Orals - Chart

Basophil + C3a

degranulation (histamine, chondroitin sulfate, trypatase (mMCP-8), carboxypeptidase A3 low)

Mast cells + C3a

degranulation (histamine, heparin, serine proteases, carboxypeptidase A3)

Gram negative

lmd pathway

Leukocytosis

2-3 fold increase number of leukocytes (PMN), normal: 4-10k cells/uL - Bacterial infections, Tissue injury release of IL-1 and TNF-a by macrophage accelerated release of PMNs from the bone marrow - Bacterial infections, tissue injury release of IL-1 and TNF-a by macrophage stimulates macrophage and T lymphocytes to product CSF induce proliferation of precursor cells in the bone marrow

97 Walton

3.17% flare-ups. Flare-ups were positively correlated with more severe presenting symptoms, pulp necrosis with painful apical pathosis, and patients on analgesics.

44 Basrani

A color change and precipitate were induced in 2.0% CHX by 0.023 % and 0.19 % NaOCl, respectively. Both XPS and TOF-SIMS showed the pres- ence of para-chloroaniline in an amount directly related to the concentration of NaOCl used.

74 Goldberg

A greater number of simulated lateral canals were obturated when Ultrafil, Thermafil, and System B 1 Obtura II were used, in comparison with canals obturated with the hybrid technique, Obtura II, or lateral compaction of gutta-percha.

Scarlette Hernandez

A literature review was carried out using the Medline/Pubmed database The Epstein-Barr virus was found in about 41 % of cases compared to controls, in which it was present in about 2 %. The main association between viruses and endodontic pathosis is between Cytomegalovirus and Epstein-Barr virus; these are found in 114 of the 406 samples of different endodontic pathosis. Some evidence supports that the Epstein-Barr virus is present in a significant number of endodontic diseases, without exact knowledge of their action in these diseases.

IE - additional considerations

Additional considerations: · The practitioner and patient should consider possible clinical circumstances that may suggest the presence of a significant medical risk in providing dental care without antibiotic prophylaxis, as well as the known risks of frequent or widespread antibiotic use. As part of the evidence-based approach to care, this clinical recommendation should be integrated with the practitioner's professional judgment in consultation with the patient's physician, and the patient's needs and preferences. · These considerations include, but are not limited to: o Patients with previous late artificial joint infection Increased morbidity associated with joint surgery (wound drainage/hematoma) o Patients undergoing treatment of severe and spreading oral infections (cellulitis) o Patient with increased susceptibility for systemic infection o Congenital or acquired immunodeficiency o Patients on immunosuppressive medications o Diabetics with poor glycemic control o Patients with systemic immunocompromising disorders (e.g. rheumatoid arthritis, lupus erythematosus) o Patient in whom extensive and invasive procedures are planned o Prior to surgical procedures in patients at a significant risk for medication-related osteonecrosis of the jaw.

Siqueira JF, Rocas IN

Although fungi, archaea, and viruses contribute to the microbial diversity in endodontic infections, bacteria are the most common micro-organisms occurring in these infections. Datasets from culture and molecular studies, integrated here for the first time, showed that over 460 unique bacterial taxa belonging to 100 genera and 9 phyla have been identified in different types of endodontic infections. The phyla with the highest species richness were Firmicutes, Bacteroidetes, Actinobacteria, and Proteobacteria. Diversity varies significantly according to the type of infection. Overall, more taxa have been disclosed by molecular studies than by culture. Many cultivable and as-yet-uncultivated phylotypes have emerged as candidate pathogens based on detection in several studies and/or high prevalence. Now that a comprehensive inventory of the endodontic microbial taxa has been established, future research should focus on the association with different disease conditions, functional roles in the community, and susceptibility to antimicrobial treatment procedures.

1. Rocket immunoelectrophoresis

Antigen into wells and electric current. Antigen moves in the direction of the opposite charge and precipitin zone as it moves at the equal concentration. Will vary according to the different concentration in the wells

Chong

Apical surgery with either MTA or IRM, RG after surgery, 12 mo, 24 mo Highest number of teeth completely health when MTA was used MTA success rate: 84% after 12 mo, 92% after 24 mo IRM: 76% after 12 mo, 87% after 24 mo No difference between both materials at 12 mo and 24 mo

Yared 1994 - Key articles for "we instrument to reduce bacteria"

Bacterial sampling showed significant reduction of bacterial growth during the treatment. No statistically significant difference was noted between the size 25 and 40 file groups after instrumentation, and after l-wk calcium hydroxide dressing.

Stevens, Grossman (1983)

Calcium hydroxide in the form of a supernatant liquid, as a slurry, or as Pulpdent was not as effective in destroying Streptococcus faecalis in the teeth of cats, or in vitro, as compared with camphorated chlorophenoL

Morse, Seltzer, Sinai, Biron

Classification of endodontic diseases is in a confused state. A review of the pitfalls of current classifications and a new, clinical, pulpal classification are given. Clinical and histopathologic findings are mixed in current endodontic classifications. A new system, based on symptomatology, may be more useful in clinical practice. The classifications are vital asymptomatic, hypersensitive dentin, inflamed-reversible, inflamed/degenerating without area-irreversible, inflamed/degenerating with area irreversible, necrotic without area, and necrotic with area

92 Sjogren **

Complete periapical healing occurred in 94% of cases that yielded a negative culture. Where the samples were positive prior to root filling, the success rate of treatment was just 68%

Pathogen entering tissue:

- Direct/indirect: release endotoxin, exotoxin, enzymes - Release of inflammatory mediators: cytokines varies local and systemic effects

Neutrophils

- Granulocytes: 64 (PMN: 93, Eosinophils: 6.7, Basophils: 0.3) - Mononuclear cells: 36 (lymphocytes: 88, monocytes:12)

Endothelial

- P-selectins, E-selectins, (Rolling) - Immunoglobulin (ICAM-1, VCAM-1, PECAM-1) (Adhesion)

Leukocyte

- Sialyl-Lewis X (oligosaccharides + glycoprotein ligands) (Rolling) - Integrin (glycoproteins) (Adhesion)

Double immunodiffusion (Ouchterlony tech)

- Similar to the previous one. Make an agar layer and punch holes. No antibody in the agar but it is in a well. Outside wells contain antigen and inner well is antibody and when they both diffuse toward each at the location of equal concentration, you get precipitation. Identitiy reaction: showing continuity of circle shows same antigen present. But on the right side a different precipitate is present so a different antigen is present

69 Miranda

Endosequence BC Sealer showed radiopacity and flow according to ISO 6876/ 2001 recommendations. The other physicochemical properties analyzed demonstrated favorable values for a root canal sealer.

IE- epidemiology

Epidemiology: · IE is a serious, life-threatening disease that affects more than 15,000 patients each year in the United States; the overall mortality rate approaches 40%. · Rare disease, most frequently occurs in middle-aged to elderly persons, more common in men than women. · In the philly area there is a larger number than average pts with IE yearly due to high incidence of intravenous drug users. (11.6 per 100,000). · Historically, previous Hx of Rheumatic heart disease was a common underlying factor. Current day there's a marked decrease in RHD and is a much less significant factor. · Mitral valve prolapse accounts for 25-30% of native valve endocarditis and is not the most common underlying condition. · Aortic valve disease accounts for about 30% of cases. · Congenital heart disease accounts for 10-20% in younger patients and 8% in older patients. · Incidence of Prosthetic valve endocarditis is increasing and accounts for 1/3 of all IE cases.

7 Noblett

Evaluation of pulse oximetry as a potential method of determining pulp vitality was the subject of this research. Pulse oximeter readings for saturation were recorded and compared with blood gas analysis results. Statistical analysis revealed no difference between pulse oximetry and blood gas analysis with a highly significant correlation coefficient.

Lee

Extracted max/mand molars perforated on mesial root 45 degrees to long axis, repair materials: amalgam, IRM, MTA placed and stained MTA (0.28mm) significantly less leakage than IRM (1.3mm) or amalgam (1.52mm) MTA showed the least overfilling tendency while IRM showed the least underfilling tendency.

pregnant - Pharmacotherapy during pregnancy:

FDA Categories A - Adequate, well-controlled studies have failed to demonstrate a risk to the fetus in first trimester of pregnancy (and later trimesters). B - Animal studies have failed to demonstrate a risk to the fetus. No adequate, well-controlled human studies. C - Animal studies have shown adverse effect on fetus. No adequate, well-controlled human studies. But potential benefits may warrant use of drug in pregnant women despite risks. D - Human studies have shown positive evidence of human fetal risk. But potential benefits may warrant use of drug in pregnant women despite risks. X - Animal or human studies have demonstrated fetal abnormalities and/or positive evidence for adverse effect on fetus, and risks do not outweigh potential benefits. Local anesthetics Category B Category C Lidocaine Bupivacaine, Articaine, Mepivacaine Prilocaine Benzocaine Pregnancy may cause increased sensitivity of nerves to local anesthetics Risk of methemoglobinemia from prilocaine and benzocaine, but low risk when recommended doses are not exceeded. Epinephrine should be used at lowest concentration, using aspiration technique to avoid inadvertent intravascular injection. Recommend: Lidocaine, topical lidocaine 2.5% + prilocaine 2.5% Analgesics Category B Category D Acetaminophen NSAIDs in 1st and 2nd trimester NSAIDs in 3rd trimester Studies showing adverse effects with acetaminophen evaluated long-term (> 28 days) use. Most studies could not establish a causal relationship. Late exposure to NSAIDs can lead to premature closure of ductus arteriosus, oligohydramnios, and maternal bleeding. Find alternatives to opioids if possible. If not, prescribe at lowest dose for the shortest duration of time. Antibiotics Category B Category C Category D Penicillins Augmentin Cephalosporins Clindamycin Metronidazole Erythromycin, Azithromycin Clarithromycin Fluoroquinolones Tetracycline Pregnancy may increase risk of infection due to hormonal changes, alterations in cell-mediated immunity, and altered pharmacokinetics. Augmentin (amoxicillin + clavulanic acid) use in third trimester is associated with development of necrotizing enterocolitis, so it should be avoided in the third trimester. Tetracyclines have an affinity for calcified tissues. Exposure in 2nd and 3rd trimesters can lead to permanent yellowish-brown staining of teeth and may affect long bone growth. Macrolide use may be associated with increased risk of miscarriage, cerebral palsy/epilepsy, and GI malformations. Other antibiotics preferred for treating endodontic infections. Corticosteroids Category C Dexamethasone Methyl prednisolone · Limit use to second and third trimesters, after organogenesis is complete. Short-term. Sedatives and Anxiolytics Category D Benzodiazepine Most studies investigated long-term use. Endodontists may prescribe this medication for short duration at lowest effective dosage. Do not combine with alcohol. Nitrous Oxide Complications have not been found with short-term exposure and low concentrations. Nitrous oxide should be used in select cases. Endodontist should consult with prenatal care provider before administration, limit concentration at 30% and for shortest duration possible.

1. Immunofluorescent assay

Fluorescent labeled antibody. Surface of antigen has antibody that is fluorescent

Paul BF, Hutter JW

For many decades, investigators have conducted studies of the interrelationship between endodontics and periodontics. This review article examines previously held concepts regarding the endodontic-periodontal continuum in light of new research and explores promising advances in understanding etiology and in diagnosis and treatment.

Hepatitis E

HEV is most common in less-developed countries such as India, Pakistan, China, Africa, and Central America. It is rare in the United States and Western Europe. HEV is spread by fecal-oral route, and typically is spread through contaminated water. Although it is infectious similarly to HAV, HEV appears to be less contagious. HEV is a small, nonenveloped, single-stranded RNA virus whose incubation period is 15-60 days. The disease is typically cholestatic, with high levels of bilirubin and alkaline phosphatase. HEV has a tendency to be more severe than other forms of epidemic jaundice as well as a high rate of acute liver failure in pregnant women. The virions and antigen of HEV can be detected in stool and liver. Anti-HEV can be detected at the onset of illness. Diagnosis involves detection of anti-HEV in the IgM subclass. There are currently no treatments or prevention methods for HEV other than using caution when traveling to underdeveloped countries.

86 Belizzi

History with dates

Hypersensitivity

Hypersensitivity type 1: cell bound antibody + soluble antigens Hypersnesitivity type 2: cell bound antigens + soluble antibodies Hypesensitivity type 3: soluble antigens + soluble antibodies Hypersensitivity type 4: sensitized lymphocytes + cell associated antigens

Fibroblasts:

IL-1 collagen production

Okuda K

In vitro phagocytosis of a pathogenic strain of bacteroides melaninogenicus, which possesses a capsular strcutre, was studied. Phagocyted cell numbers of the straian were one half of the noncapsulated strain. Futher, the encapsulated strain was found to be more resistant to the phagocytic killing activity of leukocytes than the noncapsulated strain. Phagocytosis and phagocytic killing of S. aureus were inhibited when extracted capsular material from the strain of B. melaninogenicus was added to the system. The capsular material was found to inhibit the migration of normal macrophage. The antiphagocytic effect of the capsular structure of the strain was related to its infectivity

36 VAL Rodrigues 2017 - can be cited for reduction of bacteria: high reduction with increased instrumentation size and use 2.5% sodium hypochlorite (compared to saline

Irrespective of the type of irrigant, an increase in the apical preparation size significantly enhanced root canal disinfection. The disinfecting benefit of NaOCl over saline was significant at large apical preparation sizes.

42 Jeansonne

Irrigation with chlorhexidine or sodium hypochlorite significantly reduced the numbers of postirrigant positive cultures and colony-forming units compared with saline-irrigated teeth.

epilepsy - lab findings

Laboratory findings: Diagnosis of epilepsy is generally based on the history of seizures and presence of abnormalities on electroencephalogram (EEG). Other diagnostic procedures that are useful for ruling causes of seizures are: CT, MRI, SPECT (single-photon emission computed tomography), lumbar puncture, serum chemistry profiles, and toxicology screening.

blood - management of the patient with a serious bleeding disorder

Management of the Patient with a Serious Bleeding Disorder Hemophilia A- to illustrate dealing with a serious coagulation disorder Consultation with the hematologist is essential and they will determine the dosage of replacement material to be used Preventative dentistry should be started at a young age for all hemophiliac patients, by using fluoride, sealants, providing dietary recommendations, and patient education on oral hygiene and regular dental visits. This way, the need for dental procedures requiring factor VIII replacement can be minimized. Block anesthesia, lingual infiltrations, injections into the floor of the mouth, and intramuscular injections should be avoided without replacement therapy in those with moderate to severe factor disease. Infiltration and intraligamentary injections can be given without replacement. Regarding endodontic treatment, non-vital teeth can easily be treated without replacement therapy. Over-instrumentation and over-filling must be avoided. Minimizing blood loss with vital cases is essential, by performing intracanal injection of local anesthetic with epinephrine or with paper points. Regarding orthodontic treatment, care can be provided as long as sharp edges on appliances are avoided. Periodontal surgery, root planning, extractions, dentoalveolar surgery, soft tissue surgery, and complex oral surgery usually require replacement therapy in those with moderate to severe disease. Mucoperiosteal flaps are suggested to have a buccal or labial approach and a buccal approach is recommended for surgical extractions of wisdom teeth. This is due to excessive bleeding risk on the mandibular lingual tissues and risk of airway obstruction. If local bleeding occurs, the following hemostatic agents can be used to control bleeding: -Tranexamic acid: can be administered orally, IV, or as a mouthwash. Care must be given due to the risk of thrombotic events in old patients, especially when used long-term. -When prescribed as a mouthwash, the patient should take 5 mL and hold it in the mouth for 2 minutes before spitting it out. The first dose should be taken right before the surgery and then repeated 4x/day as needed. -Cyklokapron (IV) or Lysteda (oral) is given right before the surgery and then 3x/day as needed Periodontal procedures which are non-invasive, such as polishing and supragingival calculus removal, can be performed without replacement therapy. In children, primary teeth should be extracted once they become loose Patients with mild factor VIII deficiency and no inhibitors: can be in dental office for less invasive procedures without replacement therapy. Desmopressin and aminocaproic acid or tranexamic acid may be used Patients with moderate factor VIII deficiency without inhibitors: may require replacement therapy for less invasive dental procedures and definitely major oral surgery Patients with severe hemophilia: require replacement therapy for all invasive dental treatment Hemophiliac patients with inhibitors who are either high or low responders: require replacement therapy for any invasive dental procedure, factor VIIa concentrate or factor VIII replacement therapy, respectively. Hemophiliac patients who have undergone invasive dental procedures should be followed up within 24-48 hours to check on bleeding control. Depending on the bleeding, the hematologist may give additional replacement therapy, or the dentist may use a local procedure. Also, the patient should be screened at this time for a possible allergic reaction to the concentrates and to determine if the wound is healing. Before surgery, the dentist can make splints so the displacement of the clot and healing by secondary intention is prevented. Pressure of the splint should not be applied to the soft tissues. Extraction sites should be packed with microfibrillar collagen and closed with sutures for primary healing. Endodontic treatment should be performed rather than extractions if possible. The hematologist should make the decision on whether the patient should be hospitalized for dental surgical procedures or if outpatient care is considered to be safe. Postoperative pain control should avoid NSAIDs and can use acetaminophen with or without codeine.

pregnant - during breast feeding

During Breast Feeding. · The concern is that the administered drug may enter the breast milk and be transferred to the nursing infant, in whom exposure may result in adverse effects. · The American Academy of Pediatrics concludes that "most drugs likely to be prescribed to the nursing mother should have no effect on milk supply or on infant wellbeing." · Drugs that are definitely contraindicated include lithium, anticancer drugs, radioactive pharmaceuticals, and phenindione. · Nursing mothers may take the drug just after breast feeding and avoid nursing for 4 hours or longer if possible. This timing should result in even further reduced drug concentrations in the breast milk.

Inactive precursor altered to be activated:

complement

Pain:

complement, kinins, phospholipase

Madison S,

One year following root canal treatment and internal etching and bleaching of anterior teeth in dogs, the animals were sacrificed and the teeth prepared for stereomicroscopic or light microscopic examination. Evidence of cervical root resorption and ankylosis was noted on several teeth. The bleaching factors associated with the teeth exhibiting resorption were heat with 30% hydrogen peroxide. Resorption was not related to walking bleach or to internal etching alone.

Other Causes of Thyrotoxicosis

Other Causes of Thyrotoxicosis Functional ectopic thyroid tissue, thyroid tissue in ovarian teratomas, and consumption of ground beef containing bovine thyroid may cause thyrotoxicosis.

Blood 2- physical exam

Physical Examination Physical examination should be performed by inspecting the skin and mucosa of the oral cavity and pharynx. It is important to look out for: petechiae, ecchymoses, spider angioma, telangiectasias, jaundice, pallor, and cyanosis (possible thrombocytopenia). Rarely, hemarthrosis of the TMJ is found. These patients should be referred for a medical evaluation.

Qin et al.

Previously, non-collagenous matrix proteins, such as DMP1, were viewed with little biological interest. The last decade of research has increased our understanding of DMP1, as it is now widely recognized that this protein is expressed in non-mineralized tissues, as well as in cancerous lesions. Protein chemistry studies have shown that the full length of DMP1, as a precursor, is cleaved into two distinct forms: the C-terminal and N-terminal fragments. Functional studies have demonstrated that DMP1 is essential in the maturation of odontoblasts and osteoblasts, as well as in mineralization via local and systemic mechanisms. The identification of DMP1 mutations in humans has led to the discovery of a novel disease: autosomal-recessive hypophosphatemic rickets. Furthermore, the regulation of phosphate homeostasis by DMP1 through FGF23, a newly identified hormone that is released from bone and targeted in the kidneys, sets a new direction for research that associates biomineralization with phosphate regulation.

Simon

Primary endodontic lesions Primary endodontic lesions with secondary periodontic involvement Primary periodontic lesions Primary peridontic lesions with secondary endodontic involvement True combined lesions

34 Tanalp

ProTaper, ProFile, and HERO Shaper rotary instruments respectively. ProTaper caused a significantly higher amount of debris extrusion compared to ProFile. No statistically significant difference was observed among the other groups tested.

thyroid cancer - prognosis

Prognosis Prognosis depends on the patient's age along with the extent, size, and metastases of the cancer. Younger patients with localized lesions smaller than 2 cm have the best prognosis. Papillary carcinomas have a 80-90% 10-year survival rate, 65-75% for follicular carcinomas, and 60-70% for medullary carcinomas. Cases that involve cervical lymph nodes have a higher risk of recurrence and cases with distant metastases with differentiated carcinomas have a 42% long-term survival rate. Anaplastic carcinomas have a poor prognosis and poor 5-year survival rate.

Seltzer, IB Bender, Ziontz

Purpose/Objectives: To create a more realistic basis for diagnostic classifications by determining the relationship between the clinical signs and symptoms and the actual histological state of the pulp. Materials & Methods: 166 human teeth that were scheduled for extraction were examined clinically (EPT, thermal test, and x-rays) prior to extraction. Post operatively the teeth were prepared and examined histologicaly. Results: Examiners placed the teeth into one of the following histologic categories. Intact-uninflammed pulp Atrophic pulp Intact pulp with scattered chronic inflammatory cells (transitional stage) Chronic partial pulpitis a. With partial liquefaction necrosis b. With partial coagulation necrosis Chronic total pulpitis c. With partial liquefaction necrosis d. With partial coagulation necrosis 6. Total necrosis Authors Conclusion: There is no complete categorization method of pulpal disease because of overlapping as well as differing disease states in different areas of the pulp. This results in extreme difficulty and confusion when trying to correlate clinical diagnosis with the actual histological state of the pulp. Validity of Conclusion: The conclusion is valid based on the fact that it was nearly impossible to correlate the clinical and histological findings. Reviewers Comments: This article has very important findings but could have been presented in an easier and more organized manner.

Horiba, N, Makawa, Y Marsumoto, T , Naramura H

Samples of dentinal walls from the pulpal surface of the root canal to the cementum side were prepared by an abrasive microsampling method from teeth extracted from patients diagnosed as having apical periodontitis. Endotoxin was extracted with citric acid, and endotoxin content was quantified using a colorimetric method. Endotoxin content was significantly higher in samples from the pulpal surface of root canals to 300 microns in depth than in those taken from farther toward the cementum side. Endotoxin was detected from all of a series of samples obtained from infected root canals.

Kinin

Serum Factor 12 + basement membrane components kinin activation - 12 + (neg surface, BM, collagen, LPS) 12A - Prekalikrein + 12A kallikrein (amplification loop back to 12) Kininogen + kallikrein bradykinin

Langeland

Sixty teeth with various degrees of periodontal disease were extracted and studied histologically in order to determine the effect of periodontal disease on the pulp. Pathologic changes occurred in the pulp tissue when periodontal disease was present, but the pulp did not succumb as long as the main canal—the major pathway of circulation—was not involved. The cumulative effect of periodontal disease on the pulp was manifested by pulpal inflammation, calcifications, apposition of calcified tissue, and resorption. Pulpal inflammation from involved lateral canals or root caries will damage the pulp, but total disintegration apparently occurs only when all main apical foramina are involved by bacterial plaque.

1. Immunoelectrophoresis

Slide layered with agar. Put a well into agar after it hardens. Put in extract of bacteria into SE wells. Hook up the slide to an electric current and let it run. Causes the negatively charged antigen to move toward positive electrode and vice versa. Then peel out well in the middle and add anti serum for the antigen and allow that to diffuse. You get precipitation at the equal concentration present

37 Senia

Sodium hypochlorite was found to be more effective than normal saline solution in clissolving pulp tissue and in cleaning the wider areas of the canals.

epilepsy - status epilepticus

Status epilepticus A serious acute complication of epilepsy (especially the tonic-clinic type. Repeated seizures over a short period of time without a recovery period. This condition is most frequently caused by abrupt withdrawal of anticonvulsant medication or an abused substance but may be triggered by infection, neoplasm, or trauma. Status epilepticus is a medical emergency as patients may become seriously hypoxic and acidotic. This may result in brain damage or death.

94 Goldman

Success and failure of 253 cases selected at random were determined by mounting the films and having six examiners read them. All examiners read the films independently and without consulting one another. They agreed on less than half of the cases. When the question was only one of determining whether an area of rarefaction was or was not present on one film, the agreement was still less than half. Upper molars gave the greatest percentage of disagreement, but all the other teeth gave large percentages of disagreement also.

54 Evans

The calcium hydroxide paste with 2% chlorhexidine was significantly more effective at killing E. faecalis in the dentinal tubules than calcium hydroxide with water.

56 Sjogren

The fine particles evoked an intense, localized tissue response, characterized by the presence of macrophages and mul- tinucleated giant cells. The rosin-chloroform treated gutta-percha induced a similar tissue reaction to that observed with the fine particles of gutta-percha.

88 Delivanis

The objective of this study was to determine if blood-borne bacteria can be attracted and localized inside completely instrumented but unfilled canals. none of the unfilled canals were able to attract the microorganisms from the bloodstream. Infection of the unfilled canal was possible only when the periapical tissueswere intentionally trau- matized with a file during the course of bacteremia and bleeding inside the canal was induced.

Kogushi et al

The pathway of leukocyte extravasation in experimentally induced acute pulpitis in dog teeth was investigated using light microscopy, transmission electron microscopy, freeze-fracture, and corrosion resin casts examined under a scanning electron microscope. Leukocytes emigrate from the lumen of the vessel through the intercellular junction of the endothelium primarily in the venular network located in the center of the pulp. Once complete passage through the vessel into the interstitial space is made, the leukocytes travel into the perivascular connective tissue and beyond.

Lars Fabricius, Gunna Dahlen, Goran Sundquist

The purpose of this study was twofold: first, to determine the influence on the healing of the periapical tissues when selected bacterial strains and combinations thereof remain after root canal treatment; and, second, the relationship to healing of the quality of the root filling. In eight monkeys, 175 root canals, previously infected with combinations of four or five bacterial strains and with radiographically verified apical periodontitis, were endodontically treated, bacteriologically controlled, and permanently obturated. After 2-2.5 yr, the periapical regions were radiographically and histologically examined. Of these teeth, 48 root canals were also examined for bacteria remaining after removal of the root fillings. When bacteria remained after the endodontic treatment, 79% of the root canals showed non-healed periapical lesions, compared with 28% where no bacteria were found. Combinations of residual bacterial species were more frequently related to non-healed lesions than were single strains. When no bacteria remained, healing occurred independently of the quality of the root filling. In contrast, when bacteria remained, there was a greater correlation with non-healing in poor-quality root fillings than in technically well-performed fillings. In root canals where bacteria were found after removal of the root filling, 97% had not healed, compared with 18% for those root canals with no bacteria detected. The present study demonstrates the importance of obtaining a bacteria-free root canal system before permanent root filling in order to achieve optimal healing conditions for the periapical tissues.

Bruce J. Paster* and Floyd E. Dewhirst

The spirochetes are free-living or host-associated, helical bacteria, some of which are pathogenic to man and animal. Comparisons of 16S rRNA sequences demonstrate that the spirochetes represent a monophyletic phylum within the bacteria. The spirochetes are presently classified in the Class Spirochaetes in the order Spirochetales and are divided into three major phylogenetic groupings, or families. The first family Spirochaetaceae contains species of the genera Borrelia, Brevinema, Cristispira, Spirochaeta, Spironema, and Treponema. The second family Brachyspiraceae contains the genus Brachyspira (Serpulina). The third family Leptospiraceae contains species of the genera Leptonema and Leptospira. Novel spirochetal species, or phylotypes, that can not be presently cultivated in vitro, have been identified from the human oral cavity, the termite gut, and other host-associated or free-living sources. There are now over 200 spirochetal species or phylotypes, of which more than half is presently not cultivable. It is likely that there is still a significant unrecognized spirochetal diversity that should be evaluated.

Safavi 1989 -May come up in orals regarding set time and cytotoxicity of sealers

There was no significant difference between the radi- ochromium release in Tubli-Seal and control groups. Pulp Canal Sealer (PCS) and AH26 were significantly more toxic than Tubli-Seal and controls in the 0-, 24-, and 48-h groups (p < 0.01). The toxicity of PCS was significantly higher than AH26 in the 0- and 24-h experiment groups. Forty-eight h after mixing, radiochromium release values for PCS and AH26 groups were higher than those for Tubli-Seal and controls. The difference, however, was not statistically significant (p = 0.4). In the 72-h group, radiochromium release values obtained were similar in the three experimental sealers and were equal to the control groups. These values did not significantly change up to 522 h.

Thyrotoxicosis Factitia

Thyrotoxicosis Factitia Thyrotoxicosis factitial refers to the development of thyrotoxicosis due to ingestion of excess thyroid hormone. It is seen in patients with psychiatric diseases or those ingesting thyroid-active agents in weight reduction programs.

Weber et al.

Tubular structures interpreted as being odontoblast processes can be observed with the scanning electron microscope (SEM) on fractured dentin surfaces which have been demineralized and treated with collagenase. To confirm the nature of these structures, SEM preparations exhibiting similar tubular structures were subsequently examined with the transmission electron microscope (TEM). Newly-erupted human third molars were fractured buccolingually with heavy-gauge industrial nippers or sectioned mesiodistally with a Leitz saw microtome and fixed in glutaraldehyde. The exposed dentin surfaces were decalcified to a depth of approximately 500 μm and then treated with bacterial collagenase. Half of the specimens were critical-point-dried and coated for SEM. The other half were post-fixed and processed for TEM. After examination by SEM, the specimens were embedded and thin-sectioned for TEM. SEM observations of both the fractured and cut surfaces of dentin showed tubular structures running from the surface of the pulp to the dentino-enamel junction. When the SEM preparations were examined with TEM, the tubular structures were seen to be the inner sheath of the peritubular matrix, not odontoblast processes. In the specimens directly processed for TEM, the structures lying inside the sheath could be visualized clearly. In the outer two-thirds of the dentin, the tubules were essentially empty. Well-defined odontoblast processes were seen lying inside the sheath only in the inner dentin,

Hanks et al

Until adhesiveness of dentin bonding agents and other restorative materials to dental structures can be assured, microleakage into resulting "gaps" and dentin permeability will remain major concerns in cases of pulpal irritation. The objectives of the present study were to (a) delineate the kinds and levels of metabolic cytotoxicity of the GLUMA and Scotchbond 2 systems as well as glutaraldehyde and 2-hydroxyethylmethacrylate, and (b) compare the effects of these same materials after diffusion through dentin discs approximately 0.5-mm thick. In monolayer cultures, glutaraldehyde was much more cytotoxic than 2-hydroxyethylmethacrylate. However, GLUMA sealer and Scotchbond 2 adhesive exhibited similar cytotoxicity in monolayer cultures. After diffusion through dentin, glutaraldehyde and 2-hydroxyethylmethacrylate effects were diluted 14.7 and 26.7 times, respectively. The postdiffusional effects of the GLUMA and Scotchbond 2 systems were not significantly different and less than those effects in monolayer cultures. This study should help in the evaluation of possible causes of pulpal irritation following restorative procedures.

Eda S, Saito T

Using dogs' teeth, cells displaced into the dentinal tubules due to dry cavity preparation were observed using electron microscopy. In order to obtain adequate fixation a new local-perfusion method was employed. Most of the cells which moved into the dentinal tubules were odontoblast nuclei and partly neutrophilic leukocytes and erythrocytes. Not only odontoblast nuclei but also cytoplasmic organelles, such as mitochondria, rough endoplasmic reticulum, free ribosomes, and lysosomes were displaced into the tubules. The weavings of dentinal fibers in the tubules were observed in some areas.

Fuks

Vital pulp therapy aims to treat reversible pulpal injury and includes 2 therapeutic approaches: (1) indirect pulp treatment for deep dentinal cavities and (2) direct pulp capping or pulpotomy in cases of pulp exposure. Indirect pulp treatment is recommended as the most appropriate procedure for treating primary teeth with deep caries and reversible pulp inflammation, provided that this diagnosis is based on a good history, a proper clinical and radiographic examination, and that the tooth has been sealed with a leakage-free restoration. Formocresol has been a popular pulpotomy medicament in the primary dentition and is still the most universally taught pulp treatment for primary teeth. Concerns have been raised over the use of formocresol in humans, and several alternatives have been proposed. Controlled clinical studies have been critically reviewed, and mineral trioxide aggregate and ferric sulfate have been considered appropriate alternatives to formocresol for pulpotomies in primary teeth with exposed pulps. In most of the studies reviewed, the caries removal method has not been described. The use of a high-speed handpiece or laser might result in an exposure of a "normal" pulp that would otherwise not be exposed.

Zhou

allocated to either the MTA or BP-RRM treatment group. The patients were followed up at 1 week, 3 months, 6 months, and 12 months; -The success rate in the MTA and BP-RRM groups was 93.1% (81/87 teeth) and 94.4% (67/71 teeth), respectively (P > .05). -Three significant outcome predictors were identified: quality of root filling (P < .05), tooth type (P < .05), and size of the lesion (P < .05) -Conclusions: These results suggest that BP-RRM is comparable with MTA in clinical outcome when used as root-end filling materials in endodontic microsurgery

40 Siqueira

alternated rotary motions (ARM) technique, hand nickel-titanium files and 2.5% sodium hypochlorite (NaOCl) as irrigant; ARM technique and combined irrigation with 2.5% NaOCl and citric acid; ARM technique and combined irrigation with 2.5% NaOCl and 2% chlorhexidine gluconate; and Greater Taper rotary files, using 2.5% NaOCl as irrigant. These findings support the importance of using antimicrobial irrigants during the chemomechani- cal preparation, regardless of the solutions or in- strumentation techniques used.

Membrane Phospholipid + PLA2

arachidonic acid + COX1 and COX2 (xNSAID) --> PGH2 tissue specific isomerases (TxA2, PGD2, PGE2, PGI2, PGF2a/prostaglandins, platelet-activating factor, leukotrienes, HETE) - Increase vascular permeability, promote chemotaxis, sensitize pain receptors

Song

data were collected from patients with a history of endodontic microsurgery performed between August 2004 and December 2008 and at least 1 year before being evaluated. age, sex (female), tooth position (anterior), root-filling length (adequate), lesion type (endodontic lesion), root-end filling material (mineral trioxide aggregate and Super EBA), and restoration at follow-up appeared to have a positive effect on the outcome. - tooth position was a pure predictor of an endodontic lesion affecting the clinical outcome.

49 Estrela

discuss the mechanism of action of sodium hypochlorite based on its antimicrobial and physico-chemical properties.

Histamine, bradykinin, cytokine (IL-1, TNF, IFN-y)

endothelial gaps

Repair accomplished when:

enzymatic destruction of activators (lysosomal enzymes, cytokines, histamine, superoxide anion)

Cells that continue to multiply

epithelium, endothelium, lymphoid

IL-1, IL-6, TNFa

fever

Cytokines

fever, shock, leukocytosis, leukopenia, acute phase response

Factors for repair:

fibroblasts, macrophages, epithelial cells, lymphocytes, plasma cells, blood vessels

PMN:

first neutrophils from blood vessels, phagocytosis, short-lived, degranulation release lysosomal enzymes, proteases, phospholipases, oxygen free radicals

Eosinophils

granules and lobulated nuclei, long-lived, degrade and inactivate leukotrienes, platelet activating factor, histamine, control immediate hypersensitivity

33 Barbizam

group 1, crown-down technique with rotary instrumentation using ProFile .04; group 2, crown-down technique with manual instrumentation using K-files. The manual technique was more efficient in cleaning mesial-distal flattened root canals than the rotary technique, although neither completely cleaned the root canal.

Basophils:

lease number of granulocytes, contain histamine and heparin (inhibit coagulation), participate in inflammation rxn, delayed hypersensitivity

79 Torabinejad

less periradicular inflammation and more fibrous capsules adjacent to MTA, compared with amalgam. In addition, the presence of cementum on the surface of MTA was a frequent finding.

Chronic inflammation, malnourish, cancer, viral

leukopenia (decreased WBC)

Cell membrane, leukocytes

leukotrienes vasodilation and permeability

Limited capacity to regenerate

liver, fibroblst, osteoblast

Antigen and IL-1 + T-lymphocytes

lymphokines (cytokines)

C5b-C9:

lysis

Sequestered in active form

lysosomal enzymes, histamine

Blood vessels:

macrophage FGF and VEGF new blood vessels

IgA:

major Ig in sero-mucous secretions where it defends external body surfaces

C3a/C5a:

mast cell degranulation

C3b, C3d:

microbe opsoniztion

IgG:

most abundant Ig of internal body fluids particularly extra-vascular where combats microorganisms and their toxins

C. tetani:

muscle contractions

No regeneration

myocardium, neuron

C. diphtheriae

neural and myocardial dysfunction

C5a:

neutrophil chemotaxis

77 Torabinejad

no periradicular inflammation adja- cent to five of six root ends filled with MTA; also five of six root ends filled with MTA had a complete layer of cementum over the filling. In contrast, all root ends filled with amalgam showed periradicular inflammation, and cementum had not formed over the root-end filling material, although it was present over the cut root end.

Torabinejad

no periradicular inflammation adjacent to five of six root ends filled with MTA; also five of six root ends filled with MTA had a complete layer of cementum over the filling. In contrast, all root ends filled with amalgam showed periradicular inflammation, and cementum had not formed over the root-end filling material, although it was present over the cut root end. Based on these results and previous investigations, MTA is recommended as a root-end filling material in man.

Asthma - Clinical Presentation

o Signs and symptoms: eversible episodes of breathlessness (dyspnea), wheezing, cough that is worse at night, chest tightness, and flushing. Onset usually is sudden, with peak symptoms occurring within 10 to 15 minutes. Respirations become difficult and are accompanied by expiratory wheezing. Tachypnea and prolonged expiration are characteristic. Termination of an attack commonly is accompanied by a productive cough with thick, stringy mucus. Episodes usually are self-limiting, although severe attacks may necessitate medical assistance. o Classifications of asthma: § Classified as intermittent or persistent( mild, moderate, or sever asthma).

Caries is the source of bacterial products:

organic acids, proteolytic enzymes, endotoxins

C3b

phagocytosis (opsonin)

IgD:

present on lymphocyte surface

Cell membrane, leukocytes

prostaglandins vasodilation and permeability

Synthesized de novo

prostaglandins, cytokines

IgE:

raised in parasitic infections, responsible for symptoms of atopic allergy

Injury

release of chemical mediators histamine, NO, prostaglandin, bradykinin, cytokines vascular flow, vascular leakage, migration of PMNs (leukocytes)

72 Dalat

single-cone techniques, lateral condensation, vertical condensation, Thermafil, and Ultrafil techniques. There were no statistically significant differences between the gutta-percha obturation methods.

43 Kuruvilla

sodium hypochlorite and chlorhexidine gluconate combined within the root canal resulted in the greatest percentage reduction of postirrigant positive cultures. This may be due to formation of "chlorhexidine chloride," which increases the ionizing capacity of the chlorhexidine molecule.

66 Tronstad

solubility and biocompatibility of 2 commercially available calcium hydroxide-containing root canal sealers, CRGS and Sealapex, CRCS appeared to be the most stable of the calcium hydroxide-containing sealers tested.

60 Moller

solutions tested were: 70% isopropyl alcohol, 5% chloramine and 0.5% chlorhexidine. marked decrease in the force necessary to bend the points after 1 tnonth. marked decrease in the force necessary to bend the points after 1 tnonth.

Connective tissue matrix

structural fibrous proteins, adhesive glycoproteins, proteoglycans

Release of neuropeptides

substance P, CGRP vasodilation, increased vascular permeability, pain, chemotaxis

35 Peters

tap water (group A) or alternating 5.25% NaOCl and 17% EDTA (group B). Neither technique was superior in removing debris, but larger canal preparations obtained in this study with LS instruments enabled a more effective removal of the smear layer in the EDTA-NaOCI group.

Hepworth

the orthograde retreatment of teeth associated with apical periodontitis results in a success rate of 66 per cent, an uncertain healing rate of 11 per cent, and a failure rate of 23 per cent. Apical surgery results in a success rate of 59 per cent, an uncertain healing rate of 22 per cent, and a failure rate of 19 per cent.

64 Pascon

three sealers: AH26, Kerr pulp canal sealer, and Kloroperka N.0 At short observation periods (1 to 7 days) AH26 caused severe reactions, and Kerr pulp canal sealer and Kloroperka N.0., moderate and mild reactions, respectively. At 2- and 3-year observation periods the ranking was AH26, mild; Kerr pulp canal sealer, moderate; and Kloropercha N.0..severe.

Tavares 1994 ****Has chemical composition of Gutta percha ***

two brands of gutta- percha cones, and thermoplasticized gutta-percha cylinders. 1 The results obtained with the Kerr and Ultrafil gutta-percha were in agreement with the prevalent view in the literature that gutta-percha is a material well accepted by connective tissue. 2 The severity of the initial tissue reaction caused by the Hygenic gutta-percha cones indicated that reservations might be warranted as to the biocompatibility of this brand.

1. Radioimmuno assay

unlabeled antigen compete for space at the antibody, less and less signal is proportional to the greater amount of un-labeled antigen

Macrophage:

unstimulated (ingest microorganisms wo killing), activated (release of mediators, microbicidal) - Phagocytosis, activated by lymphokines (IFN-y - microbicidal, tumoricidal, bone resorption), secrete proteolytic enzymes, complement, growth factors, immunological activity, IL-1 activate T cells and induce fever, blood clotting and fibrinolysis

52 Wadachi

we examined with a scanning electron microscope the dissolu- tion by Ca(OH) 2 paste of pulpal tissue attached to uninstrumented bovine root canal walls. Ca(OH) 2 as a root canal medicine serves as an effective agent in removing tissue debris remaining on the root canal walls.

32 Imura

when two engine-driven instruments (Quantec and ProFile) and two hand instruments (K-file and Hedström file) The results showed that overall, all instruments may leave filling material inside the root canal. During retreatment there is a risk of instrument breakage, especially rotary instruments.

Activated T cells

IL-2 stimulate T cell proliferation, enhance T cells and macrophage activity

Macrophage

TNFa (polypeptide) stimulate collagenase release, bone resorption, inhibit endothelial cell proliferation

Alternative pathway (lps + c)

C3 convertase C3bBb complement activation

Mannose Lectin

C3 convertase C4b2a complement activation

Classic pathway (Ag + IgG + C)

C3 convertase C4b2a complement activation

THYROIDITIS

THYROIDITIS Thyroiditis refers to thyroid gland inflammation and can be characterized as Hashimoto's, subacute painful, subacute painless, acute suppurative, or Riedel's. It can be caused by radiation therapy, lithium, interleukin-2, interferons, and amiodarone.

TLR

TLR1/TLR2: diacyl lipopeptide TLR6/TLR2: triacyl lipopeptide, lipoproteins TLR3: dsRNA virus TLR4: LPS TLR5: flagellin TLR7: imidazoquinoline (antiviral compounds, viral ssRNA) TLR9: CpG DNA (bacterial DNA, viral DNA)

13 Nguyen

The IL was 0.45 mm shorter than AL (P < 0.05). The differences between FL-10, FL-60 and IL were not statistically significant. Histomorphometrically, the apical constriction was absent in all the teeth, but the file tips were confined within the root. This study concluded that the Root ZX indicated the location of an apical constriction even when the anatomic constriction was eliminated. In the enlarged canals, length measurements obtained with small and large size files were comparable.

Platelets

Serotonin vasoconstriction in small vessels hemostasis

Oxygen-derived rich radicals

(hydrogen peroxide H2O2, superoxide anion 2O2-, hypochlorous acid HOCL

29 Heard

(i) step-back without initial coronal flaring; (ii) step-back with coronal flaring; (iii) step-back with initial coronal flaring and finished by ultrasonic irrigation; and (iv) ultrasonics only. none of them completely removed smear layer and all left debris.

Phillips

-mental foramen was visualized on 75% of the horizontal radiographs -specific differences were observed between the right or left s -size of the mental foramina is shown in Table 3. There was no significant difference in size between the right and left -average distance from the radiographic apex of the second premolar to the center of the foramen was 2.18 mm mesially and 2.41 mm inferiody.

Weine 1975 - K-files and rotary have a tendency to straighten the canal, zipping, teardrop

A technique has been described to reduce these problems by removing flutes from the outer portion of the enlarging instruments near the apex, and by using rasping rather than rotation and a flared preparation.

cancer - management of complications of radiation therapy and chemotherapy

A. Management of Complications of Radiation Therapy and Chemotherapy a. Mucositis Mucositis refers to oral mucosal inflammation and is seen as a side effect of head and neck radiation and chemotherapy. It can present as raw, red, and tender along with epithelial sloughing, leading to the loss of taste, dysphagia, pain, and problems with eating food. The most common sites for mucositis to appear are sites next to metallic restorations and on non-keratinized mucosa including the buccal mucosa and ventral tongue. Mucositis tends to appear between 7-14 days following chemotherapy or by the second week of head and neck radiation with doses of 200 centigrays/week or more. About 1-2 weeks following the completion of treatment, mucositis will usually resolve. Topical anesthetic and bland mouth rinses should be used for pain control and to keep the site clean. Patients should be advised to hydrate, use lip balms, and apply lubricants for comfort and minimizing trauma to the site of mucositis. Removable prostheses, such as dentures, should be cleaned in antimicrobial solution on a daily basis to minimize the risk of infection and they should not be worn during the acute phase of mucositis. b. Secondary Infections Other side effects of chemotherapy and radiation are secondary infections since chemotherapy suppresses the body's immune system and radiation reduces saliva flow in the oral cavity. i. Fungal Infections A common fungal infection that appears in the oral cavity is Candida albicans. Candida albicans can take the form of erythematous candidiasis, pseudomembranous candidiasis, hypertrophic candidiasis, and angular cheilitis. It can cause pain, burning sensations, and alterations in the patient's taste. Topical or oral antifungals are recommended to treat fungal infections and should be given prophylactically to patients with a history of recurrent fungal infections prior to the cancer treatment. ii. Bacterial Infections In patients undergoing cancer treatment that suppresses their immune system, there is a higher prevalence of gram-negative bacteria such as Klebsiella, Pseudomonas, Enterobacter, Proteus, and E. coli in the oral flora. These bacteria can cause ulcerations, swellings, erythema, and fever. Meanwhile, patients undergoing chemotherapy with low white blood cell counts may mask these features. Antibiotics and elimination of the infection source is recommended to treat bacterial infections. iii. Viral Infections Patients undergoing chemotherapy may present with signs of recurrent herpes simplex virus (HSV). In patient that have suppressed immune systems, cases of HSV may present as larger lesions and require more time to heal compared to patients not undergoing chemotherapy. Anti-viral agents should be prophylactically given to patients with a history of recurrent HSV cases. c. Bleeding Patients undergoing chemotherapy at high doses or total body radiation are at a higher risk of bleeding due to thrombocytopenia. Minor cases of trauma can lead to substantial bleeding of the oral mucosa when platelet counts fall below 50,000 cells/mm3. In addition to minor trauma, gingival bleeding can be caused by both poor oral hygiene and traumatic hygiene habits. While patients should be advised to maintain good oral hygiene, they should not brush too hard or use toothpicks and water picks that can induce trauma. d. Neural and Chemosensory changes Neural and chemosensory change can occur in patients undergoing radiation and chemotherapy. Patients may experience a lack of taste as a result of damaged taste cell microvilli caused by radiation therapy. In some cases, it may take 3-4 months following radiation treatment for patients to regain taste. Other patients may have chronic taste loss, of which there are no treatments and their tasting ability will not fully return. Chemotherapy may cause patients to experience a bitter taste in their mouths, unpleasant odors, and distaste of certain foods. When treating these patients, dentists should not use any products that may have a scent to avoid sensory stimulation. Chemotherapeutic agents such as vincristine and vinblastine can cause neurotoxicity of the peripheral nerves and present as odontogenic pain, similar to irreversible pulpitis. This odontogenic pain is often seen in bilateral molar regions. Upon evaluating this pain, dentists need to evaluate the teeth appropriately to avoid inaccurate diagnosis and unnecessary treatment.

C3d:

B-cell activation

AAE Guidance on Antibiotic Prophylaxis for Patients at Risk of Systemic Disease - background

Background · Antibiotic prophylaxis (AP) refers to the practice of the administration of antibiotics to patients without signs of infection in order to reduce subsequent postoperative or post-treatment complications by the prevention of bacterial colonization. In dentistry, the main indications for antibiotic prophylaxis have been to prevent infective endocarditis (IE) and prosthetic joint implant infection (PJI).

diabetes - background and definitions

Background and Definitions · Metabolic disease characterized by high blood glucose levels (hyperglycemia) and the inability to produce and/or use insulin. · Characterized into four groups: o Type 1 diabetes: pancreatic beta cell destruction, insulin deficiency. o Type 2 diabetes: insulin resistance, relative insulin deficiency. o Other specific types: 56 pathologic conditions attributed to genetic defects in beta cell function, as well as diseases and infections. o Gestational diabetes: abnormal glucose during pregnancy Persistent hyperglycemia causes macrovascular diseases primarily effecting eyes and kidneys

Cancer - post cancer treatment management

D. Post-Cancer Treatment Management If a patient is in remission or cured following caner treatment, the patient should be placed on a recall schedule of once every 1-3 months in the first two years, and then once every 3-6 months following the first two years. During the recall appointments, dentists should look for long-term cancer complications such as chronic xerostomia, altered bone, and a loss of taste. The following discusses common complications: a. Hyposalivation and Its Sequelae Hyposalivation is caused by damaged salivary gland tissues as a result of head and neck radiation therapy. As the radiation field and dose increases, the degree of saliva flow decreases with doses above 3,000 cGy causing the most damage. A 50-60% decrease in salivary flow is commonly found a week after radiation. In addition to the quantity of salivary flow, the quality is also affected. Since radiation affects serous acini more than mucous acini, the saliva becomes thick, ropey, and mucinous. This condition can last many months after radiation or remain irreversible. The reduction of salivary flow increases the risk of soft tissue damage, caries, and bacterial/fungal infections. Patients also face challenges with wetting, chewing, and swallowing foods along with changes in their taste, thereby altering their nutritional intake. With decreased saliva flow comes with the increased risk of caries, which forms more rapidly than in patients with normal salivary flow. These lesions have the potential to infect pulpal tissue and induce periapical infections in a matter of months. Concentrated fluoride toothpaste with 5000 ppm, regular salivary flow assessments, and frequent recalls can help address caries formation and progression. Artificial saliva, sugarless candies, sugarless chewing gum, and drinking fluids throughout the day have been recommended to provide relief in patients with xerostomia. Alcohol and tobacco use should also be discouraged. While sialogogue drugs, such as pilocarpine, have been shown to increase salivary flow, they should be used with caution as their side effects may cause additional problems. b. Tooth Sensitivity Another side effect of decreased salivary flow is tooth sensitivity, which can occur in the middle or following radiation therapy. In addition to decreased salivary flow, the low pH in saliva can also contribute to the hypersensitivity. Fluoride gel, dentinal tubule-blocking agents, oxalate-containing resin, resin-based desensitizers, and yttrium-aluminum garnet laser treatments can be used to decrease the sensitivity. c. Muscle Trismus Due to the muscle vascular damage caused by head and neck radiation, trismus of masticatory muscles and joint capsules may present following treatment. To reduce the risk of trismus, mouth blocks should be used during external beam radiation. Methods of relieving trismus include application of warm moist heat and daily stretching exercises, such as placing tongue blades in the patient's mouth 3x/day for 10 minutes, increasing the number of tongue blades over time. d. Prosthodontics Dentures should not be worn within 6 months of completing head and neck radiation treatment due to the trauma that dentures can inflict on the oral mucosa, thereby causing mucosal ulcerations and osteonecrosis. Once patients begin to wear their dentures again after having waited 6 months, they should be instructed to report any sore spots and have their dentures replaced if they are ill-fitting. Petroleum jelly can aid with denture adhesion in cases of severe xerostomia. If patients are interested in implants following radiation treatment, they should be advised to wait 12-18 months after the last dose of radiation and be evaluated for the degree of healing and vasculature in the implant site. Dentists should also keep in mind that anterior regions are less likely to develop osteoradionecrosis than posterior regions. e. Osteoradionecrosis Patients who receive radiation to their head and neck region may develop osteonecrosis because the exposed bone cannot heal due to bone hypocellularity, hypovascularity, and ischemia. It usually appears in dentate patients who receive more than 6500 cGy, smoke, and have undergone traumatic procedures. Since the mandible has less circulation and fewer blood supplies than the maxilla, it has a higher chance of developing osteoradionecrosis. Prior to performing invasive dental treatments on patients with a risk of developing osteonecrosis, dentists should consult with a radiation oncologist. Endodontic treatment with local anesthesia containing little to no epinephrine is commonly preferred to extractions since it decreases the risk of developing osteoradionecrosis. If an invasive dental procedure needs to be performed, patients should undergo hyperbaric oxygen therapy before the treatment. Additionally, antibiotics can be given before the dental treatment and a week after to limit bacteria at the surgical site. Due to the changes in blood flow within the jaw, the benefits of antibiotic may be reduced. When osteoradionecrosis is identified, saline or antibiotic solutions should be used to irrigate the site. Patients should be supplied with an irrigating device and instructions to avoid extreme pressure when they are irrigating at home. If swelling or suppuration appears, broad spectrum antibiotics can be used to address the infection. When conservative measures are unable to resolve the necrosis, the site of necrotic bone may need to undergo surgical resectioning. f. Bisphosphonate-Associated Osteonecrosis Some cancer patients have metastatic bone lesions that lead to bone loss and they are prescribed bisphosphonates. IV bisphosphonates are commonly used to address the bone loss, but they pose a higher risk of bisphosphonate-associated osteonecrosis (BON) than oral bisphosphonates. Since there are limited treatment options for BON, preventative measures should be taken, such as promoting good oral and periodontal heath. If BON appears despite the preventative measures, the site should be rinsed with antimicrobial rinse such as chlorhexidine, undergo surgical debridement, bone curettage, and hyperbaric oxygen therapy.

14 Rivera 1993 * read Divya's conclusion

Data showed that for electronically determined versus actual lengths: 1) 63% were longer, 23% equal, and 13% shorter before instrumentation 2) 30% were longer, 0% equal, and 70% shorter after instrumentation, 3) instrumentation caused a mean shortening of 0.63 mm and 4) recapitulation of nonpatient canals were necessary to obtain length reading with the electronic apex locator

Epithelium:

EGF

1. Agglutination assay

Leave the particulate antigen. At the bottom of the test tube form a button. Lattice formed at the bottom of the tube

Siqueira 1999 ****************************Oral exam********************

Mechanism of antimicrobial activity of calcium hydroxide

hashimoto - med management

Medical Management During the early stages of Hashimoto's Disease when patients are asymptomatic and the goiters are small, patients do not require treatment. As the goiters become larger and patient experience mild hypothyroidism, patients will require thyroid hormone replacement therapy as treatment. When undergoing hormone replacement therapy, these goiters will shrink in size. Goiters that have been present for a long period of time may not decrease in size with hormone therapy and will require surgery in addition to the hormone therapy.

hypertension - dental management, medical consideration

Medical Considerations Dentists can help detect undiagnosed hypertension through routine blood pressure readings during new patient and recall appointments. They may be the first providers to notify the patients of their elevated blood pressure readings. Even though dentists do not diagnose patients with hypertension, they can refer patients to their primary care providers for further evaluation and can help monitor blood pressure during recall appointments. When a hypertensive patient presents to a dental appointment, dentists should inquire about the patient's medical history, hypertension diagnosis, treatments, antihypertensive drugs, adherence status, hypertension-associated symptoms, and recent changes in the patient's blood pressure. When a patient with late stage 2 hypertension is undergoing dental treatment, the blood pressure cuff should be left on the patient's arm to check the reading throughout the procedure. A major concern during dental treatment is a sudden, acute spike in blood pressure that can lead to a stroke or MI. The increase in blood pressure can be caused by endogenous catecholamines from stress and anxiety, exogenous catecholamines in local anesthetics, and catecholamines from gingival retraction cords. The risk of a stroke, MI, acute heart failure, or death during noncardiac surgery can be evaluated by identifying the risk of the patient's cardiovascular disease, risk of the procedure, and the risk imposed by the patient's functional reserve or capacity. Major factors of perioperative cardiovascular risk include unstable coronary syndromes, decompensated heart failure, significant arrhythmias, and severe valvular disease. Intermediate risk factors include history of ischemic heart disease, compensated or previous heart failure, cerebrovascular disease, diabetes mellitus, and renal insufficiency. Minor risk factors include ages greater than 70 years old, abnormal ECG, and rhythm other than sinus rhythm. Since patients that have blood pressure readings above 180/110 are also at risk of strokes and heart attacks, their blood pressure should be brought under 180/110 prior to surgery. The type of procedures is also classified as high, intermediate, and low risk. High risk procedures include peripheral vascular surgery, aortic, and other major vascular surgeries. Intermediate risk procedures include carotid endarterectomy, head and neck surgery, orthopedic surgery, prostate surgery, and intraperitoneal and intrathoracic surgery. Low risk procedures include endoscopic procedures, superficial procedures, cataract surgery, breast surgery, and ambulatory surgery. The patient's functional capacity refers to their ability to perform certain daily activities. Patients that are unable to go up a flight of stairs without chest pain, shortness of breath, or fatigue have an increased cardiovascular risk overall. Patients that present with normal blood pressure (< 120/< 80 mm Hg), elevated blood pressure (120-129/<80 mm Hg), and stage 1 hypertension (130-139/ 80-89 mm Hg) can undergo any required dental treatment with recommendation that patients with elevated stage 1 hypertension consult with their physician. Patients with stage 2 hypertension (>/= 140/ >/= 90 mm Hg) can undergo required dental treatment with intraoperative blood pressure monitoring and should be referred to their physician within a month of the blood pressure reading. Any patients that present with a blood pressure equal to or above 180/110 should have elective treatment deferred and be referred to their physician immediately if they are symptomatic or as soon as possible if they do not show symptoms. When treating a hypertensive patient, dentists should help reduce their anxiety level to limit the release of endogenous catecholamines. This can be done with short appointments that are terminated or rescheduled if the patient becomes anxious. Other methods of reducing anxiety include short acting benzodiazepines like triazolam an hour before the dental appointment and the use of nitrous oxide during the appointment. As orthostatic hypotension is a common side effect of antihypertensive medications, sudden changes in the chair position should be avoided. If patients report dizziness or light-headedness after they stand up from the dental chair, they should be sat down again until they can regain stability. Use of Vasoconstrictors Vasoconstrictors enhance the performance of local anesthetics by slowing the rate of systemic absorption, therefore increasing the anesthetic duration and local hemostasis. While exogenous catecholamines play an important role in decreasing the release of endogenous catecholamines, they pose a risk of increasing the patient's blood pressure. Even though one cartridge of local anesthesia containing 1:100k epinephrine does not cause a significant increase in blood pressure and heart rate, it can cause the mean venous plasma concentration of epinephrine to double from 39 pg/mL to 78 pg/mL. If three cartridges of 1:00k epinephrine are used, the mean venous plasma concentration of epinephrine will increase by 5-6 times and can cause significant increases in blood pressure and heart rate, but the usage of three cartridges is not associated with an increased risk of adverse symptoms. Therefore, the use of 1-2 cartridges of 2% lidocaine with 1:100k epinephrine provides many benefits that outweigh the risks. Epinephrine should be avoided in patients with uncontrolled hypertension and they will need to have their elective treatments deferred. Similarly, Levonordefrin is associated with excessive alpha-1 stimulation and therefore, should not be used in patients with high blood pressure. In cases where a patient requires treatment, the available evidence recommends that providers should consult with the patient's physician and a modest dose of epinephrine, one or two carpules, can be used as the benefits of epinephrine outweigh the risks. Patients who are taking antihypertensive medication are at risk of adverse drug-drug interactions with vasoconstrictors. Nonselective beta-adrenergic blocking medications are commonly involved with these drug-drug interactions since they inhibit the compensatory skeletal muscle vasodilation by beta-2 receptors. When epinephrine or levonordefrin are injected, they cause uncompensated peripheral vasoconstriction due to the unopposed alpha-1 receptor stimulation. As a result of this interaction, patients may experience a significant increase in blood pressure and compensatory bradycardia. While there have been cases documenting this drug-drug interaction, the cases seem to be dose-dependent and providers can safely use one to two carpules of 1:100k epinephrine. Patients who take cardioselective beta blockers are less likely to experience this drug-drug interaction. Topical vasoconstrictors and gingival retraction cords with high concentrations of epinephrine should not be used in patients with high blood pressure. The epinephrine can be absorbed through the sulcus and cause an increase in blood pressure, putting the patient at risk of tachycardia. Tetrahydrozoline, oxymetazoline, and phenylephrine can be used to replace epinephrine in the gingival reaction cords to obtain hemostasis but minimizes the cardiovascular effects. Patients who are taking alpha blockers, alpha-beta blockers, and diuretics may experience orthostatic hypotension, while heightening the effects of anxiolytic and sedative medications. In patients taking anxiolytics and sedatives with antihypertensive medications, their medication doses may be lower than usual. When calcium channel blockers are used simultaneously with erythromycin and clarithromycin, the hypotensive effect of the calcium channel blockers may be enhanced. If patients have a history of prolonged NSAID usage, the effect of antihypertensive medications may be reduced.

