lymphatic drainage of the oral structures- mcq review

1.You notice that your patient's submandibular lymph nodes are enlarged. You would look for potential infection sites in the

a) hard palate.

b) hard palate and upper lip.

c) hard palate, upper lip and upper central incisor.

d) hard palate, upper lip, upper central incisor and lower first molar.

2.The regional lymphatic drainage of the left side of the tip of the tongue is to the

a) left submental lymph node.

b) left and right submental lymph nodes.

c) left submandibular lymph node.

d) left and right submandibular lymph nodes.

The skin of the head and neck drains

The scalp drains into the occipital, mastoid and parotid nodes.

Lower eye lid and anterior cheek drains into buccal LNs.

The cheeks drain into the parotid, buccal and submandibular nodes.

The upper lips and sides of the lower lips drain into the submandibular nodes.

 The middle third of the lower lip drains into the submental nodes

The skin of the neck drains into the cervical nodes.

The drainage of the oral structures

The gingivae drain into the submandibular, submental and upper deep cervical lymph nodes.

The palate lymph vessels may pass to submandibular or superior deep cervical nodes (level II). Retropharyngeal nodes are very rarely involved.

Teeth drain into the submandibular and deep cervical lymph nodes.

Anterior part of mouth floor drain into submental and upper deep cervical.

Posterior part of mouth floor  into submandibular and upper deep cervical.

Inferior alveolar nerve block- mcq review

During an inferior alveolar nerve block the needle ideally passes

a) posterior and medial to medial pterygoid.

b) anterior and lateral to medial pterygoid.

c) through medial pterygoid.

d) inferior to medial pterygoid.

SAQS for Dentistry- Anatomical landmarks in maxilla

Anatomical landmarks in maxilla

 Limiting structures

Labial frenum

Single band of fibrous connective tissue, must be properly relieved.

Labial vestibule

Extends from labial frenum to buccal frenum. Proper lip support should be provided.

 Buccal frenum

Consist of one or more bands. Must be Relieved

Influenced by 3 muscles-  Orbicularis oris (forward), Buccinator (backward),  Caninus (position)

Buccal vestibule

Buccal frenum to hamular notch

Influenced by Buccinator, Modiolus, Coronid process of mandible

Hamular notch

Pterygomaxillary notch, Distal extension of denture ,Situated between the tuberosity and hamulus of the medial pterygoid plate.

Posterior palatal seal area

the soft tissues along the junction of the hard and soft palates on which pressure within the physiologic limits of the tissues can be applied by a denture to aid in the retention of the denture.

Synonyms: post dam area, postpalatal seal area

Supporting structures

Hard palate

Flat areas as secondary retentive areas.

Flat palate (not good support), V shaped palate (least favorable).

Residual ridge

Ridge left after the extraction of teeth. Mucosa is firmly attached to the periosteum of the bone. Consist of dense collagenous fibers.

Considered as a secondary stress-bearing area  because it is subject to resorption contrary to horizontal portion of hard palate.

Palatal rugae

Resist the horizontal forces against the denture, Should not be over  compressed.

Relief areas

 Incisive papilla

Pad of fiberous connective tissue over incisive foramen, Proper relief should be given.

Aid in arrangement of anterior teeth and jaw relation.

 Mid palatine raphe

Junction of palatine process of maxilla. Covered by a thin mucosa, Slightly elevated or raised.

Proper relief required.

Fovea palatine

Formed by coalescence of several mucous gland ducts. Landmark for location of vibrating line.

Maxillary Tuberosity

The medial & lateral walls resist the horizontal and torquing forces which would move the denture base in lateral or palatal direction.

Therefore, maxillary denture base should cover the tuberosities and fill the hamular notches.  

MANDIBULAR FRACTURES MCQ REVIEW

TYPE OF FRACTURE

Simple

Includes a closed linear fractures of the condyle, coronoid, ramus and edentulous body of the mandible.

Compound

Fractures of tooth bearing portions of the mandible, into d mouth via the periodontal membrane and at times through the overlying skin.

