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ORAL Disese AND DENTAL CONDITION

ORAL AND DENTAL CONDITION

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Oral disease conditions are common and range from dental caries, periodontal conditions,
dental abscess and other acute bacterial infections, viral infections, fungal infections, traumatic
injuries and tumors. The lesions affecting the maxillofacial region (perioral, jaws and face) are
also considered here but for a more detail a relevant text book or manual need to be referred.
The clinician should be able tqo identify conditions requiring immediate attention by the dentist,
do the preliminary urgent and life saving measures where possible before referring the patient
to a centre with a dentist/dental surgeon. There are some cases which will need the attention
of a specialist dental surgeon (like oral and maxillofacial surgeon, orthodontist e.t.c) but in most
cases these will be identified by a general dentist.

1. 0 PERIODONTAL CONDITIONS

1.1 Gingivitis

Inflammatory changes in the gingival develop within a couple of days of undisturbed bacterial
growth on the cervical portion of the tooth surface.

Diagnostic criteria:

 Inflammation of the gingival which is initially seen as discrete colour and texture
changes of the marginal tissues.
 After few days of plaque accumulation overt gingivitis is established, characterized
by gingival redness and swelling and increased tendency of the gingival to bleed on
gentle probing, during tooth brushing or even on touch.

Prevention

Instructions for proper oral hygiene care
Treatment

Removal of accumulated plaque and oral hygiene instructions on tooth brushing and other
adjuvant means of oral hygiene (dental flossing, use of mouth washes)

Periodontitis

This is the progression of the inflammation of gingivitis into the deep tissue affecting the
periodontal membrane causing periodontal pockets, introduction of infection and destruction of
periodontium. The damage of the periodontal membrane, periodontal ligaments and eventually
alveolar bone leads to formation of pockets which eventually favours more bacterial growth. As
the destruction continues the teeth become loose and may eventually fall out.

Diagnostic Criteria

 Reddened, swollen gingiva
 Easily bleeding gingival on gently probing
 Loose/mobile teeth
 Bad breath from the mouth

 Gingival recession
 Periodontal pocket
Investigation: Mainly X-ray (orthopantomogram (OPG)) to determine extent of bone loss.

Prevention and Non Pharmacological Treatment

 Instruction and guidance to the patients on proper oral hygiene for proper plaque
control
 Plaque control by the dentists by scaling and root planning (this may need several visits
as may be found necessary)
 Advanced treatment – if refractory/resistant to treatment or patient has systemic.

diseases conditions.

Note: Patients with systemic diseases conditions like diabetes mellitus, liver and renal diseases,
HIV/AIDS and those who are pregnant or heavy smokers of cigarette are generally at increased
risk of periodontal diseases and their management may need referral to a periodontal specialist.

Pharmacological treatment

 Mouth washes:
A: Hydrogen peroxide 3% 3-4 times daily
OR
A: Chlorhexidine gluconate 0.2% 3-4 times daily
OR
A: Povidone iodine 0.5% used 3-4 times daily will argument the plaque control
treatment.
Use antibiotics only for severe cases and those with evidence of periodontal abscess
formation:

A: Metronidazole (O) 400mg 8 hourly for 5 days
Plus
A: Amoxicillin 500 mg 8 hourly for 5 days
OR
A: Tetracycline 500mg 8 hourly for 5 days.

1.3 Acute Necrotizing Ulcerative Gingivitis (ANUG)

It is a severe form of gingivitis and it

characterized by rapid destruction of gingival tissue,
particularly in the area of the interdental papilla. Patients usually present with soreness and
bleeding of the gums and foul test (fetor-ex ore). Acute Necrotizing Ulcerative Gingivitis (ANUG)
is also called Vincent’s gingivitis or Vincent’s gingivostomatitis. It is common in malnourished
children and immunocompromized individuals especially patients with diabetes and HIV/AIDS.