K.W Kelley, G. Bergenholtz and C.F Cox

Monkeys were perfused with Karnovsky phosphate-buffered formalin-glutaraldehyde (PBF-GTA). Molars were removed and postfixed in PBF-GTA, demineralized in EDTA, freeze-fractured, and critical-point dried. Odontoblast processes were observed in tubules of the predentine, the pulpal inner third of dentine and in the peripheral dentine, but not in the middle third. Peripheral processes showed close adaptation to dentinal tubules with branches penetrating into canaliculi close to the dentine-enamel junction.

Wolison 1975- classic article

Most of the specimens initially showed ar~ acute response that was followed by fibrous tissue encapsulation. The calcium hydroxide formulation elicited a phaqocytic reponse while Kloroperka N-(D with chloroform produced severe tissue destruction with abscess formation.

71 Khayat

No statistical significant difference was found between the two methods of obturation

diabetes - pathophysiology and complications

Pathophysiology and complications · Persistent elevated blood glucose put persons at risk for diabetes. · Lack of insulin or deficient action of insulin leads to abnormalities in carbohydrate, fat, and protein metabolism. · The combination of underutilization and overproduction of glucose attained through glycogenolysis and fat metabolism results in glucose accumulation in the tissue fluids and in blood. · Hyperglycemia leads to glucose excretion in urine which results in increased urinary volume. This fluid loss may lead to dehydration, if severe enough can cause hyperosmolar nonketotic coma. · Lack of glucose utilization can lead to cellular starvation. If it progresses can lead to metabolic acidosis. decreased pH can be buffered for a period of time but eventually buffer ability will fail to compensate and body fluids will become more acidic. Sever acidosis can lead to coma or death. · Hyperglycemia, ketoacidosis, and vascular wall disease contribute to the inability of patients with uncontrolled diabetes to fight infection and contributes to poor wound healing. · Diabetes effects long-term survival and its signs and symptoms impair the quality of life. Life expectancy is decreased by 5-10 yrs. · Complications of diabetes are related to the level of hyperglycemia and pathologic changes that occur within the vascular system and the peripheral nervous system. Vascular complications result from microangiopathy and atherosclerosis. Changes can be seen throughout the body, but clinical importance occurs within the retina and the small vessels of the kidney. · Retinopathy occurs in all forms of diabetes and is leading cause of blindness in America. 20 times greater risk of blindness than the general population. · Diabetics are 25 times more likely to acquire end-stage renal disease than general public. More prevalent in type 1 diabetics. Account for 37% of all dialysis patients. · Macrovascular disease (atherosclerosis) occurs earlier and is more widespread and more severe in persons with diabetes. Increased levels of LDL and decreased HDL. · Poor glycemic control accelerates atherosclerosis, increasing the risk of ulceration and gangrene in feet, hypertension, renal failure, coronary insufficiency, myocardial infarction, and stroke. Significantly increased chance of death from myocardial infarction or complications with coronary heart disease. · In the extremities, diabetic neuropathy may lead to muscle weakness, muscle cramps, a deep burning pain, tingling sensations, and numbness. Diabetic neuropathy also may involve the autonomic nervous system. Diabetic neuropathy occurs in 50% of diabetics. · Diabetes is associated with skin rashes, deposits of fat in the skin, ulcerations, poor wound healing, and gangrenous extremities. The relative risk that patients with diabetes will require amputation of an extremity because of diabetic complications is more than 40 times that of normal persons. · The severity of complications of diabetes is largely dependent on the level of glycemic control. Thus, a strong case can be made for early diagnosis and appropriate glycemic control to prevent or reduce progression of complications.

Blood - Pathophysiology

Pathophysiology: · Hemostasis is the body's ability to control bleeding and involves three phases: vascular, platelet, and coagulation. · The vascular and platelet phases are known as primary hemostasis and coagulation is known as secondary hemostasis. This is followed by a fibrinolytic phase where the clot is dissolved. · The hemostatic cascade starts with vessel injury, vasoconstriction (TXA2), platelet adhesion, platelet aggregation, initial platelet plug, stabilized platelet/fibrin plug, fibrin clot, clot retraction, followed by recanalization Vascular Phase · The vascular phase begins immediately after injury. In the region of the wound, vasoconstriction occurs in conjunction with collapse of capillaries and veins due to extravascular pressure from blood loss. The vascular endothelium plays a role in both anti-thrombotic and pro-thrombotic events. · Pro-thrombotic events start with exposure of sub-epithelial tissues, collagen, and basement membrane due to the injury. These serve as tissue factors to initiate coagulation by the extrinsic pathway. Vascular endothelium secretes prothrombin (Factor II) to generate thrombin, adenosine diphosphate (ADP) which induces platelet adhesion. Exposure of subendothelial tissues to von Willebrand factor (vWF) promotes platelet adhesion and thrombus formation as vWF binds to other proteins including Factor VIII, collagen, glycoprotein Ib, and other platelets. · Anti-thrombotic events include secretion of heparin sulfate which inactivates thrombin and Factor Xa by anti-thrombin III, and secretion of thrombomodulin which utilizes a cascade reaction to proteolyze factor Va and VIIIa to inhibit coagulation. Platelet Phase · Platelets are cell fragments derived from megakaryocytes. They have a life span of 8-12 days in circulation. 30% of platelets reside in the spleen as a functional reserve. Platelets function to maintain vascular integrity, form a platelet plug for initial bleeding control, stabilization of the platelet plug, and aid in endothelial and smooth muscle regeneration.Subendothelial tissue contact with vWF in the wound site results in contact activation where platelets become sticky and adhere to subendothelial tissues through the interaction with a variety of glycoproteins. · Platelets contain phospholipase C which aids in the creation of arachidonic acid, a substrate for the cyclooxygenase pathway resulting in prostaglandin synthesis of thromboxane A2. ADP release by damaged endothelial cells initiates aggregation of platelets known as the primary wave via the prostaglandin endoperoxide PGG2 and TXA2 (promotes vasoconstriction and platelet aggregation). These platelets than release their own secretions resulting in a second wave of platelet aggregation. · Platelets also bind to fibrinogen (Factor I) which is then converted to fibrin (Factor Ia) via the action of thrombin present on platelets, which stabilizes the platelet plug. This results in a clot of platelets and fibrin attached to subendothelial tissues. Coagulation Phase · Secondary hemostasis known as coagulation involves a cascade of processes to form fibrin. The overall time from injury to a fibrin-stabilized clot ranges from 9-18 minutes. This cascade involves a coagulation factors that are proenzymes, that need to be activated and in turn activates another factor in an ordered sequence. · The intrinsic pathway begins with contact with injury-exposed subendothelial tissues in vivo, and with contact activation of Factor XII (Hageman factor) in vitro. · The extrinsic pathway, which results in more coagulation more rapidly, is initiated through released tissue factors caused by damage and exposure to tissues. Fibrin that is generated from the faster extrinsic pathway feedbacks to accelerate the intrinsic pathway by activation of Factor XIII, enhancing Factor V and VIII activity, and stimulates aggregation of additional platelets. Fibrinolytic Phase The fibrin-lysing system activates at the same time as coagulation to prevent coagulation of intravascular blood distant from the injury site and to dissolve the clot after hemostasis has been achieved. This involves the proenzyme plasminogen that is converted to active plasmin by a variety of activator including tissue-type plasminogen activator (tPA) released by endothelial cells in the site of injury. tPA binds to fibrin and converts fibrin-bound plasminogen to plasmin, thus dissolving the clot locally without any systemic fibrinolysis effects.

C3b:

RBC mediated clearance

83 Ray

The combination of GR and GE had the highest API rate of 91.4%, significantly higher than PR and PE with a API rate of 18.1%.

Blood - Classification of Acquired Bleeding Disorders

The classification is based on bleeding problems in patients with · Normal numbers of platelets (nonthrombocytopenic purpura), · Decreased numbers of platelets (thrombocytopenic purpura), · Disorders of coagulation, and · Hypercoagulable states. Disorders affecting the vascular, platelet, coagulation, and fibrinolytic phases are discussed. Vascular Defects: Bleeding disorders caused by vascular abnormalities may be caused by structural malformation of vessels, hereditary disorders of connective tissue, and acquired connective tissue disorders. Eg Scurvy Platelet Disorders: Disorders of Platelet Function. Platelets participate directly in the clotting cascade by serving as constituents of factor X and prothrombin-converting complexes through the release of platelet factor3 (PF3). Antiplatelet agents Aspirin exerts its antiplatelet effect by irreversibly binding to the enzyme cyclo-oxygenase. Other antiplatelet agents include NSAIDs and adenosine diphosphate (ADP) receptor inhibitors, such as clopidogrel (Plavix). Mild bleeding and bruising may occur in response to trauma or surgery, but are likely to be exacerbated with coexisting medical conditions, such as haemophilia, renal disease and leukemia. The effect of aspirin and clopidogrel lasts for 5 - 7 days, i.e. the entire lifespan of the platelet. Coagulation Disorders: Disseminated Intravascular Coagulation (DIC): DIC is a condition that results when the clotting system is activated in all or a major part of the vascular system. Despite widespread fibrin production, the major clinical problem is bleeding, not thrombosis. DIC is caused when large quantities of thromboplastic substances are introduced into the vascular system and "trip" the clotting cascade. Clinical Findings. Clinical manifestations of acute DIC include severe bleeding from small wounds, purpura, and spontaneous bleeding from the nose, gums, gastrointestinal tract, or urinary tract. Lab Diagnosis: Consumption and inhibition of the function of clotting factors cause prolongation of the PT, aPTT, and thrombin time. Consumption of platelets causes thrombocytopenia. Anticoagulation agents: Warfarin, a coumarin derivative, inhibits the enzyme vitamin K epoxide reductase and thereby impairs production of vitamin K-dependent coagulation factors, i.e. FII, FVII, FIX and FX, as well as proteins C, S and Z. Patients treated with coumarin derivatives have reduced concentrations of these coagulation factors, with consequent increased risk of bleeding that is amplified when the INR is supratherapeutic (particularly >5). Management of warfarin-associated bleeding depends on the severity of bleeding, the level of the INR and the indication for anticoagulation. Heparin: Heparin is an anticoagulant that works by binding to and potentiating the activity of antithrombin, which then inhibits thrombin. Heparin is used for the treatment and prevention of thrombosis. High doses of heparin can cause severe bleeding. In this event, discontinuation of heparin is usually sufficient owing to its short half-life of 8 hours. Low-molecular-weight heparin (LMWH) can be used instead of regular heparin and is rapidly becoming the treatment of choice Non-vitamin K antagonist oral anticoagulants: NOAC (NOACs) include thrombin inhibitors, e.g. dabigatran, and FXa inhibitors, e.g. rivaroxaban and apixaban Vitamin K Deficiency: Vitamin K is critical in the synthesis of coagulation factors II, VI, IX, and X, protein C, protein S, and protein Z. Patients obtain vitamin K from food sources and from metabolism of intestinal flora. Despite being a fatsoluble vitamin, body stores of vitamin K are low and the daily requirement is 1 ug/kg/day. Vitamin K deficiency can present dramatically. Once the body stores of vitamin K are depleted, production of the vitamin K-dependent proteins ceases, and the INR will increase rapidly to extreme levels. Treatment of vitamin K deficiency is by replacement of vitamin K. Most patients will respond rapidly to 10 mg orally. For a more rapid response, 5-10 mg may be given intravenously over at least 60 minutes

Gulabivala 1998- *why do we do obturation*

There was a significant difference in the proportions of specimens that did not leak when the Alpha Seal (PCO.01) and cold lateral condensation groups (PCO.05) were compared with JS Quick Fill. Cold lateral condensation had a higher proportion of specimens with leakage in canals with curvature greater than 20" than in canals with curvatures less than 20" (X0.05). The curva- ture of canals had no effect on the sealing ability of the other techniques. The method of canal preparation had no effect on the sealing ability of Alpha Seal. Alpha Seal, Thermafil and JS Quick Fill were significantly quicker to perform than cold lateral condensation

38 Bystrom

These results suggest that 0.5 percent sodium hypochlorite solution is more effective than saline solution as a root canal irrigant.

Jontell M,

This study has identified and characterized class II (Ia) antigen-expressing cells in the normal rat incisor pulp by immunohistochemistry and flow cytometry. Two types of Ia-expressing cells occurred: one with a pronounced dendritic appearance located primarily in the periphery of the pulp, and one with morphological characteristics similar to those of macrophages. The latter cells were mainly observed in the central portion of the pulp. A numerical ratio of 1:4 was established between the two cell types. The existence of Ia-expressing cells suggests an inherent capacity of the pulp to process and present foreign antigens.

Cho et al

Title: Prognostic factors for clinical outcomes according to time after direct pulp capping Author: Cho et al

Hilton TJ et al

Traditional dental education has recommended the generous use of bases and liners under amalgam restorations, primarily to prevent postoperative sensitivity. However, new developments in bases and liners, as well as a better understanding of pulp biology, have changed the indications for the use of these materials. Understanding the properties of currently available materials and how they interact with pulpal tissues can help the practitioner decide when to use bases and liners and which products to choose.

87 Fish

Zone of infection Zone of contamination Zone or irritation Zone of stimulation

MAC C5b6, 7, 8, 9:

cell lysis

C5a

chemotaxis

Indirect mode of action:

cytokines

Histamine and Thrombin

expression of P-selectin, E-selectin, Sialyl Lewis X

Endotoxins

induction of fever, septic shock, activation of complement, activation of macrophage, leukopenia, bone resorption

Chronic Inflammation

infiltration - macrophage, lymphocyte, plasma cell, others: neutrophil, eosinophil, mast cell, epithelial cells

Fever mechanisms:

- Bacterial endotoxin, virus, lymphocyte products macrophage IL-1 prostaglandins synthesis in the hypothalamic thermoregular centers alter control of body T increase T - TNF-a, IL-6 direct action on hypothalamus alter body T increase body T

neuropeptideL

- CGRP: calcitonin gene related increased VD - SP: substance P increase vascular permeability

: Feit, J., Metelova, M. Sindelka, Z.

3H thymidine was injected intraperitoneally into six male rats on the first, second, and third days after injury to the pulp of the incisors. Forty minutes later the rats were decapitated; the teeth were fixed in formalin and prepared in the usual manner for histoautoradiography. Histologic preparations were stained with hematoxylin and eosin. No odontoblast nuclei labeled by 3H thymidine were observed on the histoautoradiographic pattern. After pulp injury, the odontoblasts behaved as irreversible postmitotic cells incapable of DNA synthesis.

Pus

leukocytes and parenchymal cell

24 Lin

quantify the efficacy of hand, rotary nickel-titanium, and self-adjusting file (SAF) instrumentation in biofilm bacteria removal. Although all techniques equally removed bacteria outside the groove, the SAF reduced significantly more bacteria within the apical groove. No technique was able to remove all bacteria. This biofilm model represents a potentially useful tool for the future study of root canal disinfection.

Macrophages:

remove dead cells, remove damaged tissues, secrete lysosomal enzymes, complement, toxic oxygen metabolites, cytokines, chemokines (IL-1, IL-8, TNF), growth factors

Asthma - Epidemiology

· Epidemiology o Effects 7% of Americans, primarily in children o Clinical manifestations resulting from dysfunction of the airway epithelium, smooth muscle, immune cells, and neuronal elements. o Four categories based on pathophysiology: o Allergic/ extrinsic asthma: most common form, accounts for 35% of all adult cases. It is an exaggerated inflammatory response that is triggered by inhaled seasonal allergens such as pollens, dust, house mites, and animal danders. dose-response relationship exists between allergen exposure and immunoglobulin E (IgE)-mediated sensitization. Inflammatory responses are mediated primarily by type 2 helper T (TH2) cells, which secrete interleukins and stimulate B cells to produce IgE. Allergens interact with IgE antibodies affixed to mast cells, basophils, and eosinophils along the tracheobronchial tree. The complex of antigen with antibody causes leukocytes to degranulate and secrete vasoactive auto-coids and cytokines such as bradykinins, histamine, leukotrienes, and prostaglandins. Histamine and leukotrienes cause smooth muscle contraction (bronchoconstriction) and increased vascular permeability, and they attract eosinophils into the airway. The release of platelet-activating factor sustains bronchial hyperresponsiveness. Release of E-selectin and endothelial cell adhesion molecules, neutrophil chemotactic factor, and eosinophilic chemotactic factor of anaphylaxis is responsible for recruitment of leukocytes (neutrophils and eosinophils) to the airway wall, which increases tissue edema and mucus secretion. T lymphocytes prolong the inflammatory response (late-phase response), and imbalances in matrix metalloproteinases and tissue inhibitor metalloproteinases may contribute to fibrotic changes. o Intrinsic asthma: accounts for about 30% of asthma cases and seldom is associated with a family history of allergy or with a known cause. Patients usually are nonresponsive to skin testing and demonstrate normal IgE levels. This form of asthma generally is seen in middle-aged adults, and its onset is associated with endogenous factors such as emotional stress, gastroesophageal acid reflux, or vagally mediated responses. o Drug induced: Ingestion of drugs (e.g., aspirin, nonsteroidal anti-inflammatory drugs, beta blockers, angiotensin-converting [ACE] enzyme inhibitors) and some food substances (e.g., nuts, shellfish, strawberries, milk, tartrazine food dye yellow color no. 5 can trigger asthma. Aspirin causes bronchoconstriction in about 10% of patients with asthma, and sensitivity to aspirin occurs in 30% to 40% of people with asthma who have pansinusitis and nasal polyps. The ability of aspirin to block the cyclooxygenase pathway appears causative. The buildup of arachidonic acid and leukotrienes mediated by the lipoxygenase pathway results in bronchial spasm. Metabisulfite preservatives of foods and drugs (specifically in local anesthetics containing epinephrine) may cause wheezing when metabolic levels of the enzyme sulfite oxidase are low. Sulfur dioxide is produced in the absence of sulfite oxidase. The buildup of sulfur dioxide in the bronchial tree precipitates an acute asthma attack. o Exercise-induced asthma: stimulated by exertional activity. Although the pathogenesis of this form of asthma is unknown, thermal changes during inhalation of cold air provoke mucosal irritation and airway hyperactivity. Children and young adults are more severely affected because of their high level of physical activity. o Infectious asthma: A term previously used to describe persons who developed asthma because of the inflammatory response to bronchial infection.

Activated systems:

arachidonic acid, kinin, complement, fibrinolutic

Phillips

average horizontal dimension was 4.6 mm -average horizontal dimension was 4.6 mm -larger on the left side than on the right side of the mandible. - most common direction of exit of the mental canal was posterior-superior 68.7% of the time and superior 22.0% of the time - line through the long axis of the clinical crown of the second premolar (line AB) intersected the mental foramen on 62.7% - average distance from the reference line to the center of the foramen was 1.9 mm to the mesial and 2.2 mm to the distal - average vertical distance from the buccal cusp tip of the mandibular second premolar to the inferior border of the mandible was 36.0 mm - average distance from the cusp tip to the center of the foramen was 21.5 mm on the left side and 22.1 mm on the right side. The average for both sides was 21.8 mm. - ratio of the distance from the buccal cusp tip to the center of the foramen versus the distance to the inferior border of the mandible (AD/AB) was 60.6%

Tissue destruction

- Leukocytes: digestive enzymes, oxygen derived free radicals - Eosinophils: oxygen derived free radicals - Fibroblasts: proteinases digesting extracellular matrix, collagen, fibrosis = scarring - Epithelial cells: give rise to cysts - Mediators: IL-1, TNF activate osteoclasts

Acute and chronic inflammation

Acute inflammation: plasma proteins and PMNs (leukocytes) Chronic inflammation: lymphocytes and macrophages

55 Xavier

Both 1-visit and 2-visit root canal treatment protocols were effective in reducing bacteria and endotoxins, but they were not able to eliminate them in all root canals analyzed. Furthermore, 2-visit root canal treatment proto- cols were more effective in reducing endotoxins than 1-visit root canal treatment protocols.

IE - background

Background: · Infective endocarditis (IE) is a microbial infection of the endothelial surface of the heart or heart valves that most often occurs in proximity to congenital or acquired cardiac defects. · Although bacteria most often cause these diseases, fungi and other microorganisms also may cause such infection. · Infective endocarditis is classified by the micro-organism which is causing the infection, they type of valve that is infected (native or prosthetic), and the source of infection (communal/hospital/ intravenous drug user). · IE is a disease of significant morbidity and mortality that is difficult to treat; therefore, emphasis has long been directed toward prevention. · Bacterial species found in mouth frequently have been found to be the causative agent. This finding led to blaming dental treatment as cause of IE and need for antibiotic prophylaxis for patients at risk for developing IE. The effectiveness of such prophylaxis in humans has never been substantiated, and accumulating evidence put the validity of this practice into question.

: Bernardo

Background: Failure of dental restorations is a major concern in dental practice. Replacement of failed restorations constitutes the majority of operative work. Clinicians should be aware of the longevity of, and likely reasons for the failure of, direct posterior restorations. In a long-term, randomized clinical trial, the authors compared the longevity of amalgam and composite. SUBJECTS, METHODS AND MATERIALS: The authors randomly assigned one-half of the 472 subjects, whose age ranged from 8 through 12 years, to receive amalgam restorations in posterior teeth and the other one-half to receive resin-based composite restorations. Study dentists saw subjects annually to conduct follow-up oral examinations and take bitewing radiographs. Restorations needing replacement were failures. The dentists recorded differential reasons for restoration failure. Results: Subjects received a total of 1,748 restorations at baseline, which the authors followed for up to seven years. Overall, 10.1 percent of the baseline restorations failed. The survival rate of the amalgam restorations was 94.4 percent; that of composite restorations was 85.5 percent. Annual failure rates ranged from 0.16 to 2.83 percent for amalgam restorations and from 0.94 to 9.43 percent for composite restorations. Secondary caries was the main reason for failure in both materials. Risk of secondary caries was 3.5 times greater in the composite group. Conclusion: Amalgam restorations performed better than did composite restorations. The difference in performance was accentuated in large restorations and in those with more than three surfaces involved. Clinical implications: Use of amalgam appears to be preferable to use of composites in multisurface restorations of large posterior teeth if longevity is the primary criterion in material selection.

Asthma Dental Management

· prevention of potential problems o The underlying primary goal in dental management of patients with asthma is to prevent an acute asthma attack. The first step in achieving this goal is to identify patients with asthma by history, followed by assessment to elucidate the surrounding details of the problem, along with prevention of precipitating factors. o Questions should be asked that ascertain the type of asthma (e.g., allergic versus nonallergic), the precipitating substances, the frequency and severity of attacks, the times of day when attacks occur, whether this is a current or past problem, how attacks usually are managed, and whether the patient has received emergency treatment for an acute attack. o Features such as shortness of breath, wheezing, increased respiratory rate (more than 50% above normal), FEV1 that has fallen more than 10% or to below 80% of peak FEV1, an eosinophil count that is elevated to above 50/mm3, poor drug use compliance, and emergency department visits within the previous 3 months suggest inadequate treatment and poor stability. Also, the use of more than 1.5 canisters of a beta agonist inhaler per month (more than 200 inhalations per month) or doubling of monthly use indicates high risk for a severe asthma attack. o For severe and unstable asthma, consultation with the patient's physician is advised. Routine dental treatment should be postponed until better control is achieved. o Care must be taken to reduce patients stress and anxiety in dental office. Dentist must also be aware that use of highly fragrant materials such as Eugenol may trigger an attack. o If sedation is required, nitrous oxide-oxygen inhalation is best. Nitrous oxide is not a respiratory depressant, nor is it an irritant to the tracheobronchial tree. o Local anesthetic containing epinephrine contain sulfites which can cause allergic-type reactions, may need to adjust dose used. o Patients on systemic corticosteroids may need supplemental steroids prior to surgical procedures. Inhaled corticosteroids do not cause adrenal suppression. · Management of potential problems: o A short-acting β2-adrenergic agonist inhaler (Ventolin, Proventil) is the most effective and fastest-acting bronchodilator. It should be administered at the first sign of an attack. o With a severe asthma attack, use of subcutaneous injections of epinephrine (0.3 to 0.5 mL, 1 : 1000) or inhalation of epinephrine (Primatene Mist) is the most potent and fastest-acting method for relieving the bronchial constriction. o Supportive treatment includes providing positive-flow oxygenation, repeating bronchodilator doses as necessary every 20 minutes, monitoring vital signs (including oxygen saturation, if possible, which should reach 90% or higher), and activating the emergency medical system, if needed · Treatment planning modifications o No specific treatment planning modifications are required for the patient with asthma. · Oral complications and manifestations o The medications taken by patients who have asthma may contribute to oral disease. o β2-agonist inhalers reduce salivary flow by 20% to 35%, decrease plaque pH and are associated with increased prevalence of gingivitis and caries in patients with moderate to severe asthma. o Oral candidiasis (acute pseudomembranous type) occurs in approximately 5% of patients who use inhalation steroids for long periods at high dose or frequency. However, development of this condition is rare if a "spacer" or aerosol-holding chamber is attached to the metered-dose inhaler and the mouth is rinsed with water after each use.

Cardiac arrest

○ Signs and symptoms: No pulse or blood pressure, sudden cessation of respiration (apnea), cyanosis, dilated pupils ○ Cause: Abrupt interruption of blood supply and oxygen to the coronary arteries and heart muscle due to ischemia (clot) ○ Treatment - Unresponsive adult Positioning: place patient in supine position and establish unresponsiveness (tap and shout). Call for help, activate EMS (call 911), and get defibrillator Circulation and compressions: Health care providers should assess pulse (carotid) for no more than 10 seconds. If no pulse is detected and the victim is not breathing and is unresponsive , promptly initiate chest compressions. ● One operator - 30 compressions per every 2 ventilations for a rate of 100 compressions/minute (depth of 2 inches), until the advanced airway is placed. ● Two operators - 15 compressions per every 2 ventilations, for a rate of 100 compressions/minute Airway: establish airway by head tilt-chin lift, or by jaw thrust if neck injury is suspected. Suction mouth/pharynx if vomitus is blocking the airway iv. Breathing: ventilate lungs with mask ambubag0 delivered positive-pressure oxygen (or mouth-to-mask resuscitation); breath every 6 to 8 seconds (8-10 breaths/minute) ● If ACLS-trained, perform endotracheal intubation and provide positive pressure oxygen Defibrillator: Attach and use automated external defibrillator (AED) as soon as available (ideally within 3 to 5 minutes of collapse) ● Check rhythm and shock if indicated ● Resume CPR beginning with compressions immediately after each shock Ensure that vital signs, drug administration, and patient response are properly monitored and recorded ● ACLS trained providers may utilize a multitude of medications to increase blood pressure/heart rate. Examples include epinephrine, vasopressin, amiodarone, lidocaine, calcium chloride, morphine sulfate and thrombolytic agents. vii. Facilitate/ensure next steps in medical care (transport to hospital); reassure the patient.

Fibroblasts

INF-B B cell growth and antibody production

Leukocytes

INF-a antitumor

Lymphocytes

INF-y -->MAF, PMN, Macrophages

Macrophage, EC

NO vasodilation and permeability

B-lymphocytes + antigen

plasmablasts plasma cell (synthesize antibody) + memory cells (respond at next encounter)

Mast cells, monocytes, leukocytes, EC

platelet-activating factors vasodilation and permeability

Pulp response inflammation

release of inflammatory cytokines: histamine, serotonin, IL's, TNF

Leukocytes

(+) ingest the offending agent, kills bacteria, digest necrotic tissue (-) induce tissue damage

Classical Pathway:

Ag + IgG + C complement activation

Monocytes

slower arrival, longer-living

91 Kakehashi

· The germ-free rats demonstrated a recovery and reparative response leading to dentinal bridging. · The conventional animals exhibited pulp changed from initial severe pulpal inflammation to complete necrosis. · The presence of microflora is a major determinant in the healing of exposed pulps in rats

diabetes - treatment planning modifications

· Treatment planning modifications o The patient with diabetes who is receiving good medical management and demonstrates good glycemic control without serious complications such as renal disease, hypertension, or coronary atherosclerotic heart disease can undergo any indicated dental treatment. o In patients with diabetes who have serious medical complications, however, the plan of dental treatment may need to be altered due to increased risk of post-operative complications.

transplant - medical and surgical managment

● Medical and surgical management ○ Immunosuppression ■ Agents: cyclosporine, azathioprine, prednisone and an antilymphocyte agent. ■ Best results obtained with triple-drug immunosuppressive therapy: cyclosporine, prednisone, and azathioprine or mycophenolate mofetil. ■ After transplantation, doses of immunosuppression agents are reduced as much as possible to prevent injection of the graft. ■ Total body irradiation (1000cGy) has been the most effective means of conditioning the bone marrow graft recipient ○ Surgical procedure ■ Heart transplantation: surgical removal of the heart from the donor , removal of diseased heart from the recipient, then attachment of the donor's heart to the major vessels of the recipient. ● Medications given: immunosuppressive agents, platelet suppression agent, antibacterial to prevent infection and nystatin (candida prophylaxis). ■ Heart-lung transplantation: same process as heart transplantation. However, an additional complication may be seen in this combination transplantation: reversible condition characterized by fever, tachypnea, diffuse pulmonary infiltrates, decreased partial pressure of oxygen in arterial blood and increased partial pressure of carbon dioxide in arterial blood. ■ Liver transplantation: Performed into three phases (1) dissection of recipient's liver from surrounding tissue, (2) anhepatic: blood flow through the vena cava, portal vein and hepatic artery is interrupted, recipient's liver removed and donor's liver is revascularized, and (3) reperfusion of implanted donor liver with blood. ■ Small bowel transplantation: Restricted to patients with end-stage intestinal failures. "Quasi-experimental" in nature. Most common cause for need of transplant is massive small bowel resection with consequent short gut syndrome, which results in rapid intestinal transit without proper absorption of nutrients. ● Small bowel is unique in that it contains a large amount of lymphoid tissue and in the heavy colonization with microorganisms and large quantities of antigens on the surface of the intestinal epithelium. These factors contribute to a high rate of GVHD (graft versus host disease) and subsequent graft rejection and sepsis. ■ Kidney transplantation: Indicated for chronic renal disease or end-stage renal disease. Immunosuppression needed to reduce likelihood of rejection of graft. With the immunosuppression, the patient is rendered susceptible to infection and poor wound healing. Sepsis is a major complication in renal transplant recipients. Adrenal function may be suppressed and, likewise, endogenous cortisol production. ● After transplant, bactrim is given daily for as long as the graft is functioning. Acyclovir and nystatin usually are given for the first 3 months to prevent HSV, cytomegalovirus and candida infections. ■ Pancreas transplantation: Can be done simultaneously with kidney transplantation, after kidney transplantation or as a separate procedure. A new technique involves transplantation of islet cells from the donor's pancreas into the liver of the recipient. The response has helped in many cases of diabetes. ■ Bone marrow transplantation: Cyclophosphamide and total body irradiation or busulfan may be used for patients with leukemia for immune suppression. ● In cancer patients, chemotherapy/radiotherapy kills the cancer. The bone marrow transplantation acts as a modality allowing the patient to combat the lethal effects of the chemoradiation therapy. ● Histocompatibility: The matching of blood type and human lymphocyte antigens (HLAs) with tissue compatibility tests usually results in longer graft and patient survival. The best matching occurs in identical twins. ○ Marrow grafts between unrelated humans carry a high probability of major histocompatibility problems because of the complex polymorphism of the histocompatibility complex. ● Complications: complications with organ transplantation generally consist of technical problems involving the surgical procedure, problems related to immunosuppression, and special problems specific to the organ transplanted. ● Immunosuppression: Excessive immunosuppression increases the risk for infection and must be avoided. Clinical evidence of such immunosuppression includes occurrence of opportunistic infections and development of tumors known to be related to these agents. ● Rejection: Rejection of the transplanted organ is evidenced by the appearance of signs and symptoms of organ failure. When evidence of rejection is found, the dose of immunosuppressive agents is usually increased. ● Drug side effects: ○ A major side effect of azathioprine is bone marrow suppression with resulting leukopenia, thrombocytopenia, and anemia: greater risk for infection and excessive bleeding. ○ Cyclosporine may cause severe kidney and liver changes which may lead to hypertension, bleeding problems and anemia. Cyclosporine associated with gingival hyperplasia. ○ Prednisone important side effects include hypertension, diabetes mellitus, osteoporosis, impared healing, mental depression/psychoses and adrenal gland suppression. ○ Immunosuppressed patients exhibit an increased incidence of certain cancers. Approximately 6% of these patients develop various forms of cancer. ● Special organ complications: The major specific organ complications of immunosuppression involve the heart and bone marrow. Graft versus host disease is often a lethal complication of allogeneic bone marrow transplantation: cyclosporine most effective at preventing GVHD.

9 Kuttler

1.the center of the foramen deviates more from the vertex or apical center with an increase in age and resulting thickening of the apical cememtum 2.the diameter of the foramen increases with age because of the apposition of new layers of cementum. The average diameter of the foramen in 18-25 year old group and in the group 55 years and older is somewhat larger vestibulolingually than ,mesiodistally 3.Because of the existence of an unevenness in the extremities of the diameter of the foramen and because of the funnel shape of the cement canal, this portion of the canal cannot be filled hermetically, unless it is overfilled with cement 4.In the majority of the sections the two points o funion cemento-dentino-canal are found at the same level. In others, one point CDC was closer to the foramen than the other 5.the minor diameter of the root canal is found usually in the dentin. Just before the canal penetrates the cementum portion, and from that point it gradually widens to the foramen, taking on a funnel shape. A constricted portion exists in the canal, but this constriction is not located in the foramen. The funnel-like aspect of this terminal part of the canal is more marked in older people, because of the larger diameter of the foramen and because of the smaller diameter of the canal 6.The average thickness of the apical cementum was above 0.5 mm in the younger age group and thicker in the older age group. The thin layers of cementum often found introduced over the dentin covering the internal ends of the dentin tubules in the last portion of the dentinal canal and the oblique inclination and occasional vertical of the tubules in the same portion directed toward the dental cervix give justification for filling the root canal only as far as 0.5 mm before reaching the foramen

: Newton CW, Hoen MM, Goodis HE, Johnson BR, McClanahan SB

A Consensus Conference on Terminology was convened by the American Association of Endodontists in Chicago on Oct 3, 2008 to review solicited papers on focused questions. This paper addressed the question: Identify and determine the metrics, hierarchy, and predictive value of all the parameters and/or methods used during endodontic diagnosis. The best available clinical evidence was used to determine the sensitivity, specificity, and predictive value of pulpal and periapical testing methods and imaging technologies. Diagnosis of dental pulp diseases suffers from operator's inability to test/image that tissue directly due to its location within dentin. In general, current pulp tests are more valid in determining teeth that are free of disease, but less effective in identifying teeth with pulp disease. Radiographic imaging is probably the most commonly used diagnostic tool to determine the status of root-supporting tissue, although interpretation of structural changes in the periradicular tissues is still considered unreliable.

Brännström M, Garberoglio R.

A scanning electron microscope (S.E.M.) was used to examine dentinal tubules transversely fractured approximately 1.5 mms below a superficial dentinal attritional surface. The material not only included vital teeth but also young, intact premolars implanted into removable dentures. In these teeth the enamel on the buccal cusps was removed and the dentine exposed to attrition for 3 years. For comparison the tubules of intact teeth transversely fractured at the same level were examined. Intact control revealed open tubules of normal size in the area examined. Under attrited surfaces many tubules on the same level were completely occluded with material similar to that seen in peri-tubular dentine. Other tubules had varying degrees of reduction of the tubule lumen. The situation was the same in 4 teeth attrited in removable dentures. The findings support the view that while tubules in sclerotic dentine in teeth subjected to attrition may be occluded by a continuous growth of peritubular dentine, the oral milieu and saliva may also contribute to this process.

Garant PR, Szabo G, Nalbandian J.

A study of the fine structure of the odontoblasts of young mice was undertaken in order to further elucidate the secretory role of this cell in the production of dentine. The observations suggested that fully differentiated odontoblasts possess all of the cytoplasmic characteristics of cells engaged in the production of proteins for external use. A large well developed granular endoplasmic reticulum occupied the greater portion of the cytoplasm. Transitional vesicles originating from the cisternae of the endoplasmic reticulum appeared to give rise to the forming face of the Golgi apparatus by a process of fusion. There was evidence that coated vesicles derived from the mature face of the Golgi apparatus fused to produce dense granules and multivesicular bodies in the vicinity of the Golgi complex, while other coated vesicles migrated to and accumulated in the secretory pole of the cell, i.e. the odontoblastic process. Dense bodies containing distinct crystalloid inclusions were also observed in the area of the Golgi complex. Fusion of coated vesicles with the cell membrane of the odontoblastic process in the region of the predentine matrix was a frequent finding. Observations suggest that coated vesicles play a role in segregation of material by the Golgi complex and in secretion of dentinal collagen and ground substance. The presence of specialized areas of membrane contact (tight junctions) between adjacent odontoblasts were regularly observed.

Cancer - treatment modifications

A. Treatment Planning Modifications When patients are diagnosed with cancer, dentists play a vital role in addressing their dental needs with pretreatment evaluation and preparation of the patient, oral health care during cancer treatment, and post-treatment management of patients. While some cancer treatments do not affect the oral cavity and do not require many treatment planning modifications, some surgeries, chemotherapy, and radiation treatments will heavily affect the oral cavity and will require more modifications.

La Fleche, Frank, Steuer

After fixation of fully formed human permanent teeth in liquid nitrogen the extent of the odontoblast process has been studied in transmission electron microscopy. The odontoblast process, limited by a trilaminar plasma membrane, was found just under the dentine-enamel junction. In cross section, the cytoplasm contained a granular mass with light and/or dense core granules. Bare unmyelinated nerve-like fibrils were seen in close connection with the odontoblast process. In the periodontoblastic space non calcified collagen fibrils were occasionally present. Cytoplasmic globules and granules limited by a trilaminar membrane, with occasional myelinic figures were also noted in the peripheral tubular lumens. The hypothesis of a retractable suspensor system is advanced to explain why in normal fixation conditions the odontoblast processes associated with nerve fibrils have not been observed in the outer layers of dentine.

47 Chong

An intracanal medicament is used to: (i) eliminate ciny remaining bacteria after canal instrumentation; (ii) reduce inflammation of periapical tissues and pulp remnants; (iii) render canal contents inert and neutralize tissue debris; (iv) act as a barrier against leakage from the temporary filling; (v) help to dry persistently wet canals.

75 Anderson

Cavit, IRM, or TERM. Cavlt and TERM provided leakproof seals while IRM demonstrated significant microleakage at 7 days and after thermal stress.

thyroid cancer - diagnosis

Diagnosis Ultrasonography and fine needle aspiration biopsies are used to diagnose thyroid nodules. 3-6 aspiration samples are collected, which contain 5-6 groups of 10-15 cells per group.

95 Burch

Eight hundred seventy-seven teeth were studied to determine the incidence of foramen deviation from the anatomic apex. An average of 92.4 per cent of the major foramina of all the classes of teeth studied opened short of the anatomic apex. The average distance between the foramen and the anatomic root apex was found to be 0:59 mm.

diabetes - etiology

Etiology · Type 1 o Result of genetic, autoimmune, and environmental factors. o 85-90% have autoantibodies against beta cell constituents, destruction of beta cells mediated by T cells. o 10-15% have unknown etiology · Type 2 o Results from genetic, environmental, and aging components. o Chances of offspring having diabetes: 38% if one parent, 60% if both. o Caused by defects in insulin receptor function, insulin receptor signal transduction, insulin secretion, glucose transport and phosphorylation, glycogen synthesis, glucose oxidation that contribute to insulin resistance, and accelerated endogenous glucose production. · Other specific types o Caused by specific gene defects, endocrine conditions, and after steroid use. · Gestational diabetes o 5-7% of all pregnant women. o Glycemic control usually returns to normal after childbirth.

Van Amerongen JP

Fibronectin, visualized in premolar pulps by indirect immunofluorescence, was abundant in the odontoblast layer, around blood vessels and in the core of the pulp. Similarity of alignment of fibronectin with the argyrophilic fibres and von Korff fibres was evident. Fibronectin was extracted from pulps after first removing blood by washing with water, confirmed by eventual negative reaction on alpha 2-macroglobulin. Extraction of fibronectin from this remaining tissue was most effectively achieved by treatment with collagenase or hyaluronidase, though in all cases some fibronectin remained, indicating that fibronectin in pulp is not exclusively associated with collagen and/or proteoglycans. The fibronectin quantified by electro-immunoassay and expressed as percentage of dry weight was 0.030 per cent in the water extract, 0.094 per cent in the collagenase extract and 0.109 per cent in the hyaluronidase extract. Twice as much fibronectin was extracted from the apical pulp as from the coronal and middle parts, in accord with earlier findings of a higher collagen content in the radicular part. It is suggested that with the loss of collagen type III during odontoblast differentiation and its reappearance with advancing vascularization of the dental papilla, the amount of fibronectin is similarly altered.

Friedman et al.

Fifty‐eight bleached pulpless teeth were re‐examined after periods of 1-8 years. Recall examination included recording of the esthetic results, clinical findings and radiographs. External root resorption was found in 4 of the cases (6.9%), and was progressive in 2 cases and arrested in 2 cases. There had not been any pre‐ or postoperative trauma in any of the 4 cases. The occurrence of resorption was not related to the bleaching technique used. Resorptive lesions were found to have been initiated apical to and not at the cemento‐enamel junction. Esthetically, the bleaching was considered successful in only 50% of the cases, acceptable in 29% and failed in 21%. These results caution against indiscriminate use of bleaching with hydrogen peroxide, and emphasize the importance of preventive measures and postoperative follow‐up of bleached pulpless teeth.

90 Ehrmann

Focal infection · There is no evidence that pulpless teeth are a source of infection. · When root canals of a pulpless tooth are debrided and sterilized with modern endodontic principles, the body's defense mechanisms can resolve the residual infection. · The retention of teeth via endodontic treatment is preferable to extraction, especially in chronically ill patients.

67 Sipert

In this laboratory study, Fill Canal, Sealapex, MTA and Portland cement presented antimicrobial activity whilst EndoRez did not.

Torneck

In this paper, the biological events that give rise to the radiographic appearance called calcific pulp obliteration will be described, as will the anatomical and histological changes that attend its presence. There will also be a review of the studies that explore the relative incidence of this pulp change subsequent to trauma, and the incidence of attending periapical disease that should indicate to the clinician that some form of treatment is required. Finally, the endodontic management of these teeth will be described with emphasis on the types of adjustments that can be made to minimize the chance for a procedural accident.

diabetes - medical management

Medical management · guidelines published by the American Diabetes Association target outcomes focused on glycemic control modified nutrient intake and weight reduction (as appropriate), blood pressure control, and a favorable lipid profile. · flexible treatment plan is devised that includes healthy food choices, physical activity recommendations, along with the use of oral hypoglycemic medications, insulin injections and insulin pumps. · Management also involves medications to address the vascular, kidney and ocular complications, including antihypertensive drugs.

hepatitis - prevention

Prevention Two vaccines are available for HAV, two for HBV, and one for a combination for HAV and HBV, called Twinrix. Comvax is a vaccine for HBV and Haemophilus influenze type b for infants. Booster doses are advised for HBV only if the patient does not respond to the primary vaccination.

IE - Regiments for a dental procedure

Regiments for a dental procedure · The above chart of recommendations is still accurate to date · The 2007 guidelines state that an antibiotic for prophylaxis should be administered in a single dose before the procedure. However, special circumstances can arise in clinical practice. For example, in the event that the dosage of antibiotic is inadvertently not administered before the procedure, it may be administered for up to 2 hours after the procedure. · For patients already receiving an antibiotic that is also recommended for IE prophylaxis, then a drug should be selected from a different class. For example, a patient already taking oral penicillin for other purposes may likely have in their oral cavity viridans group streptococci that are relatively resistant to beta-lactams. In these situations, clindamycin, azithromycin or clarithromycin would be recommended for AP. Alternatively, if possible, treatment should be delayed until at least 10 days after completion of the antibiotic to allow re-establishment of usual oral flora. In situations where patients are receiving long-term parenteral antibiotic for IE, the treatment should be timed to occur 30 to 60 min after delivery of the parenteral antibiotic. It is considered that parenteral antimicrobial therapy is administered in such high doses that the high concentration would overcome any possible low-level resistance developed among oral flora

Filipowicz F, Umstott P, England M.

Root resections were performed on 86 maxillary molars as part of periodontal therapy. The amputation sites were sealed with Dycal and amalgam. The teeth were evaluated for vitality using electric pulp testing and cold (ice) up to 9 yr postoperatively. The greatest loss of vitality occurred within 12 months. The percentage of vital teeth at 6 months was 59% and at 12 months 38%. The number of vital teeth continued to decline until only 13% tested vital at 5 yr. The long-term prognosis for a vital root resection is poor; therefore, endodontic therapy prior to resection is preferable.

Dahl

Scanning electron microscopy was used to study the formation of a dentine smear in ten premolars ground with a water-cooled diamond in an air turbine. In another ten teeth the pulp reaction in full crown preparation with the same armamentarium was investigated by histological techniques. The findings revealed the formation of a dentine smear which was easily removed by light polishing with wet pumice, leaving plugs of debris in the tubule apertures. The clinical significance of these findings needs further investigation. No bacteria were demonstrated on the prepared surfaces either in the scanning electron micrographs or histologically when stained with Brown & Brenn stain. Severe, acute pulp reactions were observed subjacent to the dentinal tubules cut in full crown preparation. This technique should therefore be limited to superficial use only.

41 Baumgartner

Significantly more chlorine gas was evolved when the sodium hypochlorite solution was mixed with the citric acid solution than with the EDTA solution. Mixing the sodium hypochlorite solution with a hydrogen peroxide solution did not evolve any detect- able concentration of chlorine gas.

hashimoto - Signs and Symptoms

Signs and Symptoms Patients with Hashimoto's Thyroiditis often present with moderately sized goiters that are rubbery and move during swallowing. Some patients experience transient hyperthyroidism prior to hypothyroidism due to lymphocytes replacing the functioning tissue.

Kakehashi S, Stanley HR, Fitzgerald RJ

T hc problem of maintaining thr vitality of a clinically exposed dental pulp by various conservative procedures to encourage the development of dentinal bridging has been the subject of numerous investigations.'--' The unpredictability of rrsults obtained from these procedures, however, ha.s been the source of great consternation to most operati\c clinicians. In those instances of successful management of pulpal exposures, a, considerable part of the success has been attributed to the extraordinary dcgrec of pulpal tissue resistance.: Reasons gi\-cn for the failure in formation of a hard-t,issue pulpal seal have included a.ge of the patient, degree of surgical trauma, excessive sealing pressures, improper choice of medication, bacterial infection, and a low threshold of host resistance. l3ecauscl of the frequency of adverse results obtained after the pulp-capping treatment of acute or chronically infected dental pulps, regardless of all the other conditions present, these particular cases arc no longer considered for this type of procedure. The microorganisms in these acute and chronically inflamed pulpal cxposurcs have therefore been thought to be the most significant cause of failures in attempts at dentinal bridging. To t,est conclusively the influence of riablc microorganisms on the fate of a surgically exposed dental pulp, a study utilizing germ-free animals was undertaken.

: Li et al.

TGFβ/BMP signaling regulates the fate of multipotential cranial neural crest (CNC) cells during tooth and jawbone formation as these cells differentiate into odontoblasts and osteoblasts, respectively. The functional significance of SMAD4, the common mediator of TGFβ/BMP signaling, in regulating the fate of CNC cells remains unclear. In this study, we investigated the mechanism of SMAD4 in regulating the fate of CNC-derived dental mesenchymal cells through tissue-specific inactivation of Smad4. Ablation of Smad4 results in defects in odontoblast differentiation and dentin formation. Moreover, ectopic bone-like structures replaced normal dentin in the teeth of Osr2-IresCre;Smad4(fl/fl) mice. Despite the lack of dentin, enamel formation appeared unaffected in Osr2-IresCre;Smad4(fl/fl) mice, challenging the paradigm that the initiation of enamel development depends on normal dentin formation. At the molecular level, loss of Smad4 results in downregulation of the WNT pathway inhibitors Dkk1 and Sfrp1 and in the upregulation of canonical WNT signaling, including increased β-catenin activity. More importantly, inhibition of the upregulated canonical WNT pathway in Osr2-IresCre;Smad4(fl/fl) dental mesenchyme in vitro partially rescued the CNC cell fate change. Taken together, our study demonstrates that SMAD4 plays a crucial role in regulating the interplay between TGFβ/BMP and WNT signaling to ensure the proper CNC cell fate decision during organogenesis.

1. Single (radial) immunodiffusion (mancini tech)

Take a slide with agar. Add anti-serum in the agar medium and let it harden on top of a glass slide. After it hardens, punch holes and add antigen and let it harden. Where the antigen reaches the zone of equivalence, you get precipitation to form. Diameter of the precipitate reaction correlates with the concentration of antigen in the well

Mejare

The aim of this systematic review was to appraise the diagnostic accuracy of signs/symptoms and tests used to determine the condition of the pulp in teeth affected by deep caries, trauma or other types of injury. Radiographic methods were not included. The electronic literature search included the databases PubMed, EMBASE, The Cochrane Central Register of Controlled Trials and Cochrane Reviews from January 1950 to June 2011. The complete search strategy is given in an Appendix S1 (available online as Supporting Information). In addition, hand searches were made. Two reviewers independently assessed abstracts and full-text articles. An article was read in full text if at least one of the two reviewers considered an abstract to be potentially relevant. Altogether, 155 articles were read in full text. Of these, 18 studies fulfilled pre-specified inclusion criteria. The quality of included articles was assessed using the QUADAS tool. Based on studies of high or moderate quality, the quality of evidence of each diagnostic method/test was rated in four levels according to GRADE. No study reached high quality; two were of moderate quality. The overall evidence was insufficient to assess the value of toothache or abnormal reaction to heat/cold stimulation for determining the pulp condition. The same applies to methods for establishing pulp status, including electric or thermal pulp testing, or methods for measuring pulpal blood circulation. In general, there are major shortcomings in the design, conduct and reporting of studies in this domain of dental research.

Peterson,

The aim of the present study was to evaluate the ability of thermal and electrical tests to register pulp vitality. Sensitivity, specificity, negative predictive value and positive predictive value were calculated by comparing the test results with a "gold standard". The thermal tests studied were a cold test (ethyl chloride) and a heat test (hot gutta-percha). For the electrical test, the Analytic Technology Pulp Tester was used. The examined teeth were 59 teeth with unknown pulpal status in need of endodontic treatment and 16 intact teeth, all with radiographically normal periapical bone structures. In total 46 teeth with vital pulps and 29 teeth with necrotic pulps were tested. This gave a disease prevalence of 39%. The gold standard was established by direct pulp inspection of the 59 teeth in need of endodontic treatment. In the 16 intact teeth the pulp was judged as vital. The number of true positive (TP), false positive (FP), true negative (TN) and false negative (FN) test results was calculated for each method as compared to the gold standard. Based on this, the sensitivity, specificity, positive predictive value and negative predictive value were calculated for each method. The sensitivity was 0.83 for the cold test, 0.86 for the heat test and 0.72 for the electrical test. The specificity was 0.93 for the cold test, 0.41 for the heat test and 0.93 for the electrical test. The positive predictive value was 0.89 for the cold test, 0.48 for the heat test and 0.88 for the electrical test, and the negative predictive value was 0.90 for the cold test, 0.83 for the heat test and 0.84 for the electrical test. This indicated that the probability of a non-sensitive reaction representing a necrotic pulp was 89% with the cold test, 48% with the heat test and 88% with the electrical test. It also indicated that the probability of a sensitive reaction representing a vital pulp was 90% with the cold test, 83% with the heat test and 84% with the electrical test

39 Bystrom

The combined use of EDTA and 5 per cent sodium hypochiorite solution was more efficient than the use of sodium hypochiorite solutions alone. An important observation was that bacteria surviving instrumentation and irrigation rapidly increased in number in the period between appointments when no intracanal medicament was used.

Narhi et al.

The arousal of the two components of pain (the first rapid or sharp pain and the second dull pain) are considered to be related to activation of A delta- and C-type nociceptive primary afferents, respectively. The same dichotomy of pain sensations may also exist in teeth, although due to the short distance between the site of stimulation and the brain the two sensations might not be as clearly separated as in stimulation of, for example, the extremities. The sensations evoked by stimulation of human teeth vary according to the type of the stimuli applied. Low-intensity electrical stimulation is able to induce non-painful (prepain) sensations. At high current intensities pain is evoked. Drilling, probing and air-drying of exposed dentin induce only pain. Most studies also indicate that thermal stimulation only induces painful sensations. The quality of dental pain can vary. Typically, dentinal stimulation of teeth with healthy pulps induces sharp pain. On the other hand intense heat stimulation can result in dull pain which radiates to a wider area of the face and jaws. This component of the stimulus-induced pain seems to share some characteristics of toothache associated with painful pulpitis. Single fibre recordings of intradental nerve activity in experimental animals have shown that in addition to A-fibres a considerable number of C-type primary afferents innervate the dental pulp. This is in accordance with the results of neuroanatomical studies, which indicate that 70-80% of pulpal axons in human, monkey, dog, and cat teeth are unmyelinated. Intradental A- and C-fibre groups seem to be functionally different and can be activated separately by certain external stimuli. Comparison of the response characteristics of the pulp nerve fibres and the sensations induced from human teeth indicate that: 1) A-fibres are responsible for the sensitivity of dentine and thus for the mediation of the sharp pain induced by dentinal stimulation, 2) Prepain sensations induced by electrical stimulation result from activation of the lowest threshold A-fibres some of which can be classified as A beta-fibres according to their conduction velocities. Comparison of the responses of the A beta- and A delta-fibres indicate that they belong to the same functional group, 3) Intradental C-fibres are activated only if the external stimuli reach the pulp proper. Their activation may contribute to the dull pain induced by intense thermal stimulation of the tooth and to that associated with pulpal inflammation.

Ullman-Lopez

The diagnosis of AP (apical periodontitis) based on PR (PA RG) data is clinically limited, and it should not be used for scientific investigations.

Cunningham et al.

The effect of a 2-hour formocresol and glutaraldehyde treatment on two enzymes of bovine pulp was measured. Lactic dehydrogenase, a respiratory enzyme, was sharply affected by 0.5 percent and one percent glutaraldehyde and a 1:5 dilution of formocresol, exhibiting 7-, 71-, and 40-fold decreases in activity, respectively. Alkaline phosphatase was much less responsive to these same agents, giving only 4.5-, 17-, and 2.5-fold reductions after treatment, respectively. These findings support histochemical studies which have suggested the sensitivity of respiratory enzymes of the pulp to fixative medicaments.

Matsumoto et al.

The existence of lymphatic vessels in the human dental pulp and their distribution were established by light and electron microscopy using an enzyme-histochemical method. The distinction between lymphatic and blood vessels was made by light microscopy on cryostat sections of undecalcified and decalcified teeth using 5'-nucleotidase(5'-Nase)-alkaline phosphatase double staining. On the tissue surface, 5'-Nase-positive lymphatic vessels were highlighted with good contrast and resolution by backscattered electron imaging using scanning electron microscopy. By transmission electron microscopy, dense granular precipitations resulting from the 5'-Nase reaction were seen on the luminal surface of the lymphatic endothelial cells as well as in the area at the basal side, but were absent in the blood vessels. These lymphatic vessels were more numerous in the central part than in the peripheral odontoblastic layer.

