE DENTAL PULP CHRONIC PERIODONTITIS Formation of granulation tissue Diffuse periodontitis Localized periodontitis granulome cystogranulome cyst (radicular) Diagnostics – no pain – X-ray : radiolucency diffuse- localized – fistule Change - from chronic to acute periodontitis (exacerbation, phoenix abscess) Clinical signs - correspond to those of acute periodontitis X- ray - radiolucency DISEASES OF THE DENTAL PULP TREATMENT a) conservative b) surgical a) Conservative treatment Removal of the gangrenous tissue Shaping, enlargment of the root canal Disinfection of the root canal (sodium hypochloride) Root canal filling b) Surgical treatment 1 - conservative treatment followed by apicoectomy 2 - extraction