Diagnostic criteria
 Painful and easily bleeding gingival swelling and erythema of the gingival margins
 Yellowish-white ulceration of the gingival
 Fever, malaise and regional lymphadenitis
 In some patients (especially malnourished children), ANUG may presents with extensive
destruction of the face and jaws in the severe form known as Cancrum Oris or noma
Treatment
 Professional cleaning with Hydrogen Peroxide 3% (under local anesthesia)
A: Metronidazole 400 mg (O) 8 hourly a day for five days
Plus
A: Amoxicillin 500mg (O) 6 hourly for 5 days
1.4 Stomatitis
This is generalized inflammation of the oral mucosal (including the gingiva) due to different
aetiologies. Such aetiologies include infections, chemical burn, radiations. Contact stomatitis (a
counterpart of contact dermatitis) also can occur due to allergy.
Diagnosis
Oral sores and ulceration
Treatment
Generally supportive
 Mouth rinse
A: Hydrogen peroxide solution 3% 4-6 hourly
OR
A: Povidone iodine 0.5% mouthwash
OR
C: Chlorhexidine 0.2%Topical oral gel: The best gel is one containing
combination of analgesics, anaesthetics and antiseptics (e.g. Choline
salycilate, Benzalkonium chloride and Lignocaine hydrochloride)
Note: Mouth washes should not be used at the same time with the gel.
Oral analgesics can be added;
A: Paracetamol 1000mg 8 hourly

OR
A: Diclofenac 50 mg 8 hourly
OR
A: Ibuprofen 400 mg 8 hourly

2.0 DENTAL CARIES

It is a condition whereby the tooth is demineralized by acid which is produced by bacteria in the
process of metabolizing sugar. Start slowly with white spots later developing to black/brown
spot and cavities in enamel, dentine and eventually the pulp. Dental caries is caused by bacteria
of the dental plaque which feed on sugary food substrates producing acid as by-products which
dissolve the minerals of the tooth surface. The bacteria which cause dental caries are mainly of
streptococcus (S.mutans, S. viridians)
Diagnostic Criteria
 Early stage – asymptomatic
 Intermediate stage:- black/brown spot which may be visible on any surface of tooth
 Cavities developing on tooth surface
 Pain/toothache elicited by hot, cold or sweet foods/drinks
 Late stage: pain may be spontaneous, intermittent, sharp and severe, even interfering
with sleep.
 There is tenderness on percussion of the tooth.
 X-Rays: Periapical x-ray of tooth/teeth may need to be done especially to confirm extent
of caries for treatment decision e.g. the caries contained in the dentine can be
distinguished from pulpal caries.
Note: The Susceptible sites are those areas where plaque accumulation can occur and be
hidden to escape active and passive cleansing mechanisms e.g. pits and fissures of the
posterior teeth, interproximal surfaces and teeth in malocclusion.
Prevention
 Proper instruction to avoid frequent use of sugary foods and drinks
 Use fluoridated toothpaste to brush teeth at least once a day
Non-pharmacological measures
 Early lesions presenting as a spot on enamel without cavitation and softening, observe
and adhering to preventive measures.
 Lesion with cavitation but confined to dentine – filling/restoration of teeth with suitable
filling materials (e.g. amalgam, composite, glass ionomer)
 Lesion involving the pulp (with or without periapical abscess), perform advanced tooth
restoration by endodontic treatment wherever possible otherwise tooth extraction is done.