11 Gutman 2016 ***Lots of insight regarding to obturation and to what point to obturate***

The issues of working length determination, its apical extent, and the position of the final root canal filling have been controversial, as differing points of view have existed between the biologically based and clinically based endodontic gurus regarding this concept for decades. Coupled with the following issues, it has become somewhat of an empirical bastion for clinicians, especially those in the limelight or who use social media to augment their clinical prowess: (1) the variable anatomy of the root apex; (2) where to terminate canal enlarging and shaping apically; (3) status of the accessory communications apically; (4) size of the apical preparation; (5) ability to debride the apical extent of the root canal and remove both bacteria and biofilm; (6) response of the periapical tissues, when both vital and necrotic, to the intracanal filling materials and techniques that may impinge on these tissues; and (7) long-term outcomes and assessments of the procedures rendered. For purposes of succinctness, the concept of working length, the apical position of instrument termination, and the position of the final filling will be addressed simultaneously in this paper.

Kawamoto and Tsujimoto

The mechanisms of bleaching of discolored coronal teeth using hydrogen peroxide (H2O2) were investigated. In a scanning-electron-microscopy study, the intertubular dentin and peritubular dentin were dissolved by high concentrations of H2O2, which is used for bleaching. The X-ray diffraction study showed that hydroxyapatite was not influenced by H2O2. In an electron-spin-resonance study, more hydroxyl radical (* OH) was detected as the H2O2 concentration was increased. When amino acids that are core components of dentin proteins, such as proline and alanine, were added to H2O2, the generation of * OH decreased, but there was no change when glycine was added. A nuclear-magnetic-resonance study showed that proline was degraded completely by H2O2, the structure of alanine changed slightly, and glycine was not affected by H2O2. It is suggested that H2O2 and * OH do not influence the inorganic tissue of dentin but attack the organic component of dentin. These facts suggest that * OH has the main role in tooth bleaching with H2O2.

93 Sundqvist

The microbial flora was mainly single species of predominantly gram-positive organisms. The isolates most commonly recovered were bacteria of the species Enterococcus faecalis. The overall success rate of re-treatment was 74%. Conclusions. The microbial flora in canals after failed endodontic therapy differed markedly from the flora in untreated teeth. Infection at the time of root filling and size of the periapical lesion were factors that had a negative influence on the prognosis. Three of four endodontic failures were successfully managed by re-treatment.

Stanley et al

The pulpo-dentinal complex responds to external injuries with dentin sclerosis (DS), dead tracts (DT), or reparative dentin (RD). This investigation correlates the prevalence of these responses with age, sex, type and surface location of tooth lesions (caries, restorations, attrition, abrasion and erosion) utilizing ground sections, microradiographs and decalcified paraffin-embedded tooth sections treated with the Pollak trichrome stains (270 teeth from 113 patients). The main response to caries, restorations and erosion was DS, followed by RD and DT. DS, RD and DT occurred equally in any tooth, on any tooth surface and even beneath the same lesion. DS did not necessarily prevent RD. Root and furcation DS and RD in the floor of the pulp chamber and root canals were unrelated to particular lesions but did relate to increasing age. Root DS extended from apical to cervical area with increasing age. Beneath caries and restorations DS and RD were more prevalent in males, but DT was more prevalent in females. Pollak staining of decalcified paraffin sections for DS was approximately 80% as accurate as ground sections and microradiography. In pulp studies, where the result is contrary to previous experience, the Pollak stains reveal whether DS has decreased dentin permeability.

Fogel

The purposes of this study were: (1) to measure the effect of distance from the pulp on the hydraulic conductance of human radicular dentin; (2) to determine the influence of dentin thickness on the rates of fluid flow; and (3) to attempt to correlate dentinal tubule densities and diameters with root dentin hydraulic conductance. Dentin slabs prepared from extracted, unerupted, human third molar teeth were placed in a split-chamber device to permit quantitation of fluid filtration rate (hydraulic conductance). In the SEM portion of the study, dentinal tubule numbers and diameters were recorded. The results indicated that radicular dentin hydraulic conductance decreased with distance from the pulp and with increasing dentin thickness. Tubule density and diameter correlated well with the measured hydraulic conductances. The relatively low hydraulic conductance of outer root dentin makes it a significant barrier to fluid movement across root structure.

2. Fuss

The reliability of several pulp testing agents was compared in intact human premolar teeth. The electric pulp tester, CO2 snow and dichlorodifluoro- methane were found to be more dependable than ethyl chloride and ice in producing a positive re- sponse. However, in young patients the electric pulp test was less reliable than CO2 snow and dichloro- difluoromethane but more reliable than ethyl chlo- ride and ice. The thermal agents were also com- pared for their ability to decrease intrapulpal tem- perature in vitro. The rate of temperature decrease was greater when CO2 snow or dichlorodifluorome- thane were applied to the tooth than in the case of either ethyl chloride or ice.

28 Cunningham

The root canals of the teeth that were ultrasonically filed and irrigated were found to be significantly cleaner.

Abou-Rass M.

The stressed pulp condition is a clinical concept that describes pulps that have received repeated previous injury and survived with diminished responses and lessened repair potentials. Before performing restorative dentistry the dentist should conduct a comprehensive pulpal health evaluation on teeth to be restored. This evaluation should include (1) traditional pulp-testing methods and (2) a review of the past, present, and planned future treatment of the tooth. This analysis will usually identify teeth with stressed pulp conditions. Teeth with stressed pulps should be treated before complex restorative dentistry.

Sonmez et al

The study evaluated the effects of formocresol (FC), ferric sulphate (FS), calcium hydroxide (Ca[OH](2)), and mineral trioxide aggregate (MTA) as pulp dressing agents in pulpotomized primary molars. Sixteen children each with at least four primary molars requiring pulpotomy were selected. Eighty selected teeth were divided into four groups and treated with one of the pulpotomy agent. The children were recalled for clinical and radiographic examination every 6 months during 2 years of follow-up. Eleven children with 56 teeth arrived for clinical and radiographic follow-up evaluation at 24 months. The follow-up evaluations revealed that the success rate was 76.9% for FC, 73.3% for FS, 46.1% for Ca(OH)(2), and 66.6% for MTA. In conclusion, Ca(OH)(2)is less appropriate for primary teeth pulpotomies than the other pulpotomy agents. FC and FS appeared to be superior to the other agents. However, there was no statistically significant difference between the groups.

Kuratate

This study investigated the reparative process of mechanically exposed pulps capped with mineral trioxide aggregate (MTA). Maxillary first molars of 8-week-old rats were MTA-capped for 1-14 days, and 5-bromo-2'-deoxyuridine-labeled proliferating cells and immunoreactivity for nestin and osteopontin were analyzed. MTA capping caused mild necrotic changes followed by progressive new matrix formation and calcified bridging. Proliferating cells peaked at 3 days when matrix formation was inconspicuous. Nestin-expressing cells appeared at 3 days, were arranged beneath the newly formed matrix at 5 days, and showed odontoblast-like morphology by 14 days. Osteopontin immunoreactivity was detected just beneath the necrotic area after 1 day. These findings suggest that pulpal responses to MTA capping involve proliferation and migration of progenitors followed by their differentiation into odontoblast-like cells, a mechanism basically similar to those to calcium hydroxide. Osteopontin might play a triggering role in initiation of the pulpal reparative process.

thyroid gland

Thyroid gland The thyroid gland, consisting of two lateral lobes connected by an isthmus, is located in the anterior neck bilaterally below the thyroid cartilage and develops from the thyroglossal duct and portions of the ultimobranchial body. Ectopic thyroid tissue may be present and have been found to become cystic, neoplastic, or secrete thyroid hormones. The third and fourth pharyngeal pouches form the parathyroid glands, which becomeintegrated within the thyroid gland. C cells can be found in the thyroid gland and they produce calcitonin, which is a calcium lowering hormone.

3 Bender

To simulate periodontal and periapical lesions, bone cuts were made in mandibles from human cadavers, and the roentgenographic and visual ap- pearances of the bone were compared. It is evident that inflammatory or tumorous lesions cannot be visualized if they are confined within the cancel- lous bone. However, if the lesions erode the junc- tion area of the cortex and cancellous bone or perforate the cortex, they can be distinguished roentgenographically. Early stages of bone dis- ease cannot be detected by means of routine roentgenograms, nor can the size of a rarefied area on the roentgenogram be correlated with the amount of tissue destruction.

Lechner JH, Kalnitsky G

Type I and type III collagens were isolated from the pulp of bovine molar teeth. The molecular species α1(I), α2, and α1(III) were identified by Chromatographic behaviour, electrophoretic mobility, amino acid composition and molecular weight distribution of CNBr cleavage products. The proportions of type I and type III collagen were determined by quantitative electrophoresis of CNBr digests of whole tissue. Pulp specimens were selected to represent stages of active, moderate and inactive dentinogenesis. The total collagen content of pulp increased with maturity, but type III was constant 45 per cent of the total collagen at each stage. Thus, the collagen of dental pulp is chemically distinct from that of dentine. These findings indicate that dental pulp collagen cannot be the immediate precursor of dentine collagen.

Vertucci 1984- root canal classifications

Type I. A single canal extends from the pulp chamber to the apex. Type II. Two separate canals leave the pulp chamber and join short of the apex to form one canal. Type III. One canal leaves the pulp chamber, divides into two within the root, and then merges to exit as one canal. Type IV. Two separate and distinct canals extend from the pulp chamber to the apex. Type V. One canal leaves the pulp chamber and divides short of the apex into two separate and distinct canals with separate apical foramina. Type VI. Two separate canals leave the pulp chamber, merge in the body of the root, and redivide short of the apex to exit as two distinct canals. Type VII. One canal leaves the pulp chamber, divides and then rejoins within the body of the root, and tinally redivides into two distinct canals short of the apex. Type VIII. Three separate and distinct canals extend from the pulp chamber to the apex.

Card 2002 - Proof that instrumentation reduces bacterial count

Typically, molars were instrumented to size 60 and cuspid/bicuspid canals to size 80. It is concluded that simple root canal systems (without multiple canal communications) may be rendered bacteria-free when preparation of this type is utilized.

50 Tronstad

Untreated teeth with pulpal necrosis showed a pH of 6.0 to 7.4 in pulp, dentin, cementum, and periodontal ligament. Replanted and nonreplanted teeth with completed root formation and treated with calcium hydroxide showed pH values in the circumpulpal dentin of 8.0 to 11.1, and in the more peripheral dentin of 7.4 to 9.6. In teeth with incomplete root formation, the entire dentin showed a pH of 8 to 10. The pH of the cementum was not influenced by the calcium hydroxide. However, in resorption areas, an alkaline pH was also observed at the exposed dentinal surfaces.

Frank RM, Steuer P.

Various methods of fixation were tried on dentine of 45 premolars from children. Two methods based on immediate or delayed use of liquid nitrogen, as well as a cryoprotector (10 per cent dimethylsulphoxid), gave the best results in transmission electron microscopy. Using these methods, the presence of an odontoblast process could be demonstrated in the inner, middle and peripheral human root dentine. The presence of unmyelinated nerve fibril in outer root dentine supports the hypothesis of direct neural stimulation in peripheral dentine.

84 Ricucci

Well-prepared and filled root canals resist bacterial penetration even upon frank and long-standing oral exposure by caries, fracture, or loss of restoration

Harrison

Wound healing responses of the tissues of the periodontium following periradicular surgery in rhesus monkeys were evaluated by light microscopy. Healing of the dissectional wound is rapid, al- though slower than the incisional wound. Granula- tion tissues replaces the fibrin clot in the wound site as early as 4 days after surgery, and is replaced by fibrous connective tissue by 14 days. Minimal differ- ences were found in the temporal and qualitative dissectional wound-healing responses to the two types of flap designs. The periosteum does not survive the flap reflection procedure. The cells of the cambium layer are destroyed and the collagen of the fibrous layer undergoes depolymerization. It is postulated that the depolymerized periosteal col- lagen plays a role in rapid reattachment of flapped tissues to cortical bone.

46 Bystrom

baeterieidal efficacy of calcium hydroxide, camphorated phenol and eamphorated paramonoehlorophenol as intracanal dressings endodontie treatment of infected root canals can be completed in two appointments when calcium hydroxide paste is used as an intraeanal dressing.

Pain

chemical mediators of inflammatory response (histamine, serotonin, bradykinin, prostaglandin

Endogenous chemotaxis

complement (C5a), leukotrienes, cytokines (IL-8)

76 Torabinejad

cytotoxicity of amalgam, Super EBA, IRM, and the MTA was evaluated. The degree of cytotoxicity of fresh and set materials was MTA least toxic followed by amalgam, Super EBA, and IRM. Based on the results of the cell culture methods used in this study it appears that MTA is a potential root end filling material and warrants further in vivo evaluations.

Estrela

determine in vitro the time required for calcium hydroxide in direct contact with microorganisms to express its antimicrobial effect. The antimicrobial effect of calcium hydroxide was shown to occur after 12 h on M. luteus and F. nucleatum, 24 h on Streptococcus sp, 48 h on E. coli, and 72 h on S. aureus and P. aeruginosa. Mixture II (M. luteus + Streptococcus sp + S. aureus) was sensitive to calcium hydroxide antimicrobial potential after 48 h, whereas mixture I (M.luteus + E. coil + P. aeruginosa), mixture III (E.coli + P. aeruginosa), and mixture IV (S. aureus + P. aeruginosa) were inactivated after 72 h of exposure.

V. cholerae and e.coli

diarrhea and water/electrolyte loss

Delay repair:

lysosomal enzymes, oxygen derived free radicals, meditors

C3a

mast cell histamine arterial smooth muscle cell contraction + increased permeability of vessels

Asthma Overview

· Overview o Chronic inflammatory disease of the airways o Characterized by reversible episodes of increased airway hyperresponsiveness resulting in episodes of dyspnea, coughing and wheezing. o provoked by allergens, upper respiratory tract infection, exercise, cold air, certain medications, chemicals, smoke, and highly emotional states such as anxiety, stress, and nervousness.

● Mild - delayed onset - allergic reaction

● Mild - delayed onset - allergic reaction ○ Signs and symptoms: Mild pruritus (itching)- slow appearance and mild urticaria (rash) - slow appearance. ○ Cause: Overreaction to allergens such as drugs, pollens, or food in which mast cells degranulate and release histamine, often in skin or mucosa ○ Treatment: Positioning: Place patient in comfortable position (upright) Airway: Ensure that airway is open by talking with patient Circulation and communication: Should be adequate in this situation. Request blood pressure cuff. There should be no tachycardia, hypotension, dizziness, dyspnea, or wheezing. Inform the patient that an antihistamine will be administered. Dispense/administer: ● Diphenhydramine (Benadryl) 25-50mg PO/IM/IV ● Repeat dose up to 50mg every 6 hours orally for 2 days if needed Ensure that vital signs, drug administration, and patient responses are properly monitored and recorded. Facilitate/ensure next steps in medical care: allergy testing should be considered and dentist should initiate discussion with physician to withdraw offending drug

Monocytes/Macrophages

CSF (glycoproteins) control production and differentiation of granulocytes/macrophage from progenitor cells in bone marrow

MyD88-independent pathway

IFN-inducible gene expression, caspase activation, costimulatory molecule induction

Monocytes, macrophages, endothelium

IL-1 induce IL-2 production, fever, bone resorption, fibroblast proliferation

Macrophage

IL-1 (polypeptide) activate T and B, fever

Monocytes, EC, fibroblasts

IL-6 (glycoprotein) stimulate T and B

MyD88-dependent pathway

cytokine production, costimulatory molecule induction

Mast Cell/Basophil

histamine increased vessel wall permeability

T-lymphocyte + antigen

lymphoblast killer/cytotoxic T cells (recognize and kill cells), helper T (stimulate B and T) + suppressor T (suppress B and helper T) + memory cells (quick response at next encounter)

Fungi and gram positive bacteria

toll pathway

Liver (100 fold)

- Ceryloplasmine: oxygen radicals scavenger - Protease inhibitors: inhibit enzymes - Complement - CRP: bacterial destruction - Fibrinogen: coagulation, bacterial clumping, anti-inflammatory activity

Cytokines

- IL-2, IL-4: regulate lymphocyte function - TNFa, IL-1B, IFNa,B: natural immunity - IFN-a,B, TNF-a,B, IL-5,10,12: activate inflammatory cells - IL-8, activated macrophages, lymphocytes: chemokines

Activation of:

- Leukocytes finection - Macrophages damage - Platelets fibrinolytic system

Blood 2 - Etiology

-Hemophilia A- born with a deficiency in factor VIII for blood coagulation -Hemophilia B- born with a deficiency in factor IX for blood coagulation -Congenital deficiencies of the other coagulation factors are very rare -Von Willebrand disease- lack of various sizes of von Willebrand factor, which are needed to attach platelets to damaged vascular wall tissues and to carry factor VIII in circulation. When severe, bleeding occurs because of lack of platelet adhesion and factor VIII deficiency -Bernard-Soulier disease- disorder of platelet adhesion to vWF due to lack of glycoprotein Ib on the platelet membrane - leads to inability to adhere to subendothelium -Glanzmann's thrombasthenia- platelet aggregation disorder due to abnormality of the platelet membrane complex glycoprotein IIb/IIIa. The platelets can adhere to the subendothelium, but can't bind to fibrinogen -HHT- multiple telangiectatic lesions in skin and mucous membranes. Inherent mechanical fragility of the affected vessels -Ehlers-Danlos disease, osteogenesis imperfecta, pseudoxanthoma elasticum, Marfan syndrome- issues with construction of connective tissue components of the vessel walls, which can lead to bleeding issues

Prostaglandin and NO

relax vascular smooth muscle

Sen

1. A layer of sludge material is always formed on the instrumented root canal walls. This layer has been called as smear layer. It has an amorphous, irreg ular and granular appearance under the scanning electron microscope. 2. Smear layer is not a strict barrier to bacteria. It only delays, but does not abolish the action of the disinfectants. 3. It may interfere with adhesion and penetration of root canal sealers into dentinal tubules. Thus, it may influence the quality of the obturation. 4. When the smear layer is not removed, it may slowly disintegrate and dissolve around a leaking filling material, or it may be removed by bacterial by-products such as acids and enzymes. 5. Different solutions and techniques have been used to remove this layer. 6. Even though Naocl has a high solvent action, it cannot remove the smear layer. 7. Organic acids are not as effective as chelating agents for the removal of this layer. 8. Findings about the effectiveness of ultrasonics in removal of smear layer are controversial. 9. Sequential use of NaOCI and EDTA solutions has been recommended to remove the endodontic smear layer. 10. Once this layer is removed, there is always a risk of reinfecting dentinal tubules if the seal fails. 11. Further studies are certainly needed to establish a correlation between endodontic smear layer and clinical performance of root canal fillings.

61 Langeland

1. Soft-tissue implantation tests have limited value in evaluation of root-filling materials, because the effect of the material on dentine and bone cannot be reproduced. 2. The implantation test may be used only as a short-term preliminary screening test, but tests in teeth would have to be performed for the decisive evaluation. 3. When used as a preliminary screening test, placement of the test material in polyethylene tubes controls the quantity and form and pre- vents the material from major disintegration, eliminating these variables. 4. The effect of a material on the remaining pulp tissue can be evaluated by introducing the material short of the apex in human teeth. 5. The effect on the periapical tissue can be evaluated in monkey teeth because adequate series of block sections are conveniently obtained. Regarding the N, material, the following conclusions are drawn : 1. N, causes a considerable initial and persisting inflammatory response in the remaining pulp tissue and in the periapical tissue. 2. N, is resorbable. 3. N, promotes dystrophic calcification. 4. N, promotes internal and external resorption and apposition.

45 Yoshida

15% EDTA solution is more effective than saline solution as a root canal irrigant.

48 Sjogren

7-day dressing efficiently eliminated bacteria which survived biomechanical instrumenudon of the canal, while the 10-mtnute applicadon was ineffective.

Leukotrienes

: (neutrophil, LTA4, Platelets, endothelial cells, mast cell and basophils, eosinophils, macrophages) cysteinyl leukotrienes vasoconstriction, eosinophils recruitment, AHR, airway smooth muscle contraction, plasma leak, mucus secretion)

Digestive enzymes

: elastase, collagenase, gelatinase

Direct mode of action

: lysozyme, proteases

Shock

: tissue injury sepsis TNFa in circulation systematic vasodilation, vascular permeability, intravascular volume loss hypotension shock

Mankornkarn et al.

A qualitative assessment was made of the type of glycosaminoglycans (GAG) present in normal human dental pulp using electrophoresis on cellulose-acetate plates. A comparison was also made between the GAG derived directly from the dental pulp (in vivo) and those derived from cultured pulp fibroblasts from the same individual (in vitro). The results of this study showed four main types of GAG in normal human dental pulp tissue, which were dermatan sulfate, heparan sulfate, hyaluronic acid, and chondroitin sulfate. GAG synthesis from cultured pulp fibroblasts in vitro was different from the GAG present in the dental pulp (in vivo). Extracellular GAG, as well as pericellular GAG consisted of dermatan sulfate, hyaluronic acid, chondroitin sulfate, and heparin. Cellular GAG, however, contained only dermatan sulfate, hyaluronic acid, and chondroitin sulfate. There was no difference in type of GAG from the second and fourth passaged pulp fibroblasts.

Chin-Lo Hahn, William Fakier, Michael A, Siegel

A study was undertaken using monoclonal antibodies to determine the types of lymphocytes present in pulpal tissues. Pulps were extirpated from teeth clinically diagnosed as normal, reversibly inflamed, or irreversibly inflamed and stained with hematoxylin and eosin and an indirect immunoperoxidase technique using monoclonal antibodies reactive to pan-B lymphocytes (B), pan-T lymphocytes (T1), and helper (T4) and suppressor (T8) T lymphocytes. T and/or B lymphocytes were observed in normal pulpal tissues with T8 lymphocytes being predominant. The pulpal tissue in the reversible group demonstrated that more than 90% of the lymphocyte population were T lymphocytes, with a T4/T8 ratio of 0.56. Higher numbers of T1, T4, T8; and B lymphocytes were observed in the pulp from teeth in the irreversible group. A ratio of 1.14 of T4/T8 lymphocytes was observed in the irreversible group. A B/T1 lymphocyte ration of 1.60 suggested this ratio might be used as an index in the immunohistological diagnosis of irreversible pulpal pathosis. There appeared to be no association between the periodontal status of the teeth and the number of immunocompetent cells observed in the pulps. An hypothesis on the regulatory functions of T4 and T8 lymphocytes as well as the interaction of T and B lymphocytes and their products in the pathogenesis of pulpal disease is presented.

cancer - other considerations in dental mangement

A. Other Considerations in Dental Management If a patient needs to undergo invasive dental treatment, their physician should be consulted to determine if they need to receive prophylactic antibiotics prior to treatment. This decision will depend on the patient's neutrophil and white blood cell count. Prophylactic antibiotics are usually recommended if the neutrophil count is less than 500 cells/mm3 and the white blood cell count is less than 2,000 cells/mm3. A common antibiotic used is 2 grams of Penicillin VK an hour prior to treatment. In patients undergoing chemotherapy, dentists should pay special attention to the patient's platelet and white blood cell count. Routine dental care can be performed in patients who are feeling well with greater than 50,000/micron platelet count and greater than 2000 cells/mm3 granulocyte count, which usually happens a few days before the patient's next chemotherapy cycle or 17 days following the patient's last cycle. In cases where the patient's platelet count is less than 50,000/micron and emergency dental treatment is needed, dentists should consult the patient's oncologist to create a treatment plan that may involve platelet replacement therapy and local hemostatic measures during the dental treatment.

cancer - pretreatment eval and considerations

A. Pretreatment Evaluation and Considerations Before patients undergo cancer treatment, patients should be evaluated by a dentist to identify any dental needs that require treatment before cancer therapy begins. The evaluation can be performed clinically and radiographically, which also serves as a baseline to monitor any damages caused by chemotherapy and radiation. Dentists also need to take into consideration the patient's type of cancer treatment in order to determine what kind of dental treatment is needed. In the case where patients are in the early stages of cancer, they can usually be managed as a regular patient with more recall visits when they start their cancer treatment. Meanwhile, in cases where patients are in the advanced stages of cancer and are planned for palliative care, the planned dental goals will likely be to treat active dental disease. Patients being treated with radiation and/or chemotherapy should be treated according to the following guidelines. These patients should be given oral hygiene instructions and advised to consume a non-cariogenic diet, along with prophylaxis and fluoride treatment. Any teeth that are deemed non-restorable and have a poor or hopeless prognosis should be extracted. Any chronic inflammatory jaw lesions that are present should be treated. Following extractions and surgeries, there should be enough time for the sites to heal prior to head and neck radiation and chemotherapy. Teeth that are non-vital and symptomatic should undergo endodontic treatment at a minimum one week before radiation and chemotherapy. When children are planned for chemotherapy, mobile deciduous teeth and teeth that will be lost during chemotherapy should be extracted. During treatment, any removable prosthetic appliances that the patient has should be removed. If patients are planned to undergo head and neck radiation, they should be warned of the reduction in salivary flow and increase of oral infections.

Kampfer J, Gohring TN, Attin T, Zehnder M.

Aim: To evaluate the hypothesis that food-borne viable Enterococcus faecalis cells could enter the root canal space via coronal leakage. Methodology: In a simulated oral environment under mastication the capacity of a calcium sulphate-based temporary filling material (Cavit W) to prevent leakage of E. faecalis from a cheese through the endodontic access cavity into the pulp chamber was assessed. Standardized class I access cavities were prepared in human maxillary molars. These were filled with Cavit of either 2 or 4 mm thickness (n=16, each). Empty access cavities served as positive, teeth filled with a light-curing composite material acted as negative controls (n=8, each). A cheese containing viable E. faecalis cells was placed on the occlusal aspects of test and control teeth, which were subsequently subjected to 680 mastication loads per day for 1 week in a masticator device perfused with artificial saliva at 37 degrees C. Leakage of E. faecalis from the cheese into the pulp chamber was assessed by culture on a kanamycin aesculin azide agar and compared between groups using Fisher's exact test. Results: All of the positive controls showed pure growth of E. faecalis. In addition, one of the negative control teeth leaked. The 4 mm application of Cavit prevented leakage of E. faecalis significantly better than the corresponding 2 mm application: 1 of 16 specimens compared with 6 of 16 specimens had leakage, respectively (P<0.05). Conclusions: The current results substantiate the suspicion that food-derived microbiota could enter the necrotic root canal system via microleakage.

Pimenta FJGS et al

Aim: To investigate the impact of inflammation on lymphangiogenesis in human dental pulp. Methodology: Eleven samples of dental pulp without inflammation and 11 dental pulps with moderate to intense mononuclear cell inflammatory infiltrate associated with dentine caries were selected. The streptavidin-biotin complex stain was used to detect CD31, vascular endothelial growth factor receptor-3 (VEGFR-3) and alpha-smooth muscle actin. The number of lymphatic vessels was obtained by counting the number of vessels positive for CD31 and VEGFR-3 and negative for alpha-smooth muscle actin. Results: The results demonstrated that the mean number (+/-SD) of vessels positive for CD31 and VEGFR-3 (lymphatic vessels) in the group with inflammation (6.09 +/- 1.81) was statistically higher (P = 0.0123) than the mean number in the group without inflammation (3.73 +/- 2.20). Conclusion: Increased co-immunostaining of CD31 and VEGF-3 in vessels associated with human dental pulp inflammation occurred, which suggests lymphangiogenesis.

Chan and R. Mclaughlin

All oral spirochetes are classified in the genus Treponema. This genus is in the family Spirochaetaceae as in Bergey's manual of systematic bacteriology. Other generic members of the family include Spirochaeta, Cristispira and Borrelia. This conventional classification is in accord with phylogenetic analysis of the spirochetes based on 16S rRNA cataloguing. The oral spirochetes fall naturally within the grouping of Treponema. Only four species of Treponema have been cultivated and maintained reliably: Treponema denticola, Treponema pectinovorum, Treponema socranskii and Treponema vincentii. These species have valid names according to the rules of nomenclature except for Treponema vincentii, which only has had effective publication. The virulence factors of the oral spirochetes updated in this mini-review have been discussed within the following broad confines: adherence, cytotoxic effects, iron sequestration and locomotion. T. denticola has been shown to attach to human gingival fibroblasts, basement membrane proteins, as well as other substrates by specific attachment mechanisms. The binding of the spirochete to human gingival fibroblasts resulted in cytotoxicity and cell death due to enzymes and other proteins. Binding of the spirochete to erythrocytes was accompanied by agglutination and lysis. Hemolysis releases hemin, which is sequestered by an outer membrane sheath receptor protein of the spirochete. The ability to locomote through viscous environments enables spirochetes to migrate within gingival crevicular fluid and to penetrate sulcular epithelial linings and gingival connective tissue. The virulence factors of the oral spirochetes proven in vitro undercore the important role they play in the periodontal disease process. This role has been evaluated in vivo by use of a murine model

98 Siqueira

Although it has been suggested that nonmicrobial fac- tors may be implicated in endodontic treatment failure, the literature suggests that persistent intraradicular or secondary infections, and in some cases extraradicular infections, are the major causes of failure of both poorly treated and well-treated root canals.

: Mandel

Although mercury vapor in high concentration can have deleterious effects on several organ systems, there is no evidence of risk at the levels generated by chewing with amalgam restorations. Epidemiological studies relating amalgam exposure to health outcomes are recommended, however, to provide the profession and the public a full sense of security.

68 Tavares

Although none of the sealers promoted ideal tissue responses, AH Plus presented the best outcomes. Although MTA Fillapex contains MTA powder, it pre- sented no biocompatibility advantages when compared with AH Plus and EndoFill.

Kerkes, K and Olsen, I

Although not universally accepted, retrospective histological, roentgenological and microbiological studies have indicated that cross-infection can occur between infected pulps and deep periodontal pockets. This review provides examples of similarities in the microfloras of these adjacent oral sites, supporting the idea that infection spreads from one site to the other. The organisms most often involved are probably bacteroides, fusobacteria, eubacteria, spirochetes, wolinellas, selenomonas, campylobacter, and peptostreptococci. Important qualities of cross-infecting organisms may be the ability to survive in highly reduced environments and motility. Precautions should be taken to prevent in vivo seeding of such micro-organisms, particularly in compromised teeth and hosts.

Skucaite N et al.

Among 58 patients with symptomatic apical periodontitis, 47 and 11 cases were caused by primary and secondary root canal infection, respectively. The micro- bial samples were taken either from the root canals (35 cases) or by aspiration from apical abscesses (23 cases). Culture methods were used to identify the microorganisms present in the samples. Antibiotic susceptibilities of all isolates were evaluated by using the E-test method. Microorganisms were isolated from 49 of the 58 samples studied and included facultative and obligate anaerobes. Streptococci and obligate anaerobes were the predominant microorganisms in cases of primary infection. Enterococcus faecalis dominated in cases of secondary infection. All tested microorganisms were highly sensitive to penicillin G, amoxicillin, and ampicillin. Susceptibilities to clindamycin and erythromycin were 73.8% and 54.7%, respectively. About 40% of the isolates were resistant to tetracycline. More than 50% of all anaerobes were resistant to metronidazole. All E. faecalis isolates were resistant to clindamycin. Conclusions: Based on the study results, penicillin and amoxicillin are suitable antibiotics for treatment of endodontic infection when conventional root canal treatment alone is insufficient. Clindamycin could be advised for penicillin-allergic patients with primary endodontic infections.

Bouillaguet

An in vitro diffusion chamber was used to measure the diffusion of 2-hydroxyethyl methacrylate (HEMA) through etched human dentin disks. Concentrations of HEMA, which diffused through dentin, were measured by ultraviolet spectroscopy, and the effect of initial HEMA concentration, dentin thickness, and back pressure on diffusion were assessed. The cytotoxicity of HEMA was determined using BALB/c 3T3 mouse fibroblasts in direct contact with HEMA for 12 or 24 h. HEMA diffused rapidly through dentin under all conditions, but increased thickness, back pressure, or decreased initial concentration all reduced diffusion. The permeability coefficient of HEMA was approximately 0.0003 cm/min, and diffusion through 0.5 mm of dentin reduced the HEMA concentration by a factor of approximately 6,000 (with 10 cm of H2O back pressure). It was concluded that the risk of acute cytotoxicity to HEMA through dentin was probably low, but that decreased dentin thickness, lack of polymerization, or extended exposure times might increase the risk significantly.

Finkelman, R.D., Butler, W.T.

An in vitro model of mineralization was devised in order to study the developmental appearance of dentin γ-carboxyglutamic acid-containing proteins (DGPs) in relation to the onset of mineralization. Maxillary third molars from 11-day-old rats were cultured with or without fetal calf serum (FCS) as modified from Navia et al. (1984).- Molars were incubated without radiolabel, or with either 45CaCl2 (5 μCi/ml) for 24 hr at various stages of a ten-day culture period or [3H]-leucine (10 μCi/ml) for 24 hr at the eighth day of culture. Molars were lyophilized and extracted with 10% formic acid overnight at 4°C. DGPs in extracts were detected by immunologic and chromatographic techniques; DGPs in molar sections were detected by immunolocalization using indirect immunofluorescence. Molar development was evaluated histologically using the Von Kossa staining technique. Molars cultured with FCS showed histologic evidence for mineralized dentin and enamel and a significant increase in 45Ca uptake after the sixth day in vitro. Eleven-day-old molars in vivo and molars cultured without FCS showed no evidence of the presence of mineralized tissues. [3H]-Leucine-labeled DGPs were isolated and identified by affinity and reversed-phase high-performance liquid chromatography and by gel electrophoresis from both mineralized and unmineralized molars. DGP antigens were localized immunohistochemically using rabbit anti-rat antibodies raised against a highly purified DGP preparation. In the unmineralized molar, antigenicity was seen in odontoblasts but not in predentin matrix, pre-odontoblasts, or in any other cell type. Antigens in the mineralized molar were localized to odontoblasts and dentin. Analysis of these data indicates that rat molars cultured with FCS show de novo mineralization in vitro and suggests that rat molar odontoblasts synthesize DGPs concurrently with the elaboration of predentin matrix but independently of mineral deposition.

Vongsavan N,

An outward flow of fluid through exposed dentine was demonstrated in anaesthetized cats. The flow was measured by observing the movement of the fat droplets of dilute milk in a glass capillary (i.d. 30 microns) with a microscope. The capillary was sealed to the dentine with a plastic cap. The resting flow rate through dentine exposed by fracturing off the tip of a cat's canine ranged from 2.8 to 50.9 pl.s-1.mm-2 (mean 18.1, SD 15.9, n = 12). Raising the pressure at the dentine surface to about 15 cmH2O stopped the flow. Immediately after cutting the pulp at the root apex, in 11 of 12 preparations, the flow reversed. The average flow rate was then 3.8 pl.s-1.mm-2 inward (range 8.4 outward to 15.9 inward, SD 5.4, n = 12). The inward flow after pulp section suggests that an osmotic effect may contribute to the net pressure causing flow. The average hydraulic conductance of the exposed dentine was 1.6 x 10(-8) m.s-1.kPa-1 (range 0.5-2.9, SD 0.8) before pulp section. After pulp section, it increased to an average of 2.5 x 10(-8) m.s-1.kPa-1 (range 0.8-5.2, SD 1.3).

Sundqvist G, 1980

Anaerobic bacteria belonging to the species Bacteroides melaninogenicus, Bacteroides asaccharolyticus, Fusobacterium nocleatum, Peptostreptococcus anaerobius and Eubacterium alactoly- tjcum, isolated from necrotic dental pulps, were tested for their capacity to induce neutrophil leukocyte chemotaxis. Geoeration of chemotactic factors in seruin by whole bacterial celis and chemotaxis induced by bacterial extracts were studied in vitro by the Boyden technique. Subcutaneously implanted wound chambers in guinea pigs were used for testing leukocyte migration in vivo. All bacterial strains had a similar Mgh capacity to induce neutrophil chemotaxis. The heavy accumulation of polymorphonuclear neutrophil leukocytes associated with clinical and experimental infections by B. melaninogenicus or B. asaccharolyticus cannot be ascribed to any eKlreme ability of these organisms to generate chemotactic factors.

Hoshino et al.

Anaerobic procedures were adopted to demonstrate the early bacterial invasion of non-exposed dental pulps, and to isolate and identify the bacteria. Of 19 freshly extracted teeth which originally exhibited deep dentinal lesions, clinical examination and electric pulp testing showed that nine of them had no pulpal exposure. Thus the pulps of these teeth were covered by clinically sound dentine beneath the carious lesion. Bacteria were found to have invaded the pulps of six of these nine teeth. The predominant bacteria were obligate anaerobes belonging to the genera Eubacterium, Propionibacterium and Actinomyces. Other obligate anaerobes were Lactobacillus, Peptostreptococcus, Veillonella and Streptococcus. The bacterial composition resembled that of the deep layers of dentinal lesions described previously, suggesting that the bacteria isolated in this study had passed through some individual dentinal tubules, to invade the dental pulp.

Baker P, Evans R, Slots J and Genco R

Anaerobic, agar-dilution, minimal inhibitory concentrations (MICs) of 18 antibiotics are given for the numerically important bacterial groups from the hutnan oral cavity. Strains are divided into suscep- tibility categories using the guidelines for interpretation of MICs suggested by the National Committee for Clinical Laboratory Standards. These guidelines are based on data on antibiotic concentrations at- tainable in serum following various dosage regimens. MICs are also compared with attainable gingival fluid levels where these are known. The highest percentages of strains were susceptible to tetracycline, with 89% of the 139 strains tested susceptible to serum levels and 97% conditionally susceptible to attainable gingival fluid levels. Ninety- eight percent of strains were conditionally susceptible to attainable gingival fluid levels of minocycline, but many strains, including Actinobacillus actinomycetemcomitans, were only moderately susceptible to attainable serum levels of this tetracycline analogue. Carbenicillin was effective against most groups of organisms, with the important exception of A. actinomycetemcomitans, at serum levels attainable with oral formulations of carbenicillin. Only 2% of the total strains tested were resistant to penicillin, while 33% of strains were cate- gorized as moderately susceptible. Clindamycin was active against many strains of Gram-negative bacteria but was not active against A. actinomycetemcomitans, some Bacteroides, Eikenella corrodens, or the anaerobic vibrios. Metronidazole was active against A. actinomycetemcomitans, allfive groups of oral Bacteroides tested, and against Capnocytophaga species. Chloramphenicol was active against A. actinomycetemcomitans, but not against most of the other groups of oral organisms. Nearly all groups contained strains non-susceptible to serum levels attainable with the usual doses of erythromycin, spiramycin, vancomycin, kanamycin, neomycin, streptomycin, doxycyc- line, oxvtetracycline, or chlortetracycline; several strains were resistant to maximum attainable serum levels of each of these antibiotics except doxycycline.

: Siqueira et al.

Apical periodontitis is an infectious disease caused by microorganisms colonizing the root canal system. For an optimal outcome of the endodontic treatment to be achieved, bacterial populations within the root canal should be ideally eliminated or at least significantly reduced to levels that are compatible with periradicular tissue healing. If bacteria persist after chemomechanical preparation supplemented or not with an intracanal medication, there is an increased risk of adverse outcome of the endodontic treatment. Therefore, bacterial presence in the root canal at the time of filling has been shown to be a risk factor for posttreatment apical periodontitis. About 100 species/phylotypes have already been detected in postinstrumentation and/or postmedication samples, and gram-positive bacteria are the most dominant. However, it remains to be determined by longitudinal studies if any species/phylotypes persisting after treatment procedures can influence outcome. This review article discusses diverse aspects of bacterial persistence after treatment, including the microbiology, bacterial strategies to persist, the requisites for persisting bacteria to affect the outcome, and future directions of research in this field.

Kilian M (1981)

Attention has recently been focused on immunoglobulin Al (IgAl) protease production as a possible virulence factor of bacteria implicated in meningitis and gonorrhea. This report demonstrates that suspected principal etiological agents in destructive periodontal disease include bacteria capable of degrading IgAl, IgA2, and IgG. Representative strains of Bacteroides melaninogenicus subsp. melaninogenicus and Capnocytophaga cleaved IgAl but not IgA2 in the hinge region to yield intact Fab and Fc fragments. All Capnocytophaga strains also cleaved IgG in the same way. The majority of strains of Bacteroides asaccharo- lyticus and B. melaninogenicus subsp. intermedius caused complete degradation of both IgAl and polyclonal IgG. However, some strains left the Fc part of IgAl intact. Several strains were also capable of completely decomposing IgA2 and S- IgA. Significant IgA-cleaving enzyme activity was detected in whole subgingival dental plaque collected from patients with destructive periodontal disease. The results indicate that colonization of the subgingival area by B. asaccharolyticus, B. melaninogenicus, and Capnocytophaga spp. can induce a local paralysis of the immune defence mechanisms, thereby facilitating the penetration and spread of potentially toxic substances, lytic enzymes, and antigens released by the entire subgingival microflora.

Love et al.

Bacterial invasion of dentinal tubules commonly occurs when dentin is exposed following a breach in the integrity of the overlying enamel or cementum. Bacterial products diffuse through the dentinal tubule toward the pulp and evoke inflammatory changes in the pulpo-dentin complex. These may eliminate the bacterial insult and block the route of infection. Unchecked, invasion results in pulpitis and pulp necrosis, infection of the root canal system, and periapical disease. While several hundred bacterial species are known to inhabit the oral cavity, a relatively small and select group of bacteria is involved in the invasion of dentinal tubules and subsequent infection of the root canal space. Gram-positive organisms dominate the tubule microflora in both carious and non-carious dentin. The relatively high numbers of obligate anaerobes present-such as Eubacterium spp., Propionibacterium spp., Bifidobacterium spp., Peptostreptococcus micros, and Veillonella spp.-suggest that the environment favors growth of these bacteria. Gram-negative obligate anaerobic rods, e.g., Porphyromonas spp., are less frequently recovered. Streptococci are among the most commonly identified bacteria that invade dentin. Recent evidence suggests that streptococci may recognize components present within dentinal tubules, such as collagen type I, which stimulate bacterial adhesion and intra-tubular growth. Specific interactions of other oral bacteria with invading streptococci may then facilitate the invasion of dentin by select bacterial groupings. An understanding the mechanisms involved in dentinal tubule invasion by bacteria should allow for the development of new control strategies, such as inhibitory compounds incorporated into oral health care products or dental materials, which would assist in the practice of endodontics.

Yamamura, T

Based on recent literature, the dynamics of mesenchymal cells in transplantation of various tissues and matrices, as well as the origin of new odontoblasts which participate in the formation of the dentin bridge, are described. Experiments involving implantation of pulp, periosteum, perichondrium, treated dentin, and bone matrices were performed to emphasize the capability of these cells to produce hard tissue. Light and electron microscopic and autoradiographic studies were carried out to clarify the origin of replacement odontoblasts. It appears that the pulp cells, endothelial cells, and pericytes become undifferentiated mesenchymal cells following pulp exposure. These mesenchymal cells differentiate into odontoblasts, which subsequently produce a dentin matrix. Pulp tissues autografted to non-pulpal sites, elaborated bone (or osteodentin) matrix, but they did not graft to tubular dentin. An experiment on dentin bridge formation, using germ-free rats, demonstrated that the pulp tissue has intrinsic healing potential. Therefore, it was concluded that the ability of pulp tissue to elaborate hard tissues depends on its environment.

Leinfelder

Bases: Traditionally, has been placed under amalgam restorations to re-establish the preparation to an ideal outline form when substantial dentin was removed during cavity preparation. Bases are also placed to provide thermal insulation, protecting the pulp as well as reducing postoperative sensitivity. Instead of enhancing the longevity of amalgam restorations, placement of bases have been found to weaken teeth. And the routine use of bases by the dental profession has diminished considerably during the last several years. Some of these bases include zinc phosphate cement, polycarboxylate cement, zinc oxide eugenol and glass ionomers. Glass ionomers provide the greatest advantage in that they release fluoride, the mixing procedures are very simple, easy to place, and prevents microleakage. Liners: In general, serve a different purpose than bases in that they are used to kill residual microorganisms and stimulate reparative dentin. Liners containing eugenol are used for palliative effects, and Ca(OH)2 based liners stimulates reparative dentin. The elevated pH causes a superficial necrosis of the pulpal cells which stimulates formation of new reparative dentin. But the Ca(OH)2 must be placed directly on the pulpal cells for this to occur. The elevated pH also creates a bactericidal environment which favors conditions for formation of reparative dentin. However, Ca[0H)2 is subject to dissolution and elimination, ZOE: Eugenol has been used to decrease or eliminate postoperative sensitivity. It depolarizes the nerve impulse and can last months and even years. Eugenol at high concentrations is effective in killing microorganisms. But eugenol interferes in the polymerization process of overlying composite resins.

Platelet disease - Bernard - Soulier Syndrome

Bernard-Soulier Syndrome Characterized by platelets that are large, defective, and unable to interact with vWF due to mutations in genes controlling the expression of the platelet glycoprotein Ib/IX complex. This causes the absence of glycoprotein Ib from the membrane of the platelet, which acts as a receptor for vWF. This can decrease the overall platelet count. Clinical findings include epistaxis, easy bruising, mucous membrane bleeding, perioperative bleeding, and menorrhagia. We may also see ecchymosis and gingival and gastrointestinal bleeding. Bleeding is typically unpredictable and intermittent. We perform laboratory testing for those with a history of life-long bleeding and family history of bleeding. Initially, these patients should be tested for von Willebrand disease since it is very common. If these studies are normal, platelet aggregation testing and platelet morphology evaluation should be performed. With ristocetin, which measures platelet aggregation, we typically see low platelet count, large platelets, faulty platelet adhesion, and poor aggregation in patients with Bernard-Soulier Syndrome. Treatment typically is supportive, with platelet transfusions and avoiding antiplatelet medications. Recombinant activated factor VII and desmopressin have been used to shorten bleeding times, but no studies have made this a definitive treatment.

1. Enzyme linked immunoabsorbant assay

Bind antigen to a plastic surface and add antibody to that surface. Indirect: secondary antibody reacts with primary antibody. You can detect how much antigen you have produced. Protein A comes from Staph A. Binds to Fc fragment

Rotstein

Bleaching materials containing 30% hydrogen peroxide have been used successfully for the treatment of discolored non-vital teeth. Intracoronal application of these materials was occasionally associated with the development of external root resorption. Extracted human teeth with intact crowns were discolored in vitro and bleached with three preparations of sodium perborate. These preparations included: sodium perborate with 30% hydrogen peroxide, sodium perborate with 3% hydrogen peroxide and sodium perborate with water. The bleaching materials were placed in the pulp chamber of the discolored teeth and sealed with IRM for 14 days. They were replaced with fresh preparations after 3 and 7 days. The coronal tooth shades were evaluated after 3, 7 and 14 days and a comparison of the bleaching success of the groups was made at each interval. It was found that after 14 days and three bleachings there was no significant difference in success between the groups. It is therefore recommended that sodium perborate be used in combination with water rather than with hydrogen peroxide to reduce the risk of post-bleaching external root resorption.

Rotstein et al

Bleaching pulpless teeth with 30% hydrogen peroxide has been reported to cause external cervical root resorption. It has been hypothesized that H2O2 penetrating through open dentin tubules can initiate an inflammatory reaction which could result in root resorption. Extracted human premolars were treated endodontically and bleached intracoronally using the thermocatalytic technique. The teeth were divided into three groups; one group with no cementum defects at the cementoenamel junction, one group with artificial cementum defects at the cementoenamel junction, and another group with artificial cementum defects at the middle third of the root. The radicular penetration of 30% hydrogen peroxide in the three groups was assessed directly and compared using an in vitro model. Radicular penetration of hydrogen peroxide was found in all of the groups tested. The penetration of hydrogen peroxide was significantly higher in teeth with cementum defects at the cementoenamel junction than in those without defects.

Blood 2 - blooding problems in relatives

Bleeding Problems in Relatives Disorders such as Hemophilia are more prominent in male offspring than female due to the X-linked trait. 33% of children with a parent with von Willebrand disease type 1 will inherit the disorder. Children of parents with hereditary connective tissue or hemorrhagic telangiectasia are at risk as well. Rarely does a family history of platelet function disorders get passed down. The most meaningful data is a recent negative or positive history of excessive bleeding after a hemostatic challenge. Keep in mind that a negative history of bleeding after minor insult does not mean that a more severe or traumatic event may produce a bleeding risk.

pregnant - blood changes

Blood changes: · Anemia and a decreased hematocrit value and iron deficiency occurs commonly. · There might be a mild decrease in platelets during pregnancy. · Several blood clotting factors, especially fibrinogen and factors VII, VIII, IX, and X, are increased. · As a result of the increase in many of the coagulation factors, combined with venous stasis, pregnancy is associated with a hypercoagulable state.

Olgart

Blood flow of mammalian dental pulp is under both remote and local control. There is evidence for the existence of parasympathetic nerves in the pulp, but functionally the cholinergic influence is weak, and the physiological significance of this autonomic system seems to be low. The evidence for sympathetic vasoconstrictor nerves in the pulp is robust, and there is convincing support for the contention that these nerves play a physiological role, operating via release of noradrenaline and neuropeptide Y. However, there is no significant functional evidence in support of sympathetic beta-adrenoceptor-mediated vasodilation in the pulp. The local control of blood flow involves a subset of intradental sensory nerves. By virtue of their neuropeptide content, these afferent fibers cause vasodilation and inhibit sympathetic vasoconstriction in response to painful stimulation of the tooth. Such locally governed control may serve to meet immediate demands of the pulp tissue. A locally triggered reflex activation of sympathetic nerves in the pulp may modulate this control and limit its magnitude. Thus, there are competitive interactions between local and remote vascular controls which may be put out of balance in the injured and inflamed dental pulp.

Bergenholtz et al.

Bovine serum albumin (BSA) was topically applied to exposed dentin to assess whether inflammatory reactions can be induced in the pulp of monkeys immunized against BSA. Four cynomolgus monkeys received repeated injections of BSA emulsified with Freund's incomplete adjuvant. Pulp challenge was performed by applying BSA in freshly cut dentin cavities prepared on the buccal surface in 34 teeth. In 29 control teeth ovalbumin (OVA) was applied. Control applications of BSA were also performed in 15 teeth prepared in three nonimmunized monkeys. Forty-eight hours after the initiation of the pulp challenge the monkeys were sacrificed and the pulp tissue examined in the light microscope. Topical application of BSA to freshly exosed dentin in immunized monkeys resulted in severe inflammatory lesions in the pulp, characterized by bleeding and extravascular infiltration of large numbers of leukocytes. Extensive tissue damage was an important feature in several pulps. Identical applications of OVA in control teeth and BSA applications in nonimmunized monkeys produced no such reactions. The results indicate that interactions between antigens and antibodies can occur within the dentin-pulp area and following the formation of immune-complexes, severe injury to the pulp can be induced.

Sakamoto et al

Bovine, rabbit and human dental pulp glycosaminoglycans were analyzed qualitatively and quantitatively using two-dimensional electrophoresis. The major components of bovine and rabbit dental pulp were chondroitin 4-sulphate and hyaluronic acid, while in the human dental pulp dermatan sulphate and chondroitin 4-sulphate were the major components.

80 Sarkar

Ca, the dominant ion released from mineral trioxide aggregate, reacts with phosphates in synthetic tissue fluid, yielding hydroxyapatite. The sealing ability, biocompatibility, and dentinogenic activity of mineral trioxide aggregate is attributed to these physicochemical reactions.

pregnant - cardiovascular changes

Cardiovascular changes: · Blood volume increases by 40% to 50%, cardiac output by 30% to 50%, but red blood cell volume increases by only about 15% to 20%, resulting in a fall in the maternal hematocrit. · Despite the increase in cardiac output, blood pressure falls (usually to 100/70 mm Hg or lower) during the second trimester. · A benign systolic ejection murmur is a rather common finding occurring in more than 90% of pregnant women, which disappears shortly after delivery. · During late pregnancy, a phenomenon known as "supine hypotensive syndrome" may occur that manifests as an abrupt fall in blood pressure, bradycardia, sweating, nausea, weakness, and air hunger when the patient is in a supine position. · Occurs due to impaired venous return to the heart resulting from compression of the inferior vena cava by the gravid uterus leading to decreased BP, reduced cardiac output, and impairment or loss of consciousness. · The remedy for the problem is for the patient to roll over onto her left side, which lifts the uterus off the vena cava.

Czarnecki and Schilder

Careful periodontal documentation and subsequent histological examination of 46 human teeth with varying degrees of periodontal involvement showed that their pulps remained within normal limits regardless of the severity of the periodontal disease. Furthermore, it was observed that very deep caries or extensive coronal restorations were associated with pulpal changes regardless of the degree of periodontal involvement. On the basis of the teeth examined in this study, no correlations could be made between the presence or severity of periodontal disease and pulpal changes.

Mjor, Tronstad

Cavities were prepared in forty-five teeth from four monkeys. Soft carious human dentine was placed in fifteen cavities, which were then filled with amalgam. Guttapercha temporary fillings were placed in seventeen teeth, and thirteen cavities were left unfilled. After about 8 days the animals were killed and the teeth were examined histologically. The insertion of carious dentine and amalgam resulted in a localized, severe pulp reaction, whereas gutta-percha gave a slight to moderate reaction. Both of these methods of inducing pulpitis were considered to be suitable for further studies related to pulpal healing. The pulp responses to open cavities varied considerably.

Fitzgerald M,

Cell migration and replication associated with odontoblast replacement occurring soon after pulp exposure in primate teeth were studied. Class 5 cavity preparations resulting in pulp exposures were restored with a calcium hydroxide-containing capping agent and amalgam. Eighty-four and 96 h after this the animals were injected with 0.5 microCi/g body wt tritiated thymidine (sp. act. 6.7 Ci/mM). Teeth were extracted 6, 8, 10 and 12 days after treatment. The number of labelled cells as well as the number of grains per labelled cell were counted for odontoblast-like, fibroblast-like and perivascular cells in three 60 x 260 microns zones. These zones represented the odontoblast and cell-free (zone 1), cell-rich (zone 2) and deep pulp (zone 3) areas of normal pulp tissue. Ten sections centred around the mid-point of the exposure were counted for each tooth. Matrix formation and labelled odontoblast-like cells were observed at the interface between the capping agent and the pulp as early as day 8. Other significant findings were: (1) an increase in labelled odontoblast-like cells in zone 1 over time, suggesting a continual influx of differentiating cells; (2) an increase in labelled cells in zone 1 over time with a concurrent decrease in zone 3, suggesting that the influx of cells in zone 1 was from the deeper pulp; and (3) differences in grain counts between zones, treatment times and cell types, indicating that at least two DNA replications had occurred between initial treatment and final odontoblast-like cell differentiation.

Blood 2 - Clinical Presentation

Clinical Presentation Signs and Symptoms -Genetic coagulation disorders: ecchymoses, hemarthrosis, dissecting hematomas -Abnormal platelets or thrombocytopenia: petechiae and ecchymoses -Vascular defects: petechiae and bleeding from skin or mucous membrane

Clinical Presentation - Hashimoto's Thyroiditis

Clinical Presentation - Hashimoto's Thyroiditis The most common cause of primary hypothyroidism in the United States is Hashimoto's Thyroiditis, which refers to an autoimmune disease with an asymptomatic diffuse goiter. High amounts of thyroid autoantibodies and thyroid antigen-specific cells are found often in young and middle-aged females. Patients usually have a family history of Hashimoto's Thyroiditis or other autoimmune thyroid disorders.

: Veis A, Goldberg M.

Collagen fibrils and non-collagenous extracellular matrix components may be extracted from the dental pulp. Differences appear between the coronal and radicular pulp after mechanical preparation. Type I, III, V, and IV collagens have been identified. Other structural proteins play a role in the dental pulp, namely, the phosphorylated proteins of the small integrin-binding ligand N-linked glycoprotein family (SIBLING), implicated in pulp mineralization as promotor or inhibitor, and in dentinogenesis imperfecta. Non-phosphorylated ECM proteins were also identified in pulp tissue. Glycosaminoglycans and proteoglycans act as tissue organizers. They influence cell growth and maturation. A series of molecules are influent as transcription or growth factors. They are acting as proteolytic enzymes including collagenases and other proteases.

51 Sjogren

Complete periapical healing occurred in 94% of cases that yielded a negative culture. Where the samples were positive prior to root filling, the success rate of treatment was just 68% importance of completely eliminating bacteria from the root canal system before obturation. This objective cannot be reliably achieved in a one-visit treatment

Cootauco JS

Components of primary (azurophilic) granules of polymorphonuclear leukocytes (PMNs) have been implicated as important mediators in pulpal inflammation. This anatomical study used ultracryoimmunocytochemical techniques and characterized and contrasted the subcellular distributions of human PMN elastase (PMN-E), PMN cathepsin-G (PMN-CG), and alpha-2 macroglobulin (alpha-2M) in healthy and inflamed dental pulps. Inflamed pulpal tissue sections revealed an intense distribution of PMN-E in the extracellular domain throughout the collagen matrix. PMN-E was also localized in the perinuclear cytoplasm of PMNs and distributed in a random fashion. PMN-CG was localized intensely in the intracellular granules of PMNs and observed moderately within the extracellular matrix. Healthy pulpal tissues exposed to PMN-E and PMN-CG antibodies revealed no evidence of PMN infiltration and no specific labeling. alpha-2M, a natural serum inhibitor of PMN-E and PMN-CG, was distributed in an intense fashion within the intravascular compartments of both inflamed and healthy pulpal samples. Immunogold-labeling for alpha-2M was observed in moderate amounts within the extravascular domain of inflamed pulpal samples but only in mild amounts within the same area of healthy tissues. These results suggest that PMN-E and PMN-CG are released to the extracellular matrix of irreversibly inflamed teeth, enabling them to facilitate pulpal connective tissue destruction. Conversely, moderate extravascular labeling for alpha-2M within inflamed samples suggests a physiological attempt at inhibiting the pulpal connective tissue destruction mediated by human PMN-E and PMN-CG.

congenital hypercoagulability

Congenital Hypercoagulability Many patients with venous thromboembolism have an inherited basis for hypercoagulability, but arterial thrombosis is unusual in patients with these inherited hypercoagulable states. Primary hypercoagulable states can result from: -Deficiency of anti-thrombotic factors (antithrombin III, protein C or protein S) -Increased prothrombotic factors (factor Va, activated protein C resistance, factor V Leiden) -Prothrombin (prothrombin G20210A mutation) -Factors VII, XI, IX, VIII; von Willebrand factor, fibrinogen -Hyperchomocysteinemia The laboratory diagnosis of primary hypercoagulable states requires testing of each disorder individually, which can be performed with functional, immunologic, or DNA-based assays. Any dental treatment can be provided for these patients.