Communited

Usually compound fractures characterized by fragmentation of bone

Pathological

Results from an already weakened mandible by pathological conditions.

SITE OF FRACTURE

Dentoalveolar

Condyle

Coronoid

Ramus

Angle

Body (molar and premolar areas)

Parasymphysis

Symphysis

CAUSES OF GINGIVAL RECESSION MCQ REVIEW

What  is Periodontal fremitus

Periodontal fremitus occurs in either of the alveolar bones when an individual sustains trauma from occlusion. It is a result of teeth exhibiting at least slight mobility rubbing against the adjacent walls of their sockets, the volume of which has been expanded ever so slightly by inflammatory responses, bone resorption or both. As a test to determine the severity of periodontal disease, a patient is told to close his or her mouth into maximum intercuspation and is asked to grind his or her teeth ever so slightly. Fingers placed in the labial vestibule against the alveolar bone can detect fremitus.

EFFECTS OF DRUGS ON THE TEETH, ORAL MUCOSA AND SALIVARY GLANDS

Best of fives for dentistry- Sjögren's syndrome mcq review

                                                           Sjögren's syndrome

What is CREST?

CREST is a form of Systemic Sclerosis (scleroderma) which is characterized by Calcinosis (calcium deposits), usually in the fingers; Raynaud's;loss of muscle control of the Esophagus, which can cause difficulty swallowing; Sclerodactyly, a tapering deformity of the bones of the fingers; and Telangiectasia, small red spots on the skin of the fingers, face, or inside of the mouth. (Also see: What is Scleroderma?, Types of Scleroderma and Systemic Symptoms)

Calcinosis            Raynaud's              Esophagus            Sclerodactyly            Telangiectasia

It takes only two of the five CREST symptoms for a diagnosis of  CREST (either "pure" or "plus") to be made. For example, a patient with Calcinosis and Raynaud's would have CREST (which for precision may also be written as CRest, but it is CREST nonetheless.)

CALCINOSIS

The systemic forms of scleroderma can cause small white calcium lumps to form under the skin on fingers or other areas of the body.

This is called calcinosis . The lumps may break through the skin and leak a chalky white liquid.

These most commonly occur on the hands, or near joints such as elbows or knees, although they may appear anywhere.

Raynaud's

Raynaud's is a vascular disorder commonly found in sclerodema. It is an extreme spasm of blood vessels in response to cold or stress. The fingers and/or toes become white and/or blue, and may become red on re-warming.

sclerodactyly

When the skin on the fingers become tight, stretched, wax-like, and hardened it is called sclerodactyly. Sclerodactyly is commonly associated with atrophy of the underlying soft tissues.

Telangiectasia are dilated superficial blood vessels

Candidosis mcq review

ANTIFUNGAL AGENTS

ANTIFUNGAL  AGENTS

Most fungal infections in the oral cavity are due to Candida species,

most commonly Candida albicans.

Where candidosis is related to dentures, denture hygiene  instruction should be stressed. Non-metal dentures should be soaked regularly overnight in sodium hypochlorite 1% (Milton’s solution) and metal-containing dentures similarly in chlorhexidine 0.2% solution.

Nystatin and amphotericin (polyenes)

These agents attach to the fungal cell membrane and disrupt fluid and electrolyte permeability. They are not absorbed from the GI tract and hence act locally .

        Dosage regimens for nystatin and amphotericin

Nystatin

Pastilles 100 000 units

Oral suspension 100 000 units/ml

Ointment/cream 100 000 units/g

Amphotericin

Lozenges 10mg

Oral suspension 100 mg/ml

Miconazole (an imidazole)

Similar action to the polyenes. Effective against some Gram-positive

bacteria such as Staph. aureus. More effective than polyenes in angular cheilitis due to possible mixed fungal/bacterial infection.

Available as oral gel, cream and in combination with hydrocortisone.

Oral gel (25 mg/ml) 5–10 ml held over area affected (after food) or applied to fitting surface of upper denture for the treatment of denture stomatitis (chronic erythematous candidosis).