Note: For significantly abscessed tooth see dental abscess]
Pharmacological treatment
Analgesics: for toothache
A: Paracetamol 1000mg 8 hourly
OR
A: Diclofenac 50 mg 8 hourly
OR
A: Ibuprofen 400 mg 8 hourly
3.0 ODONTOGENIC AND NON-ODONTOGENIC OROFACIAL INFECTIONS
3.1 Periapical Abscess
The clinical presentation arises as a complication of inflammation of the dental pulp or
periodontal pocket. The condition may be acute and diffuse or chronic with fistula or localized
and circumscribed. It is located in the apical aspect of the supporting bone.
Diagnosis
 The patient complain tooth ache
 Pain during intake of hot or cold foods/drinks
 Pain on bringing the tooth on occlusion
 Tenderness on percussion (vertical percussion)
 Swelling of gingiva around the affected tooth
Treatment
 For posterior teeth: Extraction of the offending tooth under local anesthesia
Lignocaine 2% with adrenaline 1:80,000 IU (to establish drainage) is the treatment of
choice followed by analgesics.
Adult: Paracetamol (O) 500mg – 1g, 4-6 hourly for 3 days, Child: Paracetamol (O) 10-15
mg/kg 4-6 hourly
 For anterior teeth (incisors, canine and premolars: Extraction is carried out only when
root canal treatment is not possible. Give antibiotics:
Adult
A: Amoxicillin (O) 500mg, 8 hourly for 5-7 days;
Children, Amoxicillin (O) 25 mg/kg in 3 divided doses for 5 days.
Plus
A: Metronidazole (O); Adult 400mg 8 hourly for 5-7 days.

Treatment is under local anesthesia with Lignocaine 2% socket debridement and irrigation of
hydrogen peroxide 3%. The procedure of irrigation is repeated the 2nd and 3rd day and where
necessary can be extended to 4th day if pain persists. On follow-up visits local anesthesia is
avoided unless necessary.
3.4 Dental Abscess
Dental abscess is an acute lesion characterizes by localization of pus in the structures that
surround the teeth. Dental abscess is a polymicrobial infection. Aerobic Gram positive cocci and
anaerobic Gram negative rods predominate among others. The predominant species include;
Bacteroides, Fusobacterium, Peptococcus, Peptostreptococcus and Streptococcus viridians.
Diagnosis
 Fever and chills
 Throbbing pain of the offending tooth
 Swelling of the gingiva and sounding tissues
 Pus discharge around the gingiva of affected tooth/teeth
 Trismus (Inability to open the mouth)
 Regional lymphnodes enlargement and tender
 Aspiration of pus for frank abscess
Investigations: Pus for Grams stain, culture and sensitivity and where necessary, perform full
blood count.
Treatment
Preliminaries
 Determine the severity of the infection
 Evaluate the status of the patient’s host defence mechanism
 Determine the need of referral to dentist/oral surgeon early enough
Non-pharmacological
 Incision and drainage and irrigation (irrigation and dressing is repeated daily)
 Irrigation is done with 3% hydrogen peroxide followed by rinse with normal saline.
 Supportive therapy carried out depending on the level of debilitation (most patients
need rehydration and detoxification)
Pharmacology
Drug of choice:
A: Amoxicillin 500mg (O) 6 hourly for 5 days
Plus
A: Metronidazole 400 mg (O) 8 hourly for 5 days.
 Second choice/ severe case
C: Amoxicillin with Clavulanic acid 625mg (O) 12 hourly for 5 days
Plus
A: Metronidazole 400 mg (O) 8 hourly for 5 days.

If allergic to penicillin’s:
A: Erythromycin 500 mg (O) 8 hourly for 5 days
Where parenteral administration of antibiotics is necessary (especially when the patient can not
swallow and has life threatening infection, consider
C: Ampicillin 500mg IM/IV 6 hourly for 5 days
OR
C: Ceftriaxone 1 gm IV once daily for 5 days
Plus
C: Metronidazole 500 mg IV 8 hourly for 5 days
Note: Incision and drainage is mandatory in cases of deeper spaces involvement followed
by a course of antibiotics. The practice of prescribing antibiotics to patients with abscess
and denying referral for definitive care until pus has establishes or resolved has found to
lead to more problems for orofacial infections THEREFORE early referral for definitive care
is important.
Criteria for referral
 Rapidly progressive infection
 Difficulty in breathing
 Difficulty swallowing
 Fascia space involvement
 Elevated body temperature [greater than 39 C)
 Severe jaw trismus/failure to open the mouth (less than 10mm)
 Toxic appearance
 Compromised host defenses
3.5 Ludwig’s Angina
It is a serious life threatening generalized septic cellulitis of the fascia spaces found on the floor
of the mouth and tongue. It is an extension of infection from mandibular molar teeth into the
floor of the mouth covering the submandibualr spaces bilaterally sublingual and submental
spaces.
Diagnosis
 Brawny induration
 Tissues are swollen, board like and not pit and no fluctuance
 Respiratory distress
 Dysphagia
 Tissues may become gangrenous with a peculiar lifeless appearance on cutting
 Three fascia spaces are involved bilaterally (submandibular, submental and sublingual)
Treatment
Non-Pharmacological
 Quick assessment of airway.