Blood 2 - Intro

Congenital defects can alter coagulation factors, platelets, or blood vessels. The disorders discussed today include hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome), von Willebrand disease, Bernard-Soulier disease, Glanzmann's thrombasthenia, hemophilia A, hemophilia B (Christmas disease), and congenital hypercoagulability disorders. Inherited (congenital) bleeding disorders are genetically transmitted and are not as prevalent as acquired bleeding disorders. In a dental practice of 2000 patients, there will be at most 10-20 patients with a congenital bleeding disorder. However, inherited hypercoagulability disorders either have a genetic deficiency of antithrombotic factor or increase a prothrombotic factor, which increases the risk for thromboembolism. These are more common than the inherited bleeding disorders.

Farnoush et al.

Controversy exists regarding the presence of mast cells in the dental pulp. As mast cells are present in other soft tissues throughout the body, their reported absence in the dental pulp seems puzzling and anomalous. Dental pulps from 10 caries-free permanent and 10 carious primary teeth were expamined for the presence of mast cells. The pulps were removed by splitting the teeth, frozen-sectioned at 5 μm, and stained for mast cells utilizing a technique which is proven to be highly selective for identification of mast cells in various tissues. Additional sections from inflamed and noninflamed pulps were stained with hematoxylin and eosin to assess the inflammatory response. The results indicated that mast cells were present in noninflamed as well as inflamed pulps. Mast cells from the inflamed pulps showed signs of degranulation with granules appearing outside the cell membrane.

Bergenholtz ,G et al.

Culture filtrates (extracellular components) and material obtained from disintegrated cells (intracellular components) of cultured plaque bacteria were studied for their capacity to induce inflammatory reactions in the dental pulp. Class V cavities were prepared on the buccal surface of 94 teeth: 42 test and 52 control teeth in six adult monkeys. lyophilized bacterial components were sealed into the test cavities either alone or following an 8-h topical application of a solution of the same components in phosphate-buffered saline (PBS). Culture medium and PBS were applied in two sets of control cavities. A third set was restored with zinc oxide-eugenol cement. The animals were killed 32 h after the initiation of the experiment and the pulps were examined histologically. Teeth treated trophil leukocytes in the area of the pulp subjacent to the cut dentin tubules. Abscess formation was frequently found. The severe reactions which developed were independent of differences between individual animals and differences in thickness of the remaining dentin. The controls showed damage to the odontoblasts but little or no neutrophil infiltration. The findings confirm that products of bacteria applied to exposed dentin initiate inflammatory reactions in the dental pulp.

Bergenholtz et al. *

Culture filtrates (extracellular components) and material obtained from disintegrated cells (intracellular components) of cultured plaque bacteria were studied for their capacity to induce inflammatory reactions in the dental pulp. Class V cavities were prepared on the buccal surface of 94 teeth: 42 test and 52 control teeth in six adult monkeys. lyophilized bacterial components were sealed into the test cavities either alone or following an 8-h topical application of a solution of the same components in phosphate-buffered saline (PBS). Culture medium and PBS were applied in two sets of control cavities. A third set was restored with zinc oxide-eugenol cement. The animals were killed 32 h after the initiation of the experiment and the pulps were examined histologically. Teeth treated trophil leukocytes in the area of the pulp subjacent to the cut dentin tubules. Abscess formation was frequently found. The severe reactions which developed were independent of differences between individual animals and differences in thickness of the remaining dentin. The controls showed damage to the odontoblasts but little or no neutrophil infiltration. The findings confirm that products of bacteria applied to exposed dentin initiate inflammatory reactions in the dental pulp.

Van Steenbergen (1986)

Culture filtrates of several bacterial species isolated from the oral cavity were tested for their effects on two types of tissue culture cells: Vero cells, the continuous cell line of African green monkey kidney cells; and chondrocytes, isolatedfrom 15-day-old chick embryo tibiae. Only a limited number of bacterial species - i.e., the asaccharolytic black-pigmented Bacteroides species and Fusobacterium species affected the two cell types. The effect on Vero cells, detected by the rounding of the cells, correlated with the butyric acid concentration in the bacterial supernatant, which confirms previous findings. A small enhancement of this effect was found with propionic acid and ammonium ions. The same strains which affected Vero cells also affected chondrocytes, detected by a vacuolization of the cells. However, volatile fatty acids on their own had no visible effect on these cells. Instead, ammonium ion in the culture filtrate, when present in concentrations of 20 to 60 mmol/L, proved to be responsible for vacuolization of the chondrocytes. The volatile fatty acids (butyric and propionic) had a limited additive effect. No effects were visible with cell extracts of the bacteria

Kahan et al.

Current routine methods for assessment of pulp vitality rely on stimulation of A-delta nerve fibers and give no direct indication of blood flow within the pulp. Recent papers have suggested that pulse oximeters may be used to diagnose pulp vitality by detection of blood flow. In this study, an optimized pulse oximeter probe for teeth was designed, built and tested using the Biox 3740 Oximeter (Ohmeda, Louisville, CO). Following preliminary in vitro tests, the probe was tested clinically. Pulse waveforms from maxillary and mandibular anterior teeth were noted. Simultaneous readings from the subjects' finger were used as controls. Pulse wave readings from the teeth were found to be synchronous with the finger probe, but not consistently. It was easier to maintain continuous readings from mandibular incisors than from maxillary incisors. The average percentage synchronization with the pulse was 28.95% for maxillary incisors and 50.28% for mandibular incisors. This difference was significant (p = 0.05). The overall accuracy of the commercial instrument was disappointing, and in its present form it was not considered to have clinical value.

epilepsy - definition

Definition: Epilepsy is a term that includes disorders or syndromes with widely variable pathophysiologic findings. It is not a specific diagnosis. Epilepsy covers a group of disorders characterized by chronic and recurrent, paroxysmal changes in neurologic function (seizures), altered consciousness, or involuntary movements caused by abnormal and spontaneous electrical activity in the brain. Seizures may be convulsive (motor manifestations) or may occur with other changes in neurologic function Seizures are characterized by discrete episodes which tend to be recurrent and often unprovoked. Movement, sensation, behavior, perception and consciousness are distrubed. Symptoms are produced by excessive temporary neuronal discharging. While seizures are required for a diagnosis of epilepsy, not all seizures imply presence of epilepsy. Seizures may occur during medical or neurological illness including stress, sleep deprivation, fever, alcohol or drug withdrawal, and syncope. Seizures are classified into partial and generalized. Partial seizures are limited in scope and clinical manifestations and involve motor, sensory autonomic, or psychic abnormalities. Partial seizures are subdivided into simple (consciousness is preserved) and complex (consciousness is impaired). Generalized seizures are more global in scope and manifestations. They involve both cerebral hemispheres, are associated with alteration in consciousness, and frequently produce abnormal motor activity

Trowbridge

Demonstrable evidence suggests that the pattern of inflammation in the tooth affected by carious attack is determined by the permeability of dentin and the proximity of the carious lesion to the pulp. Accumulation of immunologically competent chronic inflammatory cells either accompanies or follows retrogressive changes in the odontoblast layer beneath the lesion. Deposition of collagen and proliferation of small vessels are also features of early inflam matory changes in the pulp. A transition from a chronic to an acute inflammatory reaction occurs as the lesion approximates the pulp or invades reparative dentin. Progressive accumulation of large numbers of neutrophils, presumably drawn by chemotactic influences, results in suppuration that may be diffuse or may become localized to form an abscess. Surface ulceration may develop as a result of chronic suppuration, which remains confined to the areas of the pulp beneath the carious lesion, and results in the creation of a space. In slow progressing lesions, continued formation of reparative dentin may be capable of preventing pulp exposure. Degeneration of the pulp occurs when the number of bacteria entering the pulp exceeds the ability of the blood vessels of the pulp to furnish a sufficient number of blood leukocytes to repel the bacteria. Hyperplastic pulpitis represents a proliferation of chronic inflammatory tissue in response to carious exposure to the young pulp.

hepatitis - dental considerations

Dental Considerations Many times, carriers of hepatitis cannot be identified by taking a medical history. So, all patients who have a history of viral hepatitis should be cared for as if they are potentially infectious by using a strict asepsis program in the clinic. For those with active hepatitis, only urgent dental care should be performed, and with minimal aerosolization and avoidance of medications that are metabolized in the liver. If a patient has signs or symptoms of hepatitis, they should be treated as if they are infected. If a patient is a known hepatitis carrier, a physician consultation and laboratory screening of liver function are recommended to determine risk. Considerations in dental practice with a patient with liver disease involve avoiding drugs primary metabolized by the liver. Avoidance is essential when the patient has one of the following : (i) elevation of aminotransferase levels to greater than 4 x normal (ii) elevation of serum bilirubin above 35 mM/L or 2 mg/dL (iii) serum albumin levels less than 35 g/L or (iv) signs of ascites, encephalopathy, or malnutrition. The medications to be avoided involve analgesics such as aspirin, acetaminophen, codeine, meperidine, and ibuprofen; sedatives such as diazepam and barbiturates; and antibiotics such as ampicillin, tetracycline, metronidazole, and vancomycin, since they are all metabolized in the liver. Several local anesthetics are metabolized by the liver, such as lidocaine, mepivacaine, prilocaine, and bupivacaine. These can be administered to liver disease patients in a limiting dosage (ex. maximum of 3 cartridges of 2% lidocaine) and constant monitoring. It is also essential to monitor blood pressure in these patients, because it can be associated with portal hypertension in those with end-stage liver disease. Oral manifestations in patients with liver damage typically involve abnormal bleeding. This is because of abnormal blood clotting factor synthesis, fibrin polymerization, and thrombocytopenia. It is essential to order a platelet count before any surgical procedure to determine if platelet replacement will be required. It is important to note that chronic viral hepatitis increases the risk for hepatocellular carcinoma. Although this rarely metastasizes to the jaw, it presents as hemorrhagic expanding masses in the premolar and ramus region of the mandible.

Blood 2 - dental management

Dental Management A dentist can use four methods to identify a patient who may have a bleeding problem: good history, careful physical examination, screening laboratory tests, and occurrence of excessive bleeding after an invasive dental procedure

thyroid cancer - dental management

Dental Management During head and neck exams, dentists should look for surgical scars in the anterior neck and lingual thyroid tissue on the dorsal tongue. The pyramidal lobe can be found superior and lateral to the thyroid cartilage. The thyroid gland feels rubbery and will move superiorly when the patient swallows. Goiters will feel softer than normal thyroid glands, while adenomas, carcinomas, Hashimoto's Disease, and Riedel's Thyroiditis will have firmer thyroid glands. Diffused enlargement of the thyroid gland should be examined via auscultation to identify systolic or continuous bruit from the thyroid gland's vascular proliferation.

Blood - Dental Management

Dental Management Management begins first with a thorough medical history and examination to identify bleeding problems. This includes identifying key medications, congenital bleeding disorders including a family history, history of excessive bleeding following trauma or surgery, and history of spontaneous bleeding or excessive bruising. If the dentist suspects an undiagnosed bleeding condition, screening tests should be ordered in conjunction with a consult with the patient's physician. Physical Examination: The dentist should inspect the exposed skin and mucosa of the oral cavity and pharynx of the patient for signs that might indicate a possible bleeding disorder. These include petechiae, ecchymoses (bruises), spider angioma, telangiectasias, jaundice, pallor, and cyanosis. When any of these signs are found by the dentist and cannot be explained by the history or other clinical findings, the patient should be referred for medical evaluation Pre-operative Considerations Patients using anticoagulants should be evaluated for what risk and invasiveness of the procedure along with what medication is taken. Modification of anticoagulant therapy increases risk of thromboembolic events and should only be done in consultation with the patient's physician. Depending on the medication, minimal bleed risk procedures can be completed without any modification of the patient's anticoagulation medication with any bleeding controlled with local measures. For patients taking warfarin, a pre-operative PT/INR screening test should be taken. The clinician should consider potential drug interactions between anticoagulants and agents commonly used in dental practice (analgesics, antibiotics, sedatives) that may increase bleeding risk.

pregnant - Dental Management Considerations for Pregnant patients

Dental Management Considerations for Pregnant patients The general pattern of fetal development should be understood when dental management plans are being formulated. Normal pregnancy lasts approximately 40 weeks. During the first trimester, organs and systems are formed (organogenesis). Thus, the fetus is most susceptible to malformation during this period. After the first trimester, the major aspects of formation are complete, and the remainder of fetal development is devoted primarily to growth and maturation. Thus, the chances of malformation are markedly diminished after the first trimester. A notable exception to this relative protection is the fetal dentition, which is susceptible to malformation from toxins or radiation, and to tooth discoloration due to certain drugs. The dentist should assess the general health of the patient through a thorough medical history. Information to ascertain includes current physician, medications taken, use of tobacco, alcohol, or illicit drugs, history of gestational diabetes, miscarriage, hypertension, and morning sickness. If the need arises, the patient's obstetrician should be consulted.

Cancer - Recognition of cancer and medical considerations

Dental Management and Considerations A. Recognition of Cancer and Medical Considerations Dentists play an important role in recognizing cancer in their patients by asking about the signs and symptoms of cancer. Inquiring about patients' overall health, exercise, diet, vitamin intake, tobacco and alcohol use, and family history of cancer are helpful in assessing the risk of cancer. A few questions that are helpful in monitoring for cancer includes: "Have you experienced any change in your health since your last visit?" or "Are you aware of a lump or bump developing under your arm or in your neck for no apparent reason, a lesion changing color, pain in any body region, or abnormal bleeding from any site, such as blood in the stool?" During recall appointments, a head and neck exam along with an intraoral soft tissue exam should be performed on a regular basis. Regular exams can help identify early stages of cancer, which are usually subtle, asymptomatic, and more responsive to treatment. If suspicious lesions do not heal after 14 days, a biopsy should be taken. If a hard, fixed, or matted lymph node is identified, the patient should be referred to an otolaryngologist or a cancer treatment center. If other signs and symptoms of cancer are present, patients should be referred for lab tests and imaging studies at hospitals, commercial clinical labs, or to a physician. The blood tests would involve total red blood cell and white blood cell counts, differential white cell count, smear for cell morphologic study, hemoglobin, hematocrit count, and platelet count. If a dentist orders a screening test themselves and abnormal findings are reported, the patient should be referred to a medical professional.

pregnant - dental radiographs

Dental Radiographs: · The safety of dental radiography has been well established, provided that features such as fast exposure techniques (e.g., high-speed film or digital imaging), filtration, collimation, lead aprons, and thyroid collars are used. · Of all aids, the most important for the pregnant patient are the protective lead apron and the thyroid collar. Radiation should be avoided, especially during the first trimester, because the developing fetus is particularly susceptible to radiation damage. · The teratogenicity of ionizing radiation is dose dependent; the absorbed dose is a measure of the energy absorbed by any type of ionizing radiation per unit of mass of any type of matter. · The unit of measurement for absorbed dose is the gray (Gy): 1 Gy equals 100 rads. · An additional unit, the sievert (Sv), is used as a measure of equivalent dose to compare the biologic effects of different types of radiation on a tissue or organ. · For diagnostic x-ray examinations, 1 Sv equals 1 Gy Increased risk of adverse outcomes has not been detected among animals with continuous low-dose exposure less than 5 rad (5 cGy) throughout pregnancy. · Teratogenicity also is dependent on the gestational age of the fetus at the time of exposure. · During the organogenesis period (from the end of the 2nd to the 8th week after conception), the fetus is extremely sensitive to the teratogenic effect of ionizing radiation. The central nervous system (CNS) is particularly vulnerable · From weeks 16 to 25, there is a reduction in the radiosensitivity of the CNS and in many of the other organs. · After week 25, the central nervous system becomes relatively radio resistant, and major fetal malformations and functional anomalies are highly improbable. · Radiographs should be obtained selectively, only when necessary and appropriate to aid in diagnosis and treatment. · An additional consideration is potential fetal exposure in the pregnant dental auxiliary or dentist. The maximum permissible radiation dose for whole body exposure of the pregnant dental care worker is 0.005 Gy or 5 mSv per year. To further ensure safety, the pregnant operator should wear a film badge, stand more than 6 feet from the tube head, and position herself at between 90 and 130 degrees of the beam, preferably behind a protective wall. When these guidelines are followed, no clinical contraindication to operation of the x-ray machine by pregnant women arises.

IE - dental management

Dental management · Many dental procedures can cause bacteremia, but bacteremia can result from many normal daily activities such as toothbrushing, flossing, manipulation of toothpicks, use of oral water irrigation devices, and chewing. · frequency and cumulative duration of exposure to bacteremia from routine daily events over 1 year are much higher than those resulting from a single dental procedure. · Another assumption often made is that the magnitude of bacteremias resulting from dental procedures is more likely to cause IE than that seen with bacteremias resulting from normal daily activities. No published data support this contention. Furthermore, the magnitude of bacteremia resulting from dental procedures is relatively low (with bacterial counts of fewer than 104 colony-forming units/mL), is similar to that of bacteremia resulting from normal daily activities, and is far less than that (106 to 108 colony-forming units/mL) needed to cause experimental BE in animals.

diabetes - dental management, medical considerations

Dental management · Medical considerations: o Pt with signs and symptoms of diabetes (headache, dry mouth, marked irritability, repeated skin infection, blurred vision, paresthesias, progressive periodontal disease, multiple periodontal abscesses, loss of sensation) should be referred to primary care physician for laboratory diagnosis. o Diabetic patients can readily monitor their glucose level. Patients with an estimated fasting blood glucose level of 126 mg/100 mL or higher should be referred to a physician for medical evaluation and treatment, if indicated. Those with a 2-hour postprandial blood glucose level of 200 mg/100 mL or higher also should be referred. o Severity and control of diabetes should be established prior to treatment. What meds are taken, when are they taken, were they taken prior to appointment, how often are glucose levels checked, are they generally under well control? o Poorly controlled diabetics are at greater risk for post treatment complications and increased risk for serious cardiovascular events. o Type 2 diabetics under good control require little or no special attention. Poorly controlled or patients taking insulin may require consultation with patient's primary care physician. Watch for complications such as renal disease or cardiovascular disease, may need specific alterations to dental management. o Goal in treating patients with diabetes who are treated with insulin is to avoid insulin shock. Pt should take normal dosage and eat normal meal prior to appointment. Best to schedule patients for morning appointments. Ask patient prior to appointment if they took their insulin and have eaten. Keep source of sugar available in dental office. o Patients with brittle diabetes or who require large dosage of insulin may be at risk for postoperative infection. prophylactic antibiotics usually are not indicated. If the patient develops an infection, appropriate systemic antibiotics may be given. o An acute or oral infection in a patient with diabetes can have significant risks as the infection is not as well handled by the body's defenses as it would in a normal patient. o Risk of infection is related to blood glucose levels, infecting organisms, and invasiveness of dental procedure. § blood glucose level is between 207 and 229 mg/100 mL, the risk is predicted to be increased by 20% if surgical procedures are being performed. § If fasting blood glucose level rises to above 230 mg/100 mL, an 80% increase risk of infection postoperatively has been reported § Monitoring and appropriate use of antibiotics should be considered in the management of these patients.

Falkler

Dental pulps from teeth clinically diagnosed as having an abnormal response to cold, an abnormal response to cold and lingering pain to heat, or as having responses within normal limits were placed into pulpal explant cultures. The supematant fluids from the cultures were tested by an enzyme-linked immunosorbent assay for immunoglobulins reactive with 16 oral microorganisms implicated in endodontic infections and one nonoral microorganism. Immunoglobulins in each, group were reactive with Streptococcus mutans, Actinomyces naeslundii Lactobacillus casei, Eubacterium alactolyticum, Actinomyces israelli, Peptostreptococcus micros, and Veillonella parvula. Low or negligible reactions were observed with the rest of the bacteria tested. There was a statistically significant (p<0.05) higher level of reactive antibody observed in supermatant fluids of pulpal explant cultures from group cold than those from groups cold-heat and normal for S. mutans and L. casei. These studies demonstrate that immunoglobulins are present in the pulp which react with microorganisms that have been implicated in the carious process. The in vitro pulp explant model utilized may be important in studying the protective or immunopathological role of immunoglobulins in pulpal tissue.

MacDougall et al.

Dentin is the major mineralized extracellular matrix of the tooth. The organic components of dentin consist of type I collagen (90%) with 10% noncollagenous proteins, which are also components of bone. Two dentin proteins, dentin sialoprotein and dentin phosphoprotein, have been shown to be tooth-specific being expressed mostly by odontoblast cells. In this study, we screened a mouse molar tooth library for dentin sialoprotein and dentin phosphoprotein cDNA clones. Analysis of the clones resulted in characterization of a 4420-nucleotide cDNA that contained a 940-amino acid open reading frame. The signal peptide and NH2-terminal sequence was 75% homologous to the cDNA sequence of rat dentin sialoprotein. The continued open reading frame, however, contained a RGD sequence followed by a region of repeated aspartic acid and serine residues. This portion of the protein codes for amino acid sequence consistent with that of dentin phosphoprotein. The noncoding region contains three potential polyadenylation signals, two of which were shown to be utilized. Northern blot analysis indicated the presence of two major transcripts of 4.4 and 2.2 kilobases in odontoblasts. Chromosomal mapping localized the gene to human chromosome 4. These data suggest that the previously identified dentin extracellular matrix proteins, dentin sialoprotein and dentin phosphoprotein, are expressed as a single cDNA transcript coding for a protein that is specifically cleaved into two smaller polypeptides with unique physical-chemical characteristics. Therefore, we propose that the gene be named dentin sialophosphoprotein. The location of the human dentin sialophosphoprotein gene on chromosome 4 suggests that this gene may be a strong candidate gene for the genetic disease dentinogenesis imperfecta type II.

Arwa Siyam, Suzen Wang , Roy Stevens, Rena N D'Souza

Dentin matrix protein 1 (DMP1) is highly expressed in odontoblasts and osteoblasts/osteocytes and plays an essential role in tooth and bone mineralization and phosphate homeostasis. It is debatable whether DMP1, in addition to its function in the extracellular matrix, can enter the nucleus and function as a transcription factor. To better understand its function, we examined the nuclear localization of endogenous and exogenous DMP1 in C3H10T1/2 mesenchymal cells, MC3T3-E1 preosteoblast cells and 17IIA11 odontoblast-like cells. RT-PCR analyses showed the expression of endogenous Dmp1 in all three cell lines, while Western-blot analysis detected a major DMP1 protein band corresponding to the 57 kDa C-terminal fragment generated by proteolytic processing of the secreted full-length DMP1. Immunofluorescent staining demonstrated that non-synchronized cells presented two subpopulations with either nuclear or cytoplasmic localization of endogenous DMP1. In addition, cells transfected with a construct expressing HA-tagged full-length DMP1 also showed either nuclear or cytoplasmic localization of the exogenous DMP1 when examined with an antibody against the HA tag. Furthermore, nuclear DMP1 was restricted to the nucleoplasm but was absent in the nucleolus. In conclusion, these findings suggest that, apart from its role as a constituent of dentin and bone matrix, DMP1 might play a regulatory role in the nucleus.

Gronthos et al.

Dentinal repair in the postnatal organism occurs through the activity of specialized cells, odontoblasts, that are thought to be maintained by an as yet undefined precursor population associated with pulp tissue. In this study, we isolated a clonogenic, rapidly proliferative population of cells from adult human dental pulp. These DPSCs were then compared with human bone marrow stromal cells (BMSCs), known precursors of osteoblasts. Although they share a similar immunophenotype in vitro, functional studies showed that DPSCs produced only sporadic, but densely calcified nodules, and did not form adipocytes, whereas BMSCs routinely calcified throughout the adherent cell layer with clusters of lipid-laden adipocytes. When DPSCs were transplanted into immunocompromised mice, they generated a dentin-like structure lined with human odontoblast-like cells that surrounded a pulp-like interstitial tissue. In contrast, BMSCs formed lamellar bone containing osteocytes and surface-lining osteoblasts, surrounding a fibrous vascular tissue with active hematopoiesis and adipocytes. This study isolates postnatal human DPSCs that have the ability to form a dentin/pulp-like complex.

thyroid - enlargement and nodules of thyroid gland

Enlargement and Nodules of the Thyroid Gland Goiters refer to thyroid gland enlargement that can be either diffuse or nodular. Goiters can be characterized as primary goiters (simple goiters and thyroid cancer), thyrostimulatory secondary goiters (Graves' Disease and congenital hereditary goiter), and thyroinvasive secondary goiters (Hashimoto's Thyroiditis, subacute painful thyroiditis, Riedel's Thyroiditis, and metastatic tumors to the thyroid). Simple goiters make up 75% of thyroid gland swellings with most of them being nonfunctional and do not cause hyperthyroidism. Patients with Graves' Disease present with hyperthyroidism, while patients with Hashimoto's Thyroiditis present with hypothyroidism and thyroid enlargement.

Dahlen G et al.

Enterococci are occurring in opportunistic infections involving the oral cavity. This study has identified enterococcal species in 29 endodontic infections undergoing treatment with Ca (OH)2 dressings. The in vitro antimicrobial susceptibility of 29 isolated enterococcal strains was determined. Enterococcus faecalis was speciated for 26 isolates and E. faeclis for three isolates. In vitro antimicrobial susceptibility testing revealed enterococcal isolates resistant to benzylpenicillin, ampicillin, clindamycin, metronidazole, and tetracycline but sensitive to erythromycin and vancomycin. Due to low sensitivity to antimicrobial agents, enterococci may be selected in root canals undergoing standard endodontic treatment and significantly contribute to endodontic treatment failures

Kayaoglu G, Orstavik D

Enterococcus faecalis is a micro-organism that can survive extreme challenges. Its pathogenicity ranges from life-threatening diseases in compromised individuals to less severe conditions, such as infection of obturated root canals with chronic apical periodontitis. In the latter situation, the infecting organisms are partly shielded from the defense mechanisms of the body. In this article, we review the virulence factors of E. faecalis that may be related to endodontic infection and the peri-radicular inflammatory response. The most-cited virulence factors are aggregation substance, surface adhesins, sex pheromones, lipoteichoic acid, extracellular superoxide production, the lytic enzymes gelatinase and hyaluronidase, and the toxin cytolysin. Each of them may be associated with various stages of an endodontic infection as well as with periapical inflam- mation. While some products of the bacterium may be directly linked to damage of the periradicular tissues, a large part of the tissue damage is probably mediated by the host response to the bacterium and its products.

hepatitis - epidemiology

Epidemiology Acute viral hepatitis affects approximately 0.5-1% of Americans each year. However, the annual incidence has been decreasing since 1990 because of vaccines for Hepatitis A and B as well as decrease in high-risk behaviors. It is important to note that chronic hepatitis has a high morbidity rate, especially since the majority of people with hepatitis B and hepatitis C are unaware that they are infected. Without treatment, approximately 15-40% of infected people will develop liver cirrhosis.

epilepsy - epidemiology

Epidemiology Epilepsy is the most common chronic neurologic condition. Peak incidence in childhood and old age. Incidence in U.S. 35 to 52 cases per 100,000 people. 60-70 per 100k in young children and 45 per 100k for adolescents, 30 per 100k for early adult years, and 60-70 per 100k for people in their sixth and seventh decade. 150-200 cases per 100k in persons older than 75 years. Incidence in males i higher at every age group Prevalence of epilepsy ranging from 4.7 to 6.9 per 1000. Approximately 10% of the population will have at least one epileptic seizure in a lifetime while 2-4% will experience recurrent seizures at some point. Incidence of seizures is 0.5%. Most common during childhood with as many as 4% of children experiencing at least one seizure during the first 15 years of life. Estimated annual incidence of 134 cases per a00k for old age. In a typical dental practice, of 2000 patients, 3 or 4 can be expected to have a seizure disorder. Cerebrovascular disease is the most common factor underlying seizures occurring in elderly persons.

Blood 2 - Epidemiology

Epidemiology Von Willebrand disease is the most common inherited bleeding disorder. It is transmitted as an autosomal dominant trait and affects about 1% of the US population. Hemophilia A, a factor VIII deficiency, is the most common inherited coagulation bleeding disorders, which affects about 1 in every 5000 male births. Certain areas of the US have higher rates of hemophilia than others. Hemophilia B (also known as Christmas disease), a factor IX deficiency, affects about 1 of every 30,000 male births Of all the genetic coagulation disorders, 80% are hemophilia A, 13% hemophilia B, and 6% factor XI deficiency Rare inherited platelet disorders include Bernard-Soulier disease and Glanzamann's thrombasthenia Hereditary hemorrhagic telangiectasia (HHT) affects about 1:8000-1:50,000 people, and is a rare vascular disorder More than 60% of patients with idiopathic venothromboembolism have a reported inherited hypercoagulable state

Blood - Epidemiology

Epidemiology: Incidence and Prevalence: Patients on low-intensity warfarin therapy (with an international normalized ratio [INR] goal of 2.0 to 3.0) for prophylaxis of venous thromboembolism have a risk of major bleeding of less than 1% and about an 8% risk for minor bleeding. Patients on high-intensity warfarin therapy (with an INR goal of 2.5 to 3.5) have up to a five-fold greater risk for bleeding.

epilepsy - etiology

Etiology Epileptic seizures are idiopathic in more than half of all affected patients Vascular and developmental abnormalities, intracranial neoplasms, and head trauma are causative in about 35% of adult cases. Other common causes: hypoglycemia, drug withdrawal, infection, and febrile illness (e.g. meningitis, encephalitis). Seizures sometimes can be evoked by specific stimuli. Approximately 1 of 15 patients reports that seizures occurred after exposure to flickering lights, monotonous sounds, music or a loud noise. Syncome and diminished oxygen supply to the brain also are known to trigger seizures

hypertension - etiology

Etiology Hypertension is categorized as either primary or secondary. 90% of hypertensive patients have primary hypertension, which refers to hypertension without an identifiable cause. 10% of hypertensive patients have secondary hypertension, which refers to hypertension with an identified underlying cause or condition. Several causes of secondary hypertension include chronic kidney disease, primary aldosteronism, renovascular disease, chronic steroid therapy, Cushing syndrome, pheochromocytoma, coarctation of the aorta, thyroid/parathyroid disease, and sleep apnea. Lifestyle factors that may contribute to the severity and progression of hypertension include excessive alcohol intake, excessive dietary sodium, obesity, and the lack of physical activity.

thyroid cancer - Etiology and Clinical Findings

Etiology and Clinical Findings Patients that have received radiation to their cervical region, for acne, and to treat neck cancers are at risk of developing thyroid cancer. Environmental factors that contribute to an increased risk of thyroid cancer include high dietary iodine intake (with papillary cancer) and low iodine intake (follicular cancer). Family history of thyroid cancer and MEN2 can also increase the risk of developing thyroid cancer. Patients with thyroid cancer have firm nodules that are irregular and fixed accompanied with regional lymphadenopathy. They may present with hemoptysis, dysphagia, stridor, and hoarseness.

THYROTOXICOSIS (HYPERTHYROIDISM) Etiology, Pathophysiology, and Complications

Etiology, Pathophysiology, and Complications Thyrotoxicosis occurs when there is an excess of T3 and T4 in the blood and can result in ectopic thyroid tissue, thyroid adenomas, or multinodular goiters. It can occur with both painful and painless subacute thyroiditis, thyroid hormone ingestion, or pituitary disease. Graves' Disease refers to an autoimmune disease in which thyroid-stimulating immunoglobulins activate thyrotropic receptors, which promote gland growth and thyroid hormone synthesis by thyroid follicles. Risk factors include female gender and genetic mutations. Emotional stress involved with severe fright and separation are found to contribute to onset. Graves' Disease is commonly seen in females during puberty, pregnancy, or menopause with a 10:1 male-to-female ratio. It presents as either a cyclic pattern or a constant active state.

Blood- Etiology

Etiology: A pathologic alteration of blood vessel walls, a significant reduction in the number of platelets, defective platelets or platelet function, a deficiency of one or more coagulation factors, the administration of anticoagulant or antiplatelet drugs, a disorder of platelet release, or the inability to destroy free plasmin can result in significant abnormal clinical bleeding.

IE - etiology

Etiology: · About 90% of community-acquired cases of native valve IE are due to streptococci, staphylococci, or enterococci, with streptococci being the most common causative organism.

Bender

Evidence gathered from our studies and the work of others appears to support the presence of two distinct nerve pain pathways in the dental pulp, represented by fast conducting A-delta and slow conducting C-fibers. Each of these types of fibers has different pain characteristics: A-delta fibers evoke a rapid, sharp, lancinating pain reaction, and C-fibers cause a slow, dull, crawling pain. Pain response thresholds vary in different regions of the tooth, and thermal, osmotic, ionic, and electric stimuli involve different mechanisms to provoke nerve excitation of the dental pulp. Evidence also points to the fact that the incidence of pain increases as the histopathosis worsens. On interrogation, patients who manifest severe or referred pain almost always give a previous history of pain in the tooth with the ache. Eighty percent of patients who give a previous history of pain manifest histopathologic evidence of chronic partial pulpitis with partial necrosis, the untreatable category, for which endodontics or extraction is indicated. The other 20% exhibit histopathosis of the pulp with slight inflammation to chronic partial pulpitis without necrosis, a treatable category. Clinically, one can determine the degree of pulp histopathosis by asking the patient about a previous history of pain in the involved tooth. This history of previous pain adds another dimension in diagnosis for the clinician as to whether the painful pulpitis is reversible. This information also aids in referred pain localization.

Bergenholtz, Lindhe

Experimental breakdown of the periodontal attachment apparatus was produced in six young adult monkeys to study the effect on the tissue of the dental pulp by (1) periodontitis, (2) scaling and plaque accumulation on exposed root dentin. Periodontal tissue breakdown was induced by the placement of ligatures around the neck of 92 permanent teeth. Subsequent plaque formation caused marked loss of periodontal tissue support, which after a period of 5--7 months amounted to 30--40% of the root length. One group of teeth received no further treatment. Other teeth were subjected to scaling and root planing. Following treatment, plaque was allowed to accumulate for 2, 10, and 30 days on the freshly planed root dentin surfaces. Histologic examination revealed that in comparison to teeth with normal periodontal conditions, 57% of the teeth exposed to periodontitis exhibited pathologic pulp tissue alterations. Secondary dentin formation and/or inflammatory cell infiltrates were observed within localized areas of the pulp subjacent to root surfaces exposed to periodontal tissue destruction. The changes within the pulp were of "mild" nature and only one tooth displayed signs of total pulp necrosis. Lateral canals communicating with both the pulp cavity and the exposed root surface were never detected. Teeth subjected to scaling and subsequent plaque accumulation in comparison with teeth with periodontitis alone exhibited no obvious aggravation or increased incidence of pathologic pulp reactions. The findings show that in the monkey (1) periodontal destruction limited to the cervical half of the root and (2) plaque accumulation on exposed root dentin does not cause severe alteration in the pulp of the roots involved.

MacDougall et al.

Experiments were designed to produce and characterize a polyclonal antibody directed against mouse dentine phosphoprotein, the major non-collagenous protein of the dentine extracellular matrix. Dental extracellular matrix proteins from 2-day-postnatal Swiss-Webster-mouse tooth organs were extracted with 0.5 M-acetic acid, followed by 4 M-guanidinium chloride/0.5 M-EDTA. Mouse dentine phosphoprotein yields were further increased by precipitation with 1 M-CaCl2. Final purification was achieved by excising and eluting dentine phosphoprotein polypeptide bands from preparative sodium dodecyl sulphate/urea/polyacrylamide gels. Mouse dentine phosphoprotein is a single component of approx. 72 kDa and has a characteristic amino acid composition of 33% aspartic acid and 55% serine/phosphoserine. A polyclonal antibody was raised in rabbits against purified mouse dentine phosphoprotein and was shown to be monospecific by enzyme-linked immunoabsorbent, dot-immunobinding and 'Western transfer' assays. This antibody was used to detect the expression and localization of dentine phosphoprotein in 1-day-postnatal mouse tooth organs. This antigen was localized intracellularly within the monolayer of odontoblasts, which line the perimeter of the dental papilla mesenchyme, and within the odontoblastic cell processes, which traverse the predentine matrix. Newly forming mineralized dentine matrix was also cross-reactive with the dentine phosphoprotein specific antibody. The non-mineralized predentine matrix did not contain any detectable cross-reactive antigens.

Andrew et al.

Experiments were performed on anaesthetized cats to test the hypothesis that fluid flow through dentinal tubules is part of the mechanism involved in the transduction of pain-producing stimuli in teeth. In 11 animals, fluid flow through dentine and single- and multi-unit activity in intradental nerves were recorded simultaneously during the application of changes in hydrostatic pressure (-500 to +500 mmHg) to exposed dentine. Seventeen A-fibres (conduction velocity (CV), 10.6-55.1 m s−1) were isolated that were pressure sensitive. The thresholds of these units in terms of dentinal fluid flow were in the range 0.3-2.1 nl s−1 mm−2 during outward flow from the pulp and 2.0-3.5 nl s−1 mm−2 during inward flow. All the units were more sensitive to outward than inward flow. Twenty-eight units (CV, 0.6-48.8 m s−1) were not pressure sensitive, and 12 of these had conduction velocities in the C-fibre range (< 2.5 m s−1). The velocities of the tubular contents were calculated by estimating the number and diameters of dentinal tubules exposed. At the threshold of single-fibre responses these velocities were in the range 31.7-222.9 μm s−1 during outward flow, and 211.4-369.6 μm s−1 during inward flow. Repetitive pressure stimulation of dentine resulted in a progressive reduction in the evoked discharge, which was probably due to pulp damage. In seven animals, 10 single intradental nerve fibres were selected that responded to hydrostatic pressure stimuli and their responses to the application of hot, cold, osmotic, mechanical and drying stimuli to exposed dentine were investigated. With these stimuli dentinal fluid flow could not be recorded in vivo for technical reasons and was therefore recorded in vitro after completion of the electrophysiological recordings. With each form of stimulus, the discharge evoked in vivo was closely related to the flow predicted from the in vitro measurements. The results were therefore consistent with the hypothesis that the stimuli act through a common transduction mechanism that involves fluid flow through dentine.

Yoshiba et al.

Exposed dental pulp is known to possess the ability to form a hard-tissue barrier (dentin bridge). The exact mechanisms by which pulp cells differentiate into odontoblasts in this process are unknown. Fibronectin has been demonstrated to play a crucial role in odontoblast differentiation during tooth development. This study tested the hypothesis that fibronectin is involved in the initial stages of replacement odontoblast differentiation and reparative dentin formation. We observed its immunohistochemical localization during dentin bridge formation in human teeth, after pulp was capped with calcium hydroxide [Ca(OH)2]. One day after the capping, precipitation of crystalline structures was observed at the TEM level in association with cell debris at the interface between the superficial necrotic zone and underlying pulp tissue. This layer of dystrophic calcification showed positive reaction for fibronectin, and pulp cells appeared to be closely associated with this layer, seven to ten days post-operatively. At 14 days, an alignment of cells, some of which were elongated and odontoblast-like, was observed adjacent to the fibronectin-positive irregular matrix. Between the cells, corkscrew fiber-like fluorescence was visible. At 28 days, the irregular fibrous matrix was followed by the formation of tubular dentin-like matrix lined with odontoblast-like cells. Therefore, it would seem that fibronectin associated with the initially formed calcified layer might play a mediating role in the differentiation of pulp cells into odontoblasts during reparative dentinogenesis, after pulp was capped with Ca(OH)2.

Hepatitis exposure guidelines

Exposure Guidelines The CDC and ADA recommend that all dental health care workers are given a vaccination against hepatitis B, which is the most transmittable of the hepatitis viruses. A vaccinated healthcare worker with a needlestick or puncture wound from a patient known to be HBsAg positive should be tested for anti-HBs titer if the levels are unknown. If the titer is inadequate, the healthcare worker should receive a HBIG injection and vaccine booster dose. If the titer level is adequate, no further action is required. Since there is no present vaccination available for HCV, the patient should receive baseline anti-HCV testing and the exposed personnel should be given baseline and follow-up testing at 6 months for anti-HCV and liver enzyme activity. Postexposure prophylaxis for HCV with immunoglobulin or antiviral agents should be avoided. All healthcare workers should have an exposure control plan involving (i) hepatitis B vaccination for all employees (ii) postexposure evaluation and follow-up (iii) record-keeping for exposure data (iv) blood-borne pathogens training and (v) personal protective equipment for all employees.

Henry, M.; Reader, A.; Meck, M.

Forty-one emergency patients participated and each had a clinical diagnosis of a symptomatic necrotic tooth with associated periapical radiolucency. After endodontic treatment patients randomly received a 7-day oral dose (twenty-eight 500 mg capsules to be taken ev- ery 6 h) of either penicillin or a placebo control in a double-blind manner. Patients also received ibuprofen; acetaminophen with codeine (30 mg); and a 7-day diary to record pain, percussion pain, swelling, and number and type of pain medication taken. The majority of patients with symptomatic necrotic teeth had significant postoperative pain and require analgesic medication to manage this pain. The administration of penicillin postoperatively did not significantly (p > 0.05) reduce pain, percussion pain, swelling, or the number of analgesic medications taken for symptomatic necrotic teeth with periapical radiolucencies.

Function of the Thyroid Gland

Function of the Thyroid Gland Thyroxine (T4), triiodothyronine (T3), and calcitonin are secreted by the thyroid gland. Thyroid hormone, including both thyroxine and triiodothyronine, affects tissue growth and maturation, cell respiration, energy expenditure, and vitamin and hormone turnover. Changes in thyroid hormone concentrations will cause changes in tissue site-specific nuclear receptors that lead to gene expression changes. Thyroid hormone leads to an increase in oxygen consumption, thermogenesis, and LDL receptor expression, which in turn causes LDL cholesterol degradation. It also increases mental alertness, ventilatory drive, GI mobility, bone turnover, and brain develop along with skeletal maturation in fetuses. T3 specifically increases the heart rate and increases myocyte contraction and relaxation. Calcitonin acts with parathyroid hormone and vitamin D to regulate serum calcium and phosphorous levels and skeletal remodeling.

diabetes - Incidence and prevalence

Incidence and prevalence · Estimated 8.3% of Americans have diabetes. · Type 2 most prevalent, 90-95% of all diabetics. · Prevalence of type 2 increases with age, primarily found in adults. · Type 1 occurs in 0.3% of Americans but is 4 times more prevalent that type 2 in people under 20 years old. · Strong association with obesity, 60% of all diabetics are obese.

Platelet disorder - Glanzmann's Thrombasthenia

Glanzmann's Thrombasthenia Rare autosomal recessive disease characterized by a deficiency or defect of the fibrinogen receptor GPIIb/IIIa on the platelet surface. This receptor is important because it functions in the adhesion and aggregation of platelets. With this disease, the platelets of these patients cannot bind fibrinogen and aggregation does not occur. The platelets can adhere to the subendothelium with vWF, but not to fibrinogen. Glanzmann's thrombasthenia occurs in ethnic populations most frequently in Indians, Iranians, Iraqi Jews, Arabs, and French Gypsies. Carrier detection is important to control the disorder. Clinically, we typically find epistaxis, easy bruising, oral and gingival hemorrhage, gastrointestinal bleeding, perioperative bleeding, hemarthrosis, and menorrhagia. Bleeding is typically intermittent and unpredictable, and patients may even complain from minor cuts and trauma. Laboratory testing is similar to that described for Bernard-Soulier syndrome. Treatment includes lifestyle advise and patient education, local measures, antifibrinolytic agents, hormone treatment, platelet transfusions, and recombinant activated factor VII to control bleeding.

Vainio et al.

Growth factor-mediated signaling has been implicated in the regulation of epithelial-mesenchymal interactions during organogenesis. Bone morphogenetic protein 4 (BMP-4), a member of the transforming growth factor beta superfamily, is expressed in the presumptive dental epithelium at the initiation of tooth development. Subsequently, epithelial signaling leads to mesenchymal induction of BMP-4 expression. To address the role of this factor, BMP-4-releasing agarose beads were added to dental mesenchyme in culture. These beads induced a translucent mesenchymal zone similar to that induced by dental epithelium. Moreover, three transcription factors (Msx-1, Msx-2, and Egr-1) whose expression is governed by epithelial signaling were induced in response to BMP-4. In addition, BMP-4 induced its own mesenchymal expression. These findings support the hypothesis that BMP-4 mediates epithelial-mesenchymal interactions during early tooth development.

medical management - vascular defects

HHT, Osler-Weber-Rendu syndrome, is a rare autosomal dominant disorder with multiple telangiectatic lesions in the skin, mucous membranes, and viscera. The telangiectasias consist of focal dilation of post-capillary venules with connections to dilated arterioles, initially through capillaries and later directly. Perivascular mononuclear cell infiltrates are observed The vessels show discontinuous endothelium, incomplete smooth muscle cell layer, and a stroma which lacks elastin- these increase the bleeding tendencies due to the mechanical fragility of the abnormal vessels. These lesions usually appear by age 40 and increase with age. Clinically, venous lakes and popular, punctate, matlike, and linear telangiectasias are on all areas of the skin and mucous membranes, with a predominance of lesions on and under the tongue, face, lips, perioral region, nasal mucosa, fingertips, toes, and trunk. Recurrent epistaxis (nose bleeding) is commonly found and symptoms worsen with age Bleeding can occur in every organ, commonly involving the gastrointestinal, oral, and urogenital sites. Laboratory tests are not reliable to determine the tendency for bleeding to occur, so clinical findings and history of bleeding problems are effective. Treatment for HHT consists of laser treatment for cutaneous lesions, skin grafting, embolization of arteriovenous communications, or hormonal therapy for epistaxis. For pulmonary malformations, pulmonary resection or embolization. For gastrointestinal lesions, hormonal therapy, laser coagulation, and possibly iron supplementation/transfusion is recommended.

hypothyroidism

HYPOTHYROIDISM Hypothyroidism can be caused by primary atrophic, secondary, transient, and generalized resistance to thyroid hormone. Congenital hypothyroidism at birth may be due to ectopic, hypoplastic, or thyroid agenesis. If hypothyroidism is acquired, it can be caused by thyroid gland irradiation, surgical removal, or antithyroid drug therapy. Subclinical hypothyroidism occurs when there is an increased serum TSH concentration with normal serum FT4 and T3, which occurs in 75/1000 females and 28/1000 men. It is caused by chronic autoimmune thyroiditis, postpartum thyroiditis, 131I therapy, thyroidectomy, or antithyroid drugs.

Coagulation disorders - hemophelia A

Hemophilia A Hemophilia A is characterized by a deficiency or defect of factor VIII. Factor VIII circulates in plasma bound to vWF. When factor VIII is unbound, it is destroyed. Hemophilia A is an X-linked recessive disorder, which means an affected man will not transmit the disease to his sons, but all of his daughters will be carriers. A female carrier will transmit the disease to half of her sons and the carrier state to half of her daughters. The severity of bleeding varies from kindred to kindred, but within kindred, the severity of the disease is constant. The mutation rate for this trait is very high (about 30%), so a family history is not necessarily very valuable in diagnosis. Hemophilia A can manifest in women in either homozygous hemophilia and sometimes even in heterozygous carriers as well. This disease mainly manifests in men. Normal homeostasis requires at least 30% factor VIII activity. Symptomatic patients have factor VIII levels below 5%. Severe hemophilia: <1% normal level of factor VIII. More than 60% of hemophiliacs have severe hemophilia. Patients typically have severe, spontaneous bleeding from trivial injuries as well as hemarthrosis, ecchymoses, and soft tissue hematomas. These patients experience GI bleeding, and spontaneous bleeding from the mouth, gingiva, lips, tongue, and nose. Moderate hemophilia: 1-5% normal level of factor VIII. Patients experience moderate bleeding with minimal trauma or surgery. Mild hemophilia: 5-30% normal level of factor VIII. Patients experience mild bleeding after major trauma or surgery. Onset of bleeding in hemophiliacs is very delayed and slow. The bleeding can be life-threatening, but hemostasis may appear to be normal at the time or surgery or injury. Laboratory tests show prolonged aPTT, normal PT, and normal platelet count (except with some cases of von Willebrand disease), which indicates a problem in the intrinsic pathway. After this screening, a mixing test is performed with the patient's blood and a sample of pooled plasma to repeat the aPTT. If this test is normal, then the missing factor is identified. If the test is abnormal, tests for inhibitor (antibody to the factor) activity are performed. Those with inhibitors have had previous contact with factor VIII replacement. The prognosis for someone with Hemophilia A is often poor due to comorbidities. Contamination of donated blood increases the risk of developing HIV and HCV, leading to more than 75% of hemophilia A patients and more than 45% of hemophilia B patients being HIV-positive, increasing the mortality rate. With the exception to comorbidities, life expectancy is related to the severity of hemophilia. The mortality rate among patients with inhibitors is much greater than for those without. The efficacy of recombinant versus plasma derived factor VIII are very similar. Factor VIII replacement guidelines for control of bleeding with severe hemophiliacs are: -For minor bleeding: 25-30% replacement of factor VIII is required -For major dental surgery (treatment or prevention of severe bleeding): 50% replacement or greater is required -For treatment of life-threatening bleeding and limb-threatening bleeding during major surgery: 80-100% replacement For hemophiliacs without inhibitors, surgical procedures can be performed with desmopressin (which transiently increases the factor VIII level) alone or in combination with aminocaproic acid (which is an antifibrinolytic agent). NSAIDs which impair platelet function should not be used with these patients. Hemophiliacs with inhibitors (which are usually IgG antibodies to factor VIII) have usually received multiple factor VIII replacement therapy. They can either be a high or low responder, with high responders being more difficult to treat. About 5-10% of hemophiliacs have factor VIII inhibitors. These patients can be treated with larger amounts of human factor VIII concentrates, recombinant activated factor VIIa, or porcine factor VIII.

Coagulation disorder - Hemophilia B

Hemophilia B Hemophilia B (Christmas disease) occurs when factor IX is deficient or defective and is also an X-linked recessive trait. Severe disease affects patients who have less than 1% of normal amounts of factor IX, but is less common than in hemophilia A. The clinical manifestations and screening laboratory testing are similar for both Hemophilia A and B, and specific factor assays for factor IX establish the Hemophilia B diagnosis. Treatment for Hemophilia B involves recombinant factor IX.

hepatitis - A

Hepatitis A Hepatitis A is highly contagious and typically spread directly person-to-person in a fecal-oral route, which is easily spread in areas with poor sanitary conditions. High-risk groups include travelers to developing countries, children in day care centers, men who are sexually involved with men, injection drug users, hemophiliacs who are given plasma products, and residents and staff of institutions. HAV is a small RNA virus which is secreted into bile, and sometimes, serum. It has an incubation period of between 15-45 days and jaundice occurs in 70% of adults (not so much in children). It is the most common cause of relapsing cholestatic hepatitis. HAV is typically diagnosed by detection of IgM anti-HAV in the serum of patients. Testing for total anti-HAV is helpful to assess immunity, but not in the diagnosis of HAV. Prevention is strongly suggested by getting vaccinated against HAV. In terms of treatment, no specific therapies have been demonstrated to shorten the course of HAV. However, HAV is a self-limited infection. It can persist for months, but it does not typically lead to chronic infection or cirrhosis.

Lymphokines in chronic inflammation (cytokines):

MIP, MAF or interferon-gamma, chemotactic (C5a, leukotrienes, cytokines, IL-8), lymphotoxin (growth and proliferation of B cells), IL-1, IL-2, FAF

78 Ribeiro

MTA and Portland cements are not genotoxins and do not induce cellular death.

hepatitis B

Hepatitis B HBV is usually spread by the parenteral route or sexual contact. It can also be spread by maternal-infant contact. It is prominent in Southeast Asia, China, Micronesia, and sub-Saharan Africa. In the United States, it is the most common cause of acute hepatitis and chronic HBV affects about 0.5% of the population. HBV is common in drug users by injection, people who have multiple sexual partners, and men in sexual relations with men. The virus is a double-shelled, enveloped DNA virus. It is detected serologically. During acute and chronic infection, HBsAg can be detected largely in serum. The incubation period for HBV is 30-150 days, and during this period the HBsAg, HBeAg, and HBV DNA are detectable in serum and rise to high titers. Once symptoms arrive, anti-HBc and serum aminotransferase levels elevate. Upon recovery, HBsAg becomes undetectable and anti-HBs appears, which is a long-lasting antibody. Diagnosing HBV involves detection of HBsAg in serology. However, HBsAg can also appear with acute HAV or HDV or drug-induced liver disease. So testing for IgM anti-HBc (IgG antibody) is helpful. If a person remains positive for HBV DNA or HBeAg at 6 weeks from symptom onset, they are likely to develop chronic HBV. HBV is a common cause of fulminant hepatitis and liver cancer, so it is important for people to get vaccinated against the virus. Treatment for HBV is a regimen of interferon alfa and lamivudine, but this is controversial since it has not been thoroughly studied. If patients have signs or symptoms of fulminant liver disease, this treatment should be administered. Acute HBV should be monitored by repeated testing for HBsAg and alanine aminotransferase levels to determine if chronic disease has developed. Chronic HBV develops in about 2-7% of adults who are infected with HBV. Chronic condition correlates with age, with 90% newborns, 30% infants, and less than 10% adults who have been infected with HBV.

Hepatitis C

Hepatitis C HCV is typically spread parenterally, so the people most at risk are injection drug users or those with parenteral exposures. HCV is a double-shelled enveloped RNA virus whose incubation period is typically 15-120 days. HCV RNA can be detected within 1-2 weeks of exposure by reverse transcriptase-polymerase chain reaction. Anti-HCV tends to show up late in the course of acute HCV. If the hepatitis is self-limited, HCV RNA becomes undetectable in serum, and even anti-HCV titers are low and may become undetectable. Diagnosis of HCV is with serology by detection of anti-HCV. Since it sometimes does not appear in serology until weeks or months after illness onset, retesting during convalescence or performing direct HCV RNA tests are important. There is no vaccine available for HCV. Avoiding high-risk behaviors and using standard precautions with needles is important. If an accidental needlestick exposure occurs, no therapy is recommended other than monitoring aminotransferase levels and HCV RNA as well as anti-HCV. For patients with chronic HCV, therapy with peginterferon alfa and ribavirin has shown to be beneficial in more than 50% of cases. There is no current course of treatment suggested for acute infection. Chronic hepatitis is an important concern after diagnosis of acute HCV, especially since this occurs about 50-85% after diagnosis of acute HCV. Other complications include immune complex phenomena development and cryoglobulinemia. It is rare to develop fulminant hepatitis from HCV.

Hepatitis D

Hepatitis D HDV (hepatitis delta virus), is linked to HBV, so it has many similarities including spread by parenteral route and sexual contact. Those at risk are chronic carriers of HBV as well as people with parenteral exposures. The HDV virus is a unique RNA virus that requires HBV in order to replicate. There are two clinical patterns including: 1. Coinfection: Simultanous acute HDV and acute HBV infections. It resembles acute HBV but will involve a second elevation in aminotransferase levels during delta virus replication. Diagnosis can be made in serology with HBsAg, anti-HDV, and IgM anti-HBc. The anti-HDV antibody appears late during illness. 2. Superinfection: Acute HDV infection in person with chronic HBV or HBsAg carrier state. Diagnosis can be made in serology with HBsAg and anti-HDV but no IgM anti-HBc in the serum. The delta antigen can be stained in liver biopsy specimens as well. Superinfection is more frequent than coinfection and has a higher chance of becoming chronic. Preventing HDV can be done by preventing HBV with HBV vaccination. There is no prevention method of HDV in a person who is a HBsAg carrier. Anti-HBV agents are not effective against HDV replication, so no therapies are currently available against HDV. It is important to note that HDV has a tendency to be more severe than HBV since it is more likely to cause fulminant hepatitis, severe chronic hepatitis, and cirrhosis.

Hepatitis Non-A-E

Hepatitis Non-A-E When making a differential diagnosis for acute hepatitis, it is important to take a history for risk factors and exposure, medication use, and alcohol use. After doing differential diagnosis, if cases seem to be associated with acute hepatitis and are viral in etiology, but cannot be diagnosed to a specific known virus, we refer to them as "hepatitis non-A-E". In Western countries, approximately 2-20% of cases cannot be diagnosed into the known hepatitis viruses. Typically, there is no way to identify a source of exposure, so the etiology can be due to non-viral causes, such as drugs, environmental exposures, or autoimmune processes.

blood - history and symptoms

History and Symptoms Specific abnormal bleeding patterns can be associated to certain bleeding disorders: -Spontaneous hemarthroses and muscle hemorrhages: severe hemophilia -Epistaxis, gingival bleeding, menorrhagia: thrombocytopenia, platelet disorders, von Willebrand disease -History of prolonged bleeding after extraction: suggestive of von Willebrand disease or platelet disorders (over hemophilia) -History of bruising and bleeding but normal laboratory results: blood vessel diseases (HHT, Cushing's disease, Ehlers-Danlos) Questions to include when taking history: bleeding problems in relatives, excessive bleeding after operations/surgical procedures/dental extractions, excessive bleeding after trauma, using drugs for prevention of coagulation or chronic pain, past and present illness, and occurrence of spontaneous bleeding

Torabinejad

MTA has some known drawbacks such as a long setting time, high cost, and potential of discoloration. Hydroxyapatite crystals form over MTA when it comes in contact with tissue synthetic fluid. This can act as a nidus for the formation of calcified structures after the use of this material in endodontic treatments. MTA is the material of choice for some clinical applications.

Pavaskar R et al.

Human single-rooted premolars were instrumented up to ProTaper size F3 files. EF suspension was inoculated into each root specimen and incubated. The medicaments were syringed into each root by weight and incubated. After 72 hours, 6 samples per group (among the 5 groups) were retrieved. A hole was drilled on each root, and the dentinal shavings obtained were allowed to fall in brain-heart infusion (BHI) broth. Dilutions from the broth were plated and spread over BHI agar and blood agar. Colony-forming units (CFU) of EF were measured from BHI agar. The procedure was repeated after 8 days and 14 days. In group CH, the mean CFU (log 10 values) after 72 hours, 8 days, and 14 days were 1.17 1.16, 3.33 1.97, and 4.17 1.17, respectively (statistically significant). In group VP, the mean CFU were 0.83 0.75, 4.00 1.67, and 4.83 1.72. In group LZ, the mean CFU at 72 hours and after 8 days was 0.17 0.41, and no CFU were found on the fourteenth day. Similarly, in group LC, the mean CFU at 72 hours and after 8 days was 0.50 0.84, which increased to 1.33 +/- 1.51 on the fourteenth day (not significant). Conclusions: LZ was found to be most effective on EF, followed by LC, CH, and VP.