Cream (2%) Apply to angles of lips 2–3 times daily. Cream or ointment (2%) with hydrocortisone (1%) Apply to angles of lips 2–3 times daily. May be useful for clearing long-standing angular cheilitis but should not be used for longer than 10 days.

Fluconazole (a triazole)

This systemically acting agent inhibits fungal enzymes concerned

with ergosterol synthesis. It appears to have low systemic toxicity.

Form Capsules (50 mg) and oral suspension (50 mg/5 ml). Dose 50 mg daily for 7–14 days. Higher doses will be required in immune compromised patients.

Cautions Avoid in renal disease, pregnancy and lactation, children.

Side effects Nausea, diarrhea and allergic manifestations are the most serious effects.

Main interactions are with antihistamines, oral hypoglycaemic agents and warfarin.

Itraconazole is another potent triazole antifungal agent.

Kaposi's sarcoma

giant cell arteritis

Orofacial granulomatosis MCQ review

Bilateral parotid swelling MCQ review

Trigeminal Neuralgia mcq review

best of five in dentistry review

Recurrent herpes(herpes labialis)

                                                  Giant cell arteritis

                                              Burning mouth syndrome

Best of five Review - Angular cheilitis

Angular cheilitis

Angular cheilitis is a combined staphylococcal, streptococcal, and candidal infection, involving the tissues at the angle of the mouth, often with an underlying precipitating factor, e.g. iron deficiency and B12 deficiency anaemia. Therefore, haematological deficiency should be investigated with a FBC red cell folate, B12, and glucose.

Anecdote suggests an inadequate OVD can also predispose, but correction of this alone will not resolve the condition. Often associated with chronic atrophic candidosis. Clinically, see red, cracked, macerated skin at angles of the mouth, often with a gold crust.

Infecting organisms can be identified on culture of swabs of the area, although it is usual to make a clinical diagnosis.

Rx: miconazole cream, which is active against all three infecting organisms. Rx needs to be prolonged, up to 10 days after resolution of clinical lesion, and carried out in conjunction with elimination of any underlying factors.

Unless the classic golden yellow crusts associated with S. aureus are present, treatment should be commenced with antifungal drugs, e.g. a combined miconazole/hydrocortisone cream (miconazole has some antibacterial properties).

When clinical features indicate S. aureus infection, fusidic acid cream is appropriate. If intra-oral candidiasis is present, this must be treated concurrently or recurrence of the angular stomatitis will occur. Iron deficiency is a significant aetiological factor in angular cheilitis.

Patterson–Brown-Kelly syndrome (Plummer–Vinson syndrome)

Dysphagia (due to a post-cricoid candida web), microcytic

hypochromic anaemia, koilonychia and angular cheilitis (secondary to the anaemia)

A NOTE ON ANATOMY OF PAROTID GLAND

Parotid gland

The parotid gland is the largest of the salivary glands.

The parotid, a serous compound tubulo-alveolar gland, is yellowish, lobulated, and irregular in shape.

It occupies the interval between the sternomastoid muscle and the mandible.

Average Wt - 25gm (varies in weight from 14 to 28 gm)

Surface anatomy

The parotid gland lies inferior to the zygomatic arch, anteroinferior to the external acoustic meatus, anterior to the mastoid process, and posterior to the ramus of the mandible.

Relations

The parotid gland is enclosed in a sheath (parotid fascia) and is shaped roughly like an inverted pyramid, with three (or four) sides (fig A).

It has a base (from which the superficial temporal vessels and auriculotemporal nerve emerge),apex (which descends inferior and posterior to the angle of the mandible),and lateral, anterior, and posterior (or posterior and medial) surfaces.

The lateral surface is superficial and contains lymph nodes.

The anterior surface is grooved by the ramus of the mandible and masseter (fig.B), producing a medial lip (from which the maxillary artery emerges) and a lateral lip, under cover of which the parotid duct, branches of the facial nerve, and the transverse facial artery emerge (see fig. C).