 Incision and drainage is done (even in absence of pus) to relieve the pressure and allow
irrigation.
 Only when the airway distress is significant and there is evidence that it is not relieved
by incision and drainage then tracheostomy is needed
 Supportive care include high protein diet and fluids for rehydration, detoxification and
Pharmacological
C: Ampicillin 500 mg IV 6 hourly for 5 days
Plus
C:Metronidazole 500mg IV 8 hourly for 5 days
If allergic to penicillin use
A: Erythromycin (O) 500 mg 6 hourly for 5 days
OR
C: Ceftriaxone 1 gm IV once a day for 5 days in case of severe infection
Once the patient is able to swallow the oral replace IV drugs.
Note: For this condition and other life threatening oral conditions consultation of available
specialists (especially oral and maxillofacial surgeons) should go parallel with life saving
measures.
3.6 Pericoronitis
Inflammation of the soft tissues covering the crown of erupting tooth and occurs more
commonly in association with the mandibular third molar (wisdom) teeth. Impaction of food and
plaque under the gingiva flap provide a medium for bacterial multiplication. Biting on the gum
flap by opposing tooth causes laceration of the flap, increasing the infection and swelling. Then
more likelihood of traumatic biting, this may lead to a vicious cycle. Involved bacteria are similar
to those causing gingivitis and periodontitis.
Diagnosis
 High temperature,
 Severe malaise
 Discomfort in swallowing and chewing
 Well localized dull pain, swollen and tender gum flap
 Signs of partial tooth eruption or uneruption in the region
 Pus discharge beneath the flap may or may not be observed
 Foetor-ox oris bad smell
 Trismus
 Regional lymphnodes enlargement and tender
Treatment
A: Hydrogen peroxide solution 3% irrigation
If does not help, or from initial assessment the situation was found to require more than that then.

 Excision of the operculum/flap (flapectomy) is done under local anesthesia
 Extraction of the third molar associated with the condition
 Other means include: Grinding or extraction of the opposing tooth
 Use analgesics
 Consider use antibiotics especially when there are features infection like painful mouth
opening and trismus, swelling, lymphadenopathy and fever.
Drug of choice
A: Amoxicillin 500mg (O) 6 hourly for 5 days
Plus
A: Metronidazole 400 mg (O) 8 hourly for 5 days
If severe (rarely) refer section 3.4 on treatment of dental abscess
3.7 Osteomyelitis of the Jaw
It is an inflammation of the medullary portion of the jaw bone which extends to involve the
periosteum of the affected area. The infection becomes established in the bone ending up with
pus formation in the medullary cavity or beneath the periosteum obstructs the blood supply.
The infected bone becomes necrotic following ischemia.
Diagnosis
 In the initial stage there is no swelling. The patient has malaise and fever
 There is enlargement of regional lymphnodes.
 The teeth in the affected area become painful and loose, thus causing difficulty in
chewing.
 Later as the bone undergoes necrosis the area becomes very painful and swollen.
 Pus ruptures through the periosteum into the muscular and subcutaneous fascia.
 Eventually it is discharged on to the skin surface through a sinus.
Investigation: X-ray – OPG (Orthopantomograph ) or mandibular lateral oblique, water’s view
for maxilla/midface. The x-ray will show sequestra formation in chronic stage. In early stage
features seen in x-ray include widening of periodontal spaces, changes in bone trabeculation
and areas of radioluscency. Perform culture and sensitivity of the pus to detect the specific
bacteria.
Treatment
Non-pharmacological
 Incision and adequate drainage to confirmed pus accumulation which is accessible
 Culture should be taken to determine the sensitivity of the causative organisms.