Hyperventilation

Hyperventilation · Signs and symptoms: Rapid and shallow breathing, confusion, dizziness, paresthesias, cold hands, carpal-pedal spasms; can progress to seizure. · Cause: Anxiety-induced excessive loss of CO2 from deep and rapid breathing; also respiratory alkalosis. · Treatment o Positioning: Place patient in an upright position. Explain the problem and reassure the patient. o Airway: Maintain open airway by talking with patient. o Breathing: Instruct the patient to be calm and breathe slowly into a paper bag or into the cupped hands over the nose and mouth (i.e., rebreathe carbon dioxide). o Circulation: No treatment required. o Dispense (i.e., provide) reassurance. o Ensure that vital signs, drug administration, and patient responses are properly monitored and recorded. o Facilitate/ensure next steps in medical/dental care: Consider rescheduling appointment with antianxiety measures/presedation.

Seltzer S.

INEVITABLY associated with crown preparation of a tooth are increases of pressure, temperature, and vibration. The effects of pressure on the dental pulp have not been comprehensively investigated. As an incidental finding, we have noted that human teeth which have been extracted with forceps invariably presented an area of odontoblastic destruction. This area coincided precisely with the dentinal tubules which had been exposed and crushed by the beaks of the forceps. In some cases, there was, in addition, some capillary hemorrhage between the odontoblasts. It appeared that for each tubule exposed to pressure, the corresponding odontoblast was ruptured. Others have noted and recorded these same phenomena. 2, 3 The effects of pressure and heat on the dental pulp cannot be separated since there apparently exists a direct correlation between the 2 factors. The greater the pressure of the cutting instrument, the higher the frictional heat developed.3-6 Investigators6-'2 have measured the rise in temperature within a tooth when it has been cut with stones, burs, and diamond instruments. The implications that these increases are capable of producing serious irreparable damage to the dental pulp were not borne out by the investigations of Lisanti and Zander.13 They found that temperatures of 1250 F. to 600iF. applied to the dentin of dogs' teeth for 5 seconds to 1 minute were capable of producing changes in the pulp, ranging from separation of the odontoblastic layer from the dentin to destruction of the odontoblastic layer and blister formation within the pulp. In all cases, however, healing took place as time elapsed and within 2 months there was repair with no pulp deaths. In full crown preparation, however, where all the dentinal tubules are exposed, and the total drilling time exceeds 1 minute, repair might not be so complete. When extra increments of irritation in the form of heat and pressure from modelling compound are added, the pulp reaction might not be so favorable. Lisanti and Zander13 listed many factors which may influence the amount of heat produced during operative procedures. An important method of controlling the heat produced is by the use of water coolants on the teeth while cutting is taking place.5' 6, 9 The purposes of this investigation were (1) to study the effects of crown preparation with rotary tools run at comparatively low speeds on the pulps of Collapse

Pettiette

Immediate postoperative periapical status was found to be similar. Teeth instrumented with the NiTi files demonstrated a higher mean change in densitometric ratio, compared with SS-K files (p < 0.05). Further tests of success (values: >0) and failure (value: <0) with the Fisher exact test showed more success (2radiographic density) with NiTi files and more failures (1radiographic density) with SS-K type files. This study indicates that maintaining the original canal shape after instrumentation leads to a better prognosis of endodontic treatment.

Hahn

Immunoglobulin molecules in the supernatant fluids (SF) from pulpal explant cultures have been observed to react with microorganisms implicated in infections of root canals. In this study, the reactivity of immunoglobulin molecules in the SF from normal and irreversible pulpitis pulps to six strains of predominant microorganisms isolated from the immediate layer of carious lesions above the pulps used for explant cultures was investigated using an enzyme-linked immunosorbent assay. Two ATCC strains of Eubacterium were also included in this assay. Specific antibodies to Lactobacillus casei subsp. casei, Lactobacillus casei subsp. rhamnosus, Lactobacillus acidophilus (I), (II), Streptococcus mutans, Bacteroides intermedius, Eubacterium brachy, and Eubacterium alactolyticum in the SF from the normal and irreversible pulpitis tissues were observed with a large variation of antibody levels in both groups. Immunodiffusion assays of the SF revealed that IgG was the major class of immunoglobulin in the normal as well as the irreversible groups. The presence of natural antibodies in the normal pulps suggested a possible protective role of antibodies during the invasive process of caries.

pregnant - immune changes

Immunologic changes: · The WBC count increases progressively due to an increase in neutrophils, · The reason for the increase is unclear but may involve elevated estrogen and cortisol levels. · The immune system shifts from helper T cell type 1 (TH1) dominance to TH2 dominance. · This shift leads to immune suppression which leads to increased susceptibility to viral infections and heightened inflammatory activities.

Fletcher H (1995)

In a previous study we cloned and determined the nucleotide sequence of the prtH gene from Porphyromonas gingivalis W83. This gene specifies a 97-kDa protease which is normally found in the membrane vesicles produced by P. gingivalis and which cleaves the C3 complement protein under defined conditions. We developed a novel ermF-ermAM antibiotic resistance gene cassette, which was used with the cloned prtH gene to prepare an insertionally inactivated allele of this gene. This genetic construct was introduced by electroporation into P. gingivalis W83 in order to create a protease-deficient mutant by recombinational allelic exchange. The mutant strain, designated V2296, was compared with the parent strain W83 for proteolytic activity and virulence. Extracellular protein preparations from V2296 showed decreased proteolytic activity compared with preparations from W83. Casein substrate zymography revealed that the 97-kDa proteolytic component as well as a 45-kDa protease was missing in the mutant. In in vivo experiments using a mouse model, V2296 was dramatically reduced in virulence compared with the wild-type W83 strain. A molecular survey of several clinical isolates of P. gingivalis using the prtH gene as a probe suggested that prtH gene sequences were conserved and that they may have been present in multiple copies. Two of 10 isolates did not hybridize with the prtH gene probe. These strains, like the V2296 mutant, also displayed decreased virulence in the mouse model. Taken together, these results suggest an important role for P. gingivalis proteases in soft tissue infections and specifically indicate that the prtH gene product is a virulence factor.

Kikuchi et al

In an organ culture system under a three-dimensional microenvironment that provides the conditions needed for odontoblast differentiation, a row of odontoblasts can be induced (Kikuchi et al. 1996, 2001). Therefore, in a newly designed three-dimensional cell culture system that fulfils the conditions necessary for odontoblast differentiation (Kikuchi et al. 2002), we examined whether dental papilla cells in rat mandibular incisors could differentiate into tubular dentine-forming cells. In our previously established organ culture system, CM-Dil-labeled cells that were microinjected into isolated dental papillae were replaced by a row of odontoblasts. In a three-dimensional cell culture system, which consists of two kinds of type I collagen in the upper layer over multi-layered cells seeded onto collagen containing Matrigel in the lower layer and which acts as a structural meshwork, dental papilla cells were incubated as multi-layered cells in an artificial extracellular matrix (ECM). The cells aggregated to form a cell mass and invaginated as a cell mass into the ECM. The cells also extended fine fibrillar processes into the ECM. With regard to invagination, the proteolytic activities of matrix metalloproteinase-2 (MMP-2)/membrane type 1-matrix metalloproteinase (MT 1-MMP) were observed on the outer multi-layers of cells within a cell mass adjacent to the ECM. The cell mass progressively shrank to about one-half to one-third of its original diameter and was organized as a tissue surrounded by a newly secreted ECM, like dental pulp-dentine. The cells adjacent to the secreted ECM were constructed as a row of polarized columnar cells. They extended slender processes into the new ECM, which is characteristic of tubular matrix. Dentine sialophosphoprotein (DSPP) and dentine matrix protein 1 (DMP 1) genes, which are specific for odontoblast differentiation, were expressed in an aggregated cell mass where tubular matrix-forming cells were induced. Furthermore, the tubular matrix became mineralized under prolonged culture. These results imply that the putative progenitor cells/stem cells residing in dental papillae can differentiate into odontoblasts under appropriate conditions in vitro.

hypertnesion - medical management

In order to properly treat hypertension, accurate blood pressure readings should first be recorded by taking the average of two or more readings over two or more appointment visits. Prior to taking a blood pressure reading, the patient should sit for 5 minutes with both feet on the ground. Their arm should be at the level of the heart, resting on a ledge when the blood pressure is taken. Although mercury sphygmomanometers have been considered the gold standard in recording blood pressure, their use is limited due to environmental concerns and the risk of mercury spills. Digital devices are commonly used in the dental office since they are reasonably accurate and easy to use but require regular calibration. Patients with prehypertension are recommended to make lifestyle modifications as they are not candidates for drug therapy. These modifications include daily aerobic physical activity, diets rich in fruits, vegetables, and low-fat dairy products, elimination of trans-fast, minimize saturated fats, alcohol, and sodium. In patients with stage 1 and stage 2 hypertension, the goal of treatment is to decrease the blood pressure below 140/90 mm Hg and below 130/80 mm Hg in patients with diabetes and kidney disease. The most commonly used antihypertensive drugs include thiazide diuretics, angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), and calcium channel blockers (CCBs), with thiazide diuretics being the first drugs of choice. Less commonly used drugs include alpha-1-adrenergic blockers, central alpha-2-agonists, centrally acting drugs, and direct vasodilators. Single-drug therapy is usually effective during early stage 1 hypertension but if it progresses to late stage 1 and stage 2 hypertension, dual-drug therapy may be required. Patients with blood pressure above 180/110 may need immediate treatment and hospitalization. Hypertensive emergencies involve high blood pressure with organ dysfunction like hypertensive encephalopathy, intracerebral hemorrhage, acute MI, left ventricular failure with pulmonary edema, or unstable angina pectoris and should be treated in the ICU. High blood pressure with symptoms such as headache, shortness of breath, nosebleeds, and anxiety are not emergencies and can be treated with short-acting oral antihypertensive agents with hours of observation afterwards

Bystrom 1981 - Instrumentation with saline reduces bacterial count (advised use of hypochlorite)

In summary we found that tnechanical instrumentation and irrigation with saline re- duced the ntimber of bacteria in the root canal. In the majority of cases a thorough cleansing of the canal leaves bacteria in the site and the supporting action of disinfectants would be necessary for successful removal of the bacteria from the root canal.

Berggreen E, Bletsa A, Heyeraas KJ.

In the pulp, arteries branch into a capillary network before they leave the pulp as venules through the apical foramina. The tissue has low compliance, as it is enclosed in dentin, and has a relatively high blood flow and blood volume. The interstitial fluid pressure (IFP) and colloid osmotic pressure are relatively high whereas the net driving blood pressure is low. The high pulsatile IFP is probably the major force for propelling lymph in the dental pulp. Vasodilation in neighboring tissue as well as arteriovenous (AV) shunts in the pulp itself can contribute to a fall in total and coronal pulpal blood flow, respectively. The pulp blood flow is under nervous, humoral, and local control. Inflammatory vascular responses, vasodilation, and increased vessel permeability induce an increase in IFP that can be followed by a temporarily impaired blood flow response. Lipopolysaccharides (LPS) from bacteria may cause endothelial activation in the pulp, leading to vasoconstriction and reduced vascular perfusion. Lymphatic vessels are identified with specific lymphatic markers in the pulp but so far, little is known about their function. Because of the special circulatory conditions in the pulp, there are several clinical implications that need to be considered in dental treatment.

thyroid - incidence and prevalence

Incidence and Prevalence Grave's Disease is found in 2% of females and 0.2% of males typically between 20-50 years old. Congenital hypothyroidism is found in 1/4000 newborns and the annual incidence of autoimmune hypothyroidism is 4/1000 in females and 1/1000 in men with a mean age of 60 years old. Subclinical hypothyroidism appears in 6-8% of females and 3% of males. Subacute painful thyroiditis occurs three times more often in females then males. Subacute painless thyroiditis is found in patients with autoimmune thyroid diseases and when it occurs in females 3-6 months after pregnancy, it is referred to as postpartum thyroiditis. Riedel's Thyroiditis refers to a type of chronic thyroiditis and is common in middle-aged women. While thyroid nodules are present in 5% of adults in the United States, 1-5% of solidary thyroid nodules are cancerous.

: Okiji et al.

Inflammation was induced in rat dental pulp by applying bacterial lipopolysaccharide (LPS). Extirpated tissue samples from inflamed pulps were incubated in vitro in a Krebs buffer containing Ca2+ ionophore A23187, and leukotriene (LT) B4 released into the medium was determined by radio-immunoassay. Production of LTB4 could be detected three to 24 h after the application of LPS and showed a maximum at 12 h. Histologically, marked infiltration of neutrophils, but not other leukocytes, was characteristically observed in the LPS-applied pulps, and the temporal change in neutrophil infiltration was almost parallel, but somewhat more delayed than LTB4 production. When BW755C, a dual inhibitor of cyclo-oxygenase and lipoxygenase, was given to the animals before the application of LPS, both the production of LTB4 and the number of infiltrated neutrophils were significantly decreased, whereas administration of indomethacin had no effect. These results suggest that LTB4 may be involved in neutrophil infiltration in pulpal inflammation. It was also suggested that a major early source of LTB4 in experimental pulpitis was leukocytes, primary neutrophils, because the synthesis of LTB4 in the inflammed pulp was diminished by depletion of circulating leukocytes with cyclophosphamide prior to the application of LPS.

diabetes - insulin shock

Insulin shock · A hypoglycemic reaction also may be due to an overdose of insulin or an oral hypoglycemic agent, particularly sulfonylurea drugs. · Mild Stage: The mild stage, which is the most common, is characterized by hunger, weakness, trembling, tachycardia, pallor, and sweating; paresthesia may be noted on occasion. · Moderate Stage: In the moderate stage, because blood glucose drops substantially, the patient becomes incoherent, uncooperative, and sometimes belligerent or resistant to reason or efforts at restraint; judgment and orientation are defective. · Severe Stage: Complete unconsciousness with or without tonic or clonic muscular movements occurs during the severe stage.

Cancer - Introduction

Introduction Cancer refers to the uncontrolled growth of neoplastic cells that invade tissues and metastasize to other parts of the body through the blood and lymph. Malignant cells are derived from mutations, chromosomal translocations, and abnormal expression of factors, which disrupts the regulation of cell division, differentiation, apoptosis and adhesion, allowing uncontrolled proliferation and distribution. 3-6 somatic mutations from exposure to chemicals and pathogens are required for normal cells to turn into malignant cells. Dentists help reduce the risk of cancer through performing cancer screens and educating patients on the risks of smoking and alcohol consumption. They also play a crucial role in helping patients maintain good oral hygiene to minimize complications during chemotherapy, radiation therapy, and marrow and stem cell transplantation.

Tzanetakis

Introduction Elucidating the microbial ecology of endodontic infections (EI) is a necessary step in developing effective intra-canal antimicrobials. The aim of the present study was to investigate the bacterial composition of symptomatic and asymptomatic primary and persistent infections in a Greek population, using high throughput sequencing methods. Methods 16S amplicon pyrosequencing of 48 root canal bacterial samples was conducted and sequencing data were analyzed using an oral microbiome-specific (HOMD) and a generic (Greengenes; GG) database. Bacterial abundance and diversity were examined by EI type (primary or persistent) and statistical analysis was performed by using non-parametric and parametric tests accounting for clustered data. Results Bacteroidetes was the most abundant phylum in both infection groups. Significant, albeit weak associations of bacterial diversity were found, as measured by UniFrac distances with infection type (ANOSIM R=0.087, P=0.005) and symptoms (ANOSIM R=0.055, P=0.047). Persistent infections were significantly enriched for Proteobacteria and Tenericutes as compared to primary ones; at the genus level, significant differences were noted for 14 taxa, including increased enrichment of persistent infections for Lactobacillus, Streptococcus, and Sphingomonas. More but less-abundant phyla were identified using the GG database; among those, Cyanobacteria (0.018%) and Acidobacteria (0.007%) were significantly enriched among persistent infections. Persistent infections showed higher Phylogenetic Diversity (asymptomatic: PD=9.2, [standard error (se)=1.3]; symptomatic: PD=8.2, se=0.7) compared to primary infections (asymptomatic: PD=5.9, se=0.8; symptomatic: PD=7.4 se=1.0). Conclusions The present study revealed a high bacterial diversity of EI and suggests that persistent infections may have more diverse bacterial communities than primary infections.

hypertension - introduction

Introduction Hypertension refers to an elevation of the arterial pressure above a defined normal range. Patients with hypertension are often asymptomatic and if left untreated, can cause damage to the brain, heart, lungs, eyes, kidneys, and vascular system. Recent guidelines categorize blood pressure in adults with readings less than 120 mm Hg systolic blood pressure and less than 80 mm Hg diastolic blood pressure as normal, between 120-139 mm Hg systolic blood pressure and less than 80 diastolic blood pressure as elevated, between 130-139 mm Hg systolic blood pressure or 80-89 mm Hg diastolic blood pressure as stage 1 hypertension, and above 140 mm Hg systolic blood pressure or above 90 mm Hg diastolic blood pressure as stage 2 hypertension. Children are diagnosed with hypertension when their blood pressure falls in the 95th percentile or greater for their age, height, and gender.

pregnant - intro

Introduction: Pregnancy is a unique period during a woman's life and is characterized by complex physiological changes, which may adversely affect oral health. At the same time, oral health is key to overall health and well-being. Preventive, diagnostic, and restorative dental treatment is safe throughout pregnancy and is effective in improving and maintaining oral health. A pregnant patient, although not considered medically compromised, poses a unique set of management considerations for the dentist. Dental care must be rendered to the mother without adversely affecting the developing fetus, and although routine dental care generally is safe for the pregnant patient, the delivery of such care involves some potentially harmful elements, including the use of ionizing radiation and certain drugs. Thus, the prudent practitioner must balance the beneficial aspects of dentistry with potentially harmful procedures by minimizing or avoiding exposure of the patient (and the developing fetus).

Blood Dyscrasias- Introduction

Introduction: · Bleeding disorders are conditions that alter the ability of blood vessels, platelets, and coagulation factors to maintain hemostasis. · Acquired bleeding disorders may occur as the result of diseases, drugs, radiation, or chemotherapy for cancer in which vascular wall integrity, platelet production or function, or coagulation factors are impaired.

Ricucci, Loghin, Siqueira

Introduction: Clinicians routinely face conditions in which they have to decide whether the dental pulp can be saved or not. This study evaluated how reliable the clinical diagnosis of normal pulp/reversible pulpitis (savable pulp) or irreversible pulpitis (nonsavable pulp) is when compared with the histologic diagnosis. Methods: The study material consisted of 95 teeth collected consecutively in a general practice over a 5-year period and extracted for reasons not related to this study. Based on clinical criteria, teeth were categorized as having normal pulps, reversible pulpitis, or irreversible pulpitis. The former 2 were grouped together because they represent similar conditions in terms of prognosis. Teeth were processed for histologic and histobacteriologic analyses, and pulps were categorized as healthy, reversibly inflamed, or irreversibly inflamed according to defined criteria. The number of matching clinical/histologic diagnosis was recorded. Results: The clinical diagnosis of normal pulp/reversible pulpitis matched the histologic diagnosis in 57 of 59 (96.6%) teeth. Correspondence of the clinical and histologic diagnosis of irreversible pulpitis occurred in 27 of 32 (84.4%) cases. Infection advancing to the pulp tissue was a common finding in teeth with irreversible pulpitis but was never observed in normal/reversibly inflamed pulps. Conclusions: Findings using defined criteria for clinical and histologic classification of pulp conditions revealed a good agreement, especially for cases with no disease or reversible disease. This means that the classification of pulp conditions as normal pulps, reversible pulpitis, and irreversible pulpitis has high chances of guiding the correct therapy in the large majority of cases. However, there is still a need for refined and improved means for reliable pulp diagnosis.

Tranasi et al.

Introduction: The dental pulp undergoes age-related changes that could be ascribed to physiological, defensive, or pathological irritant-induced changes. These changes are regulated by pulp cell activity and by a variety of extracellular matrix (ECM) macromolecules, playing important roles in growth regulation, tissue differentiation and organization, formation of calcified tissue, and defense mechanisms and reactions to inflammatory stimuli. The aim of this research was to better understand the genetic changes that underlie the histological modification of the dental pulp in aging. Methods: The gene expression profile of the human dental pulp in young and older subjects was compared by RNA microarray analysis that allowed to simultaneously analyze the expression levels of thousands of genes. Data were statistically analyzed by Significance Analysis of Microarrays (SAM) Ingenuity Pathway Analysis (IPA) software. Semiquantitative and real-time reverse-transcriptase polymerase chain reaction analyses were performed to confirm the results. Results: Microarray analysis revealed several differentially expressed genes that were categorized in growth factors, transcription regulators, apoptosis regulators, and genes of the ECM. The comparison analysis showed a high expression level of the biological functions of cell and tissue differentiation, development, and proliferation and of the immune, lymphatic, and hematologic system in young dental pulp, whereas the pathway of apoptosis was highly expressed in older dental pulp. Conclusions: Expression profile analyses of human dental pulp represent a sensible and useful tool for the study of mechanisms involved in differentiation, growth and aging of human dental pulp in physiological and pathological conditions.

Rodriguez 2017 - instrumentation with saline , retreat

Irrespective of the type of irrigant, an increase in the apical preparation size significantly enhanced root canal disinfection. The disinfecting benefit of NaOCl over saline was significant at large apical preparation sizes

Beeson 1998: ***Board question: which pushes more material out of the apex? Hand vs. rotary instrumentation? Answer: Hand instrumentation pushes more debris out of the apex ***

K-files used to the apical foramen extruded significantly more debris than the other three groups (p < 0.01). The .04 Taper files used 1 mm short extruded less debris than themother groups. Significantly more irrigant was extruded when filing was performed to the apical foramen (p < 0.007), regardless of the technique used. More apical plugs were created in teeth filed short of the apical foramen, but the difference between the two preparation techniques was not statistically significant. It took significantly less time to instrument canals with the .04 Taper system than with K-files

Alternate Pathway:

LPS + C complement activation

hyperthyroidism - lab findings

Laboratory Findings Although hyperthyroidism can be identified with T3, T4, TSH, and TBG tests, TSH serum assays and free T4 concentration measurements are most used. Low TSH and high free T4 concentrations correlate with hyperthyroidism. Low levels of TSH and normal free T4 concentrations along with increased free T3 concentrations also correlate with hyperthyroidism. Patients with TSH-secreting pituitary adenoma and thyroid hormone resistance syndrome may present with normal or increased TSH and free T4 concentrations.

hashimoto - lab finding

Laboratory Findings In the early stage of Hashimoto's Disease, there is an increase in RAIU, anti-TPoAb, anti-TgAb, and TSH levels. During the early stage, Hashimoto's Disease can be confirmed with a fine needle biopsy of the thyroid gland. Later on, T3 and T4 serum levels will decrease while TSH increases.

hypertension - lab findings

Laboratory Findings Lab tests that can be used for patients who are suspected to have hypertension include 12-lead electrocardiogram, urinalysis, blood glucose, hematocrit, and a serum potassium, creatinine, calcium, and lipid profile. If the lab results suggest that there is an underlying condition responsible for the hypertension, additional tests should be ordered.

Blood - Laboratory Testing

Laboratory Testing Several tests are available, each evaluating a different portion of the coagulation cascade. The three tests recommended for screening include activated partial thromboplastin time (aPTT), prothrombin time (PT), and platelet count. Thrombin time can also be utilized if the cause of the bleeding problem is unknown. Partial Thromboplastin Time (PTT) PTT is used to check the intrinsic system (Factors VIII, IX, XI, and XII) and the common pathways (Factor V and X, prothrombin, and fibrinogen). It is the preferred screening test for coagulation disorders. PTT testing involves a phospholipid platelet substitute that is added to a patient's blood which initiate coagulation via the intrinsic pathway. If a contact activator, such as kaolin, is added it is referred to as aPTT. Normal values for aPTT range from 25-35 seconds and results greater than 35 seconds are considered abnormal or prolonged, which correlates with deficiency of Factor VIII and IX by as much as 15-30% below normal values. Prothrombin Time (PT) PT is used to check the extrinsic system (Factor VII) and the common pathways (Factor V and X, prothrombin, and fibrinogen). The PT test involves addition of tissue thromboplastin as an activator to a patient's blood sample which initiates coagulation via the extrinsic pathway. Normal values for PT range from 11-15 seconds until thrombus formation, and times in excess of 15 seconds is considered abnormal and correlates with plasma levels of any factor below 10% of normal values. When PT is used to investigate the levels of anticoagulation with drugs such as warfarin, the International Normalized Ratio (INR) format is recommended as it standardizes PT assays. INR is calculated from the PT result to display standardized results for all patients. This is necessary as standard PT results that are deemed "normal" will vary depending on the brand of thromboplastin and type of instrumentation used. The INR goal ranges from 2-3 for patients taking warfarin and results greater than 3 indicate elevated risk of bleeding. Platelet Count Platelet count screens for bleeding disorders due to thrombocytopenia (low platelet count). The normal range of platelet count is 140,000-400,000/L of blood. Platelet counts in the range of 50,000-100,000/L of blood will manifest excessive bleeding only with severe trauma, of 20,000-50,000/L of blood will manifest skin and mucosa purpura and excessive bleeding only with minor trauma. Platelet counts below 20,000/L of blood may experience spontaneous bleeding. Thrombin Time The TT test utilizes added thrombin as the activating agent to patient's blood sample, which will convert fibrinogen in the blood to insoluble fibrin. This test bypasses both the extrinsic and intrinsic pathways and the majority of the common pathway. The normal range for the TT test ranges from 9-13 seconds, results greater than 16-18 seconds is considered abnormal or prolonged.

Blood 2- lab tests

Laboratory Tests -Test for initial screening: activated partial thromboplastin time (aPTT), prothrombin time (PT), platelet count, and sometimes thrombin time (TT) -With positive results, the hematologist performs further evaluation is needed to identify the specific deficiency and rule out presence of inhibitors to make a diagnosis -With prolonged aPTT, PT, and TT- the defect involves the last stage of the common pathway where fibrinogen is activated to form fibrin and stabilize the clot. The plasma level of fibrinogen can be determined, and fibrinolysis tests are performed

thyroid - lab tests

Laboratory Tests Tests used to evaluate thyroid function involve radioactive iodine, commonly measuring the thyroid radioactive iodine uptake (RAIU). 123I is commonly used as opposed to 131I because it emits a lower radiation dose. The RAIU is measured 24 hours after the isotopes are administered, which is inversely proportional to the plasma iodine concentration and proportional to the status of thyroid function. The average RAIU in the United States is 10-30% with higher percentages suggesting thyroid hyperfunction. Radioimmunoassay measures T3 and T4 concentrations with the normal T4 concentration ranging between 64-154 nmol/L and the normal T3 concentration ranging between 1.2-2.9 nmol/L. Concentrations higher than the normal suggest hyperthyroidism and concentrations lower than normal suggest hypothyroidism. Immunoradiometric and chemiluminescent techniques measure serum TSH with normal TSH ranges between 0.5-4.5 mIU/L. Low levels of TSH suggest hyperthyroidism, while higher TSH levels suggest hypothyroidism. Thyroid nodules and functional ectopic thyroid tissues can be identified with various methods depending on their size. Nodules that are 1 cm or larger can be identified with thyroid scans that involves the injection of 123I or 99T c and localization with a scanner. In cases where the nodules are 2-3 mm, a pinhole thyroid scan can be used to localize the lesion. Ultrasonography can be utilized to localize nodules 1-2 mm, differentiate solid lesions from cystic ones, measure glands, and aid in aspirations and biopsies. CT and MRIs are used to evaluate lesions that are greater than 3 cm and extends to adjacent tissues.

hyperthyroidism - management of thyrotoxic crisis

Management of Thyrotoxic Crisis Thyrotoxic crisis occurs in patients with untreated thyrotoxicosis. Patients usually have goiters, wide pulse pressures, eye symptoms, and a history of thyrotoxicosis. Early symptoms include restlessness, vomiting, nausea, and abdominal pain, followed by fever, sweating, tachycardia, pulmonary edema, arrhythmias, and congestive heart failure. If left untreated, patients will enter a stupor and coma, followed by severe hypotension and then death. Patients experiencing a thyrotoxic crisis are treated with antithyroid drugs, potassium iodide, propranolol, hydrocortisone, dexamethasone, IV glucose, vitamin B complex, and ice packs. In severe cases, CPR may be required.

Blood - Management Strategies

Management strategies: Local Hemostasis Control Many patients with increased bleeding risk can be managed interoperatively using local hemostasis control techniques. For normal bleeding, the blood clot is allowed to form under firm and direct sustained pressure using gauze for several minutes, followed by suturing (ideally with primary closure), if needed. In the event of excessive bleeding, several strategies exist to manage the bleeding depending on the situation. The use of local anesthetic containing epinephrine can aid in hemostasis of the wound due to capillary vasoconstrictions from the epinephrine binding adrenergic receptors. Depending on the situation the following strategies may prove appropriate including: 1) using mechanical means such as burnishing bone or bone wax, 2) chemical agents including topical epinephrine or ferric sulfate, 3) biological agents including topical thrombin, or 4) resorbable agents such as calcium sulfate, Gelfoam (gelatin based), absorbable collagen, microfibrillar collagen, or surgical (regenerated cellulose) may be appropriate. Collagen based materials activate platelet adhesion and aggregation upon contact with the collagen, and activation of Factor XII (Hageman factor). Clotting agents such as fibrin sealants can also be beneficial as it provides a framework for platelet adhesion and aggregation, and activation of clotting pathways. Use of antifibrinolytic agents such as tranexamic acid and -aminocaproic acid prevent plasminogen activation to plasmin (competitive inhibition), thereby preventing existing clot breakdown thus decreasing bleeding. For severe, uncontrolled bleeding, transfusion of six units of platelets (if available), is warranted. Patients on Cox Inhibitors and ADP Receptor Inhibitors No adjustment is needed for healthy patients, no adjustment for patients taking COX inhibitors, avoid prescribing patients medications that would increase bleeding risk through adverse drug reactions (e.g. steroids). Control bleeding using local measures. Hold NSAIDs or Plavix for 3-7 days (life of a platelet) if normalization of platelet function is needed. If medication is held, restart as soon as possible. Patients on Heparins LMWH patients require consult with the patient's physician as only hospitalized patients are typically on IV heparins. If needed, the antidote is protamine sulfate. If medication is held, restart as soon as possible. Patients on Direct acting Oral Anticoagulants DOACs - avoid procedure during peak plasma levels (1-3 hours after DOAC), advise patient to not take their medication 1-3 hours prior to the procedure. No need to hold DOAC for low risk procedure include SRP, apex resection, flap surgery, alveoloplasty. Hold DOAC for 12 hours if surgical procedures are high bleeding risk. If medication is held, restart as soon as possible. If needed, the antidote for Pradaxa is Idarucizumab (Praxbind), and for Xarelto, Eliquis, and Savaysa the antidote is Andexenet. Patients on Warfarin (Coumadin) Warfarin (Coumadin) treatment entails an INR goal of 2-3, As long as INR is less than 3, warfarin regimen can be continued prior to the procedure with any bleeding events controlled using local measures. May consider INR less than 4 as upper limit for simple oral surgery procedures, and INR less than 3 for high bleeding risk procedures (multiple extractions with alveoloplasty, etc.). INR should be taken within 1 week of procedure and if greater than 4 than postpone treatment until INR is less than 3. INR results within a week are acceptable if patient condition is stable. For major surgeries or unstable hemostasis control, INR should be performed the day of surgery. Drugs interactions should be kept in mind so as to not worsen patients bleeding risk. Warfarin drug interactions include antibiotics (ciprofloxacin (Cipro), metronidazole (Flagyl), sulfamethoxazole/trimethoprim (Bactrim)), amiodarone, digoxin, NSAIDs, azole antifungals (fluconazole), and corticosteroids. Patients with Thrombocytopenia: Patients found to have severe thrombocytopenia may require hospitalization and special preparation for surgery. A hematologist should be involved with the diagnosis, presurgical assessment, preparation, and postsurgical management of these patients. Infiltration and block injections of local anesthesia can be provided in patients with platelet counts above 30,000/µL. Also, most routine dental procedures can be performed. If the platelet count is below this level, routine dental treatment involving minor tissue injury should be delayed. For urgent or emergency dental needs, platelet replacement is indicated. If the platelet count is above 50,000/µL, extractions and dentoalveolar surgery can be performed. For more advanced surgery, the platelet count should be 80,000/µL and 100,000/µL or higher. Patients with platelet counts below these levels will need platelet replacement before undergoing the planned procedures.

diabetes - lab findings

Laboratory findings · The diagnostic criteria for diabetes rely on the plasma glucose level, either (1) at a random sampling, (2) after fasting, or (3) after a 75-g glucose test (oral glucose tolerance test, OGGT). · The primary diagnostic criterion for impaired fasting glucose is fasting plasma glucose levels of 100 to 125 mg/dL and for impaired glucose tolerance (IGT) is 140 to 199 mg/dL at 2 hours in the OGTT. · Blood glucose determination: measures levels of glucose in blood. · Oral glucose tolerance test: reflects how quickly glucose is cleared from the blood. The most characteristic alterations seen in diabetes are an increased fasting blood glucose (126 mg/100 mL or higher), an increased peak value (200 mg/100 mL or higher), and a delayed return to normal in the 2-hour sample. · Glycohemoglobin: The extent of glycosylation of hemoglobin A (a nonenzymatic addition of glucose) that results in formation of HbA1c (i.e., glycated hemoglobin) in red blood cells is used to detect and assess the long-term level (and control) of hyperglycemia in patients with diabetes. In health, patients should have HbA1c levels less than 6%. In well-controlled diabetes, the level should stay below 7%, without the occurrence of clinically significant hypoglycemia. Measured twice a year for well controlled and 4 times if goal not met. Urinary Glucose and Acetone. Determination of urinary glucose and acetone is of limited value in detecting overt diabetes

Warfvinge et al.

Lipopolysaccharides (LPS) from Bacteroides oralis and Veillonella parvula and cell wall material from Lactobacillus casei were studied for their capacity to induce leukocyte migration in the dental pulp and in an implanted wound chamber. Three adult monkeys were challenged using lyophilized material sealed into buccal Class V cavities prepared in dentin. Pulp tissue responses were observed histologically eight and 72 hours after initiation of the experiment. Subjacent to cut dentinal tubules, bacterial materials induced polymorphonuclear leukocyte (PMN's) infiltration in the pulp tissue of the majority of test teeth examined. Responses were similar for the three bacterial test materials at both time periods. Topical applications of bovine serum albumin (BSA), used as a control, induced significantly less accumulation of PMN's. Assessments of induced exudate volumes and leukocyte densities in chambers implanted in rats showed comparable rankings with pulpal experiment between test (i.e., bacterial) and control (BSA) materials. Analysis of the data indicates that high-molecular-weight complexes of bacterial cell walls may adversely affect pulpal tissue across freshly exposed dentin.

Sveen K (1980)

Lipopolysaccharides (LPS) isolated from oral strains of Veillonella, Fusobacterium and Bacteroides stimulated the release of ""^Ca from prelabeled fetal rat bones in culture. There was a typical dose-response relationship between the quantities of released ''^Ca and LPS used for stimulation. Bacteroides-LPS proved £o be the less active inducer of *^Ca release. LPS had no stimulating effect on the release of *^Ga from devitalized bone. The stimulated *^Ca release was paralleled by an increase in the cukpre medium of hydroxyproline and lactate. This, together with tlie ftndings of numerous osteociastsin stained histological specimens ofthe experimental bomes, indicates that LPS stimulated the osteoclasts to bone resorption. Heparin, which did not directly induce *^Ca release, potentiated the bone resorption stimulating capability of LPS. The hpid A and the polysaccharide portion of Fusobacterium LPS also stimulated bone resorption and, remarkably, the polysaccharide portion showed the greatest activity. This may explain the mode of action of LPS lacking a typical hpid A. It is suggested that stimuladon of osteociasts by LPS may result from activation of complement components by lipid A or its polysaccharide portion.

Dahlen

Lipopolysaccharides (LPS) prepared from one strain of Fusobacterium nucleatum and one strain of Bacteroides oralis were examined for immunological responses in rats. The LPS were applied to the pulp chamber of the two mandibular incisors. Using the plaque forming cell (PFC) method both antigens showed a rapid IgM response in the spleen, and a slower one in the submandibular lymph nodes. In comparison with the IgM response, the IgG response was somewhat slower and weaker for LPS of Bacteroides, while for LPS of Fusobacterium it was hardly detectable. After about 3 weeks both antigens gave a significant antibody titer in serum. The results showed that locally applied antigens of oral microorganisms can stimulate to an immune response both in the lymph nodes and the spleen resulting in circulating antibodies. The nature of this response is dependent on the chemical characteristics of the LPS-antigen.

Chung et al

Little is known about the molecular mechanisms that cause excitation of neurons which innervate the teeth. We investigated whether rat dental sensory neurons express the vanilloid (capsaicin) receptor (VR1). Dental sensory neurons were identified by retrograde transport of the fluorescent dye DiIC18 placed in maxillary molars. Patch-clamp recordings in culture showed that 65% of DiIC18-labeled rat trigeminal ganglion neurons are excited by capsaicin. Responders covered the entire range of cell sizes examined (soma diameter, 24 to 48 microm). All non-responders had a soma diameter > 33 microm. Capsazepine (1 microM) reduced the capsaicin-evoked membrane current (6/6) and depolarization (7/7 responders). RT-PCR amplified a 375-bp product from DiIC18-labeled neurons which was identical to that expected for VR1. Thus, many rat dental primary afferent neurons are excited by capsaicin, and the response appears to be mediated by VR1. These results suggest that pharmacological blockers of VR1 may provide significant relief of dental pain.

Longwill, D. Marshall, F. , Creamer, H.

Lymphocyte transformation induced by Formocresol-treated and untreated extracts of homologous pulp tissue was evaluated in groups of children who differed in past experience with Formocresol pulpotomies. Significant transformation responses were observed in studies of 25 of the 40 children. Neither the ability to respond nor the level of lymphocyte response to the pulp extracts was related to a clinical history of Formocresol pulpotomy. Sensitization to pulp-related antigens was a common finding in this study and was moderately well correlated with indexes of past and current dental disease.

Adachi T,

Marked infiltration of inflammatory cells, such as activated T-cells, is observed in the progression of pulpitis; however, little is known about the mechanism of their recruitment into pulpal lesions. It has been recently demonstrated that CXC chemokine ligand 10 (CXCL10) chemoattracts CXC chemokine receptor 3 (CXCR3)-positive activated T-cells. We therefore examined whether CXCL10 is involved in the pathogenesis of pulpitis. CXCL10 mRNA expression levels in clinically inflamed dental pulp were higher than those in healthy dental pulp. Immunostaining results revealed that CXCL10 was detected in macrophages, endothelial cells, and fibroblasts in inflamed dental pulp, and that CXCR3 expression was observed mainly on T-cells. Moreover, cultured dental pulp fibroblasts produced CXCL10 after stimulation with live caries-related bacteria, peptidoglycans, and pro-inflammatory cytokines. In contrast, heat-killed bacteria did not induce CXCL10 secretion. These findings suggest that CXCL10-CXCR3 may play an important role in the pulpal immune response to caries-related bacterial invasion.

Mechanical trauma, heat energy, UV radiation, bacterial toxins, complement system, proteolytic enzymes, allergens

Mast cells/basophils/platelets histamines endothelial cell contraction, intercellular gap, increase cellular permeability

Yeon et al

Mechanical allodynia is a common symptom found in neuropathic patients. Hyperpolarization-activated cyclic nucleotide-gated channels and their current, I(h), have been suggested to play an important role in neuropathic pain, especially in mechanical allodynia and spontaneous pain, by involvement in spontaneous ectopic discharges after peripheral nerve injury. Thus, I(h) blockers may hold therapeutic potential for the intervention of mechanical allodynia under diverse neuropathic conditions. Here we show that eugenol blocks I(h) and abolishes mechanical allodynia in the trigeminal system. Eugenol produced robust inhibition of I(h) with IC(50) of 157 μM in trigeminal ganglion (TG) neurons, which is lower than the dose of eugenol that inhibits voltage-gated Na channels. Eugenol-induced I(h) inhibition was not mediated by G(i/o)-protein activation, but was gradually diminished by an increase in intracellular cAMP concentration. Eugenol also inhibited I(h) from injured TG neurons which were identified by retrograde labeling with DiI and reversed mechanical allodynia in the orofacial area after chronic constriction injury of infraorbital nerve. We propose that eugenol could be potentially useful for reversing mechanical allodynia in neuropathic pain patients.

Won et al.

Mechanosensitive ion channels have been suggested to be expressed in dental primary afferent (DPA) neurons to transduce the movement of dentinal fluid since the proposal of hydrodynamic theory. Piezo2, a mechanosensitive, rapidly inactivating (RI) ion channel, has been recently identified in dorsal root ganglion (DRG) neurons to mediate tactile transduction. Here, we examined the expression of Piezo2 in DPA neurons by in situ hybridization, single-cell reverse transcriptase polymerase chain reaction, and whole-cell patch-clamp recordings. DPA neurons with Piezo2 messenger RNA (mRNA) or Piezo2-like currents were further characterized based on their neurochemical and electrophysiological properties. Piezo2 mRNA was found mostly in medium- to large-sized DPA neurons, with the majority of these neurons also positive for Nav1.8, CGRP, and NF200, whereas only a minor population was positive for IB4 and peripherin. Whole-cell patch-clamp recordings revealed Piezo2-like, RI currents evoked by mechanical stimulation in a subpopulation of DPA neurons. RI currents were pharmacologically blocked by ruthenium red, a compound known to block Piezo2, and were also reduced by small interfering RNA-mediated Piezo2 knockdown. Piezo2-like currents were observed almost exclusively in IB4-negative DPA neurons, with the current amplitude larger in capsaicin-insensitive DPA neurons than the capsaicin-sensitive population. Our findings show that subpopulation of DPA neurons is indeed mechanically sensitive. Within this subpopulation of mechanosensitive DPA neurons, we have identified the Piezo2 ion channel as a potential transducer for mechanical stimuli, contributing to RI inward currents. Piezo2-positive DPA neurons were characterized as medium- to large-sized neurons with myelinated A-fibers, containing nociceptive peptidergic neurotransmitters.

Goodis et al

Mediators produced during inflammation are responsible for hyperalgesia and expression of neurotransmitters and receptors in the nervous system. The production of bradykinin (BK) and the prostaglandins (PGs) may regulate initiation of pain. This study tested the hypothesis that BK and prostaglandin E2 (PGE2) have a positive interaction in evoking neurosecretion of immunoreactive calcitonin gene-related peptide (iCGRP). Bovine dental pulp was prepared and stimulated by the superfusion method with BK alone and in combination with PGE2. Kinin receptor antagonists to bradykinin-evoked release of iCGRP were also tested. Also tested was the hypothesis that dental pulp contains cither the B, or B2 or both BK receptors. Results showed that PGE2 enhanced BK-evoked iCGRP release by more than 50%. Western immunoblots revealed detectable B, receptor protein with no detectable B1 receptor protein. We conclude that BK evokes iCGRP release from bovine dental pulp which is enhanced by a positive interaction with PGE2. Neurosecretion is evoked from isolated terminals of dental pulp fibers via the bradykinin B2 receptor-dependent mechanism.

epilepsy - medical mangement

Medical management: Usually based on long-term drug therapy. Phenytoin (Dilantin), carbamazepine, and valproic acid are considered first-line agents. Adverse effects of Phenytoin: anemia, ataxia, gingival overgrowth, cosmetic changes (coarsening of facial features, hirsutism, facial acne), lethargy, skin rash, and gastrointestinal disturbances. Adverse effects are more common at start of therapy. These drugs reduced the frequency of seizures by elevating the seizure threshold of motor cortex neurons, depressing abnormal cerebral electrical discharge, and limiting the spread of excitation from abnormal foci. Other antiepileptic drugs augment GABA, which inhibits glutamate activity (the major determinant of brain excitability). Drug therapy usually is continued in children until a 1 to 2-year seizure-free period is attained or until around age 16. If medication is ineffective, vagus nerve stimulation is attempted before surgical intervention/brain surgery. VNS acts like a pacemaker by delivering electrical signals to the left vagus nerve which provides direct projection to regions in the brain potentially responsible for the seizure.

thyroid - medical considerations

Medical Considerations A. Thyrotoxicosis Dentists play an important role in identifying clinical symptoms of undiagnosed thyrotoxicosis and referring these patients to their physicians for evaluation and treatment. Symptoms to keep in mind include restlessness, fever, tachycardia, pulmonary edema, tremors, and swelling. Patients with untreated thyrotoxicosis are at risk of a thyrotoxic crisis when they undergo dental surgery. In cases when a crisis happens, emergency treatment and calling for medical assistance should be done immediately. If available, cold towels, 100-300 mg of hydrocortisone, antithyroid drugs, potassium iodine, and IV hypertonic glucose can be utilized. Dentists should monitor the patient's vital signs and be prepared to perform CPR if necessary. Epinephrine and pressor amines found in local anesthetics and gingival retraction cords should not be used in patients with untreated thyrotoxicosis. Patients with well-controlled thyrotoxicosis but are taking nonselective beta blockers may experience an increase in blood pressure if they are given epinephrine due to the blockage of B2-receptors, that in turn inhibits the vasodilatory effect of epinephrine. Patients treated with propylthiouracil can develop agranulocytosis and leukopenia, causing them to be at risk for serious infections. Prior to performing dental surgery, dentists should consult with the patient's physician and obtain a complete blood count to avoid complications during the treatment. Propylthiouracil is also found to enhance warfarin's anticoagulation effect. Aspirin and NSAIDs can complicate the management of thyroid disease as they increase the amount of T4. After thyrotoxicosis is well managed, patients can undergo dental treatments without any modifications but should be referred to their physician if an acute oral infection forms. B. Hypothyroidism Patients with hypothyroidism may have an enhanced reaction to CNS depressants, sedatives, and narcotic analgesics. These drugs should not be given to patients who have severe hypothyroidism and should be used with caution at reduced dosages in patients with mild hypothyroidism. CNS depressants, surgeries, and infections can induce a myxedematous coma. In cases when myxedema comas occur, dentists should seek medical aid, provide 100-300 mg of hydrocortisone, conserve the patient's heat, and perform CPR. C. Thyroid Cancer Dentists should palpate the thyroid gland during their head and neck examines to identify thyroid enlargements even when patients appear to have normal thyroid function. If thyroid enlargements are identified, the patients should be referred to their physician for evaluation prior to dental treatment. Diffused thyroid enlargements may be an indicator of a simple goiter, subacute thyroiditis, and chronic thyroiditis in hyperthyroid, hypothyroid, or euthyroid patients. Adenomas and carcinomas can present as isolated nodules, multinodular, and diffused enlarged glands.

hypothyroidism - medical management

Medical Management Hypothyroidism can be treated with sodium levothyroxine (LT4) and sodium liothyronine (LT3). Patients taking oral anticoagulants and treated with T4 are at risk of hemorrhage due to the prolongation of prothrombin time. When diabetic patients with decreased need for insulin or sulfonylureas are treated with T4, they are at risk of hyperglycemia. Levothyroxine can be used to treat patients with severe myxedema that experience congestive heart failure. If hypothyroidism remains untreated, patients will be more sensitive to narcotics, barbiturates, and tranquilizers. These patients can experience a hypothyroid coma as a result of stressful stimuli such as cold, operations, infections, and trauma. Hypothyroid coma presents with myxedema, bradycardia, and severe hypotension, commonly treated with parenteral levothyroxine (T4) and steroids.

hyperthyroidism - medical management

Medical Management Treatment options for patients with hyperthyroidism include antithyroid agents that inhibit hormone production, iodides, radioactive iodine, or subtotal thyroidectomy. Common antithyroid agents include propylthiouracil and methimazole. These agents block thyroid peroxidase function and thyroid hormone synthesis. Propylthiocuracil has an additional function of inhibiting the extrathyroidal deiodination of T4 to T3 and is the drug of choice in North America. Antithyroid agents are commonly used for 18 months and may lead to mild leukopenia. If patients experience sore throat, fever, or mouth ulcers, they should be referred to their PCP for a white blood cell count. If white blood cell counts become severely low, treatment via antithyroid agents may be stopped. Antithyroid drugs are recommended in patients below the age of 50 for their first Graves' Disease episode and radioactive iodine is recommended for patients older than 50 years old. Radioactive iodine is contraindicated in patients that are pregnant and breast feeding. It has been found to accentuate ophthalmopathy, especially in smokers. Patients undergoing radioactive iodine treatment may experience hypothyroidism and have an increased risk of thyroid cancer. Those with severe hyperthyroidism are treated with antithyroid drugs for 4-8 weeks prior to radioactive iodine treatment to decrease the risk of a thyrotoxic crisis. Patients that have large goiters with thyroid nodules of unknown etiology are treated with subtotal thyroidectomy. These patients are initially treated with antithyroid drug and then inorganic iodine is given 7 days prior to surgery. Propranolol can be used to treat adrenergic symptoms like sweating, tachycardia, and tremors.

Blood 2 - medical considerations

Medical considerations Surgical procedures should be deferred on patients who have a suspected bleeding problem and referred to a hematologist. Patients under medical care who may have a bleeding problem should only receive dental treatment after consultation with the physician and appropriate preparations have been made to avoid excessive bleeding during the procedure.

epilepsy - medical considerations

Medical considerations: First step to identify if a patient has the disorder. Learn as much as possible about the seizure history, including type of seizures, age at onset, cause (if known), current and regular use of medications , frequency of physician visits, quality of seizure control, frequency of seizures, date of last seizure, and any known precipitating factors. History of previous injuries associated with seizures and their treatment may be helpful. Most epileptic patients are able to attain good control of their seizures with anticonvulsant drugs. If history reveals a degree of seizure activity that suggests noncompliance or a severe seizure disorder that does not respond to anticonvulsants, a consultation with a physician is advised prior to dental treatment. Phenytoin, carbamazepine, and valproic acid can cause bone marrow suppression, leukopenia, and thrombocytopenia resulting in an increased incidence of microbial infection, delayed healing, and gingival and postoperative bleeding. Valproic acid can decrease platelet aggregation leading to spontaneous hemorrhage and petechiae. Propoxyphene and erythromycin should not be administered to patients taking carbamazepine because of interference with metabolism of carbamazepine which could lead to toxic levels of the anticonvulsant drug. Aspirin and other nonsteroidal antiinflammatory drugs (NSAIDS) should not be administered to patients who are taking valproic acid, because these agents can further decrease platelet aggregation, leading to hemorrhagic episodes. No contraindication has been identified to the use of local anesthetics in proper amounts. Patients with a VNS device implanted in their chest do not need antibiotic prophylaxis prior to treatment.

Jacinto RC, Gomes BPFA, Ferras CCR, Zaia AA, Souza Filho FJ

Microbial samples were taken from 48 root canals, 29 symptomatic and 19 asymptomatic using adequate techniques 218 cultivable isolates were recovered from 48 different microbial species and 19 different genera. Root canals from symptomatic teeth harbored more obligate anaerobes and a bigger number of bacterial species than the asymptomatic teeth. More than 70% of the bacterial isolates were strict anaerobes. Relationships were found between specific microorganisms, especially gram-negative anaerobes, and the presence of spontaneous or previous pain, tenderness to percussion, pain on palpation, and swelling amoxicillin, amoxicillin and clavulantate and cephaclor were effective against all the strains tested. The lowest susceptibility rate was presented by prevotella intermedia/migrescens against penicillin G. Our results suggested that specific bacteria re associated with endodontic symptoms of infected teeth with periapical periodontitis and the majority of the anaerobic bacterial species tested were susceptible to all antibiotic studied

Pashley et al.

Most authorities agree that the hydrodynamic theory of dentine sensitivity best explains the stimulus-response relations of most painful stimuli. However, as the usual hydrodynamic stimuli are so different, it has been impossible to compare them. The equivalency of hydrodynamic stimuli can be evaluated from measurements of the fluid movement induced in vitro and relating this to the hydraulic conductance (Lp) of the same dentine specimen. From this determination, a common denominator is obtained which is equivalent to the hydrostatic pressure that would be required to cause the same magnitude of fluid movement. The purpose of this study was to measure the direction and magnitude of fluid shifts across dentine in extracted human crown segments with a flat, dentine occlusal surface in response to the following hydrodynamic stimuli; air blast, 56 degrees C water, 2 degrees C water, tactile and osmotic. In acid-etched superficial dentine, which simulates hypersensitive dentine, the largest to the smallest fluid flows obtained were: hot > cold > air blast > osmotic > tactile. When these were converted to equivalency units, the ranking of stimuli from strongest to weakest was hot > cold > air blast > osmotic > tactile. This new approach to comparing hydrodynamic stimuli should be verified in vivo.

Endodontic Considerations for Diabetic Patients

Much has been written and studied in regards to the effect diabetes has on patients undergoing endodontic therapy. Cases of poorly controlled diabetes exhibited PA radiolucencies that developed during treatment. However, diabetes considered to be under control showed periapical lesions to heal as readily as those in non-diabetics (Bender, 1963). A study by Cheraskin in 1968 monitored radiographic healing of periradicular lesions in 12 patients with low plasma glucose and 13 patients with high plasma glucose. At an assessment after 30 weeks, the low glucose group saw a reduction in radiolucency size by 74%, compared to 48% for the high glucose group. The periodontal disease of diabetics has been well documented, and evidence suggests that patients with diabetes have increased periodontal disease with root-filled teeth, reducing the likelihood of success of RCT in cases with preoperative periradicular lesions (Fouad, 2003.) There is an increased prevalence of apical periodontitis in untreated teeth of Type 2 diabetic patients (Marotta et al 2012). This same study found no significant differences between success rates of endodontically treated teeth in diabetics (54%) compared with non-diabetics (62%), though this data is limited as the nature of cross-sectional studies such as this time since treatment was rendered is unknown. [Radiographic study, 60 patients with status of diabetics not stated] Well-controlled Type 2 diabetic patients have a higher prevalence of apical periodontitis (OR = 3.9) and are more likely to have endodontically treated teeth (OR = 2.3) (Lopez-Lopez et al 2011). There was no statistically significant difference of incidence of persistent apical periodontitis in previously endodontically treated teeth (though 46% of diabetics had AP on endodontically treated teeth and only 24% in non-diabetics, this was not statistically significant). [Radiographic study, 50 well-controlled diabetics] Men with type 2 diabetes have with RCTs completed have been shown to have a higher likelihood of residual lesions (Britto, 2003), while diabetics displayed apical periodontitis in 81.3% of individuals, while this was the case in 58% of control subjects, with 7% of teeth in diabetic patients having AP compared to 4% of control subject teeth (Segura 2005). According to Doyle et al, diabetes was associated with the outcome of NSRCT with borderline significance (Doyle, 2007). Additionally, diabetes has been shown to be a significant risk factor for tooth extraction following NSRCT (Wang, 2011) and diabetics have been shown to have a higher prevalence of teeth with previous NSRCT completed compared to healthy nondiabetic patients (Cabanillas-Balsera). Bearing this in mind, we as endodontists should be mindful not only of the challenges diabetic patients may present from a medical management standpoint, but also the challenges they present in our goals of carrying out successful endodontic therapy.

pregnancy - physiology

OVERVIEW OF PREGNANCY Physiology : The storm of hormones which is induced during pregnancy causes changes in the mother's body and the oral cavity is no exception. An increase in the secretion of the female sex hormones, estrogen by 10-fold and progesterone by 30-fold, is important for the normal progression of a pregnancy. The increased hormonal secretion and the fetal growth induce several systemic, as well as local physiologic and physical changes in a pregnant woman. The main systemic changes occur in the cardiovascular, haematologic, respiratory, renal, gastrointestinal, endocrine, and genitourinary systems. The local physical changes occur in different parts of the body, which include the oral cavity.

: Killough et al.

Neurogenic inflammation describes the local release of neuropeptides, notably substance P (SP), from afferent neurons and might play a role in the pathogenesis of pulpal disease. The fibroblast is the most numerous cell type in the dental pulp, and recent work has suggested that it is involved in the inflammatory response. Primary pulp fibroblast cell populations were isolated by enzymatic digestion. Whole pulp tissue was obtained from freshly extracted sound (n = 35) and carious (n = 39) teeth. Expression of SP and neurokinin-1 receptor (NK-1) mRNA by pulp fibroblasts was determined by reverse transcriptase polymerase chain reaction (RT-PCR). SP was expressed by pulpal fibroblasts at both mRNA and protein levels. In addition, NK-1 mRNA and protein expression was detected in fibroblast cultures by RT-PCR and Western blotting, respectively. SP levels, determined by radioimmunoassay, were significantly greater (P < .05) in carious compared with sound teeth. These findings suggest that pulp fibroblasts play a role in neurogenic inflammation in pulpal disease.

: Rahemtulla et al.

Newly synthesized proteoglycans of rat incisors were labelled in vivo for 6h with [35S]-sulphate in order to facilitate their detection during purification and characterization. Proteoglycans were extracted from non-mineralized portions (predentine) of rat incisors with 4M-guanidinium chloride and subsequently from dentine by demineralization with a 0.4M-EDTA solution containing 4M-guanidinium chloride. Both extractions were performed at 4 degrees C in the presence of proteinase inhibitors. Purification of proteoglycans was achieved with a procedure involving gel-filtration chromatography, selective precipitation of phosphoproteins, affinity chromatography and ion-exchange chromatography. Two proteoglycan populations were found in the initial extract (Pd-PG I and Pd-PG II), whereas only one fraction (D-PG) was obtained after demineralization. The minor proteoglycan fraction from the first extract, Pd-PG I, although not totally characterized, differed sharply from the other proteoglycans in that it had a larger molecular size with larger glycosaminoglycan chains composed of chondroitin 4- and 6-sulphate isomers. In contrast, the major proteoglycans Pd-PG II and D-PG had smaller hydrodynamic sizes with smaller glycosaminoglycan chains (but larger than those from bovine nasal cartilage proteoglycans) composed exclusively of chondroitin 4-sulphate. The major proteoglycans were incapable of interacting with hyaluronic acid. In general, the amino acid compositions of the major proteoglycans of rat incisors resembled that of bovine nasal cartilage proteoglycans, but the former had lower proline, valine, isoleucine, leucine, and higher aspartic acid, contents.