The posterior surface is grooved by  the mastoid process and the sternomastoid and digastric muscles and  more medially by the styloid process and its attached muscles.

Medially, the superior part of the gland is pierced by the facial nerve and the inferior part by the external carotid artery.

The following structures lie partly within the parotid gland, from superficial to deep:

1. The facial nerve forms the parotid plexus within the gland and separates the glandular tissue partially into superficial and deep layers ("lobes"). In surgical excision of the parotid gland (e.g., for a tumor), damage to the facial nerve is a possibility.

2. The superficial temporal and maxillary veins unite in the gland to form the retromandibular vein, which contributes in a variable manner to the formation of the external jugular vein (see fig. D).

3. The external carotid artery divides within the parotid gland into the superficial temporal and maxillary arteries.

Parotid duct

The parotid duct is about 7 cm long

The parotid duct, emerging under cover of the lateral surface, runs anteriorward on the masseter and turns medially to pierce the buccinator.

The branching of the duct can be examined radiographically after injection of a radio-opaque medium. 

The parotid duct, which is palpable, opens into the oral cavity on the parotid papilla opposite the upper second molar tooth.

Innervation of parotid gland ( fig. E)

Preganglionic parasympathetic secretomotor fibers (from the glossopharyngeal, tympanic, and lesser petrosal nerves) synapse in the otic ganglion.

Postganglionic fibers travel with the auriculotemporal nerve and so reach the gland.

Cranial nerves VII and IX communicate, so that secretory fibers to each of the three major salivary glands may travel in both the facial and glossopharyngeal nerves.

The sympathetic supply to the salivary glands includes vasomotor fibers.

Blood supply

The arteries supplying the parotid gland are derived from the external carotid, and from the branches given off by that vessel in or near its substance. The veins empty themselves into the external jugular, through some of its tributaries.

Lymphatics

The lymphatics end in the superficial and deep cervical lymph glands, passing in their course through two or three glands, placed on the surface and in the substance of the parotid.

A Note on Anterior cross bite

Anterior cross bite

Possible causes

Class III skeletal pattern

Crowding

Retained primary teeth and roots

Presence of supernumerary teeth

Trauma

Clinical features

• Instanding maxillary incisor occluding behind the corresponding lower incisors.
• Over bite which can vary from nothing to excessive depth.
• Gingival recession of the lower incisor involved.
• Forward displacement of the  mandible-  instanding tooth comes into premature contact along the normal path of closure.
•      mobility of the lower incisor involved in the cross bite.

Methods available for correction

Spoon handle biting.

Removable appliance with either cantilever spring or screw.

Lower inclined bite plane.

     

Spoon handle biting

Instruct the child to bite on a spoon handle to guide the incisor which is erupting into cross bite.

 Do not attempt this on an erupted incisor which has a positive over bite.

Once cross bite established,

Identify predisposing factors and remove them to prevent development of the cross bite

Once the cross bite is established, identify and remove aetiological factors responsible and select appropriate method for correction.

Removable appliance

Selection of appliance and the spring design depend on,

      Axial inclination of the tooth

Depth of the over bite.

Amount of forward movement required

Number of teeth involved in the cross bite

Appliance design

Select the best active component which should be used depending on the above factors discussed.

Adequate number of clasps

Add adequate number of clasps to the appliance to resist the reaction of the vertical component of the active force.

Appliance design

Add posterior bite plane to disocclude teeth

Instruction to the technician

Adams clasps on 6/6 d /d

Double cantilever spring(Z spring) on /1

Posterior bite plane (half molar capping)

Management of patient

Fit the appliance and give adequate instructions to the patient to wear it regularly including meal time.

Activate the spring by the correct amount.

Adjust clasps and check the thickness of the molar capping.

Give adequate instruction to the parents as well.

Monitor progress of treatment

If cross bite is corrected and depth of the over bite adequate to ensure the stability of the occlusion discontinue appliance

Monitor the development of the occlusion until the occlusion of the permanent dentition is established.

Incisors cross bite before and after correction

Incisor cross bite not corrected early lead to a severe malocclusion