 Removal of the sequestrum is by surgical intervention (sequestrectomy) is done after
the formation of sequestrum has been confirmed by X-ray.
Pharmacological
A: Amoxicillin or cloxacillin 500mg 6 hourly
Plus
A: Metronidazole 400mg gram 8 hourly before getting the culture and sensitivity
then change according to results.
For details on antibiotics see section 3.4
 Antibiotic therapy may be continued for about 1-3 months.
 Referral is recommended to a zonal referral hospital for any case with long standing
pus discharge and sinuses from the jaws
4.0 FUNGAL INFECTIONS
Oral Candidiasis (Thrush)
This is a fungal infection of the oral mucosa caused by Candidal infection mainly Candida
albicans. Candida albicans is yeast and is a normal oral commensally. Under certain
circumstances candida becomes pathogenic producing both acute and chronic infection. Acute
oral candidiasis (Thrush) is seen most commonly in the malnourished, the severely ill, neonates
and HIV-AIDS patients or patients on long term oral corticosteroids use. In chronic oral
candidiasis dense white plaques of keratin are formed. Other risks for candidiasis is chronic
diseases like diabetes mellitus, prolonged use of antibiotics and ill/poorly fitting dentures.
Diagnosis
Feature of candidiasis are divided according to the types
Pseudomembranous
 White creamy patches/plaque
 Cover any portion of mouth but more on tongue, palate and buccal mucosa
 Sometimes may present as erythematous type whereby bright erythematous mucosal
lesions with only scattered white patches/plaques
Hyperplastic
White patches leukoplakia-like which is not easily rubbed-off.
Angular cheilitis (angular stomatitis)
 Soreness, erythema and fissuring at the angles of the mouth
 It is commonly associated with denture stomatitis but may represent a nutritional
deficiency or it may be related to orofacial granulomatosis or HIV infection
 Investigation where available: For confirmation cytologic smear in solution of 20%
potassium hydroxide for microscopy to see typical hyphae
Treatment
B: Nystatin (suspension) 100,000 IU (1 ml) mixture held in the mouth before
swallowing, 4 times a day (after each feed).
OR
C: Miconazole (O) gel 25 mg/ml 5-10 mls in mouth –hold it before swallowing.

The treatment is continued for 5 days after cure/clearance
Where topical application has failed or candidal infection has been considered severe
add
B: Fluconazole (O) 150mg once daily for 7-14days
OR
C: Ketoconazole (O) 400mg once daily for 7 days is reserved only for severe
cases
Note: Candidiasis has several risk factors; it is recommended that for HIV/AIDS patients
with candidiasis the HIV guidelines should be referred.
5.0 VIRAL INFECTIONS
Herpes Simplex Virus
It is a viral infection commonly affecting the lips and perioral soft tissues presenting as
papulovesicular lesions which ultimately ulcerate. The condition is recurrent following a primary
herpes infection which occurs during childhood leaving herpes simplex viruses latent in the
trigeminal ganglia. The primary infection affects mainly the gingiva and palate.
Diagnosis
 A prodrome of tingling, warmth or itching at the site usually precedes the recurrence
 About 12 hours later, redness appears followed by papules and then vesicles
 These vesicles then burst, weep, dry, scab and then heal
 The length of the cycle is variable (5-12 days mean time being 7 days)
 There are no investigation required unless patient has systemic diseases
Treatment
Non Pharmacological Treatment
 Adequate hydration
 Avoid salty and acidy drinks
 Cover lesions on the lips with Petroleum jelly and control any underlying cause
Pharmacological treatment
The disease is otherwise self-limiting condition but sometimes may need drug treatment
Herpes labial
B: Acyclovir Cream apply 4 hourly for 5 days