: Iqbal M.,

Nine hundred fifty-one emergency and 997 nonemergency patients seeking endodontic treatment were the basis of this study. Variables of interest were 10 pain descriptors, percussion and palpation tests, causative factors, and paired pulpal and periapical diagnoses. A higher number of patients suffering from symptomatic pulpal conditions sought emergency care. Odds of caries being a causative factor were high in symptomatic pulps compared with asymptomatic pulpal and periapical conditions. Higher odds ratios were obtained for sharp pain in symptomatic pulps versus symptomatic periapical conditions. Conversely, odds ratios for dull pain were higher in symptomatic periapical conditions compared with asymptomatic periapical conditions. Percussion and palpation tests were significant in differentially diagnosing between pulpal and periapical conditions. In conclusion, caries was associated with painful pulpitis. The results confirm the differential diagnostic power of sharp and dull pain and percussion and palpation tests. Several symptoms previously believed to have differential diagnostic power were found insignificant.

Sol Bernick

Noncarious teeth obtained from individuals 15 to 50 years of age were used to study the lymphatic drainage of the human pulp. Thick sections (50 to 150 microns) were stained with iron hematoxylin for the demonstration of lymph and blood vessels. Lymph capillaries originated as blind sacs in the odontoblastic layer and in the pulp proper near the pulpo-odontoblastic border. They drained into small thin-walled collecting vessels that were irregular in shape and showed great variability in their drainage patterns. Communications between these vessels were very common. The larger conducting lymphatic vessels accompanied the blood vessels and nerves in their course through the pulp. They could be identified by their thin walls and small size. The large caliber lymphatic vessels contained valves, a structure not present in the veins of the same size. The conducting lymphatic vessels passed through the roots as individual units without draining into a large single vessel. The lymphatic vessels of the human pulp must be considered as a pathway for the removal of excessive tissue fluid in normal and diseased pulps.

Takada

Normal human gingival fibroblasts stimulated in vitro by lipopolysaccharides (LPS) from oral Bacteroides species produced ceUl-free and cell-associated thymocyte-activating factors (TAF). Neutralization assays using antisera to human interleukin-la (HuIL-la), HuIL-l0, and HuIL-6 revealed that ceUl-free TAF was attributable mainly to IL-1" and that IL-6 augmented the TAF activity of IL-1" in the culture supernatant. Another factor(s), however, may also be involved in cell-free TAF. By contrast, the active entity of cell-associated TAF was ascribed to IL-la alone. Furthermore, IL-6 was detected mainly in the supernatant of fibroblast cultures stimulated with Bacteroides LPS. Fibroblasts pretreated with natural human beta or gamma interferon, but not those pretreated with alpha interferon, synthesized higher levels of cell-associated IL-la in response to stimulation by Bacteroides LPS; however, no interferons exhibited direct IL-i-inducing activity or synergistic IL-i-inducing activity with LPS. Endogenously induced beta interferon was suggested to be necessary for fibroblasts to produce cell-associated IL-la in response to Bacteroides LPS.

Huang et al

Objective: Elevated levels of interleukin-8, a potent chemoattractant and activator of neutrophils, are associated with infectious and inflammatory diseases. However, little is known about interleukin-8 expression in human dental pulp. The purpose of this study was to determine whether tissue levels of interleukin-8 are elevated in irreversibly inflamed human pulps. Study design: Experimental samples were from teeth clinically diagnosed with irreversible pulpitis (diseased pulps). Controls were from freshly extracted, caries-free third molars (normal pulps). Samples were subjected to enzyme-linked immunosorbent assay and/or immunohistochemical analysis with specific antibodies to interleukin-8. Results: The enzyme-linked immunosorbent assay studies showed elevated levels of interleukin-8 in diseased pulps (mean, 1.82+/-0.79 pg/mL/microg protein), as compared to detectable interleukin-8 levels in samples from normal pulps (mean, 0.08+/-0.04 pg/mL/microg protein; P<.05). Immunohistochemical analyses demonstrated that diseased samples exhibited a higher density of localized interleukin-8 staining in areas with heavy infiltration of inflammatory cells. In contrast, normal pulps showed negative or weak interleukin-8 staining. Conclusions: Interleukin-8 concentration was higher in pulps diagnosed with irreversible pulpitis; only negligible amounts of interleukin-8 were present in normal pulps.

Chugal et al.

Objective: Many biological variables, endodontic treatment factors, and restorative considerations have been suggested in the literature to affect the outcome of endodontic treatment. However, few attempts have been made recently to study these variables further. The purpose of this study was to identify the biologic and endodontic treatment-associated variables that are most predictive of treatment outcome for conventional endodontic therapy and to determine the magnitude of risk these variables pose on the outcome. Study design: The population of this historical prospective cohort study comprised a total of 200 teeth with 441 root canals. Diagnostic and treatment information was abstracted from the original patient records. An endodontic follow-up examination was conducted 4 +/- 0.5 years after obturation. Each tooth/root was analyzed according to 3 indices of periradicular status at 2 time points. The main outcome measure was the presence of apical periodontitis. The criteria used for evaluation of the outcome were modified from Strindberg. Data were subjected to univariate and multivariate analysis. Logistic regression models were fit by using various clinical measures to determine which combination of biologic and treatment-associated factors best predicted treatment outcome. Results: The preoperative pulp diagnosis, the periapical diagnosis, the preoperative periapical radiolucency size, and the sex of the patients were revealed, by means of univariate analysis, to exert a significant influence on endodontic treatment outcome (P <.05). In the logistic regression model, the strongest effect on postoperative healing was the presence and magnitude of preoperative apical periodontitis. In the presence of this variable, no other factor contributed value to the prediction. The correct prediction of this model was 74.7% (P <.05). Conclusion: The major biologic factors influencing the outcome of endodontic treatment appear to be the extent of microbiological insult to the pulp and periapical tissue, as reflected by the periapical diagnosis and the magnitude of periapical pathosis.

Arandi

Objective: This review integrates the literature on cavity liners and current concepts of pulp protection with the aim of establishing a better understanding of the role of calcium hydroxide as a cavity liner. Materials and methods: A search was conducted through PubMed, MEDLINE, and Ovid for articles with the criteria for the following terms: cavity liners and bases, pulp protection, and calcium hydroxide liners. No specific inclusion or exclusion criteria were applied as to what articles would be included in this review. It was hoped that the extent of the literature reviewed would be as comprehensive as possible. Conclusion: This review underlines the fact that calcium hydroxide liners should only be used in the deepest spots in the cavity where the remaining dentine thickness is ≤0.5 mm. A protective layer of resin-modified glass ionomer should always follow the application of calcium hydroxide liners.

Neelam Chandwani

Objective: To study and compare the effects of dental amalgam and composite restorations on human dental pulp. Materials and methods: One hundred sound premolars scheduled for orthodontic extraction were divided equally into two groups: group A, teeth restored with silver amalgam, and group B, teeth restored with composite resin. Each group was equally subdivided into two subgroups [extracted after 24 h (A-1 and B-1) or 7 days (A-2 and B-2)], and the histological changes in the pulp related to the two different materials at the two different intervals were studied. Results: It was found that after 24 h, the inflammatory response of the pulp in teeth restored with amalgam and composite was similar (p = 1.00). However, after 7 days, the severity of the inflammatory response of the pulp in teeth restored with amalgam was less compared to that in teeth restored with composite (p = 0.045). Conclusion: This study confirmed that amalgam continues to be the mechanically as well as biologically more competent restorative material. Composite could be a promising restorative material to satisfy esthetic needs for a considerable period of time. However, its biological acceptance is still in doubt.

About et al

Objectives: Dentinal repair following cavity restoration is dependent on several parameters including the numbers of surviving odontoblasts. The purpose of this study was to examine the effects of cavity cutting and restoration treatments on post-operative odontoblast numbers. Methods: 353 Standardised non-exposed rectangular Class V cavities, were cut into the buccal dentin of intact 1st or 2nd premolar teeth of 165 patients, aged between nine and 25 years of age. Composite cavity restorations with various etching treatments were compared with resin-modified glass ionomer cements, enamel bonding resins, as well as polycarboxylate, calcium hydroxide, and zinc oxide eugenol materials. Following tooth extraction (20-381 days) for orthodontic reasons, the area of the reactionary dentine and the area of the odontoblasts was measured histomorphometrically. Results: Odontoblast numbers and dentine repair activity were found to be influenced more by cavity restoration variables, than the choice of cavity filling materials or patient factors. The most important cavity preparation variable was the cavity remaining dentine thickness (RDT); below 0.25mm the numbers of odontoblasts decreased by 23%, and minimal reactionary dentine repair was observed. Conclusions: Odontoblast injury increased as the cavity RDT decreased. In rank order of maintaining odontoblast numbers beneath restored cavities with a RDT below 0.5mm, and using calcium hydroxide for comparison; calcium hydroxide (100%), polycarboxylate (82.4%), zinc oxide eugenol (81.3%), composite (75.5%), enamel bonding resin (49.5%) and RMGIC (42.8%). The vitality and dentine repair capacity of the pulp is dependent on odontoblast survival. Variations in the extent of odontoblast injury caused during operative procedures, may be the major underlying reason for the success or failure of restorative treatments.

Kaminishi H

Porphyromonas gingiL,alis protease, which had been isolated from a culture supernatant, caused vascular permeability enhancement in a dose-dependent manner when injected into guinea pig skin. The permeability-enhancing reaction caused by the protease was not affected by treatment with antihistamine, but was greatly augmented by simultaneous injection of a kinin potentiator, carboxypeptidase N inhibitor. However, the reaction was inhibited by soybean trypsin inhibitor or a2-antiplasmin, although both of these inhibitors could not inhibit P. gingit'alis protease at all by themselves. A bradykinin-degrading enzyme, carboxypeptidase B, weakened this vascular reaction. Results described indicate that the permeability-enhancing reaction induced by the protease is caused by activation of the kallikrein-kinin cascade in the tissue.

de Souza Costa et al.

Objectives: This study evaluated the human pulp response to the application of two RMGICs in deep cavities in vivo. Methods: The cavity floor prepared on the buccal surface of 34 premolars was lined with VBP (VBP), Vitrebond (VB) or Dycal® (DY), and restored with composite resin. Additional teeth were used as an intact control group. After 7 or 30-60 days, the teeth were extracted and processed for histological evaluation. The following histological events were scored: inflammatory response, tissue disorganization, reactionary dentin formation and presence of bacteria. Results: At 7 days, VBP and VB elicited a mild inflammatory pulpal response in about 70% of specimens and in 1 specimen for DY. Only 1 specimen of each RMGICs exhibited moderate tissue disorganization. Bacteria and reactionary dentin formation were not found. At 30-60 days, about 20% of specimens lined with RMGICs showed a persistent mild inflammatory pulp response while no inflammatory reaction was observed for DY. Moderate tissue disorganization occurred with both materials. Bacteria were found only in 1 VBP specimen. The mean remaining dentin thickness (RDT) in specimens lined with VBP, VB or DY ranged from 342.3 to 436.1μm, and no statistically significant differences in RDT were found among materials or periods (two-way ANOVA, p>0.05). Comparison of the two RMGICs tested for the histological events at each period showed statistically similar results (Kruskal-Wallis, p>0.05). Significance: The use of the new Vitrebond formulation (VBP) in deep cavities in vivo caused mild initial pulp damage, which decreased with time, indicating acceptable biocompatibility.

hepatitis - occupational transmission

Occupational Transmission HAV, HEV, and non-A-E hepatitis viruses have little to no risk from occupational exposure. HCV is less infectious in transmission than HBV, but both should be recognized for risk in occupational exposure. HBV can actually survive in dried blood on contaminated surfaces for at least one week, and the risk of contraction after a sharps injury is from 6-30%. The risk of contracting HCV is from 2-8%. Interestingly, there has not been a report of transmission of HCV from a dental health care worker to patient, but there has been documentation of HBV transmission.

Staquet

Odontoblasts and fibroblasts are suspected to influence the innate immune response triggered in the dental pulp by micro-organisms that progressively invade the human tooth during the caries process. To determine whether they differ in their responses to oral pathogens, we performed a systematic comparative analysis of odontoblast-like cell and pulp fibroblast responses to TLR2-, TLR3-, and TLR4-specific agonists (lipoteichoic acid [LTA], double-stranded RNA, and lipopolysaccharide [LPS], respectively). Cells responded to these agonists by differential up-regulation of chemokine gene expression. CXCL2 and CXCL10 were thus increased by LTA only in odontoblast-like cells, while LPS increased CCL7, CCL26, and CXCL11 only in fibroblasts. Supernatants of stimulated cultures increased migration of immature dendritic cells compared with controls, odontoblast-like cells being more potent attractants than fibroblasts. Analysis of these data suggests that odontoblasts and pulp fibroblasts differ in their innate immune responses to oral micro-organisms that invade the pulp tissue.

Bishop

Odontoblasts are known to be involved in the process of dentinogenesis but it is not clear whether substances may also be deposited in predentine and dentine by passing between these cells. Although tight junctions have been described, it is not clear if they are macular or "leaky" as opposed to continuous or "tight". In this study use has been made of the permeability of fenestrated capillaries amongst the odontoblasts to deposit the penetrative tracer lanthanum in the interodontoblastic space. This was done by perfusion of anaesthetized rats with physiological solutions containing lanthanum nitrate at 37° C. Immersion fixation of transverse segments of mandibular incisors and examination with an electron microscope showed that lanthanum could permeate 40-50 μm between the odontoblasts to reach the peripheral pulp. Towards the predentine, often less than 10 μm from the capillaries, its progress was abruptly and completely halted by the junctions at the apical ends of the odontoblast cell bodies. Lanthanum was not found in the predentine. The mature secretory odontoblasts in the rat incisor have therefore been shown to be joined by continuous tight junctions. In the process of dentinogenesis this means that all substances deposited in predentine and dentine must arrive by passing through the odontoblasts.

Ruch et al

Odontoblasts are post-mitotic, neural crest-derived, cells which overtly differentiate according to tooth specific temporo-spatial patterns and secrete predentin-dentin components. Neither the timing nor the molecular mechanisms of their specification are known and the problem of their patterning in the developing jaws is far from being solved. On the other hand, some significative strides were made concerning the control of their terminal differentiation. Fibronectin interacting with a 165 kDa, non integrin, membrane protein intervenes in the cytoskeletal reorganization involved in odontoblast polarization and their terminal differentiation can be triggered in vitro by immobilized members of the TGF beta family. Histological aspects and the transcriptional phenotypes (transcripts of TGF beta s, BMPs, msxs, IGF1, fibronectin, osteonectin, bone sialoprotein genes) are very similar in vivo and in vitro. In vivo members of the TGF beta super family secreted by preameloblasts, trapped and activated by basement membrane associated components, might initiate odontoblast terminal differentiation.

A.R Son, Y.M Yang, J.H Hong, S.I. Lee

Odontoblasts function as mechanosensory receptors because of the expression of mechanosensitive channels in these cells. However, it is unclear if odontoblasts direct the signal transmission evoked by heat/cold or osmotic changes. This study investigated the effects of heat/cold or osmotic changes on calcium signaling and the functional expression of the thermo/mechanosensitive transient receptor potential (TRP) channels in primary cultured mouse odontoblastic cells, with the use of RT-PCR, fluorometric calcium imaging, and electrophysiology. TRPV1, TRPV2, TRPV3, TRPV4, and TRPM3 mRNA was expressed, but TRPM8 and TRPA1 mRNA was not. The receptor-specific stimulation of TRPV1-3 (heat-sensing receptors) and TRPV4/ TRPM3 (mechanic receptors) caused increases in the intracellular calcium concentration. Moreover, the channel activities of TRPV1-4 and TRPM3 were confirmed by a whole-cell patch-clamp technique. These results suggest that primary cultured mouse odontoblasts express heat/mechanosensitive TRP channels and play a role in the underlying mechanisms of thermo/mechanosensitive sensory transmission.

Author: Goldberg and Smith

Odontoblasts produce most of the extracellular matrix (ECM) components found in dentin and implicated in dentin mineralization. Major differences in the pulp ECM explain why pulp is normally a non-mineralized tissue. In vitro or in vivo, some dentin ECM molecules act as crystal nucleators and contribute to crystal growth, whereas others are mineralization inhibitors. After treatment of caries lesions of moderate progression, odontoblasts and cells from the sub-odontoblastic Höhl's layer are implicated in the formation of reactionary dentin. Healing of deeper lesions in contact with the pulp results in the formation of reparative dentin by pulp cells. The response to direct pulp-capping with materials such as calcium hydroxide is the formation of a dentinal bridge, resulting from the recruitment and proliferation of undifferentiated cells, which may be either stem cells or dedifferentiated and transdifferentiated mature cells. Once differentiated, the cells synthesize a matrix that undergoes mineralization. Animal models have been used to test the capacity of potentially bioactive molecules to promote pulp repair following their implantation into the pulp. ECM molecules induce either the formation of dentinal bridges or large areas of mineralization in the coronal pulp. They may also stimulate the total closure of the pulp in the root canal. In conclusion, some molecules found in dentin extracellular matrix may have potential in dental therapy as bioactive agents for pulp repair or tissue engineering.

thyroid - Oral Complications and Manifestations

Oral Complications and Manifestations A. Thyrotoxicosis Children with thyrotoxicosis present with rapidly growing jaws, premature loss of primary teeth, and early eruption of permanent teeth. Mothers with hyperthyroidism can give birth to infants that have erupted teeth at the time of birth. There have been instances of patients with thyrotoxicosis and lingual thyroid tissue located below the foramen cecum. Radioactive iodine scanning should be performed prior to the lingual thyroid removal. These patients may present with osteoporosis of the alveolar bone and rapid progression of dental caries and periodontal disease. B. Hypothyroidism Hyperthyroid infants have thick lips, large tongues, delayed teeth eruption, and malocclusion. Adults that have acquired hypothyroidism have large tongues. A study suggests a correlation between burning mouth syndrome with hypothyroidism, but further research is required to establish this relationship. C. Thyroiditis Patients with subacute painful thyroiditis experience pain extending to their ears, jaw, and occipital regions. They may report hoarseness, dysphagia, palpitations, nervousness, and lassitude. Their thyroid glands are usually enlarged, firm, nodular, and tender. D. Radioactive Iodine (RAI) Although RAI can be used to treat hyperthyroidism and thyroid cancer, it can also put the patients at risk for salivary gland swelling, pain, loss of taste, recurrent sialadenitis, hyposalivation, xerostomia, mouth pain, and caries. E. Thyroid Disease and Lichen Planus There may be a relationship between thyroid disease and lichen planus but further research is required.

hypertension - oral manifestations

Oral Manifestations Aside from occasional reports of patients with malignant hypertension presenting with facial palsy, there are no well-established relationships between oral manifestations with hypertension itself. Although excessive bleeding following trauma or surgery has been reported in patients with severe hypertension, excessive bleeding is not commonly reported in hypertensive patients. Xerostomia is commonly reported in patients taking antihypertensive medications, particularly diuretics. Oral lesions have been reported in patients taking mercurial diuretics and lichenoid reactions are seen in patients taking thiazides, methyldopa, propranolol, and labetalol. Neutropenia, angioedema, persistent cough, and oral burning have been reported in patients taking ACEIs and gingival overgrowth is seen in patients taking calcium channel blockers.

epilepsy - oral complications and manifestations

Oral complications and manifestations Most significant oral complication: gingival overgrowth which is associated with phenytoin. Incidence of phenytoin-induced gingival overgrowth in epileptic patients ranges from 0-100% with an average rate of ~42%. Occurs more in younger patients than adults. Meticulous oral hygiene is important for preventing overgrowth and should be combined with removal or irritants such as overhanging restorations/calculus. Traumatic injuries such as broken teeth, tongue lacerations, and lip scars are also common in patients who experience generalized tonic-clonic seizures. Stomatitis, erythema multiforme, and Stevens-Johnson syndrome are rare adverse effects associated with use of phenytoin, valproic acid, lamotrigine, phenobarbital, and carbamazepine. These complications are more common during the first 8 weeks of treatment

IE - Organ and stem cell transplant patients

Organ and stem cell transplant patients · These patients require special treatment when being provided dental care both before and after the transplant because they take immunosuppressive medications. There is currently no evidence to suggest that prophylactic antibiotics would offer the patients benefits that outweigh the risks of the antibiotics. However, the endodontic provider should consult with the patient's medical team before providing dental care.

Author: Peters and Balling

Organs have to develop at precisely determined sites to ensure functionality of the whole organism. Organogenesis is typically regulated by a series of interactions between morphologically distinct tissues. The developing tooth of the mouse is an excellent model to study these processes and we are beginning to understand the networks regulating reciprocal tissue interactions at the molecular level. Synergistic and antagonistic effects of signaling molecules including FGFs and BMPs are recursively used to induce localized responses in the adjacent tissue layer (mesenchyme or epithelium). However, at different phases of odontogenesis these secreted growth factors have distinct effects and at the same time they are regulated by different upstream factors. The mesenchymal transcription factors Msx1 and Pax9 are initially regulated by epithelial FGFs and BMPs, but subsequently they function upstream of these signaling molecules. This cascade provides a molecular model by which reciprocal tissue interactions are controlled.

IgM:

very effective agglutinator; produced early in immune response - effective first line defense vs bacteraemia

Butler W

Osteopontin is an acidic glycoprotein of about 41,500 daltons that has been isolated from rat, human and bovine bone. It is rich in aspartic acid, glutamic acid and serine and contains about 30 monosaccharides, including 10 sialic acids. Several types of data suggest that the carbohydrate is present as 1 N-glycoside and 5-6 O-glycosides while the phosphate is present as 12 phosphoserines and 1 phosphothreonine. The cDNA sequence indicated the presence of a Gly-Arg-Gly-Asp-Ser- (GRGDS) amino acid sequence identical to a cell binding sequence in fibronectin, and suggested that osteopontin might function as a cell attachment factor. This conclusion is supported by a number of studies showing that the protein promotes attachment and spreading of fibroblasts and osteoblasts to substratum, and that this attachment is inhibited by RGD-containing peptides. Despite this evidence that it contains an RGD recognition sequence and probably interacts with the family of receptors known as integrins, it appears that osteopontin does not possess a collagen-binding domain. Osteopontin is synthesized by preosteoblasts, osteoblasts and osteocytes, is secreted into osteoid and is incorporated into bone. The expression at an early developmental stage is an indication that osteopontin is an important component in the formation of bone. The level of synthesis of osteopontin by osteoblasts in culture is increased by treating these cells with 1,25-dihydroxyvitamin D3 and TGF-beta. The effect of these agents is at the transcriptional level. In addition to bone cells, osteopontin is synthesized by extraosseous cells in the inner ear, brain, kidney, and deciduum and placenta. It is also synthesized by odontoblasts, certain bone marrow cells and hypertrophic chondrocytes. Studies with several fibroblast and epithelial-derived cell lines in culture indicate that secretion of osteopontin can be dramatically increased when these cells are treated with phorbol esters, growth factors and hormones. However, osteopontin does not appear to be expressed by mesenchymal cells, fibroblasts, epidermal cells or by most epithelial cells in vivo.

Other genetic clotting factor deficiencies

Other Genetic Clotting Factor Deficiencies Rarely, deficiency of prothrombin occurs. Other rare conditions include deficiencies in factor V, VII, X, XI, and XIII. Factor XIII deficiency, a2 plasmin inhibitor deficiency, and PAI-1 deficiency will not affect PT, aPTT, or TT; so, if we suspect a defect in the coagulation system, a 5M urea test may be beneficial. Although there is a risk of infection with replacement products, particularly to HIV, HCV, HBV, and HGV; by screening blood donors, viral inactivation procedures, preparing ultrapure concentrates, and using porcine factor VIII, the incidence of infection has been greatly reduced in hemophilic patients.

Livermore DM.

Oxazolidinones are prominent among the new Gram-positive antimicrobial agents now becom- ing available. They were discovered by DuPont Pharmaceuticals in the late 1980s but linezolid, the first analogue suitable for development, was found only when the family was re-examined by Pharmacia in the 1990s. Oxazolidinones bind to the 50S subunit of the prokaryotic ribosome, preventing formation of the initiation complex for protein synthesis. This is a novel mode of action; other protein synthesis inhibitors either block polypeptide extension or cause misread- ing of mRNA. Linezolid MICs vary slightly with the test method, laboratory, and significance attributed to thin hazes of bacterial survival, but all workers find that the susceptibility distribu- tions are narrow and unimodal, with MIC values between 0.5 and 4 mg/L for streptococci, enterococci and staphylococci. Full activity is retained against Gram-positive cocci resistant to other antibiotics, including methicillin-resistant staphylococci and vancomycin-resistant enterococci. MICs are 4-8 mg/L for Moraxella, Pasteurella and Bacteroides spp. but other Gram- negative bacteria are resistant as a result of endogenous efflux activity. Resistance is difficult to select in vitro but has been reported during therapy in a few enterococcal infections and in two MRSA cases to date; the mechanism entails mutation of the 23S rRNA that forms the binding site for linezolid. Risk factors for selection of resistance include indwelling devices, undrained foci, protracted therapy and underdosage.

Blood 2 - Pathophysiology

Pathophysiology 3 phases of hemostasis: vascular, platelet, and coagulation Vascular and platelet phases are the primary phases Coagulation is secondary After hemostasis, there is the fibrinolytic phase, which dissolves the clot

Cancer Pathophysiology

Pathophysiology Cancer cells lose their regulatory control, leading to hyperproliferative epithelium, dysplasia, and then ultimately carcinoma. Four characteristics of genetic changes in cancer include specific chromosomal changes, genomic instability allowing continuing change, cells tracing back to a single progenitor cells and are clonal, and tumor progression with specific chromosomal changes. Some of the chromosomal changes include aneuploidy, duplication, monosomy, deletion, rearrangement, and amplification. Malignant cells undergo antigenic, karyotypic, biochemical, and membrane changes, resulting in alteration of chromosomal morphology and increased permeability. As cells lose control of the cell cycle, they replicate, and the malignant tumors can be detected after 30 cell doublings with masses of 109 cells. Over time, cells in the malignant tumors loose cell adhesion and metastasize beyond anatomic boundaries through blood and lymphatic vessels, often leading to organ failure and death.

Searls

Rat incisors were evaluated radioautographically for metabolic changes induced by high-speed cavity preparation. Label uptake was reduced substantially in those odontoblasts whose processes had been cut; labeling also was diminished in all other areas of the pulp, especially in that area immediately adjacent to the cavity preparation.

hepatitis - pathophysiology and complications

Pathophysiology & Complications Jaundice (icterus) is the accumulation of bilirubin in the plasma, epithelium, and urine. It is highly associated with hepatitis. Bilirubin is a large degradation product of hemoglobin, and a large portion of bile. It usually transports to the liver by the plasma. In liver disease, bilirubin usually accumulates in the plasma because of decreased liver metabolism and transportation. Fulminant hepatitis is a major complication of acute viral hepatitis, and characterized by hepatocellular destruction, with a large mortality rate of 80% Another complication of acute viral hepatitis is chronic infection, in carrier state, characterized by persistent low levels of virus in the liver and serum viral antigens for longer than 6 months with the absence of liver disease. Those with chronic infections can potentially be infectious to those around them. The carrier rate in dentists in the United States is about 3-10 times more than the general population, although this has been decreasing. A person can develop chronic active hepatitis if the carrier state persists, which is classified by the presence of the following for over 6 months: HBsAg, HBeAg, or HCVA in serum, signs and symptoms of chronic liver disease, hepatic cellular necrosis, or elevation of liver enzymes. It is important to note that hepatocellular carcinoma is a leading cause of death in the United States, and chronic HBV and HCV accounts for about 78% of global cases of hepatocellular carcinoma. The clinical presentation of hepatitis after the incubation phase is interesting, considering many cases are asymptomatic: about 10% for HAV, 60-70% for HCV, and 70-90% for HBV. We typically can characterize the prodromal (preicteric) phase with symptoms of abdominal pain, nausea, vomiting, and fever. The icteric phase typically shows jaundice, yellow-brown cast to the conjunctivae, skin, oral mucosa, as well as urine. The convalescent or recovery (posticteric) phase has disappearing symptoms, but hepatomegaly and abnormal liver function values may persist. Laboratory findings that are helpful in determining liver disease are bilirubin, albumin, prothrombin time, ALT, AST, alkaline phosphatase, and antigen-antibody serologic tests, in addition to taking history and a physical examination.

hypertension - pathophysiology and complications

Pathophysiology and Complications Primary hypertension is caused by the lack of vascular resistance regulation. Vascular resistance is controlled by many factors including neural reflexes, persistent maintenance of symptomatic vasomotor tone, neurotransmitters like norepinephrine, extracellular fluid, sodium stores, renin-angiotensin-aldosterone pressor system, prostaglandins, kinins, adenosine, and hydrogen ions. In elderly patients, common causes are central arterial stiffness and the loss of elasticity. An increase in blood viscosity, increase in blood volume or tissue fluid volume, and an increase in cardiac output from exercise, fever and thyrotoxicosis correlates with an increase in blood pressure, whereas a decrease in blood volume or tissue fluid volume leads to a decrease in blood pressure. There is an increased risk of cardiovascular disease when the systolic blood pressure is above 115 mm Hg and the diastolic blood pressure is above 75 mm Hg. The risk of death from stroke and coronary heart disease is proportionate to the increase in blood pressure above normal levels. With every 20 mm Hg increase in systolic blood pressure and every 10 mm Hg increase in diastolic blood pressure the risk of death from ischemic heart disease or stroke doubles. If patients with hypertension are left untreated, 50% die from congestive heart failure or coronary heart disease, 33% from stroke, and 10-15% from renal failure.

thyroid - pathophysiology and etiology

Pathophysiology and Etiology The hypothalamic-pituitary-thyroid axis regulates T3 and T4 levels, which is influenced by the metabolic demand, drugs, illness, thyroid disease, pituitary disorders, and aging. The hypothalamus releases thyrotropin-releasing hormone (TRH) when external stimuli are present such as stress, illness, metabolic demand, and low T3 levels. TRH causes the thyroid-stimulating hormone (TSH) to be release from the pituitary. TSH is responsible for stimulating the thyroid gland to release T3 and T4. T3 and T4 act on the pituitary gland by blocking the release of TSH at high levels and stimulating TSH release at low levels. T3 and T4 are found bound to plasma proteins including thyroxine bind globulin (TBG), transthyretin, thyroid-binding albumin (TBA), and high-density lipoproteins. Autoimmune diseases like Graves' Disease and Hashimoto's Thyroiditis are associated with antibodies in the thyroid. These antibodies involve TSH receptor antibodies (TSHRAb), thyroid peroxidase antibodies (TPoAb), and thyroglobulin antibodies (TgAb). TSHRAb are found in 80-95% of patients with Grave's Disease and in 10-20% of patients with autoimmune thyroiditis. TSHRAb causes thyroid hormone to be released, while TSH receptor blocking antibodies (TSHR-blocking Ab) impede thyroid hormone from being released. The proportions of the TSHRAb to TSHR-blocking Ab dictates the patient's thyroid gland status. TgAB is found in 50-70% of patients with Graves' Disease and in 80-90% of patients with autoimmune thyroiditis. TPoAb is present in 50-80% of patients with Graves' Disease and 90-100% of those with autoimmune thyroiditis.

epilepsy - pathophysiology and complications

Pathophysiology and complications The basic event underlying an epileptic seizure is an excessive focal neuronal discharge that spreads to thalamic and brain stem nuclei. The cause of the abnormal electrical activity is not precisely known. Theories on causes: altered sodium channel function, altered neuronal membrane potentials, layered synaptic transmission, diminution of inhibitory neurons, increased neuronal excitability and decreased electrical threshold for epileptic activity. During seizures, blood becomes hypoxic with consequent development of lactic acidosis. 60-80% of patients with epilepsy achieve complete control over their seizures within 5 years. The remainder achieve partial or poor control. A significant problem in the medical management of epileptic patients, like with many chronic diseases, is compliance with prescribed treatment regimens/medication. Evidence suggests that patients who have epilepsy from an early age have a higher incidence of future complications and die at an earlier age: Noncompliance may be a clinically important consideration. Complications of seizures include: trauma (as a result of falls) to the head, neck, and mouth and aspiration pneumonia. Frequent and severe seizures are associated with altered mental function, dullness, confusion, argumentativeness, and increased risk of sudden death.

IE - pathophysiology and complications

Pathophysiology and complications: · Although combination antibiotic and surgical treatment is effective for many patients, complications are common and serious. The most common complication of IE, and the leading cause of death, is heart failure, which results from severe valvular dysfunction. · Embolization of vegetation fragments often leads to further complications such as stroke. Myocardial infarction can occur as the result of embolism of the coronary arteries, and distal emboli can produce peripheral metastatic abscesses.

IE - Patients at risk of infective endocarditis

Patients at risk of infective endocarditis · 2017, the AHA and American College of Cardiology (ACC) published a focused update · "Prophylaxis against IE is reasonable before dental procedures that involve manipulation of gingival tissue, manipulation of the periapical region of teeth, or perforation of the oral mucosa in patients with the following: 1. Prosthetic cardiac valves, including transcatheter implanted prostheses and homografts. 2. Prosthetic material used for cardiac valve repair, such as annuloplasty rings and chords. 3. Previous IE. 4. Unrepaired cyanotic congenital heart disease or repaired congenital heart disease, with residual shunts or valvular regurgitation at the site of or adjacent to the site of a prosthetic patch or prosthetic device. 5. Cardiac transplant with valve regurgitation due to a structurally abnormal valve." · The 2017 AHA/ACC report also noted that, based on limited data, IE appears to be more common in heart transplant recipients than in the general population; the risk of IE is highest in the first six months after transplant because of endothelial disruption, high-intensity immunosuppressive therapy, frequent central venous catheter access, and frequent endomyocardial biopsies

IE - Patients at risk of prosthetic joint implant infection

Patients at risk of prosthetic joint implant infection · 2014 update: o "In general, for patients with prosthetic joint implants, prophylactic antibiotics are not recommended prior to dental procedures to prevent prosthetic joint infection." o "The practitioner and patient should consider possible clinical circumstances that may suggest the presence of a significant medical risk in providing dental care without antibiotic prophylaxis, as well as the known risks of frequent or widespread antibiotic use. As part of the evidence-based approach to care, this clinical recommendation should be integrated with the practitioner's professional judgment and the patient's needs and preferences." o "In cases where antibiotics are deemed necessary, it is most appropriate that the orthopedic surgeon recommend the appropriate antibiotic regimen and when reasonable write the prescription." · The clinical rationales for the 2015 recommendations were based upon evidence that: (i) dental procedures are not associated with PJI, (ii) antibiotics provided before care do not prevent PJI, (iii) there are potential harms of antibiotics including risk for anaphylaxis, antibiotic resistance, and opportunistic infections ike Clostridium difficile, (iv) the benefits of AP may not exceed the harms for most patients, and (v) the individuals circumstances and preferences should be considered when deciding whether to prescribe prophylactic antibiotics prior to dental procedures.

Blood - Oral Manifestation

Patients with bleeding disorders may experience spontaneous gingival bleeding. Oral tissues (e.g., soft palate, tongue, buccal mucosa) may show petechiae, ecchymoses, jaundice, pallor, and ulcers. Spontaneous gingival bleeding and petechiae usually are found in patients with thrombocytopenia. Hemarthrosis of the temporomandibular joint (TMJ) is a rare finding in patients with coagulation disorders and is not found in patients with thrombocytopenia

: Fouad, A; Rivera, E; Walton, R.

Patients with pulp necrosis and periapical pain and/or localized swelling were considered. Those eligible did not have any signs of spreading infections. Patients received appropriate local treatment, and a double-blind protocol was used to randomly assign them to one of three groups: penicillin VK group, placebo group, or neither medication group. All received ibuprofen 600 mg four times daily for 24 hours. Patients entered their pre- and postoperative pain and swelling experience on a visual analog scale for up to 72 hours. Resolution was fairly rapid in most patients. Statistical analysis of the scores of 32 respondents revealed no significant differences (at p < 0.05) between the three groups in course of recovery or symptoms at any time period. Conclusions. Patients with localized periapical pain or swelling generally recovered quickly with local treatment. The data did not show a demonstrable benefit from penicillin supplementation.

Patella V (1990)

Peptostreptococcus magnus strain 312 (lo6 to 108/ml), which synthesizes a protein capable of bind- ing to K L chains of human Ig (protein L), stimulated the release of histamine from human basophils in vitro. P. magnus strain 644, which does not synthesize protein L, did not induce histamine secretion. Soluble protein L (3 x lo-' to 3 pg/ml) induced histamine release from human basophils. The characteristics of the release reaction were similar to those of rabbit IgG anti-Fc fragment of human IgE (anti-IgE): it was Caz+- and temperature-dependent, optimal release occurring at 37°C in the presence of 1.0 mM extracellular Ca'+. There was an excellent correlation (r = 0.82; p c 0.001) between the maximal percent histamine release induced by protein L and that induced by anti-IgE. as well as between protein L and protein A from StaphyZococcus au- reus (r = 0.52; p c 0.01). Preincubation of basophils with either protein L or anti-IgE resulted in complete cross-desensitization to a subsequent challenge with the heterologous stimulus. IgE purified from myeloma patients PS and PP (X-chains) blocked anti-IgE-induced histamine release but failed to block the histamine releasing activity of protein L. In con- trast, IgE purified from myeloma patient ADZ (K-chains] blocked both anti-IgE- and protein L-induced releases, whereas human polyclonal IgG se- lectively blocked protein L-induced secretion. Pro- tein L acted as a complete secretagogue, i.e., it activated basophils to release sulfidopeptide leukotriene C4 as well as histamine. Protein L (lo-' to 3 @ml) also induced the release of preformed (histamine) and de novo synthesized mediators (leukotriene C4 and/or PGD') from mast cells isolated from lung parenchyma and skin tissues. Intradermal in- jections of protein L (0.01 to 10 pg/ml) in nonallergic subjects caused a dose-dependent wheal-and-flare reaction. Protein L activates human basophils and mast cells in vitro and in vivo presumably by inter- acting with K L chains of the IgE isotype.

diabetes - pharmacologic treatment of type 1 diabetes

Pharmacologic Treatment of Type 1 Diabetes · Patients with type 1 diabetes are treated with some form of insulin. · Many patients wear an external programmable insulin pump used to deliver insulin by subcutaneous injection. · Insulins are characterized as either rapid-acting, short-acting, intermediate-acting, or long-acting preparations. · Insulin regimens and delivery: · Rapid-acting and short-acting preparations are used at meals (for bolus delivery), and intermediate-acting and long-acting insulins serve as basal insulins. · External insulin pumps with a real-time glucose sensor are available. The pumps are worn around the waist and provide continuous subcutaneous infusion of rapid-acting (or less frequently short-acting) insulin through a catheter inserted into the subcutaneous tissue of the abdominal wall.

diabetes - Pharmacologic Treatment of type 2 diabetes

Pharmacologic Treatment of type 2 diabetes · The management of type 2 diabetes involves lifestyle interventions, drug therapy, and control of risk factors for cardiovascular disease. · This includes control of blood glucose levels, blood pressure, lipid levels, and aspirin (antiplatelet) therapy, as indicated. · Most patients with type 2 diabetes under medical care are treated with one or more pharmacologic agents. · If monotherapy is insufficient, additional agents are used to achieve glycemic control. Injectable drugs (exenatide and pramlintide and insulin) are used to treat type 2 diabetes when oral agents alone fail to provide adequate glycemic control. · Drug treatment for Type 2 Diabetes · Oral agents: o Insulin sensitizers: Insulin sensitizers can have their primary action in the liver or in peripheral tissues. § Primary Action in Liver: Biguanides- Metformin (Glucophage) is the only biguanide available in the United States. Its major action is to suppress hepatic glucose output and gluconeogenesis. Its main pharmacologic advantage is that it lowers blood glucose levels without increasing insulin levels, so it is not associated with significant risk of hypoglycemia. § Primary Action in Peripheral Tissues: Thiazolidinediones-Thiazolidinediones (TZDs) are agonists of peroxisome proliferator-activated receptor gamma (PPARγ). This class of drugs decrease insulin resistance primarily by making muscle and adipose cells more sensitive to insulin, and they mildly decrease hepatic glucose production. o Insulin secretagogues: agents that bind to the sulfonylurea receptor on the plasma membrane of pancreatic beta cells, causing insulin secretion from the pancreas. These drugs have a hypoglycemic potential. Second generation drugs have fewer side effect due to their extended release and are dosed once daily. Relatively low risk of hypoglycemia and weight gain with second generation drugs. o Glinides: Glinides increase the secretion of insulin in the presence of glucose in a manner similar to that for the sulfonylureas; however, they are more rapid in action and of shorter duration. o Alpha-Glucosidase Inhibitors (AGIs): AGIs inhibit the enzyme α-glucosidase at the brush border of the intestinal epithelium, thus blocking the absorption of carbohydrates in the small intestine. o Fixed Combination Pills: Several combinations of oral hypoglycemic agents are available. o Dipeptidyl Peptidase-4 Inhibitors: These drugs block the enzyme responsible for the breakdown of incretins. · Injectable agents: o Insulin: Patients with type 2 diabetes with failing beta cell function may require insulin therapy to gain tighter glycemic control. o Incretin Mimetics: Incretins are a group of GI hormones that increase insulin release from beta cells in the pancreas. They also inhibit glucagon secretion and slow absorption of carbohydrates. o Amylinomimetics: Analogue of human amylin. Amylin is co-secreted from beta cells of the pancreas with insulin and modulates gastric emptying. It has an incretin effect that prevents postprandial rise in serum glucagon and also suppresses appetite.

prenant - oral complications and manifestations

Pregnancy gingivitis · This condition results from an exaggerated inflammatory response to local irritants and less-than-meticulous oral hygiene during periods of increased secretion of estrogen and progesterone and altered fibrinolysis. · Pregnancy gingivitis begins at the marginal and interdental gingiva, usually in the second month of pregnancy. · Progression of this condition leads to development of fiery red and edematous interproximal papillae that are tender to palpation. In approximately 1% of gravid women, the hyperplastic response may exacerbate in a localized area, resulting in a pyogenic granuloma or "pregnancy tumor". · The most common location for a pyogenic granuloma is the labial aspect of the interdental papilla. The lesion generally is asymptomatic; however, toothbrushing may traumatize the lesion and cause bleeding. Pregnancy Gingivitis Pyogenic Granuloma Hyperplastic gingiva: Usually appears in the second month and persist until after parturition, at which time the gingival tissues usually regress and return to normal, provided that proper oral hygiene measures are implemented and any calculus present is removed. Surgical or laser excision occasionally is required as dictated by symptoms, bleeding, or interference with mastication.

Van Amerongen et al

Premolar and third molar dental pulps were studied. The amount of collagen in the dried pulps was 25.7 per cent in premolars and 31.9 per cent in third molars. These percentages are much higher than those reported for pulps in other species. Significant differences were further found in the collagen content and cell distribution (DNA) of the coronal, middle and apical parts of the pulp. Collagen content was the lowest in the coronal part, while the cell content was the lowest in the middle part. The extractability of collagen in a neutral salt solution or 0.5 M acetic acid was found to be extremely low (less than 1 per cent). Pretreatment of the pulp with hyaluronidase in order to remove proteoglycans had no effect on the solubility. It is concluded that human pulp collagen is highly cross-linked and cannot be considered as immature. Characterization of collagen was performed by methods in which limited pepsin digestion or CNBr cleavage was used. The digests were analysed by means of quantitative electrophoresis which revealed an amount of 42.6 per cent type III of the total collagen. Because of the large differences between dental pulps from man and experimental animals, extreme caution should be exercised in drawing conclusions from data of other species to explain phenomena observed in human teeth.

hypertension - prevalence

Prevalence The percentage of patients aware of their hypertension has increased in recent years from 51% to 70%, and the percentage of patients undergoing treatment has increased from 31% to 59%, correlating with a decrease in deaths from coronary heart disease and strokes. Diastolic blood pressure increases with age until 50 years old and then stops increasing or starts to decrease. Systolic hypertension increases with age and is the most prevalent type of hypertension in patients older than 50 years old. Prevalence of hypertension is the highest in African Americans, and higher in Asian Americans, Native Americans, and Native Alaskans than in whites, and higher in whites than in Hispanics.

: Tsuzaki et al

Pulp was essentially solubilized by partial pepsin digestion. The various genetic types of collagens were isolated by differential salt precipitation and extraction. Types I, III and V collagen represented 56, 41 and 2% of the total collagen, respectively. The type V collagen comprised two different molecular species consisting of [α 1(V)]2 α 2(V) and α 1(V)α2(V)α3(V), the ratio of which was approx. 1:1.3. The major portion of the type III collagen was present as a high molecular weight aggregate which released α 1(III) chains upon reduction with 2-mercaptoethanol.

: Ramsay DS, Artun J, Martinen SS

Pulpal blood flow can now be measured non-invasively in the clinic utilizing laser Doppler flowmetry. The purpose of our study was to test (1) whether the position of the measurement probe on the tooth affects blood-flow measurements and (2) whether measurements from identical locations vary over time. Blood flow of one maxillary central incisor was measured in each of 13 volunteers. Measurements were recorded at five different locations on the labial surface of each tooth. Four measurement sessions were performed, and two sets of measurements were recorded at each session. Custom-made splints ensured accurate and reproducible positioning of the measurement probe at each session. Spatial position of the probe had a clear effect on the pulpal blood-flow measurements (p less than 0.0001). Measurements made at incisal and gingival locations were less and greater (p less than 0.05), respectively, than those made at central locations. Measurements from various mesio-distal locations did not differ (p greater than 0.05) when made at the same height on the tooth. Pulpal blood-flow measurements recorded at a given site were not consistent across all of the testing sessions (p less than 0.0001). Our data suggest that reliable interpretation of longitudinal measurements of pulpal blood flow obtained with laser Doppler flowmetry requires accurate repositioning of the measurement probe. In addition, an adequate control condition should be included to account for bias due to temporal variation.

Mjor

Pulpal complications involving inflammation, degradation, and necrosis are the result of a series of traumatic injuries. The restorative dentist must minimize the trauma to dentin and pulp inflicted during clinical procedures, including that inflicted during tooth preparation. Part 11 of this series discusses the structural and physiologic changes in the pulp-dentin complex that result from crown and cavity preparation and the clinical implication of these changes.

: Etty Tagger, Michael Tagger

Pulpotomies were performed in 23 young posterior teeth of two vervet monkeys. Two dressings were compared: glutaraldehyde in ZOE paste and paraformaldehyde in the same vehicle and ZOE alone served as control. The teeth and their surrounding structures were examined histologically after 3 and 9 months. Paraformaldehyde induced total pulpal necrosis and chronic apical inflammation. In all glutaraldehyde-treated teeth, the pulp remained mostly vital and there was no periapical reaction. Calcifications in the pulp cavity were evident. The vehicle alone, ZOE, also permitted the pulp to remain vital, exhibiting calcifications but no full bridges. None of the experimental specimens showed complete pulpal healing; however, in contrast to paraformaldehyde-treated teeth, glutaraldehyde-treated ones retained their vitality and produced no apical involvement.

: Carson et al

Thermography was employed to determine the pattern of heat generation, distribution and dissipation during ultra-high speed cavity preparation. Results indicate an increase in intrapulpal temperature during cutting procedures. No significant differences in the cooling effectiveness between air-water spray and air alone were found. Thermography appears to be an effective research tool for determining thermal changes.

Robinson and Boling

Purpose/Objective: The paper studies the phenomenon of anachoresis in cat teeth. Discussion: The paper discusses 4 series of experiments in which pulps of teeth were irritated and bacteria introduced into the blood stream. Cavities were prepared in selected cats teeth with efforts having the cavity as deep as possible without exposure. An irritant was applied to experimental teeth and were left open. Bacteria were injected into a vein of the hind leg a few minutes to 20 days after cavity preparation. The cats were then sacrificed and experimental and control pulps of the teeth were compared. The timing of the cavity preparation and actual bacteria injection were varied in the subsequent follow up experiments. 72 % of the pulps from 64 teeth operated upon were infected while only 8.5% of the control pulps showed bacteria by culture. Irritation of the pulp is known to result from several stimuli such as cavity preparation, application of filling material, thermal stimuli. Transient bacteremias may occasionally be present in normal healthy individuals and it is suggested that postoperative idiopathic pulpitis may be a result of anachoresis. The term anachoretic pulpitis is suggested for this pulpal inflammation. Reviewers comments: This is a classic article stating that anachoresis occurs in the presence of pulpal inflammation and transient bacteremias. The term anachoretic pulpitis was coined.

Seltzer S, Bender IB, Ziontz M

Purpose/Objective: To make a more accurate assessment of the status of pulps from teeth with periodontal lesions. Materials and methods: 85 teeth that have evidence of periodontal disease such as deep pockets, interradicular bone resorptions, lateral root resorptions and mobility were evaluated. Prior to extraction, subjective symptoms were recorded. The presence of periodontal involvement was confirmed by histologic examination of the periodontal membranes attached to the teeth following extraction. Results and discussion: 1) When the nutrition of the pulp was interfered with involvement of foramina from lateral canals by periodontal disease, small regions of necrosis or infarction occurred within the pulp, causing pulp-tissue breakdown, fatty degeneration and calcification. 2) Periodontal lesions can cause the pulp to atrophy as periodontal lesions produce a degenerative effect on the dental pulp by means of dystrophic calcifications discovered throughout the pulp tissue that often almost obliterate the coronal portions of the pulp and reparative dentin deposition along the dentinal walls. 3) Teeth subjected to a combination of pulp and periodontal irritants had a greater incidence of inflammatory reaction than those subjected to operative procedures alone. 4) Resorptions of the sides of the roots were frequently found subjacent to the granulation tissue overlying the roots. 5) Extensive pulp lesions cause periodontal changes through lateral and accessory foramina and also through the crestal extension of the granulomatous lesions. In those instances, periodontal treatment alone could not be effective in eliminating the lesion. Only effective endodontic treatment could result in eradication. Conclusions: Periodontal lesions produced a degenerative effect on the pulps of the involved teeth. Pulps subjected to a combination of pulpal and periodontal irritants showed a greater incidence of inflammatory reactions than those subjected to operative procedures alone. Pulp lesions were found to have an effect on the severity of the periodontal lesion. Thus, retention of these teeth could be accomplished only through combined endodontic and periodontal therapy. Reviewers comments: The authors believe unequivocably that pulpal lesions have an effect on the severity of periodontal lesions AND periodontal lesions produced a degenerative effect on the pulp. Some of the samples used had fractures and caries; this may have somehow skewed the results.

: Bernick and Nedelman

Purpose/Objectives: To determine the interrelationship between collagen, ground substance and the vascular and neural structures during the aging process and to determine the factors that produce fibrosis in old pulps of human teeth. Materials & Methods: One hundred non-carious extracted human teeth from patients age 15 to 75 were used in the study. The teeth were separated into two groups, teeth from patients younger than 40 and from patients older than 40. Immediately after extraction, the teeth were fixed in an alcoholic Formalin and acetic acid solution. The teeth were decalcified, embedded, sectioned from 15 to 100 micrometers and stained for microscopic evaluation. Results: The following observations were made on examination of the sections: 1) pulps of unerupted teeth showed stromas of loose connective tissue (CT) and only few blood vessels and nerves in the pulp; 2) the pulpal stroma of erupted functional teeth still consisted of loose CT but showed an increase in the number of blood vessels and nerves in the coronal pulp; 3) one of the characteristic changes in the pulp as a result of aging was the decrease in the pulpal area which was a result of continual deposition of occlusal dentin, calcified masses and dentinal apposition at and above the furcation area; 4) only large blood vessels were evident in the coronal pulp of unerupted teeth and large nerve bundles were limited to the apical region; 5) there was an extensive branching of both vascular and neural structures in young functional teeth; 6) there was an apparent decrease in the number of blood vessels and nerves that supplied the pulps of older teeth, along with a progressive deposition of calcified bodies; 7) as teeth aged, it was evident that a fibrosis of the pulp occurred and appeared to be related to the pathways of the degenerated vessels and nerves; 8) there seemed to be little difference in the appearance of the ground substance amongst the groups. Authors Conclusion: In the aging process there is a progressive reduction in size of the pulpal chamber and a progressive deposition of calcified masses that originate in the root pulp and progress into the coronal pulp. As a result of the calcification of the blood vessels and nerves in the pulp, there is a decrease in the number of blood vessels and nerves in the coronal pulp. Regardless of age, the stroma of the pulp consists of fine collagenous fibers and an abundance of ground substance. Validity of Conclusion: Conclusions are valid. Reviewers Comments: This paper is a good review of the histology of the human pulp and changes that occur within the pulp throughout the development process.

Holland GR

Purpose/Objectives: To review the odontoblast structure, extent, lateral branching, function in dentinogenesis, changes post-maturation, and in sensory reception. Structure: The structure only became clear once preparatory methods available allowed for ultra-thin preservation and sectioning. The process is the direct extension of the cell body, and their plasma membranes are continuous. Cytoplasmic content changes with microfilaments and microtubules predominating. Organelles like rER, mitochondria, ribosomes become more rare the further the process extends from the body. Extent: The length of extension is controversial. Much of the debate is reviewed. Questions of whether or not the process extends from the DEJ - the pulp are considered. Studies show the process does not extend more than a third of the length of the tubule. SEM evidence as well as radioactive tracers aids detection. Lateral Branches: The branching of process is discussed. Each tubule gives off side branches seen at right angles to the main process. The system may provide pathways for the movement of nutrients and matrix constituents. Dentinogenesis: Role of the process in dentinogenesis is the transport of secretory vesicles and their release into the extracellular space. Collagen precursors are secreted in vesicles from the odontoblastic process. Processes play a role in calcification of dentin by initiating the process, transporting calcium, modification of matrix composition and in changes that produce peritubular and secondary dentin. Post-maturation changes: After primary dentin, secondary dentin, tubular dentin and reparative dentin form. Debate over how the processes contribute to these formations are mentioned. Sensory reception: The possible role of the odontoblastic process in the sensory mechanism is reviewed including mention of the debate between the hydrodynamic theory and the theory of the odontoblastic process being directly stimulated and acting like a nerve receptor.

Mazur B, Massler M

Purpose/Objectives: To study the influence of periodontal disease on the dental pulp. Materials & Methods: The study consists of two parts: Part I: Survey Study 106 periodontally involved teeth were selected from patients 19-70 years of age. The teeth were divided into four groups according to the severity of periodontal disease, based on how much of the root was exposed on radiographic examination. The teeth were sectioned and looked at histologically. Part II: Paired Control Series Twenty-two teeth from four patients, ages 39-50 years, were collected. Seven of the teeth had normal periodontium and served as controls. The remaining 15 teeth were divided into four groups according to severity of periodontal disease, as was done in Part I. All teeth were sectioned and examined microscopically. Results: Control teeth showed pulpal changes similar to periodontally involved teeth. In Part I, no relationship was observed between the amount of exposed root and the changes in the pulp. In each of the four periodontal disease groups there was a full array of pulpal changes, from mild to most severe, including complete pulpal degeneration and/or calcification. In Part II, it was found that the teeth from the same patient having a wide variety of periodontal involvements had pulps that were histologically the same or similar. Between patients, the pulpal condition varied from almost normal to advanced degeneration. There was no correlation to age and pulpal status. Authors Conclusion: The authors conclude that the investigation disproves any influence of periodontal disease on the pulpal tissue of the involved teeth and that the pulpal structures of teeth from the same patient are similar, regardless of the degree of severity of periodontal involvement Validity of Conclusion: Conclusions are of questionable validity. Reviewers Comments: I think this was a good study, but the criteria for severity of periodontal disease was based solely on radiographic information/bone loss and not in conjunction with clinical findings such as probing depths and overall health status of soft tissues. This may or may not make a difference on the findings of the study, but this information would be valuable in trying to make these types of conclusions.

Timpawat 2001 -Removal of the smear layer does not seem to be a major factor in microleakage of obturated root canals.

Removal of the smear layer caused significantly more apical microleakage (p < 0.05, Student's t test) than when the smear layer was left intact.

pregnant - respiratory changes

Respiratory changes: · Elevation of the diaphragm decreases the volume of the lungs in the resting state, thereby reducing total lung capacity by 5% and the functional residual capacity (FRC), the volume of air in the lungs at the end of quiet exhalation, by 20%. · These ventilatory changes produce an increased rate of respiration (tachypnea) and dyspnea that is worsened by the supine position · Preeclampsia, defined as hypertension with proteinuria, progresses to eclampsia if seizures or coma develop. The cause of eclampsia is unknown but appears to involve sympathetic overactivity associated with insulin resistance, the renin-angiotensin system.

Montagner F, et al.

Root canal samples from teeth with acute endodontic infections were collected and Porphyromonas, Prevotella, and Parvimo- nas micra strains were isolated and microbiologically identified with conventional culture techniques. The sus- ceptibility of the isolates was determined by the minimum inhibitory concentration of benzylpenicillin, amoxicillin, and amoxicillin + clavulanate using the E- test method (AB BIODISK, Solna, Sweden). The presence of the cfxA/cfxA2 gene was determined through primer-specific polymerase chain reaction. The nitrocefin test was used to determine the expression of the lac- tamase enzyme. Prevotella disiens, Prevotella oralis, Porphyromonas gingivalis, and P. micra strains were susceptible to benzylpenicillin, amoxicillin, and amoxicillin + clavulanate. The cfxA/cfxA2 gene was detected in 2 of 29 isolates (6.9%). Simultaneous detection of the cfxA/cfxA2 gene and lactamase production was observed for 1 Prevotella buccalis strain. The gene was in 1 P. micra strain but was not expressed. Three strains were positive for lactamase production, but the cfxA/cfxA2 gene was not detected through polymerase chain reaction. Conclusions: There is a low prevalence of the cfxA/ cfxA2 gene and its expression in Porphyromonas spp., Prevotella spp., and P. micra strains isolated from acute endodontic infections. Genetic and phenotypic screening must be performed simultaneously to best describe additional mechanisms involved in lactamic resistance for strict anaerobes.

Gomes BFPA et al.

Root canal samples were collected from in- fected teeth at different periods of time (2000-2002, 2003-2005, and 2007-2008) and microbiologically identified with conventional culture techniques. The susceptibility of Prevotella intermedia/nigres- cens, P. oralis, Fusobacterium nucleatum, and P. micra isolated strains was determined by the minimum inhibitory concentration (MIC) of amoxicillin, amoxicillin + clavulanate, benzylpenicillin, clindamycin, erythromycin, and metronidazole by using the E-test method. Amoxicillin and amoxicillin + clavula- nate were effective against the majority of species at the different periods of study. Overall, there were low statistical differences regarding the microbial susceptibility between the experimental periods. However, an increase in the anaerobic resistance to penicillin G and clindamycin was observed. Resistance to erythromycin was observed in all species, and there were statistically significant differences between 2000-2002 and 2003- 2005 periods for F. nucleatum (P < .05) and between 2003-2005 and 2007-2008 periods for P. intermedia/nigrescens and P. oralis (P < .05). Conclusions: The antimicrobial resistance of anaerobes isolated from primary endodontic infections showed an increase throughout a period of time regarding a specific Brazilian population.

epilepsy - Signs and symptoms of generalized tonic-clonic convulsions (grand mal seizures):

Signs and symptoms of generalized tonic-clonic convulsions (grand mal seizures): An aura, a momentary sensory alteration that produces an unusual smell or visual disturbance, precedes the convulsion in one third of patients. Irritability. After the aura, the patient emits a sudden "epileptic cry" caused by spasm of the diaphragmatic muscles, and immediately loses consciousness. The tonic phase : generalized muscle rigidity, pupil dilation, rolling of the eyes upward or to the side, and loss of consciousness. Breathing may stop due to spasm of respiratory muscles. The clonic phase: uncoordinated beating movement of limbs and head, forcible jaw closing, and up and down head rocking. Urinary incontinence is common. The seizure usually does not last longer than 90 seconds. Afterwards, movement ceases and muscles relax with a gradual return to consciousness accompanied by stupor, headache, confusion, and mental dulling. Several hours of rest or sleep may be needed for the patient to regain full cognitive and physical activity

blood 2 - screening lab tests

Screening Laboratory Tests The 4 laboratory tests to screen patients: platelet count, aPTT, PT, and TT -Platelet count: to screen for thrombocytopenia -aPTT: shows the ability of blood remaining within vessels in the area of injury to coagulate. Typically, is prolonged in coagulation disorders affecting intrinsic and common pathways (hemophilia, liver disease) and excessive fibrinolysis If positive, patient should go to a hematologist to have more specific testing performed

epilepsy - seizure management

Seizure management: Preventative measures include knowing patient's history, scheduling at a time within a few hours of taking the anticonvulsant medication, using a mouth prop, removing dentures, and discussing the urgency of mentioning an aura as soon as sensed. If irritability is observed then a seizure will most likely follow: 0.5 to 2mg of lorazepam can be given sublingually or diazepam 2 to 20mg can be given IV. If Seizure takes place while the patient is in the chair: primary objective is to protect the patient and try to prevent injury. No attempt should be made to move the patient to the floor. Instead, instruments/trays should be cleared from the area and chair placed in a supported supine position. Patient's airway should be maintained by patent. No attempt should be made to hold or restrain the patient. Passive restraint should be used only to prevent injury. If a mouth prop is used, it should be inserted at the beginning of the dental procedure. Inserting a mouth prop during the seizure is not advised. Exception: when a patient senses an impending seizure and cooperates. A grand mal seizure generally does not last longer than a few minutes. Afterwards, the patient may fall into a deep sleep from which he or she cannot be aroused. 100% oxygen , maintenance of a patent airway and mouth suction should be provided during this phase. Alternatively, the patient may be turned to the side to control the airway and to minimize aspiration of secretions Within a few minutes, the patient gradually regains consciousness but may be confused, disoriented, and embarrassed. Headache is a prominent feature during this period. If the patient does not respond within a few minutes, the seizure may be associated with low serum glucose, and delivery of glucose may be needed. No further treatment should be attempted after a generalized tonic-clonic seizure, although examination for sustained injuries should be performed. In the case of avulsed or fractured teeth, an attempt should be made to locate the tooth/fragment to rule out aspiration. A chest x-ray may be necessary if the tooth/fragment is not located. In the event that a seizure becomes prolonged (status epilepticus) or is repeated: IV lorazepam (0.05 to 0.1mg/kg) 4-8mg, or 10mg diazepam, generally is effective in controlling it. Lorazepam is preferred over diazepam because it is more efficacious and lasts longer. Oxygen and respiratory support should be provided as respiratory function may become depressed. If seizure lasts longer than 15 minutes: secure intravenous access, repeat lorazepam dosing, administer fosphenytoin, and activate the emergency medical service (EMS) system.

1. Qualitative Precipitin Assay

Series of tubes with equal concentration of antigen i. In each of the same tubes you have a suspension of serum with different dilution in each tube ii. When you have equal concentration, you are able to see precipitation right at the interface 1. This is due to lattice being formed

Author: Ngassapa et al.

Several inflammatory mediators including serotonin (5-HT) have been indicated to play a role in the sensitization of intradental nerves. In the present investigation, using the single fibre recording technique, the effect of locally applied 5-HT (1 mg/ml) and calcitonin gene-related peptide (rat CGRP 2 micrograms/microliters) on the function of intradental nerves in the dog was studied. The effect of these substances on the pulpal blood flow was also investigated to check their effective diffusion into the dental pulp. 5-HT induced a low-frequency background firing in 11 out of 30 nerve fibres. The number of fibres responding to probing, air blast and osmotic stimulation was increased significantly after 5-HT application. Three fibres responded to cold stimulation after 5-HT application; no responses were induced before. After CGRP application, a continuous low-frequency firing was induced only in 1 fibre out of 11 and 1 fibre which before did not respond to osmotic stimulation gave responses to saturated glucose. The responses to probing and air blasts were qualitatively unchanged. Local application of either of the substances induced a change in pulpal blood flow. It is suggested that while 5-HT is able to sensitize intradental nerves to various hydrodynamic stimuli, CGRP seems to be less effective. Pulpal inflammation with the release of inflammatory mediators may significantly affect the degree of dentine sensitivity.

Byers et al.

Several studies dealing with the reactions of dental nerve fibers to injury and inflammation are reviewed in this article. The subgroup of dental nerve fibers that contains calcitonin gene-related peptide (CGRP) was examined by immunocytochemistry at various times (1 to 35 days) after one of three degrees of injury: (a) Mild: Four days after making shallow cavities into cervical dentin of first molars of anesthetized adult rats, we found that CGRP fibers had sprouted into the subjacent odontoblast layer and dentin, and then returned to normal by 3 wk. (b) Intermediate: If the cervical cavities were acid etched, we found damage to the odontoblast layer, microabscess formation, and sprouting of CGRP fibers near the abscess, with subsequent formation of reparative dentin and healing. (c) Severe: If the pulp was exposed, a variety of reactions could occur, the most prevalent of which was a severe necrosis leading to development of periapical lesions. Analysis of the progressive stages of pulpal abscess and necrosis showed sprouting CGRP nerve fibers (a) at the retreating interface between abscess and vital pulp; (b) in periapical areas during onset of lesions; and (c) around chronic abscesses in granulomatous periodontal tissues. These studies are discussed in relation to various dental clinical problems such as hypersensitive teeth, episodic toothache, early onset of periapical lesions, dental anesthesia, and possible roles for sensory fibers and neuropeptides in tissue defense and healing.

cancer - signs and symptoms

Signs and Symptoms Cancer presents as a mass that grows larger over time. Often times when tumors grow, there is an increase in blood vessels that causes reddening and ulceration of the epithelial surfaces. The initial characteristics of cancer include color change, lump formation, lymph node enlargement, and changes in organ function. Additionally, symptoms associated with cancer include paresthesia and pain. Tissue samples can be collected via cytologic smears, needle biopsy, and incisional or excisional biopsies to diagnose cancer. Cell markers, ploidy, and DNA expression can be studied by processing cells through flow cytometry, chromosomal analysis, and in situ hybridization. These investigations can help to better characterize the cancer and guide treatment.

hyperthyroidism - signs and symptoms

Signs and Symptoms More than 50% of patients with Graves' Disease experience fatigue, nervousness, rapid heartbeat, palpations, weight loss, and heat intolerance. As patients get older, decreased appetite and weight loss become more common, while heat intolerance and irritability become less common. Patients usually present with moist, warm, and rosy skin accompanied with palmar erythema, sweating, and melanin pigmentation. Their hair may appear friable and fine, while their nails may be softened. Fifty percent of patients present with Graves' ophthalmopathy, which refers to inflammation of extraocular muscles and an increase of orbital fat and connective tissue. Ophthalmopathy involves eyelid retraction, proptosis, chemosis, bilateral exophthalmos, periorbital edema, and can cause vision loss. Other symptoms involving eyes include infrequent blinking, lid lag, jerky eye movements, and inability to wrinkle brows with an upward gaze. One to two percent of patients with Graves' Disease present with dermopathy, which is an increase in chondroitin sulfate and hyaluronic acid in the dermis that causes dermal lymphatic compression and nonpitting edema. If dermopathy persists, nodules and plaques will commonly form on the anterolateral shin. Patients may also present with thyroid acropachy, which is clubbing of the last phalanx on fingers and toes accompanied by thickening and discoloration of the overlying skin caused by glycosaminoglycan deposits. Increased heart rate, stroke volume, palpitations, and congestive heart failure partially resistant to digitalis are common in patients with Graves' Disease. If patients with hyperthyroidism remain untreated, they become sensitive to epinephrine and other pressor amines. Dyspnea can be present due to respiratory muscle weakness and weigh loss may persist even with an increased appetite. Patients experience an increase in bowel movements, poorly formed stools, and increased calcium and phosphorous concentrations in urine and stool. Bone loss is often seen in radiographs of young patients. Patients with Graves' Disease concurrently with diabetes may need to increase their insulin dose. While individual red blood cells appear normal, the number of red blood cells increases due to the increased oxygen demand required for the increased metabolic activity. Patients may have decreased white blood cells, increased eosinophils, and enlarged spleen and lymph nodes.

hypertension - signs and symptoms

Signs and Symptoms Most hypertensive patients do not present with many symptoms besides elevated blood pressure, highlighting the importance of regular blood pressure readings. Blood pressure readings include the systolic and the diastolic blood pressure. The systolic blood pressure refers to the pressure during peak ventricular contraction and the diastolic blood pressure refers to the total resting resistance in the arterial system after the passage of the pulsating force from left ventricular contraction. Pulse pressure is the difference between the diastolic pressure and the systolic pressure, and the mean arterial pressure is calculated by the adding one-third of the pulse pressure to the diastolic pressure. In patients with untreated stage 1 hypertension, 15-20% experience white coat hypertension, which refers to an elevation of blood pressure only when a health care worker is present but nowhere else. These patients should self-measure their blood pressure at home for more accurate readings. Early signs of hypertension include general symptoms that are often seen in normotensive patients such as dizziness and tinnitus. Later stages of hypertension can involve the kidney, brain, heart, and eyes. Patients that have retinal vessel hemorrhage, exudate, and papilledema should seek immediate medical care as they are signs of accelerated malignant hypertension. Other symptoms of untreated hypertension include hypertensive encephalopathy, left ventricle enlargement, hematuria, proteinuria, renal failure, peripheral arterial changes, and cognitive decline with age.

hypothyroidism - signs and symptoms

Signs and Symptoms Neonatal cretinism presents with dwarfism, overweight, broad and flat noses, wide-set eyes, thick lips, large protruding tongues, lack of muscle tone, pale skin, stubby hands, delayed teeth eruption, and malocclusion. These characteristics can be prevented through early detection and treatment. When hypothyroidism occurs in older children and adults, patients present with dull expressions, puffy eyelids, eyebrow alopecia, yellow palmar, rough skin, brittle hair, increase tongue size, slurred and hoarse speech, anemia, constipation, cold sensitivity, capillary fragility, weight gain, muscle weakness, and deafness. Subcutaneous fluid accumulation is more noticeable in patients with primary myxedema than those with pituitary myxedema. Increased serum cholesterol levels are found in patients with primary myxedema, while patients with pituitary myxedema have close to normal levels of serum cholesterol. Patients with severe myxedema may experience hypothyroid coma, which is fatal.

: Harrison, J; Svec, T.

The antibiotic era began in the early 1940's with the clinical use of penicillin. Subsequent discovery, development, and clinical use of other antibiotics resulted in effective therapy against major bacterial pathogens. These drugs were so effective that bacterial infectious diseases were considered by many experts to be under complete therapeutic control. However, the scientific community grossly underestimated the remarkable genetic plasticity of these orgnaisms and their ability, through mutations and genetic transfer, to develop resistance to antibiotics. Infectious diseases are now the world's major cause of death. The cause of bacterial reemergence as a threat to human health and life is the abuse of the miracle drugs. The ubiquitous nature of antibiotics in the human ecosystem foments bacterial resistance and threatens to eliminate antibiotics as effective drugs for human therapeutic use

Brannstrom M,

Silicate cement was inserted in deep unlined cavities in 70 human teeth; 35 cavities were cleaned with an antibacterial cleanser, and the other 35 cavities in the contralateral teeth were treated with water spray only. In all teeth, invasion of bacteria from the tooth surface was prevented with a surface seal. Histologic examinations after 4 weeks revealed bacterial growth on dentinal walls in 9 of the uncleaned and in 2 cleaned cavities. Only in these 11 teeth was an inflammatory reaction seen in the pulp. Under eight cavities without bacterial growth and with silicate cement placed directly on an exposed pulp, no serious injury and no inflammatory reactions were observed. It was concluded that silicate cement per se does not seriously irritate the pulp. Infection of cavity walls should be avoided, not only by removing grinding debris and antibacterial cleansing, but also by use of a liner to prevent invasion of bacteria from the surface of the tooth.

Tucker et al.

Specific, well-characterized antisera to the extracellular matrix glycoprotein tenascin were used. Immunoreactivity was detected in association with dentinal tubules; it was particularly prominent in the tooth crown, and was stronger within matrix than within predentine. In contrast, there was no anti-fibronectin staining in dentinal tubules. In periodontium, anti-tenascin immunoreactivity was stronger in the oral and sulcular gingival epithelia than in the underlying connective tissue, in contrast to the strong staining of connective tissue by anti-fibronectin. The appearance of tenascin immunoreactivity in gingival epithelia indicates that this protein is not exclusively a component of mesenchymal extracellular matrix.

Syncope and psychogenic shock

Syncope and psychogenic shock ○ Sign and symptoms: pallor, sweating, nausea, anxiety, pupillary dilation, yawning, decreased blood pressure, bradycardia (slow heart rate), convulsive movements, unconsciousness ○ Cause: Cerebral hypoxia (reduced blood flow to brain), sitting or standing stiff (orthostatic hypotension), anxiety (vasovagal response) ○ Treatment i. ii. iii. iv. v. vi. vii. Positioning: Place patient in supine position; lower head slightly and elevate legs (for pregnant women, roll on left side) - assess consciousness A: Airway: Ensure open airwayB: Breathing: Check breathing - should be adequateC: Circulation: Check carotid pulse - should be adequateD: Dispense/administer: ● Oxygen at flow rate 5-6 L/minute ● Aromatic ammonia (eg. Vaporole) - "smelling salts" (optional) ● Cold compresses to forehead Ensure that vital signs, drug administration and patient response are properly monitored and recordedFacilitate next steps in medical/dental care and reassure patient

THYROID CANCER

THYROID CANCER Three types of thyroid cancer include differentiated, medullary, and anaplastic. They can be subdivided into papillary, follicular, mixed, and Hurthle Cell Carcinoma. Primary lymphomas and metastasized cancers are also found in the thyroid gland. Multiple endocrine neoplasia type 2 (MEN2) presents with medullary thyroid carcinoma, parathyroid hyperplasia or adenoma, and pheochromocytoma in 50% of the patients.

5 Pope

Teeth with necrotic pulps were more likely to have PDL widening, but the PDL space of a healthy tooth demonstrated significant variation when examined by CBCT. The radiographic interpretation of health and disease on CBCT must be further investigated before usage in outcome or epidemiologic investigations. This research questions the traditional radiographic interpretation of the PDL space.

82 Damas

The Brasseler EndoSequence Root Repair Materials were shown to have similar cytotoxicity levels to those of ProRoot MTA and MTA-Angelus.

Wilkinson et al.

The FGF-related proto-oncogene int-2 is implicated in mouse embryogenesis, since it is expressed in specific tissues during gastrulation and neurulation (Wilkinson et. al. 1988). Here, we describe the expression of this gene during subsequent fetal development, int-2 transcripts are restricted to Purkinje cells in the cerebellum and to regions of the developing retina containing early-stage differentiating cells. This high level expression is not detected in the mature cerebellum or retina. In addition, int-2 RNA is detected in the mesenchyme of the developing teeth and in sensory regions of the inner ear. This complex and dynamic pattern suggests multiple roles of this proto-oncogene during fetal development of the mouse.

: Lockhart, et al.

The authors conducted a search of the literature in MEDLINE, Embase, the Cochrane Library, and the Cumulative Index to Nursing and Allied Health Literature to retrieve evidence on benefits and harms associated with antibiotic use. The authors used the Grading of Recommendations Assessment, Development and Evaluation approach to assess the certainty in the evidence and the Evidence-to-Decision framework. The panel formulated 5 clinical recommendations and 2 good practice statements, each specific to the target conditions, for settings in which DCDT is and is not immediately available. With likely negligible benefits and potentially large harms, the panel recommended against using antibiotics in most clinical scenarios, irrespective of DCDT availability. They recommended antibiotics in patients with systemic involvement (for example, malaise or fever) due to the dental conditions or when the risk of experiencing progression to systemic involvement is high. Conclusion and Practical Implications. Evidence suggests that antibiotics for the target con- ditions may provide negligible benefits and probably contribute to large harms. The expert panel suggests that antibiotics for target conditions be used only when systemic involvement is present and that immediate DCDT should be prioritized in all cases.

Seux D et al

The cement produced microcrystals of calcite by reaction with culture medium supplemented with calf serum. Human dental pulp cells seeded on such a substrate preferentially adhered and aggregated around the microcrystals. Immunofluorescence and immunogold labelling revealed a high affinity of serum fibronectin molecules for the calcite crystals. At 4 weeks in culture, the cells had various features of differentiated odontoblasts, notably nuclear polarization, typical appearance of the Golgi apparatus, synthesis of type I collagen and absence of type III, and apical accumulation of actin and vimentin. These cells also elaborated a collagenous extracellular matrix which did not mineralize.

Bramanti T (1989)

The chemistry and selected biological activity of lipopolysaccharide (LPS) from Bacteroides gingivalis strains W50, W83, and ATGG 33277 were compared, as well as the role of this molecule as a mediator of selected inflammatory responses. Chemically, the LPSs consisted of 47-58% Lipid A, 5-10% carbohydrate, 0.05% 3-deoxy 2-octulosonic acid, 0,3% heptose, 3.8-5.2% hexosamine, and 2% phos- phate. Rhamnose represented the dominant sugar (26-36%)), with lesser amounts of glucose (18-34%), galactose (18-25%), mannose (9-12%), glucosa- mine (7-1 T/o), and galactosamine (2-5%). The major fatty acids were: 13-methyl-tetradecanoate (42-45%), 3-OH-heptadecanoate (21-23%), hexadecanoate (16-19%), and 12-methyl-tetradecanoate (6-8%). SDS-PAGE and sodium deoxy-cholate-PAGE revealed the LPS to be a smooth chemotype. Differences in mi- gration patterns between the virulent and avirulcnt strain LPSs also occurred. C3H/HeN macrophages (Mo) exposed to 1 //g/ml of LPS released 3.2^,2 ng of prostaglandin E (PGE)/ml of supernatant, representing 236-278% of control, Interleukin-1 (IL-1) activity in G3H/HeN and G3H/HeJ M0 exposed to 50 /ig of LPS/ml was 382-724% and 270-300% of control, respectively; similar Mo exposed to 10 /(g of LPS/ml released 1.6-2.0 ng and 0.3-0.5 ng of tumor necrosis factor (TNF)/ml of supernatant, respectively. Maximum TNF release in G3H/HeN M 0 occurred in response to 50 ^<g of LPS/ml, and was sustained for up to 96 hours. These results suggest that LPS from the B. gingivalis strains stimulate cytokine production from Mo which, in turn, may play a role in orchestratitig the inflammatory response for the development of periodontal diseases.

Linde, A.; Goldberg, M.

The formation of dentin, dentinogenesis, comprises a sophisticated interplay between several factors in the tissue, cellular as well as extracellular. Dentin may be regarded as a calcified connective tissue. In this respect, as well as in its mode of formation, it is closely related to bone. Using dentinogenesis as an experimental model to study biomineralization provides several practical advantages, and the results may be extrapolated to understand similar processes in other tissues, primarily bone. After describing dentin structure and composition, this review discusses items such as the morphology of dentinogenesis; the dentinogenically active odontoblast, transport, and concentrations of mineral ions; the constituents of the dentin organic matrix; and the presumed mechanisms involved in mineral formation.

Garberoglio et al

The fractured coronal dentine of 30 intact human teeth, in various age groups, was examined at various distances from the pulp. Near the pulp the number of tubules per square millimeter was 45,000 and the diameter 2.5 μm, in the middle of the dentine, there were 29,500/mm2 tubules and the diameter was 1.2 μm. Peripherally the corresponding values were 20,000/mm2 and 0.9 μm. The tubule volume in coronal dentine was calculated as 10 per cent. No great difference was observed between old and young teeth. The diameter of tubules increased considerably on decalcified fractured surfaces due to the total removal of peritubular dentine. Previous values based on such sections are not valid. Odontoblast processes were seen only in tubules near the pulp.

Linde A

The dental pulp is a loose connective tissue, characterized by its specific anatomical location. Its extracellular components are obvious subjects for study, since such components are largely responsible for the physiological properties of the tissue. Several clinically important processes occur extracellularly, e.g., defense mechanisms such as inflammatory reactions and formation of calcified tissue. The dental mesenchyme has a crucial role during early tooth morphogenesis. The dental pulp, or rather the dental papilla, seems to have only an indirect role during dentinogenesis. This review discusses proteoglycans and glycosaminoglycans, fibronectin and other non-collagenous proteins, and the different types of collagen that have been studied in pulp connective tissue. With regard to its biochemical constituents, the pulp is similar to other loose connective tissues. Collagen type I is the major fibrous component, but collagen type III also constitutes a large portion. Fibronectin is present, as is a high content of proteoglycan. In the proteoglycans, all normally occurring connective tissue glycosaminoglycans can be demonstrated. The composition of the pulpal extracellular matrix during tooth development is quite different from that of the mature tooth. Thus, it is important not to draw any too-far-reaching conclusions about the situation in human pulp from results obtained by studying pulp from animal teeth with ongoing dentinogenesis. In spite of their common ancestry, pulp and dentin differ considerably in extracellular matrix composition. Proteoglycans and collagen type I are present in dentin. No type III collagen or fibronectin can be found in the dentin, although it is present in the dental pulp.(ABSTRACT TRUNCATED AT 250 WORDS)

Dong

The developing murine tooth has been used as an excellent model system to study the molecular mechanism of organ development and regeneration. While the expression patterns of numerous regulatory genes have been examined and their roles have begun to be revealed in the developing murine tooth, little is known about gene expression and function in human tooth development. In order to unveil the molecular mechanisms that regulate human tooth morphogenesis, we examined the expression patterns of the major BMP signaling pathway molecules in the developing human tooth germ at the cap and bell stages by in situ hybridization, immunohistochemistry, and real-time RT-PCR. Expression of BMP ligands and antagonist, including BMP2, BMP3, BMP4, BMP7, and NOOGGIN, exhibited uniform patterns in the tooth germs of incisor and molar at the cap and bell stages with stronger expression in the inner dental epithelium than that in the dental mesenchyme. Both type I and type II BMP receptors were present in widespread expression pattern in the whole-enamel organ and the dental mesenchyme with the strongest expression in inner dental epithelium at the cap and bell stages. SMAD4 and SMAD1/5/8 showed an expression pattern similar to that of BMP ligands with more intensive signals in the inner dental epithelium. Despite some unique and distinct patterns as compared to the mouse, the intensive expression of BMP signaling pathway molecules in the developing human tooth strongly suggests conserved functions of BMP signaling during human odontogenesis, such as in mediating tissue interactions and regulating differentiation and organization of odontogenic tissues. Our results provide an important set of documents for studying molecular regulatory mechanisms underlying tooth development and regeneration in humans.

Stevens R, Hammond B (1988

The direct cytotoxicity of sonic extracts (SE) from nine periodontal bacteria for human gingival fibroblasts (HGF) was compared. Equivalent dosages (in terms of protein concentration) of SE were used to challenge HGF cultures. The cytotoxic potential of each SE was assessed by its ability to (1) inhibit HGF proliferation, as measured by direct cell counts; (2) inhibit 3H-thymidine incorporation in HGF cultures; or (3) cause morphological alterations of the cells in challenged cultures. The highest concentration (500 μg SE protein/ ml) of any of the SEs used to challenge the cells was found to be markedly inhibitory to the HGFs by all three of the criteria of cytotoxicity. At the lowest dosage tested (50 /¿g SE protein/ml); only SE from Actinobacillus actinomycetemcomitans, Bacteroides gingivalis, and Fusobacterium nucleatum caused a significant effect (greater than 90% inhibition or overt morphological abnormalities) in the HGFs as determined by any of the criteria employed. SE from Capnocytophaga sputigena, Eikenella corrodens, or Wolinella recta also inhibited cell proliferation and thymidine incorporation at this dosage; however, the degree of inhibition (5-50%) was consistently, clearly less than that of the first group of three organisms named above. The SE of the three other organisms tested (Aclinomyces odontolyticus, Bacteroides intermedius, and Streptococcus sanguis) had little or no effect (0-10% inhibition) at this concentration. The data suggest that the outcome of the interaction between bacterial components and normal resident cells of the periodontium is, at least in part, a function of the bacterial species.

Jontell et al

The existence and location of various immunocompetent cells in the human dental pulp were investigated. Pulp tissue for analysis was obtained both from clinically intact pre-molars and from third molars without restorations or caries. Frozen and acetone-fixed pulp tissue sections were subjected to indirect immunohistochemistry with monoclonal antibodies to the following cell types: all peripheral T cells, helper/inducer T cells, cytotoxic/suppressor T cells, macrophages, B cells, and Class II antigen-expressing cells. Dendritic cells expressing Class II antigens (HLA-DR, -DQ), indicating a capacity for presentation of antigen to T helper cells, were seen in the odontoblastic layer as well as in the central portions of the pulp tissue. T lymphocytes, divided into helper/inducer and cytotoxic/suppressor cells, were observed in all pulp specimens. B cells were not seen in any of the pulp samples examined. The data demonstrate that the human dental pulp is equipped with immunocompetent cells essential for the initiation of immunological responses.

: Cvek

The exposed pulps of 60 permanent incisors with a complicated crown fracture were treated with partial pulpotomy and calcium hydroxide dressing. The interval between accident and treatment varied from one to 2,160 hours and the size of the pulpal exposure varied from 0.5 to 4.0 mm. Of the teeth, 28 had immature and 32 had mature roots. The treatment was successful in 58 teeth or 96% according to the following criteria: no clinical symptoms, no radiographically observed intraradicular or periradicular pathologic changes, continued development of an immature root, radiographically observed and clinically verified hard tissue barrier, and sensitivity to electrical stimulation. The follow-up examination varied from 14 to 60 months, with an average of 31 months.

Chen,

The interrelationship between periodontal and endodontic disease has aroused much speculation, confusion, and controversy. Pulpal and periodontal problems are responsible for more than 50% of tooth mortality today. Diagnosis is often difficult since these diseases have been studied primarily as separate entities. The toxic substances of the pulp may initiate periodontal defects through canal ramifications and patent dentinal tubules, thus impairing wound healing in regenerative procedures. Although no studies exist addressing the direct effect of pulpal infection on the outcome of guided tissue regeneration (GTR) procedures, several studies do indicate that pulpal status may play a significant role toward the end results of GTR. This review article discusses the potential influence of endodontic treatment on the long-term outcomes of GTR. Potential pathways between the pulp and periodontal ligament, which may be responsible for the failure of the regeneration of new periodontal attachment apparatus, are explored. Examination and review of the clinical and research findings in the literature relating to perio-endo lesions are made to demonstrate that a negative influence may exist between GTR outcomes and the status of the pulp.

Karjalainen

The life span of odontoblasts may be as long as the body itself but may become shortened in case of lack of space or severe damage. New odontoblasts derived from the cell-rich zone may then replace the destroyed original ones. Odontoblasts in mature teeth sustain a level of metabolic activity enough for continuous secondary dentin formation. If mildly injured, this may become enhanced to form reparative dentin in a previously undefined manner and rate. The results presented in this communication further suggest that a dentin injury involving two thirds of its thickness, or more, constitutes a point from which no return is possible for the underlying original odontoblasts. When the formation of primary dentin shifts to secondary dentin formation both the rate of dentin formation and the metabolic activity of the odontoblast layer are reduced by approximately 70%. Mildly injured odontoblasts display an enhanced metabolic activity which, depending on the parameter measured, may be 30 to 50% or more higher than the activity of odontoblasts of fully matured healthy teeth. Deep injuries, on the other hand, cause organizational degradation of the most severely injured odontoblats and the consequent release of lysosomal enzymes.

Moss-Salentijn

The literature on pulpal calcifications has been reviewed. The incidence of calcified bodies in human dental pulps is probably higher than most studies have suggested because of the problem of underreporting. Two possible modes of development exist: initial calcification of isolated pulp tissue components, which may occur anytime and anywhere in the pulp tissue, and epithelio-mesenchymal interactions during odontogenesis, which may occur only in the furcation areas and near the root sheath. The composition of the calcified bodies varies.They may be composed of "ortho" dentin, nontubular "fibro" dentin or irregular calcified material. Frequently the calcified bodies are conglomerates of these different tissues. The traditional classification of true and false denticles, based on histological characteristics, is difficult to maintain in view of this complexity of composition. Clinically, pulpal calcifications most likely are symptoms, not the cause of pathosis.

4 Bender

The mandible proved to be well-suited for this study because there were variations in cancellous and cor- tical bone thickness. These could be measured in millimeters with subsequent radiographic estimation of percent of volume bone loss and percent- age of MBL to produce radiographic visualization. The results indicate that the highest concentration of mineral per unit volume is located in the periosteal cortex, with slightly less in the endosteal cor- tex, and the least amount in the cancel- lous bone. The amount of MBL in cancellous bone does not significantly affect the radiographic results. Although experimental lesions were made in three different bone sites, the radiographs as visualized included the summation of the entire thickness of the mandible. The lowest percent of MBL in the direct path of the X-ray beam to create a radiolucent area in conical bone was 6.6%. It is suggested that a 7.1% MBL average be considered, to compensate for soft tissue X-ray absorption under clinical conditions and for consistency in radiographic visualization. Although there was general agreement that 30% to 50% mineral loss is required before radiographic rarefaction is visualized in osteoporotic bone, these percentages do not apply in local resorptive lesions.

8 Dummer

The mean A—F distance was 0,38 mm and the mean A—C distance 0,89 mm, although it must bemstressed that a wide range of values was observed. Four distinct types of apical constriction were routinely found, whilst a proportion of canals were apparently blocked. The study confinns the view that it is impossible, with complete certainty, to establish the position ofthe apical canal constriction during root canal therapy, but indicates that a combination of methods might be more successful than reliance on one.

Thesleff I, Lehtonen E, Saxén L

The mesenchymal cells of the developing tooth differentiate into odontoblasts as a result of an epithelio-mesenchymal interaction. Odontoblast differentiation was studied in vitro by cultivating dental mesenchyme and epithelium with interposed filters. Separation of the two components by enzyme treatment resulted in removal of the basement membrane. When the epithelium was grown alone, or transfilter from killed lens capsule, the basement membrane was not restored. Transfilter cultivation with dental mesenchyme resulted in basement membrane formation, but only if the filter pores allowed penetration of cytoplasmic processes. Hence, a close association between the epithelial and the mesenchymal cells seems to be a prerequisite for the restoration of the basement membrane. Differentiation of odontoblasts took place only in explants in which a basement membrane was formed. Differentiation did not occur when contact of the mesenchymal cells with the basement membrane was prevented by small pore size filters. Further experiments demonstrating an intact basement membrane suggested that membrane contacts between the epithelial and the mesenchymal cells are not needed for odontoblast differentiation. Hence, we suggest that differentiation of odontoblasts is triggered via contact of the mesenchymal cells with the basement membrane.

Kenneth 2005 - Efficacy of irrigation improves as preparation/instrumentation size increases

The percentage of bacteria remaining following irriga- tion was 26.95 " 9.71%, 10.46 " 5.87%, and 10.64 " 6.01% for sizes 36, 60, and 77, respectively (p # 0.001; repeated-measures ANOVA), with no difference be- tween sizes 60 and 77 (p $ 0.05; Tukeys). Irrigation 1mm from WL was significantly less effective in canals prepared to size 36.

Okiji et al

The precise distribution of various immunocompetent cells in rat molar pulp was immunohistochemically examined by use of seven anti-rat monoclonal antibodies. It was demonstrated that rat molar pulp contained many OX6 (anti-Ia antigen)-positive cells and a large number of ED1 (anti-monocytes, macrophages, and dendritic cells)-positive, ED2 (anti-tissue macrophages)-positive, and/or OX35 (anti-macrophages and CD4+ lymphocytes)-positive cells. Macrophage-like cells predominated in the central portion of the pulp, while cells of dendritic appearance usually existed in the periphery of the pulp. Double-immunoperoxidase staining revealed that these cells showed some heterogeneity, but the majority could be classified as ED1+/OX6-/ED2+ cells, which may be Ia-histiocytes. Findings also suggested that true dendritic cells may be included in the ED1+/OX6+/ED2- category of cells. A small number of T lymphocytes and plasma cells were also detected. These results suggest that the normal dental pulp contains a variety of immunocompetent cells, with macrophages as the most dominating. Following the exogenous invasion of pathogenic stimuli in the pulp, these cells may participate in the defense reaction by acting as phagocytes or antigen-presenting cells, which are essential for the initiation of immune responses.

Butler W

The precise mechanisms involved in dentinogenesis are not understood; however, the information to date suggests that a number of highly controlled extracellular events are involved. Mature odontoblasts secrete collagen at the cell border into predentin. They synthesize and secrete other non-collagenous proteins (NCPs) at the mineralization front, possibly through odontoblastic processes. A collagen-NCP complex is formed at the predentin-dentin border and apatite crystal initiation and growth takes place. One of the research needs is to uncover the nature of this dentin collagen-NCP complex and to understand how it controls mineralization. At least three dentin specific NCPs are known: phosphophoryn(s), dentin sialoprotein (DSP) and AG1 (Dmp1). Other macromolecules are commonly made by osteoblasts and odontoblasts and participate in bone and dentin formation. Some progress in understanding dentin mineralization has been gained by focusing upon the role of phosphophoryns. These highly phosphorylated proteins are secreted at the mineralization front, where a small portion binds in the gap region of type I collagen fibrils. This portion of phosphoproteins probably initiates formation of plate-like apatite crystals. Additional phosphoryns in higher concentrations bind to the growing apatite crystals and slow their growth, possibly influencing their size and shape. Other areas which need careful investigations are those involving the mechanisms involved in odontoblast differentiation, how the synthesis of the dentin specific NCPs is controlled and the precise roles of these macromolecules in dentinogenesis. Future experimentation will focus on the gene structures for these NCPs and the mechanisms of tissue specific gene regulation.(ABSTRACT TRUNCATED AT 250 WORDS)

: Tziafas et al.

The pulps of 36 permanent dog teeth were mechanicallyexposed and capped with Dycal, calcium hydroxide powder mixed with saline, or Teflon. At 2, 14, and 28 days postoperatively, nine teeth treated with the materials were extracted (treated control teeth): A suspension of streptococci was then injected intravenously. Twenty-four h later the dogs were killed and both the 27 treated teeth (experimental group) and 6 unoperated control teeth were removed in tissue blocks. Tissue sections were examined for the presence of bacteria, hard tissue formation, inflammatory cell response and necrosis. Bacteria were not observed in the unoperated and treated control teeth or in three of four teeth capped with Teflon for 29 days. In all the remaining specimens colonies of gram-positive cocci were found.

Jansson L et al *

The purpose of the present investigation was to explore possible relationships between clinical periodontal status in periodontally involved teeth with and without endodontic infection. The investigation was conducted as a retrospective study on a consecutive referral population. The periapical conditions in endodontically-involved single-rooted teeth from a selected patient sample were evaluated and correlated to their periodontal status. There was a significant correlation between periapical pathology and vertical bony destructions. An intra-individual comparison between pocket depth in teeth with and without periapical pathology showed that periapical pathology was significantly correlated to an increased pocket depth in the absence of a vertical bony destruction. It was concluded that an endodontic infection, evident as a periapical radiolucency, promotes periodontal pocket-formation on an instrumented marginal root surface and, consequently, should be regarded as a risk factor in periodontitis progression and be given appropriate consideration in periodontal treatment planning.

Kaga et al.

The purpose of this study was to compare the relative cytotoxicity of amalgams and to determine whether their toxicity depends upon composition and aging time, by means of a rapid and sensitive in vitro cell culture test. Zinc-containing amalgams showed higher cytotoxicity than did any other amalgams. High-copper amalgams had the same cytotoxicity as did the low-copper amalgam. The addition of selenium did not reduce the cytotoxicity of amalgam. Moreover, excessive additions of selenium increased the cytotoxicity of amalgam compared with that of a similar selenium-free material. The cytotoxicity of amalgam was decreased with aging time, possibly due to the combined effects of surface oxidation and further amalgamation.

Mendoza

The purpose of this study was to describe the ultrastructuralchanges in the vasculature and connective tissue in human apical pulps of teeth clinically diagnosed as having an irreversible pulpitis. Ten pulp specimens were obtained from eight teeth with irreversible pulpitis. The apical pulp was processed for investigation by electron microscopy and evaluated subjectively for moderate to severe changes in the structure of the vasculature, connective tissue stroma, mineralizations, bacterial invasion, and inflammatory infiltrates. The results showed that there were individual variations of moderate to severe changes within the vasculature and connective tissue of the apical pulp in the clinical condition of irreversible pulpitis. We cannot predict, based on the clinical tests and radiographs, the exact histological condition of these pulps.

Cohen JS,

The purpose of this study was to determine the concentrations of prostaglandin E2 and prostaglandin F2α in painful and asymptomatic human dental pulps. Pulps were obtained from three groups of teeth: uninflamed pulps, asymptomatic teeth with caries and/or large restorations, and symptomatic teeth with the clinical diagnosis of irreversible pulpitis. Pulps were dissected from the teeth and stored in liquid nitrogen. They were homogenized in 40% ethanol and a lipid solvent extraction was performed. Prostaglandin levels were measured using radioimmunoassay. The pulps which were likely to demonstrate inflammation had significantly higher mean concentrations of prostaglandin E2 than did the uninflamed pulps (p<0.05). Painful pulps had a much higher level of both prostaglandin E2 and prostaglandin F2α than the asymptomatic pulps (p < 0.01).

Hanazawa S (1991)

The purpose of this study was to examine whether Bacteroides (Porphyromonas) gingivalis fimbriae, an important structure involved in attachment of the bacteria to periodontal tissues, activate macrophages and subsequently induce gene expression and production of interleukin-1 (IL-1) in the cells. The fimbriae increased glucose consumption and lysozyme activity in BALB/c macrophages, both criteria of macrophage activation of peritoneal macrophages, in a dose-dependent fashion. A marked increase in the mRNA level of the c-myc gene, an oncogene, in the cells was observed after a 1-h treatment with the fimbriae, and the level decreased rapidly after 3 h. The fimbriae (4 ,ug of protein per ml) markedly induced IL-la and IL-10 gene expression in the cells and IL-1 production. The expression of IL-la and IL-1I genes measured in terms of specific mRNA increased 1 h after the start of treatment and peaked at 6 h. Such increased expression of IL-1I was also observed in C3H/HeJ mice, a lipopolysaccharide low-responder strain. The fimbriae stimulated transcriptional activity of IL-1D in the cells, but not that of IL-la. We also observed that fimbriae-induced IL-1 gene expression was not regulated by endogenous prostaglandin triggered by the fimbriae. Therefore, these observations suggest that B. gingivalis fimbriae may be involved in the pathogenesis of adult periodontal disease via triggering of IL-1 production by monocytes/macrophages in periodontal diseases.

Fachin

The purpose of this study was to histologically investigate steroid effects on the dental pulp. Three steroid preparations, hydrocortisone, betamethasone and triamcinolone, were locally applied to the exposed pulp tissue in rat incisor after pulpectomy. After 24 h, the effects on the tissues were assessed by light microscopy. The results showed that topical application of corticosteroids as an intracanal medicament reduced inflammatory changes in the pulp as compared with controls. Furthermore, triamcinolone and betamethasone demonstrated more potent anti-inflammatory effects than did hydrocortisone.

Linde A et al.

The purpose of this study was to investigate the mineral induction capacity in vitro of polyanionic proteins covalently bound to a surface. Rat dentin gamma-carboxyglutamate-containing protein of the osteocalcin type (Gla-protein), proteoglycan (PG), and phosphoprotein (PP-H), as well as phosvitin (PhV) and bovine serum albumin (BSA), were covalently linked to agarose beads. There were incubated at 37 degrees C in solutions with a Ca/P molar ratio of 1.67, [Ca][P] molar products in the range 1.0-1.8 mM2, and an ionic strength of 0.165. The incubations were performed at constant pH and composition conditions; no spontaneous precipitation occurred under these conditions. Mineral formation, as monitored by scanning electron microscopy (SEM), was induced by all immobilized polyanions, including enzymatically dephosphorylated PP-H and PhV. No mineral was induced by BSA. The mineral inductive capacity of immobilized polyanionic proteins, as judged by the SEM after identical incubations, was found to differ between the different ligands. The mineral induced by PP-H and PG was shown by X-ray diffraction to be apatitic. It was concluded that, although polyanionic proteins in solution may inhibit mineral induction and growth, very minute quantities of such molecules, when immobilized on a surface, induce mineral at physiological concentrations of calcium and phosphate ions. The data presented may be taken to suggest that PP-H and PG, and perhaps other polyanions, may possibly be responsible for mineral nucleation in dentin and bone. The results, however, also point to the rather limited specificity in this type of reaction.

Caviedes-Bucheli J et al.

The purpose of this study was to quantify the effect of tooth bleaching on substance P (SP) expression in healthy human dental pulp. Forty pulp samples were obtained from healthy premolars in which extraction was indicated for orthodontic reasons. Thirty of these premolars were assigned into three different tooth-bleaching protocols: group 1 (n = 10): Opalescence Xtra Boost (Ultradent Products, South Jordan, UT) (38% H(2)O(2)) for 15 minutes; group 2 (n = 10): Lase Peroxide (DMC, Brazil) (35% H(2)O(2)) activated with infrared laser diode (Biolux; BioArt, Brazil) for 3 minutes, and group 3 (n = 10): Zoom! Whitening System (Discuss Dental, Culver City, CA) (25% H(2)O(2)) light activated for 20 minutes. The remaining 10 healthy premolars serve as a control group. Teeth were anesthetized immediately after bleaching and were extracted 10 minutes later. All pulp samples were processed and SP was measured by radioimmunoassay. Greater SP expression was found in the Zoom! Whitening System, followed by the Lase Peroxide group, Opalescence Xtra Boost, and the lower SP values were for the control group. Analysis of variance showed statistically significant differences between groups (p = 0.0001). Tukey HSD post hoc tests showed significant differences in the light (p < 0.01) and laser (p < 0.05) activated bleaching systems when compared with control values. It can be concluded that light- and laser-activated tooth-bleaching systems increase SP expression in human dental pulp significantly higher than normal values.

10 Ricucci

The results of an in vivo histological study involving apical and periapical tissues following root canal therapy after different observation periods demonstrated the most favourable histological conditions when the instrumentation and obturation remained at or short of the apical constriction. This was the case in the presence of vital or necrotic pulps, also when bacteria had penetrated the foramen and were present in the periapical tissues. When the sealer and/or the gutta-percha was extruded into the periapical tissue, the lateral canals and the apical ramifications, there was always a severe inflammatory reaction including a foreign body reaction despite a clinical absence of pain.

: Bender. IB, Seltzer. S and Turkenkopf

The results of root canal therapy in 2,335 teeth after 6 months and 706 teeth after 2 years were studied statistically in an attempt to uncover a significant relationship between success of repair in teeth with and without areas of rarefaction, positive or negative cultures, method of filling canals, and other variables. 1. 1. Repair was successful in 82 per cent of the teeth in all categories. 2. 2. Among the root canals of teeth which in the previous visit had yielded a negative culture, 16.6 per cent yielded positive cultures immediately prior to filling of the canal. 3. 3. On the basis of roentgenographic evidence alone, the prognosis for successful repair was less favorable in teeth with areas of rarefaction, regardless of the bacteriologic status of the root canal (88.8 per cent success in teeth without areas of rarefaction, 77 per cent success in teeth with such areas). 4. 4. There was no statistically significant difference between success of repair in teeth yielding positive or negative cultures prior to filling. 5. 5. The lateral-condensation methods of filling canals yielded slightly better results than the single-cone method, but the difference was not statistically significant in all groups. 6. 6. Overfilling of the root canal gave the worst percentage of success (69 per cent), and canals filled flush with the apex showed the best results (87.4 per cent success). 7. 7. A 2 year follow-up gives a more significant evaluation of success than a 6 month follow-up in teeth without areas of rarefaction. In teeth with areas of rarefaction a 6 month follow-up period is as reliable as a follow-up period of 1 to 2 years after treatment for evaluation of success. 8. 8. Differences in successful results may be due to an individual investigator's technique of débridement and pus evacuation, filling, and diagnosis, as well as other factors, but are not based on culture results. 9. 9. Differences in degree of success in this study were dependent upon roentgenographic interpretation and not on other clinical factors.

96 Torabinejad

The results of this study show that some factors, such as age, sex, tooth type, presence of preoperative pain, presence of allergies, absence of periapical lesions, sinus tract stomas, retreated cases as well as those receiving prescribed analgesics, had significant effects on the incidence of endodontic interappointment emergencies.

15 Sjogren 1990**memorize this article**

The results of treatment were directly dependent on the preoperative status of the pulp and periapical tissues. The rate of success for cases with vital or nonvital pulps but having no periapical radiolucency exceeded 96%, whereas only 86% of the cases with pulp necrosis and periapical radiolucency showed apical healing. The possibility of instrumenting the root canal to its full length and the level of root filling significantly affected the outcome of treatment. Of all of the periapical lesions present on previously root-filled teeth, only 62% healed after retreatment. The predictability from clinical and radiographic signs of the treatment-outcome in individual cases with preoperative periapical lesions cases was found to be low. Thus, factors which were not measured or identified may be critical to the outcome of endodontic treatment.

Seltzer et al.

The use of the scanning electron microscope has been investigated as a modality for pulpal diagnosis. Findings in ten normal, inflamed, and necrotic human pulps were correlated with light microscope findings. Inflammatory cell identification by SEM was found to be difficult. The inflammatory cells, especially lymphocytes, appeared in varying forms in SEM. Polymorphonuclear leukocytes and macrophages had similar surface structure. Degenerative changes of cells and fibers and dystrophic mineralizations were graphically depicted by SEM.

Fujisawa S,

The visible-light (VL) polymerizing resin system with photoinitiators (photosensitizer and reducing agent) is widely used in modern dentistry. In this system, polymerization is initiated by photochemical reactions between the photosensitizers (aromatic or aliphatic ketones) and reducing agents (tertiary amines) during VL irradiation. In order to simulate the VL resin-induced toxicity in dental pulps, the present investigation was conducted to determine whether hemolysis of dog erythrocytes and lipid peroxidation of their components occur on exposure to a VL resin system containing aromatic (9-fluorenone, benzil) or aliphatic ketones (camphoroquinone) plus tertiary amine [2-(dimethylamino) ethyl methacrylate]. It was demonstrated that the hemolysis and lipid peroxidation with aromatic ketones were markedly higher than with those of aliphatic ketones, even when the latter were used at higher concentrations. It was clear that peroxidation-induced hemolysis occurred and, further, that surface-active complexes between photosensitizers and reducing agents, which are formed by irradiation, promote hemolytic activity due to their hydrophobic interactions. VL resin-induced responses to dental pulps are probably promoted due to the double effects of unpolymerized monomers and of both radicals and surface-active complexes formed during irradiation.

89 Goldman

There is circulation and interchange of fluids both in and out of the tube shown in 1 week and 5 months -There was no evidence of inflammation at the ends of the tubes and the reaction was same whether the implant was hollow or solid at all time periods

Chailertvanitkul 1996 -the presence or absence of the smear layer did not affect bacterial leakage

There was no statistical signiflcant difference (P > 0.05) in leakage between the obturated canal when the smear layer was either removed or intact.

Fugaro

This study evaluated the histological changes in dental pulp after nightguard vital bleaching with 10% carbamide peroxide gel. Fifteen patients between 12 and 26 years of age with caries-free first premolars scheduled for orthodontic extraction were treated with 10% Opalescence (Ultradent Products, Inc). Tooth #5 had four days of bleaching, tooth #12 was treated for two weeks, tooth #21 was bleached for two weeks followed by two weeks without treatment and tooth #28, serving as the control, was without treatment. All teeth were extracted at the same time. Immediately after extraction, 4 mm of the most apical portion of the root was sectioned off and each specimen was placed in a vial containing 10% neutral buffered formalin. The samples were prepared for histological evaluation at the Scandinavian Institute of Dental Materials (NIOM) and microscopically examined independently at both NIOM and Indiana University School of Dentistry (IUSD). Pulp reactions were semi-quantitatively graded as none, slight, moderate and severe. Slight pulpal changes were detected in 16 of the 45 bleached teeth. Neither moderate nor severe reactions were observed. The findings indicate that the slight histological changes sometimes observed after bleaching tend to resolve within two weeks post-treatment. Statistical differences existed only between the untreated control and the four-day (p=0.0109) and two-week (p=0.0045) treatment groups. The findings from this study demonstrated that nightguard vital bleaching procedures using 10% carbamide peroxide might cause initial mild, localized pulp reactions. However, the minor histological changes observed did not affect the overall health of the pulp tissue and were reversible within two weeks post-treatment. Therefore, two weeks of treatment with 10% carbamide peroxide used for nightguard vital bleaching is considered safe for dental pulp.

Peters et al

This study investigated the positive and negative responses of 1488 teeth in 60 patients to two electric pulp testers and a cold thermal pulp test. Three subgroups of known pulpless or pulpally diseased teeth (teeth receiving root canal therapy, teeth with root canal fillings, or teeth with confirmed associated apical radiolucencies) were identified and their responses evaluated separately. Testing was performed on two tooth surfaces, the facio-occlusal and faciocervical, and on all restorations. The gingival tissue of each patient also was tested using both electrical tests. The primary findings were: (a) teeth not responding to cold and either not responding or responding at readings greater than the tissue response to electrical had a high probability of being in the known pulpless or pulpally diseased subgroups; (b) the only false positive responses to cold in the three subgroups were in multirooted teeth with probable vital tissue remaining in at least one canal; and (c) in the three subgroups, if the false positive responses to electrical that responded at levels higher than the patient's tissue response were considered to be negative responses, the difference in false positives between cold and electrical became not statistically significant (p = 0.07).

Sjogren et al.

This study investigated the role of infection on the prognosis of endodontic therapy by following-up teeth that had had their canals cleaned and obturated during a single appointment. The root canals of 55 single-rooted teeth with apical periodontitis were thoroughly instrumented and irrigated with sodium hypochlorite solution. Using advanced anaerobic bacteriological techniques, post-instrumentation samples were taken and the teeth were then root-filled during the same appointment. All teeth were initially infected; after instrumentation low numbers of bacteria were detected in 22 of 55 root canals. Periapical healing was followed-up for 5 years. Complete periapical healing occurred in 94% of cases that yielded a negative culture. Where the samples were positive prior to root filling, the success rate of treatment was just 68%--a statistically significant difference. Further investigation of three failures revealed the presence of Actinomyces species in each case; no other specific bacteria were implicated in failure cases. These findings emphasize the importance of completely eliminating bacteria from the root canal system before obturation. This objective cannot be reliably achieved in a one-visit treatment because it is not possible to eradicate all infection from the root canal without the support of an inter-appointment antimicrobial dressing.

Reeves and Stanley

This study was based on the histologic examination of forty-six virgin carious human teeth. In each specimen measurements were made of the distance between the deepest penetration of the bacteria and the pulpal tissue. The pulpal pathosis was graded according to the type of lesion and the amount of reparative dentine formation. Specimens in which the distance between the penetrating bacteria and the pulp, including the thickness of the reparative dentine, averaged 1.11 mm. or more revealed insignificant pathologic lesions. Specimens with no reparative dentine also presented only minimal pathosis or none at all. When the reparative dentine itself was invaded by the bacteria, however, pathosis of real consequence and of an irreversible nature was found.

Isermann G, Kaminski E

Twenty-six teeth from 8-month-old beagle dogs were used to evaluate the pulpal response to bacteria in bacterially contaminated minimally exposed and unexposed pulp in the dog. The effects were evaluated by means of serial radiographs, consecutive vital dye injections, and histologic sections. Periapical lesions developed in all of the eight teeth which were bacterially infected and exposed. Out of ten teeth which were bacterially infected and had cavities without pulp exposure, only two teeth in the acute group demonstrated inflammatory changes and loss of odontoblastic function directly beneath the infected dentinal tubules. Within the limits of the experimental design, this study demonstrated the pulpal responses of the dog with respect to bacteria.

Mutoh et al

Toll-like receptors (TLRs) are important factors in innate immune responses because they mediate signals from bacterial cell wall components during inflammatory reactions. However, the role of TLR in dental pulp, which is bounded by hard tissues, is little understood. The present study investigated the expression of TLR-2 and TLR-4 in experimentally inflamed pulp by quantitative real-time polymerase chain reaction and immunohistochemistry. Total RNA isolated from pulp tissue from 0 to 72 hours after bacterial dentinal infection. The TLR-2 messenger RNA (mRNA) level was 30-fold higher than the TLR-4 mRNA level at 9 hours. The TLR-2 mRNA level in pulp began to increase by 3 hours after bacterial infection, reaching a maximum level after 9 hours and gradually decreasing from 9 to 72 hours. Numerous TLR-2- and CD64-positive cells detected on macrophage and dendritic-like cells, TLR-4-positive cells detected a little in the pulp at 9 hours. These results suggest that TLR-2 may be mainly regulated during the early stage of pulp inflammation triggered by bacterial infection.

Markowitz K, Pashley DH

Tooth sensitivity is a common dental pain condition where sufferers experience brief episodes of sharp well-localized pain when their teeth are subjected innocuous stimuli such as cold, air-currents and probing with a metallic instrument. In this review, we will make no attempt to describe all the treatments that have been developed to treat tooth sensitivity. We will review the basic anatomic and physiological mechanisms responsible for sensitivity. The insights into the dental lesions responsible for tooth sensitivity, as well as the physiological processes linking stimuli and pain generation have suggested several treatments and preventive strategies. Unfortunately, many tooth sensitivity treatments fail to perform better than placebos in clinical trials that seek to assess the effect of agents on pain symptoms. In the case of the most commonly used self-applied desensitizing agent, potassium salts, the mechanism of action established by laboratory and animal models may not apply to clinical use. Thus results obtained with laboratory and animal models must be applied with care to clinical use. Clinical literature suggests that tooth sensitivity is the symptomatic manifestation of significant dental problems, such as wear and other forms of non-carious tooth structure loss. These conditions are increasing in frequency as people age, retaining their natural teeth longer. They are frequently the consequences of aggressive oral hygiene practices and diets rich in acids. Treatments directed at the underlying causes rather than the symptoms of tooth sensitivity would hinder the development of these lesions and provide researchers with objective targets for assessing therapeutic efficacy.

hepatitis - introduction

Topic: Hepatitis The most important organ for metabolism is the liver: where bile secretion, sugar to glycogen conversion, and bilirubin excretion occur. If the liver has any issues, this can cause problems in the metabolism of amino acids, ammonia, protein, carbohydrates, and lipids as well as synthesis of coagulation factors and drug metabolism. A very important topic to be addressed is the bleeding problems associated with liver impairment, since this can contribute to a change in the dental treatment plan. Liver dysfunction may continue to progress over time and can lead to end-stage liver disease or cirrhosis, which is irreversible. Hepatitis is inflammation of the liver and can be derived from infection causes, such as viral hepatitis or non-infectious causes such as drug or alcohol toxicity.

cancer - treatment

Treatment The goal of cancer treatments is to remove the multiplying cancer cells, while keeping the patient alive. Methods of treatment include surgery, radiation, stem cell or bone marrow transplantation, and chemotherapeutic drugs. Surgery can be used if the tumor is small enough and it does not impinge on any vital structures. In cases where the tumor cannot be removed by surgery, radiation therapy can be used to impair cell replication and reduce tumor size. Radiation therapy can also damage tissues immediately surrounding the tumor, leading to formation of fibrotic scarring and impaired wound healing. Advanced stage cancers are often treated with chemotherapeutic agents due to its ability to interfere with DNA and protein synthesis within cancer cells. Chemotherapeutic drugs are given systemically and therefore reach all the tissues of the body. This allows them to attack microscopic tumor cells that have begun to metastasize, which are commonly seen in cancers that are aggressive or have reached advanced stages. The combined use of these treatment methods increases the tumoricidal efficacy.

thyroid cancer - treatment

Treatment Lobectomy and total thyroidectomy are recommended for papillary carcinomas with lobectomies having fewer complications but higher recurrence rates. Although radioiodine ablation does not improve the survival rate, it can be used in cases where cervical lymph nodes cannot be resected and for thyroglobulin interpretation. Surgeries such as thyroid lobectomy and total thyroidectomy are recommended to treat follicular carcinomas, followed with radioiodine ablation and levothyroxine replacement therapy. If the carcinoma is minimally invasive, lobectomy and levothyroxine suppression of thyrotropin secretion can be used. In cases of recurrence, the remaining parts of the thyroid are removed. Total thyroidectomy with cervical lymph node dissection is recommended in cases of medullary carcinomas and Hurthle cell cancers. Cases of medullary carcinoma should be followed with serum calcitonin monitoring for recurrences. Although they may only increase the patient's lifespan by a few months, surgery, external beam radiotherapy, and chemotherapy can be used to treat anaplastic carcinomas to relieve the symptoms and to reduce airway obstruction. If a patient experiences bone pain due to metastases, external bean radiotherapy can be used to relieve the pain. After thyroidectomies are performed, patients may experience hypoparathyroidism, recurrent laryngeal nerve damage, and hemorrhage. Those that undergo external beam radiotherapy may experience spinal cord damage, skin damage, and ulcerations on the mucosa. Chemotherapy can induce nausea, vomiting, mucosal damage, hair loss, bleeding, and infection.

hepatitis - treatment

Treatment Treatment of chronic hepatitis is essential, because the disease does not have the tendency to resolve by itself. Therapy involves interferon alfa-2b and newer modalities of the pegylated form of interferon. Corticosteroid use is used for patients with fulminant hepatitis. The last resort for patients, who develop cirrhosis, is liver transplantation.