Treatment
A: Prednisolone 20 mg tid for 3 days then dose tapered to 10 mg tid for 2 days
then 5 mg tid for other 2 days.
OR
S: Topical triamcinolone in base used twice daily
Plus
A: Paracetamol 1 gm 8 hourly for three days
IDEAL: Oral gel containing ant inflammatory agent preferably combined with analgesic and
antiseptic.
Referral criteria: If the ulcers persist for more than 3 weeks apart from treatment, such
lesion may need histological diagnosis after specialist opinion.
7.0 POST EXTRACTION BLEEDING
Commonly due to disturbing the blood clot by the patient through rinsing or inadequate
compression on the gauze, though at times may be due to bony/tooth remnants.
Diagnosis
Bleeding socket can be primary (occurring within first 24 hours post extraction) or secondary
occurring beyond 24 hours post extraction.
Primary bleeding socket
 Active bleeding from the socket
 The socket may or may not have blood clot
 Patient may be dehydrated and pale if has lost significant amount of blood
 Features of decreased pulse rate and volume, hypotension also if has lost significant
amount of blood
 Examine well the socket may be having traumatic area of surrounding bone of the socket
Secondary bleeding socket may show features of infection or trauma
Treatment Guidelines
 After quick survey make sure the patient airway, breathing and circulation are restored if
there were derangements
 Check Blood pressure and pulse rate and take quick history
 Give Local anesthesia (lignocaine 2% with adrenaline 1 in 80,000 IU)
 Clear any clot available and examine the socket to identify source of bleeding
 If the bleeding was from soft tissue (which is common) remove any foreign body like
bone spicule if found, smoothen any sharp edges
 Suturing of the wound only when necessary (like significantly traumatize gingiva)
 Check and repack the socket with gauze.
 Give proper instructions to follow (bite on gauze pack for 30 minutes, not to rinse or eat
hot foods on that day at least of 12 hours and avoid disturbance to the wound)
Packing can be done by material which stimulate blood clotting like oxidized cellulose (e.g.surgicel/gauze) or Thrombin containing gel foam sponges Medication may be needed especially analgesics example [Paracetamol/diclofenac/ibuprofen]
and
D: Tranexamic acid 500 mg (O/IV) 8 hourly for first 24 hours.
Intravenous fluid especially Normal saline 0.9% or Ringer’s lactate in case of dehydration then
followed by blood transfusion in case of hemoglobin below 7 g/dl in a patient who was
otherwise healthy before tooth extract
Rule out bleeding disorders: if bleeding continued after 24 hours despite steps above,
consult a hematologist or available physician for further management
8.0 TOOTH SENSITIVITIES
Usually is due to attrition of teeth, abrasion or gingival recession
Treatment
Self care: Tooth brushing with toothpaste for sensitive teeth.
Professional care:
C: Fluoride Gel application
9.0 TOOTH ERUPTION, SHEDDING AND EDENTULOUSNESS
9.1 Eruption of Teeth
Eruption of deciduous /primary teeth usually starts at five months of age. Symptoms associated
with it like fever and diarrhea are normal and self limiting unless any other causes can be
established. The following conditions usually are associated with tooth eruption and should be
referred to dental personnel: eruption cysts, gingival cysts of the newborn and pre/natal teeth.
NOTE: There is nothing like “nylon teeth” what is a myth/believe existing in some traditions
instead there are various above mentioned conditions associated with eruption of
deciduous/primary teeth
9.2 Shedding of Deciduous/Primary (Milk) Teeth
Phenomenon of loosing of deciduous/primary teeth occurring between aged of 5-12 years is
normal physiological changes. Deciduous/primary teeth should be left to fall out on themselves
unless the teeth are carious or there is any other indication. Parents should be counseled
accordingly and be instructed to assist their children to loosen the teeth the already mobile
teeth and when there is no success or the permanent teeth are erupting in wrong direction
should consult a dentist. Most of carious teeth will need management by a dentist. Early loss of
primary teeth may lead to crowding of permanent teeth.
9.3 Edentulousness
It is the partial or full loss of natural teeth and subsequent resorption of the alveolar bone.

Treatment: It is by designing and constructing dental prosthesis according to aesthetic and
functional needs. Materials to be used are many and include: alginate impression materials,
calcium chloride powered, acrylic and porcelain, (refer NEMLIT for dental supplies)
10.0 MALOCCLUSIONS
Malocclusion is any variation in the arrangement of teeth leading to abnormal occlusion to the
extent that may be functionally harmful or aesthetically objectionable.
Diagnosis
There are several forms of malocclusion
Class 1
The sagittal arch relationship is normal. The anterior buccal groove of the lower permanent
molar should occlude with the anterior buccal cusp of the upper first permanent molar.
Class II
The lower arch is at least one half a cusp widths too far distal to the upper.
Class III
The lower arch is at least one half a cusp widths too far mesial to the upper.
Treatment
Rationale for treatment:
 Reduce possibility of temporomandibular joint pain dysfunction syndrome especially in
case of cross bites
 Reduce risks of traumatic dental injuries especially in overjet
 Traumatic occlusion and gum diseases and caries especially in crowing
 Avoid psychosocial effects resulting from to lack of self esteem, self confidence personal
outlook and sociocultural acceptability
Removable orthodontic appliances are those designed to be removed by the patient then
replaced back. They are very useful in our local settings especially for mild to moderate
malocclusion in teenagers.
Appliances for active tooth movement fall into two groups
 Simple removable appliances which have mechanical a component to move the
teeth
 Myofuctional appliances, which harness the forces generated by the orofacial
muscles.
Passive removable appliances may also save two functions:
 Retainers used to hold the teeth following active tooth movement
 Space maintainers, used to prevent space loss following the extraction of teeth.
Fixed orthodontic appliances (braces) are useful in malocclusion which have resulted in
relapses of failure after use of removable appliances and moderate to severe malocclusion
which can not be managed by removable appliances especially adult patients. Adolescents and
adult patients requiring fixed appliances should be referred to an orthodontist.

Preventive orthodontic treatment by serial preventive extraction to create a space for anterior
permanent teeth can be done by qualified dental personnel, if in he/she is in doubt it is
recommended to consult dental specialist available.
11.0 TRAUMATIC DENTAL INJURIES
It may result to loosening, displacement and or loss of teeth, fracture of teeth and or bone,
lacerations and bleeding. The commonest causes are alls (in sports and play) at home or
school and motor accidents. Most affected are teeth upper incisors.
Table 1: Diagnosis
Type Presentation
Tooth Concussion Injury to supporting tissues of tooth, without displacement.
Subluxation partial displacement, but is commonly used to describe
loosening of a tooth without displacement
Luxation Displacement of tooth (laterally, labially, or palatally).
Intrusion Displacement of tooth into its socket. Often accompanied by
fracture of alveolar bone
Avulsion Complete loss of the tooth from the socket
Soft tissue injuries
Abrasion: does a friction between an object and the surface of the soft tissue cause a wound.
This wound is usually superficial, denudes the epithelium, and occasionally involves deeper
layer.
Contusion: is more commonly called a bruised and indicates that some amount of tissue
disruption has occurred within the tissues, which resulted in subcutaneous or sub mucosal
hemorrhage without a break in the soft tissue surface.
Laceration: is a tear in the epithelial and sub epithelial tissues. It is perhaps the most frequent
type of soft tissue injury, is caused most commonly by a sharp object
Treatment
 Give tetanus toxoid (0.5% IU)
 Check for facial fractures and trauma to other sites, rule out evidence of head Injury
(amnesia, loss of consciousness, neurological signs)
 Intra-oral examination: Look for soft-tissue lacerations, dentoalveolar fractures and damage
to teeth.
 Check for tooth fragments which may be displaced in soft tissues
 Examine traumatized teeth for mobility and check mobility
 X-rays: (periapical x-ray) especially for suspected root fracture, and OPG x-ray for
suspected alveolar bone fracture and jaw fracture
 Suture for any soft tissue wounds
 Wash mouth with warm saline solution of 3% hydrogen peroxide solution. Repeat mouth
wash3 times daily.
 Medication prescribed for elimination of pain; give analgesic (paracetamol or diclofenac or
ibuprofen).
 Give prophylactic antibiotics if indicated. Antibiotic cover in cases of suspected
contamination or extensive damage (Amoxicillin (oral) 500 mg 8hrly for 5 days).

 Efforts should be made to save the permanent tooth unless there is root fracture.
Restoration of aesthetics (composite filling, prosthesis).
 Extraction is treatment of choice for significantly traumatized primary/deciduous teeth with
mobility and or displacement. Judge the time which the tooth had to remain before
expected exfoliation.
Refer to a dentist, where available orthodontics or endodontic specialist depending on the need
of advanced treatment
Note: Referral to oral and maxillofacial surgeon is done to patients with complicated
maxillofacial injuries.
Prevention
Proper design of playing grounds, observe road traffic rules, early orthodontic treatment
12.0 TUMOURS AND TUMOUR-LIKE CONDITIONS OF ORAL CAVITY AND
FACIAL REGION
Benign Odontogenic Tumors
Ameloblastoma, Calcifying Odontogenic Tumors, Amelobastic fibroma, Adenomatoid Tumors
(Adeno Ameloblastoma), Calcifying Odontogenic Tumors, Ameloblastic Fibro-Odontoma, Odonto
Ameloblastoma, Complex Odontoma, Compound Odontoma, Odontogenic Fibroma,
Odontogenic myxoma, Cementoma and Cementifying Fibroma.
Non Odontogenic Benign tumors
Benign osteogenic tumors (arise from bone): Osteomas, Myxomas, Chondromas, Ewing’s tumor,
Central giant cell and Fibro-osteoma. Benign soft tissues non-Odontogenic tumors Papilloma,
Fibroma, Fibrous Epulis, Peripheral Giant Cells, Pregnancy Tumors, Hemangioma,
Lymphangioma, Lipoma and Pigmented nerves
Treatment: Tumors enucleation or excision in the treatment of choice depending on the type.
Can be hemimandibulectomy, total mandibulectomy, hemimaxillectomy or total maxillectomy
Note: The tumors or oral and maxillofacial regions are of wide range and variable
presentation, a dental surgeon is trained in identification and diagnosis. Treatment of most
of these condition need expertise of oral and maxillofacial surgeon and patients should be
referred early enough
Malignant soft and bone tumors
Squamous cell carcinoma, Sarcoma, Lymphosarcoma, Myosarcoma, Chondrosarcoma,
Fibrosarcoma, Adenosarcoma, Adenocystic carcinoma and Epidermoid carcinoma.
Treatment
Palliative – but this depends on stage of the tumor: stage I and II surgical excision (squamous
Cell carcinoma) with wide margin then curative radiotherapy. Others, surgical excision,
radiotherapy followed by chemotherapy, if lesion is not advanced or in stage I and II.Lymphomas

Bur, ,,,kitt’s tumor is an undifferentiated lymphoblastic lymphoma. It shows close association and
infection with the Epstein Barr virus. (For management refer to the CANCER/ONCLOGY
SECTION
NOTE: Of emphasize is early detection and referral since Burkitt’s lymphoma
respond very quickly on chemotherapy

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