Blood 2 - Treatment plan modifications

Treatment Planning Modifications Good oral health is essential for those with congenital coagulation defects. Avoidance of NSAIDs and other compounds that contain aspirin, as well as herbal medications that are associated with excessive bleeding, is very important.

hypertension - treatment planning modifications

Treatment Planning Modifications While patients with a blood pressure less than 180/110 mm Hg can undergo required dental treatment, patients with a blood pressure higher than 140/90 mm Hg are recommended to consult with their physician. Patients that have a blood pressure higher than 180/110 mm Hg should have any elective dental procedures deferred.

epilepsy - treatment plan considerations

Treatment planning considerations: Maintain optimal level of oral hygiene as gingival overgrowth is associated with phenytoin administration. If gingival overgrowth is significant, surgical reduction will be necessary. A missing tooth or teeth should be replaced if possible to prevent the tongue from being caught in the edentulous space during a seizure. Fixed bridge or implant is preferable to a removable prosthesis (removable prosthesis is dislodged easily during seizure). When fixed prostheses are used, all-metal units are recommended to minimize the chance of fracture.

pregnant - treatment timing

Treatment timing: · Elective dental care is best avoided during the first trimester because of the potential vulnerability of the fetus. · The second trimester is the safest period during which to provide routine dental care. Emphasis should be placed on controlling active disease and eliminating potential problems that could occur later in pregnancy or during the immediate postpartum period, because providing dental care during these periods often is difficult. Extensive reconstruction or significant surgical procedures are best postponed until after delivery. · The early part of the third trimester is still a good time to provide routine dental care. After the middle of the third trimester, however, elective dental care is best postponed. This is because of the increasing feeling of discomfort that many expectant mothers may experience. · Prolonged time in the dental chair should be avoided, to prevent the complication of supine hypotension. If supine hypotension develops, rolling the patient onto her left side affords return of circulation to the heart. · Scheduling short appointments, allowing the patient to assume a semireclining position, and encouraging frequent changes of position can help to minimize problems.

Foschi F

Treponema denticola is a consensus periodontal pathogen that has recently been associated with endodontic pathology. In this study, the effect of mono-infection of the dental pulp with T. denticola and with polymicrobial "red-complex" organisms (RC) (Porphyromonas gingivalis, Tannerella forsythia, and T. denticola) in inducing disseminating infections in wild-type (WT) and severe-combined-immunodeficiency (SCID) mice was analyzed. After 21 days, a high incidence (5/10) of orofacial abscesses was observed in SCID mice mono-infected with T. denticola, whereas abscesses were rare in SCID mice infected with the red-complex organisms or in wild-type mice. Splenomegaly was present in all groups, but only mono-infected SCID mice had weight loss. T. denticola DNA was detected in the spleen, heart, and brain of mono-infected SCID mice and in the spleen from mono-infected wild- type mice, which also had more periapical bone resorption. The results indicate that T. denticola has high pathogenicity, including dissemination to distant organs, further substantiating its potential importance in oral and linked systemic conditions.

Yoshiyuki shibukawa, masaki sato, maki kimura, miyuki shimada

Various stimuli induce pain when applied to the surface of exposed dentin. However, the mechanisms underlying dentinal pain remain unclear. We investigated intercellular signal transduction between odontoblasts and trigeminal ganglion (TG) neurons following direct mechanical stimulation of odontoblasts. Mechanical stimulation of single odontoblasts increased the intracellular free calcium concentration ([Ca(2+)]i) by activating the mechanosensitive-transient receptor potential (TRP) channels TRPV1, TRPV2, TRPV4, and TRPA1, but not TRPM8 channels. In cocultures of odontoblasts and TG neurons, increases in [Ca(2+)]i were observed not only in mechanically stimulated odontoblasts, but also in neighboring odontoblasts and TG neurons. These increases in [Ca(2+)]i were abolished in the absence of extracellular Ca(2+) and in the presence of mechanosensitive TRP channel antagonists. A pannexin-1 (ATP-permeable channel) inhibitor and ATP-degrading enzyme abolished the increases in [Ca(2+)]i in neighboring odontoblasts and TG neurons, but not in the stimulated odontoblasts. G-protein-coupled P2Y nucleotide receptor antagonists also inhibited the increases in [Ca(2+)]i. An ionotropic ATP (P2X3) receptor antagonist inhibited the increase in [Ca(2+)]i in neighboring TG neurons, but not in stimulated or neighboring odontoblasts. During mechanical stimulation of single odontoblasts, a connexin-43 blocker did not have any effects on the [Ca(2+)]i responses observed in any of the cells. These results indicate that ATP, released from mechanically stimulated odontoblasts via pannexin-1 in response to TRP channel activation, transmits a signal to P2X3 receptors on TG neurons. We suggest that odontoblasts are sensory receptor cells and that ATP released from odontoblasts functions as a neurotransmitter in the sensory transduction sequence for dentinal pain.

Turner et al.

Vascular injection of the macromolecular tracer, horseradish peroxidase (HRP), was used to study the permeability of the odontoblast cell layer in developing and mature rat molar teeth, and to investigate the effect of cavity preparations on the permeability of this epithelioid cell layer in adult animals. HRP injected into the vascular system of normal animals 28 days of age and older was localized histochemically (from 5 to 90 min after injection) throughout the extracellular spaces of the maxillary dental pulps; however, the tracer did not penetrate beyond the tight junctions at the apical region of the odontoblast cell layer, and was absent from the predentin and dentin. In contrast, HRP injected into very young neonatal animals (e.g., day 3) resulted in free passage of HRP between odontoblasts and into the overlying predentin and dentin. When Class V cavities had been prepared in adult maxillary molars after HRP was injected into the blood stream, HRP reaction product penetrated the predentin and dentin immediately beneath the cavity preparation; however, adjacent, untraumatized areas of predentin and dentin in the operated teeth were devoid of reaction product. These results provide evidence that: (1) a physiological barrier develops between the distal segments of odontoblast cell bodies in normal rat molar teeth between days 15 and 28 of postnatal life, and this barrier prevents the passage of macromolecules from the pulp into the predentin and dentin; and (2) this barrier is perturbed following routine restorative procedures in adult animals.

12 Sunada

When the tip of the reamer reached the apex through the canal, the resistance value was 6.5 Kfi (current 40 pA). The electrical resistance between the oral mucous membrane and the periodontium by accidental perforation of the reamer was the same. Therefore, the electrical resistance between them registered consistent values in any portion of the periodontium, regardless of the age of patients or the shape and type of teeth. When the reamer remained in the canal, the measured electrical resistance varied greatly, being influenced by the contents of the canals. Nevertheless, electrical resistance registered approximately 9.0 Kf2 (37 ptA) as the reamer reached 0.5-1.0 mm. from the apex. When the microammeter showed 40 1A, the real length of the canal for root-canal therapy was accurately and easily determined by measuring the length of the reamer remaining beyond the incisal edge or cavity margin and then subtracting this length from the total length of the reamer.

hepatitis - viral hepatitis

Viral Hepatitis The known causes of viral hepatitis are Hepatitis virus types A (HAV), B (HBV), C (HCV), D (HDV) and E (HEV). They are all RNA viruses except for HBV. HAV and HEV are forms of infectious hepatitis, which means they are spread through an fecal-oral route and occur in outbreaks. They are highly contagious but cause self-limited hepatitis. HBV, HCV, HDV are forms of serum hepatitis, so they are spread by parenteral routes as well as sometimes sexually. They are not as contagious and do not commonly cause outbreaks. They are more sporadic in general. Liver injury typically results in immune responses, usually cytotoxic T cell responses to viral antigens on hepatocyte cell membranes. This can cause cell injury and inflammation during viral infection. Acute resolving viral hepatitis has a typical course: starting with the incubation period (virus detectable in blood), preicteric phase (nonspecific symptoms begin and virus-specific antibody appears in blood), icteric phase (presence of dark urine, jaundice, worsening nonspecific symptoms), and convalescence (recovery, which may be prolonged). Acute viral hepatitis can lead to complications- including chronic infection, fulminant hepatic failure, relapsing or cholestatic hepatitis, as well as extrahepatic syndromes. A very reliable prognostic factor in acute hepatic failure is the prolongation of prothrombin time. Diagnosis for acute viral hepatitis is performed with serologic tests. Liver biopsy is only performed if the diagnosis is still unclear, in which you would see parenchymal inflammation and necrosis in a spotty formation. Treatment for acute viral hepatitis is dependent on the type, which will be discussed in summaries of each virus. In general, bedrest and good nutrition are recommended, along with alcohol avoidance. If fulminant hepatic failure occurs, antiviral therapy and evaluation for liver transplantation should be considered. All cases of acute hepatitis should be reported to the health department as soon as possible following diagnosis.

Platele Disorders - Von Willebrand disease

Von Willebrand Disease Characterized by deficiency or qualitative defect in vWF, which is made by a group of glycoproteins which are produced by megakaryocytes and endothelial cells vWF is needed to carry factor VIII and allow platelets to adhere to surfaces. When factor VIII is unbound, it is destroyed in circulation. The disease has several variants, and type I is the most common form, accounting for 70-80% of cases. Types 1 and 2 are transmitted through an autosomal dominant trait, and type 3, which is rare, is transmitted through an autosomal recessive trait leading to a more severe deficiency. In mild and moderate cases, bleeding occurs only after surgery or trauma. In type 2N and type 3, more severe cases, spontaneous epistaxis or oral mucosal bleeding may be noted. In mild cases, the disease is characterized by history of cutaneous and mucosal bleeding because platelet adhesion is lacking. Many of these patients may have a negative history for bleeding problems. In the more severe forms, hemarthroses and dissecting intramuscular hematomas are common, as well as gastrointestinal bleeding, epistaxis, and menorrhagia. Petechiae is rare in these patients. These patients may have a history of bleeding and a family history of bleeding. Laboratory testing is needed for diagnosis of vWD and may show prolonged aPTT, normal or slightly reduced platelet count, normal PT, and normal TT. Additional tests are needed after screening to establish the diagnosis and type of vWD. Treatment depends on the clinical condition and type of vWD that is diagnosed. Treatment options include cryoprepitate, factor VIII concentrates that retain HMW vWF multimers (Humate-P, Koate HS) and desmopressin. Desmopressin therapy cannot be started without previous testing, since it is not effective for type 3 and most variants of type 2 disease. It is best for type 1 disease. Women are typically given oral contraveptive agents to suppress menses and avoid blood loss.

Karavanova et al

We have analyzed the expression of early growth response gene (Egr-1) by mRNA in situ hybridization during mouse embryonic tooth development and in experimental recombinations of dental epithelium and mesenchyme. Egr-1 was transiently and recurrently expressed both in epithelial and mesenchymal cells starting from day 13 of gestation and up to 4 days after birth. The expression correlated with developmental transition points of dental mesenchymal and epithelial cells suggesting a role for Egr-1 in sequential determination and differentiation of cells. In recombination cultures of early dental epithelium and mesenchyme Egr-1 RNA was localized at the epithelial-mesenchymal interface in mesenchymal cells, and in two cases also in epithelial cells. These data indicate that Egr-1 expression may be regulated by epithelial-mesenchymal interactions when they are specific enough to initiate differentiation. We have also analyzed by in situ hybridization whether Wilms' tumour-1 gene (wt-1) is expressed in the developing tooth as it was proposed on the bases of in vitro studies that it may inhibit Egr-1 expression. No wt-1 expression was detected at any stage of tooth development showing that wt-1 is not obligatory for regulation of Egr-1 expression.

Butler et al

We isolated a sialic-rich protein from rat dentin extracts and have named it dentin sialoprotein, DSP (formerly called 95K glycoprotein). DSP is rich in aspartic acid, glutamic acid, glycine and serine, but contains no cysteine or phosphate. The 30% carbohydrate content includes about 9% sialic acid and indicates that several N-glycosides and O-glycosides are present. Sedimentation equilibrium analysis gave a M(r) of 52,570. Based on this molecular weight we calculated that DSP contains about 350-amino acids and 75 monosaccharides. With automated Edman degradation the sequence of the first 8-amino acids was shown to be: Ile-Pro-Val-Pro-Gln-Leu-Val-Pro. The initial 3 residues of this sequence are identical to the first 3 in human osteopontin (OPN) and are closely similar to the Leu-Pro-Val sequences of OPN from other species, as well as at the beginning of bone acidic glycoprotein-75 (BAG-75). On Western immunoblots, purified polyclonal antibodies reacted only with DSP in dentin extracts and with none of the proteins from bone. Similarly, immunolocalization experiments showed the presence of DSP in dentin but not in enamel or alveolar bone. Along with immunohistochemical localization data reported elsewhere, these observations suggest that DSP may be an important marker for cells in the odontoblast lineage.

Tronstad L, Langeland K

abstract - Undecalcified sections of human dentin exposed by attrition were studied by electron microscopy. Many tubules contained calcified deposits or inclusions with a high degree of variability in structure and density. The presence of big crystals, some needle‐like, others angulated and often rhombohedral, was conspicuous. The deposits seemed to be formed by a precipitation of minerals in the lumen, or by a repetitive deposition on the walls of the tubules. In the region of the last formed primary dentin, tubules without peritubular dentin occurred. Most of the tubules of the irritation dentin were surrounded by peritubular dentin of varying width and density. Groups of tubules contained a great amount of mineralized collagenous fibers, oriented parallel to the long axis of the tubule. The large angulated crystals were also present in tubules of the irritation dentin. Electron diffraction patterns indicated that the big needle‐like crystals were apatite in nature whereas the inclusions seemed to contain whitlockite when the angulated, rhombohedral crystals were present.

Ischemic necrosis, tumor growth, surgery, chemical irrigant, injuring agent

acute phase response

Lymphocytes

chronic apical periodontitis - T-lymphocytes: cell mediated immunity - B-lymphocytes: antibody mediated immunity, humoral response

73 Veis

compare in V iiro the sealing ability of root canal treatments performed in situ with injected thermopiasticized gutta-percha compared with the lateral condensation technique. No significant difference vvas found (P>0.05). The technique of lateral condensation proved to be better in the first five sections (1.2 mm from the foramen) while thermopiasticized gutta-percha tech- nique was superior in the rest of the root canal.

Bradykinin

contraction of endothelial cells, leakage from vessels, potential pain producing mediator

58 Pascon

evaluate the toxicity of marketed endodontic GP The raw materials and barium sulfate were not toxic, whereas zinc oxide and zinc ions showed marked toxicity. All GP points tested were toxic at longer observation periods, and the toxicity was attributed to leakage of zinc ions into the fluids.

Plasma

factor 12, kinin, coagulation, complement

85 Gillen

for healing of apical periodontitis increase with both adequate root canal treatment and adequate restorative treatment. Although poorer clinical outcomes may be expected with adequate root filling-inadequate coronal restoration and inadequate root filling-adequate coronal restoration, there is no significant difference in the odds of healing between these 2 combinations.

Widner C

ntroduction: Advances in culture-independent molecular biotechnologies have driven a greater appreciation for the function of mutualistic microorganisms in the maintenance of states of health in humans. The purpose of this study was to test the long-held hypothesis that healthy pulp lack bacteria. Methods: Strict inclusion criteria were used to identify 10 pristine teeth from 10 healthy patients that were scheduled to be electively extracted in compliance with an orthodontic treatment plan. Using a rigorous disinfection protocol to isolate the operating field, the pulp space was accessed, and pulp tissue was collected in vivo from each tooth using a barbed broach. Genomic DNA was extracted from each pulp sample and analyzed for the presence of bacterial DNA using universal 16S ribosomal RNA polymerase chain reaction primers and MiSeq sequencing (Illumina, San Diego, CA) of community amplicons. Results: One hundred percent (10/10) of the tested pulp tissues demonstrated the presence of bacterial DNA, with a mean of 343 operational taxonomic units per sample (range, 191-479). These were derived from 12 genera in which Ralstonia, Actinetobacter, and Staphylococcus were predominant (43%-78% of total community). None of the negative-field controls and none of the instruments used in the study tested positive for the presence of contaminating DNA. Conclusions: This study presents evidence to support the conclusion that the pulp spaces of pristine healthy teeth contain detectable bacterial DNA.

Cytokines:

protein products of lymphocyte, macrophage, endothelial cells - Mononuclear cells: monokines - Macrophage/Endothelial cells: chemokines (IL-8), leukocyte movement - Lymphocyte: lymphokines (CSF, IL, TNF)

Walton

relative effectiveness of filing, reaming, and step-back filing was compared,. step-back filing was significantly the most effective method in removing debris and a layer of dentin from the pulpal walls; walls were more thoroughly planed, in straight canals than in curved ones; and smooth walls and clean, white shavings did not indicate that dentin had been removed from all surfaces of the canal.

Phospholipase C

release of calcium

31 Siquera

step-back technique using stainless steel files; step-back technique using nickel-titanium files; ultrasonic technique; balanced force technique; and Canal Master U technique and instruments. no significant differences among the techniques. Although the five instrumentation methods were effective in removal of major amounts of tissue from the canals, none totally debrided the entire root canal system, especially when variations in the internal anatomy were present.

63 Holland

to determine whether this inflammation was induced by the sealer rather than arising as a result of tissue damage and whether, if inflammation is eliminated or reduced, the neural changes are also reduced. In In all the teeth with inflammatory lesions the normal arrangement of nerves in a periodontal 'plexus' was disrupted but there was no statistically significant difference between the overall innervation density in inflamed and non-inflamed periapical areas nor between areas beneath teeth sealed with Grossman's sealer and with calcium hydroxide. The incidence of periapical inflammation is related to the nature of endodontic sealer used. The pattern but not the quantitative extent of the periapical innervation is related to the presence of inflammation.

Kollar et al.

· Dissected ERS from mesenchyme and recombine with papilla. · Root fragments in two weeks in rat eye. · ERS induces papilla cells to diff. into odontoblasts. (mesenchyme is specific, epi not)

diabetes - local anesthetic and epinephrine

· Local anesthetic and epinephrine o No issues if diabetes is well controlled. For diabetic patients with concurrent hypertension or history of recent myocardial infarction, or with a cardiac arrhythmia, dose of epinephrine should be limited to no more than two cartridges containing 1:100,000 epinephrine.

Asthma - Medical Mangement

· Medical management o The goals of asthma therapy are to limit exposure to triggering agents, allow normal activities, restore and maintain normal pulmonary function, minimize frequency and severity of attacks, control chronic and nocturnal symptoms, and avoid adverse effects of medications. o Best management strategy is educating patients. o peak expiratory flowmeters should be used regularly at home and levels recorded daily in diaries. o Antiasthmatic drug selection is based on the type and severity of asthma and whether the drug is to be used for long-term control or quick relief. o Current guidelines recommend a "stepped-care" approach with the use of inhaled antiinflammatory agents as first-line drugs for the long-term management and prophylaxis of persistent asthma. The preferred inhalational agent is a corticosteroid preparation, with a leukotriene inhibitor as an alternative. o β-adrenergic agonists are recommended for intermittent asthma and are secondary agents that should be added (i.e., not to be used alone) for persistent asthma when antiinflammatory drugs are inadequate alone. o Alternative drugs include mast cell stabilizers (cromolyn and nedocromil), immunomodulators, and theophylline. o Inhaled corticosteroids are the most effective antiinflammatory medications currently available for the treatment of persistent asthma. o They act by reducing the inflammatory response and preventing the formation of cytokines, adhesion molecules, and inflammatory enzymes. Aerosol dosage is two (for mild to moderate disease) to four times daily (severe asthma). Onset of action usually is after 2 hours, and peak effects occur 6 hours later. Long-term use of steroid inhalers rarely is associated with systemic adverse effects, provided the maximum recommended dose of 1.5 mg per day of inhaled beclomethasone dipropionate (Vanceril) or equivalent is not exceeded. o Use of systemic steroids is reserved for asthma unresponsive to inhaled corticosteroids and bronchodilators, and for use during the recovery phase of a severe acute attack. o For relief of acute asthma attacks, inhaled short-acting β2-adrenergic agonists are the drugs of choice because of their fast and notable bronchodilatory and smooth muscle relaxation properties. Short-acting β2-adrenergic agonists produce bronchodilation by activating β2 receptors on airway smooth muscle cells, generally in 5 minutes or less. o β2-adrenergic agonists (administered by a metered-dose inhaler) and cromolyn sodium (Intal) and nedocromil may be used in preventing exercise-induced bronchospasm. They are taken about 30 minutes before initiation of physical activity.

Lewin D

· Mesenchymal cells migrate from NEURAL CREST. · Mesenchyme induces epi to thicken forming DENTAL LAMINA. · Epi invaginates into mesenchyme creating ENAMEL ORGAN and making mesenchyme into DENTAL PAPILLA. (tooth germ together) · Enamel organ: OEE,IEE,SI,SR (enamel+HERS) · Dental sac: surrounds, cementum, PDL, alveolus · Papilla: pulp and dentin · Enamel Knot: SR, signaling

J.V Ruch, H.Lesot, V Karcher -Djuricic, J.M Meyer, M Mark

· Odontoblast differentiation: withdraw from cell cycle, polarize, secrete predentin. IDE causes odontoblast differentiation with mediation by BM · Ameoloblast differentiation: after odontoblasts, cytoskeleton integrity, predentin necessary. · Cementocyte differentiation: absence of enamel epithelium required. · BM: dense basal lamina (densa), lamina lucida (close to epi), lamina diffusa. Made of collagen I, III and IV, fibronectin, Heparan Sulfate, laminin.

diabetes - signs and symptoms

· Onset of symptoms is sudden and acute · Signs and symptoms include polydipsia, polyuria, polyphagia, weight loss, loss of strength, marked irritability, recurrence of bed wetting, drowsiness, malaise, and blurred vision. · Other signs and symptoms related to the complications of diabetes include skin lesions, cataracts, blindness, hypertension, chest pain, and anemia.

diabetes - oral complicatons and manifestations

· Oral Complications and Manifestations o Oral complications of poorly controlled diabetes mellitus may include xerostomia; bacterial, viral, and fungal infections (including candidiasis); poor wound healing; increased incidence and severity of caries; gingivitis and periodontal disease; periapical abscesses; and burning mouth symptoms. o The effects of hyperglycemia lead to increased amounts of urine, which deplete the extracellular fluids and reduce the secretion of saliva, resulting in dry mouth. A high percentage of patients with diabetes present with xerostomia and low levels of salivary calcium, phosphate, and fluoride. o Saliva glucose levels are elevated in persons with uncontrolled and controlled diabetes. o increased incidence and severity of gingival inflammation, periodontal abscess, and chronic periodontal disease in diabetic patients. o Diabetes results in enhanced inflammatory responses, depressed wound healing and small blood vessel changes that contribute to increased risk for periodontitis. Uncontrolled diabetes patients have more sever manifestation of periodontal disease than normal patients. o Caries appears to be more significant in patients with diabetes who have poor glycemic control. o Oral fungal infections, including candidiasis and the rarer mucormycosis, may be noted in the patient with uncontrolled diabetes. o Healing is delayed in persons with uncontrolled diabetes, and they are more prone to various oral infections after undergoing surgical procedures. o Significantly higher percentage of oral lesions, especially candidiasis, traumatic ulcers, lichen planus, and delayed healing, have been noted in patients with type 1 diabetes. Altered immune system function contributes to the appearance of these lesions in diabetes. o Diabetic neuropathy may lead to oral symptoms of paresthesias and tingling, numbness, burning, or pain. o Metformin is associated with a metallic taste.

Asthma - Pathophysiology and complications

· Pathophysiology and complications o In asthma, obstruction of airflow occurs as the result of bronchial smooth muscle spasm, inflammation of bronchial mucosa, mucus hypersecretion, and sputum plugging. o Histologic findings are those of inflammation and airway remodeling, including: o Histologic findings are those of inflammation and airway remodeling, including: § thickening of the basement membrane (from collagen deposition) of the bronchial epithelium § edema § mucous gland hypertrophy and goblet cell hyperplasia § hypertrophy of the bronchial wall muscle, accumulation of mast cell and inflammatory cell infiltrate § epithelial cell damage and detachment § blood vessel proliferation and dilation o These changes contribute to decreased diameter of the airway, increased airway resistance, and difficulty in expiration. o Usually, a benign condition seen in children which can resolve spontaneously after puberty. o In some case asthma can continue and possibly progress to COPD and respiratory failure, or status asthmaticus o Status asthmaticus is a particularly severe and prolonged asthmatic attack (one lasting longer than 24 hours) that is refractory to usual therapy.

Bronchial Asthma

· Signs and Symptoms: Sense of suffocation, pressure in chest, nonproductive cough, expiratory wheezes, prolonged expiratory phase, increased respiratory effort, chest distension, thick, stringy mucous sputum, cyanosis (in severe cases). · Causes: Can be induced by allergy, infection, exercise, anxiety leading to bronchial inflammation, bronchoconstriction, vascular permeability, occlusion of bronchioles by thick mucous plugs, and bronchospasm. · Treatment o Positioning: Place patient in an upright comfortable position. o Airway: Ensure that airway is open by removing dental materials and listening to breath sounds. o Breathing: Encourage relaxed slow breathing. o Circulation and communication: generally, circulation is adequate if patient is conscious. Communicate with patient and/or staff to get a rapid bronchodilator for use. o Dispense/administer: § Two deep inhalations of fast-acting, β2-agonist bronchodilator (e.g., albuterol, Isuprel mistometer) § Repeat with two additional deep inhalations of bronchodilator if attack persists 5 minutes. § Oxygen at flow rate of 5-6 L/minute, if needed o Ensure that vital signs are properly monitored and recorded. § If attack persists, activate EMS (call 911). o Facilitate next steps in medical care (transport to hospital); reassure patient. § Maintain oxygen at flow rate of 5-6 L/minute. § With unresponsive Patient: administer epinephrine 1 : 1000 (0.3-0.5 mL SC); repeat every 20 minutes as needed. o If transport to hospital is pending: § Give theophylline ethylenediamine (aminophylline) 250-500 mg IV slowly over a 10-minute period. § Administer hydrocortisone sodium succinate (Solu-Cortef), 100 mg IV. § NOTE: Because aminophylline may cause hypotension, it should be given with extreme caution to patients with asthma who are hypotensive.

62 Phillips

· The fibrous encapsulation of the polyethylene tube implants, which was similar in every section examined, is a characteristic inflammatory response of all fibrous connective tissue to non-irritating substances · Invagination of the connective tissue into the open ends observed in tubes of short length and large diameter and was absent in all other samples. Most likely due inadequate nourishment in thinner/longer tubes. This study opposes Rickert and Dixons' hypothesis of a "hollow tube effect" as no inflammatory response was found at the open ends of any of the tubes implanted.

unknown cause

○ When a likely cause for the patient's response cannot be identified, a period of observation is justified Positioning: place patient in supine position and activate EMS (call 911) Airway: Ensure open airway, support respiration, and administer oxygen Breathing: Ensure that breathing is adequate Circulation: Request blood pressure equipment or pulse oximeter to check blood pressure and circulation Dispense/administer intravenous 5% dextrose with lactated Ringer's solution Ensure that vital signs, drug administration and patient responses are properly monitored and recorded Facilitate/ensure next steps in medical/dental care: ● Keep patient off all medication ● Reassure patient ● Transfer to hospital if patient's condition is serious ● Be prepared to do CPR and use the AED if needed

transplant - intro

○ In the past 10 years: more than 26,000 solid organ transplant procedures in the U.S. annually ○ Key outcomes: (1) survival of transplant recipients and (2) the function of transplanted grafts. ○ Survival as high as kidney and pancreas recipients at 95% and 98% to heart-lung recipients at around 58%. ● Definition: Ideally, transplant from an identical twin (syngenic). The next best option is from one living relative to another (allogeneic). Lastly, the organ transplantation from a non-relative (xenograft). ○ These definition mean donor must have at least two organs in order to survive. Thus, this classification is limited to, for example, kidney and bone marrow transplantations. Some cases showing success with transplantation of a portion of liver or pancreas from living donors. ● Incidence and prevalence: First successful human organ transplant (kidney from identical twin) was performed by Dr. Joseph E. Murray in Boston in 1954. ○ Initially, total body radiation was used for immunosuppression. In 1962, azathioprine, an immunosuppressive, was introduced. ● Pathophysiology/complications: All candidates for heart/liver/bone marrow transplant have severe end-stage organ disease and would die without transplantation. Patients with end stage kidney failure or severe diabetes may be kept alive with adjunct treatment but at a cost of quality of life.

transplant - oral complications and manifestations

○ Oral complications and manifestations ■ Usually seen in patient because of (1) rejection, (2) over-immunosuppression, (3) side effects of the immunosuppressive agents, and (4) in bone marrow transplants. ■ Oral findings associated with graft rejection are the same as those in patients with organ failure before transplantation. ■ Oral findings that may indicate over-immunosuppression include mucositis, herpes simplex infections, herpes zoster, CMV infection, candidiasis, large and slow-to-heal ulcers, unusual alveolar bone loss, and on occasion, lymphoma, Kaposi sarcoma, squamous cell carcinoma of the lip, and hairy leukoplakia. ■ Oral complications associated with the side effects of the immunosuppressive agents include infection, bleeding, poor healing, and tumor formation. ■ Oral manifestations of GVHD include nonspecific mucosal ulcerations, salivary gland hypofunction, and palatal mucoceles

respiratory arrest

○ Signs and symptoms: cessation of breathing, cyanosis ○ Cause: Physical obstruction of airway (tongue or foreign object), drug induced apnea○ Treatment: Positioning: Place patient in supine position and activate EMS/911 Airway: Maintain open airway, tilting the patients head back as indicated Breathing: Respirations will be absent ● Open mouth to see if foreign object is readily accessible; remove object if visible ● If foreign object cannot be removed, perform a heimlich maneuver (abdominal thrusts) until the object is removed or no pulse is detected. If no pulse is felt, initiate CPR (using the C-A-B sequence) and chest compressions in a ratio of 30 per 2 ventilations. arrest ● Once airway is open, ventilate patient 12-15 times/minute Circulation: support blood pressure through position of patient, parenteral fluids and vasopressors Dispense/administer ● Oxygen or artificial respiration● If apnea is secondary to sedative/benzodiazepine overdose, administer reversal agent ○ Flumazenil if diazepam ● If apnea is secondary to narcotic/opioid overdose, administer reversal agent ○ Naloxone hydrochloride ● Keep patient awake Ensure that vital signs, drug administration and patient responses are properly monitored and recorded Facilitate/ensure next steps in medical/dental care. Pressure patient ● Monitor patients carefully for the duration of action of reversal agent (naloxone) which may be less than that of the narcotic. ● No reversal agent exists for barbiturate overdose (central nervous system depressors used for anesthesia and to treat seizures).

severe (intermediate onset) allergic reaction

○ Signs and symptoms: skin reaction - rapid appearance such as severe pruritus (itching of skin, throat, palate); severe urticaria (rash); swelling of lips, eyelids, cheeks, pharynx and larynx (angioneurotic edema); and anaphylactic shock (cardiovascular - fall in blood pressure), (respiratory-wheezing, choking, cyanosis, hoarseness), (central nervous system - loss of consciousness, dilation of pupils). ○ Cause: Overreaction to allergens such as drugs, pollens, or food in which mast cells degranulate and release histamine in cardiopulmonary system ○ Treatment i. Positioning: With conscious patients, place in an upright /comfortable position. With unconcious patient, place in a supine position and activate EMS/911. (immediate onset) allergic reaction Airway: Assess to ensure that airway is open Breathing: Ensure breathing is adequate by talking to and reassuring patient Circulation: No immediate requirement. Apply blood pressure cuff (pulse oximeter) to assess circulation within 5 minutes. Dispense/administer ● Epinephrine 0.3-0.5mg 1:1000 SC/IM/IV ● Oxygen maintained at 5-6L/min flow ● Repeat epinephrine every 5-10 minutes as needed Ensure that vital signs, drug administration and patient responses are properly monitored and recorded. Note: monitor blood pressure to ensure hypertension is not occuring. Facilitate/ensure next steps in medical care. If transport to hospital is pending: ● Give repeat doses of epinephrine ● Administer 25-50mg diphenhydramine (benadryl), once patient's life is no longer in danger ● If dentist is ACLS trained and laryngeal edema is involved then ○ Provide steroids ○ Perform CPR if patient stops breathing including the use of AED if no pulse ○ Use cricothyrotomy if needed ○ Aminophylline may cause hypotension and should be used with extreme caution in patients with asthma who also are hypotensive

● Low blood pressure/ slow pulse (systolic is less than previous diastolic)

○ Treatment for low blood pressure Positioning: Place patient in supine position; lower head nad raise legs. Airway: Ensure open airway Breathing: Check breathing - should be adequate Circulation: Check pulse and ensure adequate circulation, may be weak Dispesne/administer: ● Intravenous drip of 5% dextrose in lactated Ringer's solution (IV) ● In unresponsive patient: a vasopressor drug such as phenylephrine 10mg/mL (1 ampule), or epinephrine 0.3-0.5mg given subcutaneously or intramuscularly, or intravenously with ACLS training Ensure that vital signs, drug administration, and patient response are properly monitored and recorded. Facilitate next steps in medical/dental care; reassure patient ○ Treatment for slow pulse (less than 60 BPM) Positioning: Place patient in supine position; lower head and raise arms and legs Airway: Ensure and maintain patent airway Breathing: Check breathing - should be adequate Circulation: Check- should be adequate in this situation Dispense/administer: ● Oxygen at flow rate of 5-6 L/minute is patient is hypoxemic ● Atropine 0.5mg IV (to increase heart rate). Repeat dose up to 3mg; then consider use of additional vasopressors (dopamine or epinephrine) Ensure that vital signs, drug administration and patient responses are properly monitored and recorded Facilitate next steps in medical/dental care; reassure patient

Acute adrenal insufficiency

● Acute adrenal insufficiency ○ Signs and symptoms: Altered consciousness, wet, clammy, confusion, weakness, fatigue, headache, pain in abdomen or legs, nausea and vomiting, hypotension and syncope, coma ○ Cause: Adrenal suppression (low adrenocorticotropic hormone) by exogenous steroids. The patient may be medicated with steroid for many medical problems or the cause may be primary or secondary malfunction of the adrenal cortex ○ Treatment: Position: place patient in semi reclined position and raise feet slightly; call for help. Airway: Ensure open airway Breathing: should be adequate Circulation: Check pulse and confirm adequate circulation Dispense● Conscious patient: provide oxygen at flow rate 5-6L/min, give hydrocortisone 100mg or dexamethasone 4mg (IV)● Unconscious patient: Place in supine position, activate EMS/911, administer oxygen at 5-6L/min, confirm diagnosis from review of medical history/signs/symptoms, start intravenous administration of 5% dextrose in Ringer's lactate and run the intravenous drips as fast as possible. Additionally, provide hydrocortisone 100mg or dexamethasone 4mg (IV. Give a vasopressor drug such as epinephrine 1:1000, 0.5ml) Ensure that vital signs, drug administration and patient responses are properly monitored and recorded. Facilitate/ensure next steps in medical care; reassure patient

angina pectoris

● Angina Pectoris○ Signs and symptoms: Substernal myocardial pain that can radiate to arms, neck, jaw or abdomen; myocardial pain lasting less than 15 minutes and possibly radiating to the left shoulder; pain relieved by nitroglycerin; patient usually has a history of the condition. i. Vital signs are normal; no hypotension, sweating or nausea occurs ○ Cause: Blood supply to the cardiac muscle is insufficient for oxygen demand (atherosclerosis or coronary artery spasm). Angina episodes may be precipitated by stress, anxiety or physical activity. ○ Treatment: Positioning: place patient in sitting-up or semi-sitting up position with head elevated. Airway: Ensure open airway Breathing: Ensure that breathing is adequate Circulation and communication: Check pulse and communicate with patient and staff to get the nitroglycerin Dispense/administer ● Nitroglycerin 0.4mg tablet sublingually or one or two metered spray doses (0.3-0.6mg) of nitroglycerin sublingually. ● Repeat 1 nitroglycerin tablet every 5 minutes to a total of 3 tablets or 3 sprays in 15 minutes. ● Oxygen at 5-6L/min flow ● If pain is not relieved with 3 doses of nitroglycerine then 325mg aspirin and call 911 Ensure vital signs, drug administration, and patient responses are properly monitored and recorded Facilitate next steps in medical care; reassure patient ● If there is doubt if the episode is myocardial infarction (pain continues, worsenes, subsides then return), activate EMS/911 or transport the patient to hospital. ● Once the nitroglycerin tablet container has been opened, the shelf life to the remaining tablets is poor. A new supply should be stocked.

● Aspiration or swallowing a foreign object

● Aspiration or swallowing a foreign object ○ Signs and symptoms: coughing or gagging associated with a foreign object; inability to speak; possible cyanosis from airway obstruction; violent respiratory effort; suprasternal retraction; rapid pulse ○ Cause: Foreign body in larynx or pharynx ○ Treatment with conscious patient Keep the patient standing or sitting leaning forward. Ask: "can you speak?" or "are you choking?" a patient may indicate need for help by demonstrating the "universal choking sign" - clutching hands wrapping around the neck or nodding. Airway: open airway by placing arms around patient and applying Heimlich maneuver Breathing: Repeat maneuver until object is cleared and breathing is reestablished or until patient becomes unconscious. ○ Treatment with unconscious patient Positioning: place victim in supine position. Activate EMS/911 then initiate CPR in C-A-B sequence (circulation, airway, breathing) Circulation: check pulse; begin CPR if no pulse is felt. Provide chest compressions in a ratio of 30 per 2 ventilations. Airway: open airway by administration quick upward abdominal thrusts (up to 5) Breathing: check the airway for breathing and attempt to ventilate . Each time the airway is opened, the rescuer should look for an object in the victim's mouth and remove it if found.Do not delay the 30 chest compressions for longer than 10 seconds while looking for objects. Continue CPR until EMS arrives. If ventilation is not possible, cricothyrotomy might be necessary. Once breathing has been reestablished, dispense administer Oxygen 5-6L/min Ensure that vital signs, drug administration, and patient responses are properly monitored and recorded. Facilitate/ensure next steps in medical care (maintain supine position and transfer to hospital); reassure patient ● Inform patient and request radiographs to locate forein object or trauma to chest cavity is suspected. If forein object is in GI tract, track with x-ray examinations. If the object is in airway/lung, bronchoscopy or thoracotomy might be necessary.

● Bronchial asthma

● Bronchial asthma ○ Signs and symptoms: sense of suffocation, pressure in chest, nonproductive cough, expiratory wheezes, prolonged expiratory phase, increased respiratory effort, chest distension, thick, stringy mucus sputum, cyanosis (in severe cases). ○ Causes: Can be induced by allergy, infection, exercise, anxiety leading to bronchial inflammation, bronchoconstriction, vascular permeability, occlusion of bronchioles by thick mucous plugs, and bronchospasm. ○ Treatment: Positioning: place patient in un upright comfortable position Airway: Ensure that airway is open by removing dental materials and listening to breath sounds Breathing: encourage relaxed slow breathing Circulation and communication: generally circulation is adequate if the patient is conscious. Communicate with the patient and/or staff to get a rapid bronchodilator for use. Calm the patient and the staff Dispense/administer ● Two deep inhalations of fast-acting, B2 agonist bronchodilators (eg. albuterol, isuprel mistometer) ● Repeat with two additional dep inhalations of bronchodilators if attack persists 5 minutes ● Oxygen at 5-6L/min flow rate if needed Ensure that vital signs are properly monitored and recorded. If attack persists, activate EMS/911 vii. Facilitate next steps in medical care ● Maintain oxygen and administer epinephrine 1:1000 if patient is unresponsive. Repeat every 20 minutes as needed. ● If transport to hospital is pending, give theophylline ethylenediamine (aminophylline) 250-500mg mg IV over 10 minutes if patient is not hypotensive ○ Administer hydrocortisone sodium succinate 100mg IV

● Cerebrovascular accident (stroke)

● Cerebrovascular accident (stroke) ○ Signs and symptoms: Dizziness (patient may fall), vertigo and vision changes, nausea and vomiting, transient paresthesia, unilateral weakness or paralysis, headache, nausea, vomiting, convulsions, coma.NOTE: blood pressure and pulse generally normal. Raised blood pressure and body temperature and lowered pulse and respiration indicate increased intracranial pressure. ○ Cause: Interruption of blood supply and oxygen to the brain occurring as a result of ischemia or hemorrhage ○ Treatment Positioning: place patient in reclined, semi sitting position with the head elevated. Call for help and activate EMS/911 Airway: Ensure that airway is open and maintained open Breathing: Ensure that breathing is adequate Circulation: Check pulse and confirm adequate circulation Dispense/administer: ● Use pulse oximeter to determine oxygenation and administer oxygen at flow rate of 5-6L/min if needed Ensure that vital signs, drugs administration and patient responses are properly monitored and recorded Facilitate/ensure next steps in medical care (transport to hospital); reassure patient (seizure).

transplant - clinical presenttion

● Clinical presentation: ○ Signs and symptoms Advanced cardiac disease Advanced liver disease End-stage renal disease Advanced diabetes mellitus Red blood cell disorders and white blood cell disorders ○ Laboratory findings Elevation of aspartate aminotransaminase, alkaline phosphpatase, prothrombin time, and serum bilirubin would suggest advanced liver disease Increased bleeding time, low platelet count, decreased WBC count and decreased hematocrit are associated with blood disordres Elevation of serum creatinine and blood urea nitrogen and increased specific gravity of urine and proteinuria are associated with advanced renal disease. Low hematocrit, prolonged partial thromboplastin time and decreased WBC count can be found in patients with renal disease. Patient with the values above are potential bleeders who are prone to infection and will experience buildup of toxic levels of drugs that are metabolized by kidney/liver.

● Convulsions (Seizure)

● Convulsions (Seizure) ○ Signs and symptoms: Aura (flash or light or sound, an unusual smell), mental confusion, excessive salivation, rolling back of eyes, loss of consciousness, tonic phase (contractions - clenching of teeth) followed by clonic phase (tremors, convulsive movements of extremities). ○ Cause: There are several potential causes including syncope, drug reactions (local anesthesia overdose), hypoglycemia, hyperventilation, cerebrovascular accident, and convulsive seizure disorder. ○ Treatment: Positioning: place patient in supine position; clear instruments and protect patient from injury (i.e. lightly restrain arms and legs from gross movements). Call for help. After convulsions ceases then Airway: ensure that the airway is open. Suction mouth along buccal surfaces of teeth if excessive secretions are making breathing difficult. Breathing: ensure that breathing is adequate Circulation: check pulse and confirm adequate circulation Dispense/administer: ● Oxygen at flow of 5-6L/min ● For status epilepticus (seizure lasting more than 5 minutes), activate EMS/911. ○ Adult: give diazepam (valium) 5-20mg IV or intranasal lorazepam 2-5mg or intranasal midazolam 5mg, one half volume per nostril. If convulsions persist for 5 minutes after treating, repeat with one-half dose. vi. Ensure vital signs, drug administration and patient responses are properly monitored and recorded. Support respiration (seizures introduce risk of respiratory arrest). vii. Facilitate/ensure next steps in medical care and reassure patient

● Cricothyroid membrane puncture

● Cricothyroid membrane puncture○ The approach to a patient with acute airway obstruction should consists of the following steps Recognition of obstruction Use of nonsurgical maneuvers to relieve obstruction (heimlich/back blows) Administration of mouth-to-mouth breathing to bypass obstruction or to diagnose obstruction Activate EMS with 911 call Establishment of an emergency surgical airway (cricothyrotomy) if Heimlich maneuver is unsuccessful ○ Cricothyrotomy Place patient in head-down position with neck hyperextended Ensure chin and sternal notch are held in median plane Cut skin or puncture with very-large-bore needle over cricothyroid cartilage Insert cricothyrotomy cannula or very large bore needle through skin overy cricothyroid cartilage. Insert pointed end caudally to avoid damage to vocal cords Use positive pressure or enriched oxygen flow if patient is breathing independently Arrange for rapid transfer of patient to hospital

Transplant - dental managemeent

● Dental Management: ○ Pretransplant medical considerations ■ First, the patient will have significant end-organ disease from the organ system for which a transplant is necessary ■ Second, diagnosis and treatment of any existing dental disease, particularly any infection or any oral condition that could result either in an infection or the need for oral surgery during the immediate posttransplantation phase, when the patient is immunocompromised and very susceptible to infection. ■ Infections are a very serious concern in the transplant patient and any potential source of infection in the posttransplant period must be identified and prevented. ■ It is best to avoid any dental treatment for about 6 months after transplantation due to the many associated potential complications aside from infections, such as fatigue, medication interactions and side effects, and inadvertent saliva aspiration leading to aspiration pneumonia. ■ Past dental history as well as prognosis and attitudes toward maintenance of oral health may strongly influence the scenario of aggressive treatment before the transplant. Priority must be given to the patient's overall medical status and the ultimate success of the transplant procedure. ○ Posttransplantation medical considerations ■ Immediate posttransplantation period (first ~3 months) ● Greatest risk of technical complications, acute rejection, and infection. Medical complications are relatively common during the immediate post transplant period. ● The patient should receive only emergency treatment. Antibiotics should be used during this time because of the immunosuppression and increased risk of infections. ■ Stable posttransplantation period (~3 months after transplantation) ● The medical considerations during this stage relate to the effects of immunosuppressive agents. ● Posttransplant patients are especially susceptible to fungal infections. ● Transplanted heart has no nerve supply thus pain is not associated with angina or infarction. ■ Chronic rejection period (begins with signs and symptoms associated with organ failure) ● Retransplantation is only definitive treatment

● Hyperventilation

● Hyperventilation ○ Signs and symptoms Rapid and shallow breathing, confusion ,dizziness, paresthesias, cold hands, carpal-pedal spasms, can progress to seizure ○ Cause: Anxiety induced excessive loss of CO2 from deep and rapid breathing. Also, respiratory alkalosis. ○ Treatment: Positioning: place patient in an upright position and explain the problem to reassure the patient Airway: Maintain open airway by talking with patient Breathing: INstruct patient to be calm and breath slowly into a paper bag or into the cupped hands over the nose and mouth (i.e. rebreathe carbon dioxide). Circulation: No treatment required Dispense: Reassurance Ensure that vital signs, drug administration and patient responses are properly monitored and recorded Facilitate/ensure next steps in medical/dental care: consider rescheduling appointments with anti anxiety measures/presedation.

Hypoglycemia (insulin shock)

● Hypoglycemia (insulin shock) ○ Signs and symptoms: Hunger, weakness, trembling, tachycardia, pallor, sweating, paresthesias, uncooperative, mental confusion (headache), incoherent, uncooperative, belligerent, unconscious, tonic-clonic movements, hypotension, hypothermia, rapid thready pulse, coma. ○ Cause: Lack of blood glucose to the brain; taking insulin and not eating ○ Treatment Position: In conscious patient: place in upright sitting position. In unconscious patient: place in supine position Airway: ensure open airway Breathing: ensure that patient is breathing Circulation: check pulse and confirm adequate circulation; pulse could be weak Dispense: ● Conscious patient: Give drink with high sugar content such as orange juice or a glucose paste applied to the buccal mucosa ● Unconscious patient: activate EMS by calling 911 then administer ○ Oxygen at flow rate of 5-6L/minute ○ 5% dextrose in Ringer's lactate IV: run the intravenous drip as fast as possible ○ Alternatively, give glucagon 1mg SC/IM/IV or epinephrine (for transient relief) Ensure vital signs, drug administration and patient responses are properly monitored and recorded Facilitate next steps in medical care. Transport to hospital if improvement is not fairly rapid. When the patient regains consciousness, provide reassurance and information about what happened.

● Local anesthesia drug toxicity

● Local anesthesia drug toxicity ○ Signs and symptoms: confusion, talkative, restless, apprehensive state, excited manner, headache, lightheadedness, convulsion, increase in blood pressure and pulse rate.NOTE: Stimulation is followed by depression of the central nervous system. Late features can include drowsiness, disorientation, convulsions followed by depression, drop in blood pressure, weak or rapid pulse or bradycardia, apnea, unconsciousness, death. NOTE: Lidocaine toxicity is documented to occasionally exhibit depression only without the usual prodromal of the excitatory phase. ○ Causes: Too-large a dose of local anesthetic per body weight, rapid absorption of drug or inadvertent intravenous injection, slow detoxification or elimination of drug. ○ Treatment Positioning: place patient in comfortable position; convulsing or unconscious patient should be in supine position.If the patient is convulsing: clear instruments and protect the patient from injury. Call for help. After convulsions cease: Airway: ensure airway is open Breathing: ensure that breathing is adequate Circulation: Check pulse and confirm adequate circulation Dispense/administer:● Oxygen at flow rate of 5-6L/min ● If local anesthesia overdose results in seizure, a benzodiazepine (diazepam, lorazepam or midazolam) as described in the seizure algorithm may be administered. Ensure vitals signs, drugs administration are properly monitored and recorded. Maintain blood pressure. Facilitate/ensure next steps in medical care(provide supportive therapy) ● Treat bradycardia (0.4mg atropine IV with ACLS trained rescuer) ● Transport to hospital ● Reassure patient NOTE: If patient becomes unconscious, maintains airway, administer CPR, and activate EMS/911.

MI

● Myocardial infarction ○ Signs and symptoms: Development of chest pain, sometimes manifested as a crushing, squeezing, or heavy feeling, that is more severe than with angina, possibly radiating to the neck, shoulder or jaw; lasting longer than 15 minutes and not relieved by nitroglycerin tablets in the conscious patient. Cyanotic, pale or ashen appearance; weakness, cold sweat, nausea, vomiting, air hunger and sense of impending death; increased irregular pulse beat of poor quality with palpitations, feeling of impending doom. ○ Cause: Interruption of blood supply to the heart, most commonly due to occlusion of coronary vessels. Anoxia, ischemia and infarct are present ○ Treatment Positioning: Place patients in a comfortable position. Call for help and activate EMS. Airway: ensure open airway Breathing: ensure that breathing is adequate by communication with and reassuring patient Circulation: Request equipment to check pulse and blood pressure Dispense/administer: ● Aspirin 325mg tablet in conscious patient ● Oxygen at flow of 5-6L/min Ensure that vital signs, drug administration and patient responses are properly monitored and recorded. Facilitate/ensure next steps in medical/dental care. Reassure patient ● Keep patient in most comfortable position ● Administer nitrous oxide-oxygen at 30%/70% if available ● Alternatively, demerol or morphine may be administered if the dentist had ACLS training. ● If the condition progresses to cardiac arrest and the patient is unresponsive, initiate CPR, including the use of AED.

transplant - treatment planning considerations

● Treatment planning considerations ○ Pretransplantation patients ■ Active dental disease should receive indicated dental care before the transplant operation ● Patients with advanced periodontal disease or those who demonstrate little interest in or ability to improve their level of oral hygiene are advised to have teeth extracted. ● Patients with good oral health should be encouraged to keep their teeth and educated on maintenance and potential problems. ● Before invasive dental procedures are performed, the dentist must consult with the patient's physician to establish the degree of organ dysfunction and the need for prophylactic antibiotics. ○ Posttransplant patients ■ Immediate posttransplantation period ● No routine dentistry is indicated. Only emergency dental care should be provided as confirmed by medical consultation. ■ Stable posttransplantation period. ● Must be confirmed by the physician that the patient is stable. Treat as indicated. ● Risk of infection: While no solid data shows reason to premedicate patients, many centers recommend antibiotic prophylaxis when patients undergo dental treatment that may cause transient bacteremia. This decision should be made with consult of the medical side and a decision should be reached based on the individual patient and their status. ● Viral infections: Posttransplant patients may be especially susceptible to viral infections. HSV, epstein-barr virus, cytomegalovirus, hepatitis B, C and HIV. The most common infection is cytomegalovirus. ● Excessive bleeding: Liver or heart transplant patients may be taking anticoagulants. INR greater than 3.5 is contraindicated for surgery. ● Adverse reaction to stress: Transplant patients who are receiving steroids may not be able to adjust to the stress of various dental surgical procedures because of adrenal suppression and may require additional steroids before and after these surgical procedures to protect against an acute adrenal crisis. The need for supplemental steroids should be established by medical consultation. ● Hypertension: An important side effect of cyclosporine is renal damage with associated hypertension. Prednisone also can cause hypertension as well as other adverse effects. ○ Must determine, with the help of a physician, what's the baseline blood pressure for the patient and monitor it at each visit. ■ Chronic rejection period: ● Signs and symptoms of chronic rejection of the graft or GVHD. Onset should be confirmed with a physician. Only emergency or immediate dental needs should be treated during this period.

Frankle

- increase in thickness of the buccal aspect as one proceeds posteriorly - mean horizontal distance between the mesial apices of the first and second molars and the outer surface of the buccal cortical plate was 4.2 and 7.4 mm - vertical distances of the anatomical sections between the anatomical apices and the neurovascular bundle of the first and second molars were found to be 5.3 mm and 3.6 mm, - distances between the radiographic apex of the mesial root and the superior border of the canal were found to be 6.0 mm for the first molar and 3.7 mm for the second molar - significant correlation existed between the vertical anatomic distances and the vertical radiographic distances - correlation between the vertical anatomic distance and the horizontal anatomical distance existed. No significant correlation - neurovascular bundle in the first molar region was observed to be 81% of the time in the lingual half of the mandible and 16% of the time in the buccal half - one specimen (3%) it existed in the center of the mandible - none of the specimens was the neurovascular bundle adjacent to the apex of the first molar. - one specimen, as seen in Fig. 5, the neurovascular bundle exited in the mandible inferior to the mesial apex of the first molar - level of the second molar, the neurovascular bundle was observed in the lingual half of the mandible with a frequency of 84% and was not observed to be located in the buccal half in any of the specimens. - three specimens (9%) the neurovascular bundle was found adjacent to the apex of the second molar and in two specimens (6%) the bundle was observed in dead center.

Torabinejad

- the main molecules present in MTA are calcium and phosphorous ions. -MTA has a pH of 10.2 initially, which rises to 12.5 three hours after mixing. MTA is more radiopaque than Super-EBA and IRM. Amalgam had the shortest setting time (4 min) and MTA the longest (2 h 45 rain). At 24 h MTA had the lowest compressive strength (40 MPa) among the materials, but it increased after 21 days to 67 MPa. Finally, except for IRM, none of the materials tested showed any solubility under the conditions of this study.

Velvart

12 patients with marginal incision involving complete mobilization of the entire papilla in one interproximal space and in the other interproximal space the PBI was performed. Height of interdental papilla evaluated 1, 3, 12 months -The mean recession for the PBI measured between a reference point and the most coronal point of the papilla comparing the preoperative and the recall at 1 month was 0.07 ± 0.09, 0.10 ± 0.15 mm at 3 months and )0.06 ± 0.21 mm at 12 months. -the total papilla mobilization of the papilla the readings were 1.10 ± 0.72 mm at 1 month, 1.25 ± 0.81 mm at 3 months and 0.98 ± 0.75 mm at 12 months. - The PBI incision showed significantly less shrinkage than total mobilization of the papilla at all recall appointments (Fig. 3) compared with the preoperative levels -In complete papilla mobilization at the 3-month recall the retraction had increased in nine sites, whereas in three sites the loss of height had diminished compared with 1 month. -Changes between the 3- and 12-month visit were in general small; in two patients further minimal loss of up to 0.2 mm occurred, in all other cases creeping was observed. -four sites still displayed considerable loss of papilla height of 1.4 mm or more compared with the preoperative situation. -papilla height changes between the recall appointments, when complete papilla elevation was performed, was not statistically significant Conclusions In the short as well as long-term the PBI allows predictable recession-free healing of the interdental papilla. In contrast, complete mobilization of the papilla displayed a marked loss of the papilla height in the initial healing phase although this was less evident 1 year postoperatively. In aesthetically relevant areas the use of the PBI is recommended, to avoid opening of the interproximal space, when peri- radicular surgical treatment is necessary.

Christiansen

44 patients, comparing the MTA and GP treatment methods. Radiographs produced 1-week and 12 months post-operatively GP group: seven teeth (28%) showed complete healing, six teeth (24%) incomplete healing, six teeth (24%) uncertain healing and two teeth (8%) unsatisfactory healing after 1 year. MTA group: 22 teeth (85%) showed complete healing, three teeth (12%) incomplete healing, and none were scored as uncertain or unsatisfactory healing after 1 year. The difference in healing between the GP and the MTA groups was significant (P < 0.001). Conclusions The results emphasize the importance of placing a root-end filling after root- end resection. Teeth treated with MTA had significantly better healing (96%) than teeth treated by smoothing of the orthograde GP root filling only (52%).

Halse

474 treated with periapical surgery examined after 1 year 41 cases completely healed after one year, 5% failed later 76 showed incomplete healing (scar) after 1 year ended as completely healed or persistent incomplete healing 72 uncertain cases equally redistributed as success or failed Conclusion: one year control will provide a valid x for the majority of cases, only a minor number the uncertain healings need further follow-up -cases that with a reasonable degree of certainty can be diagnoised as completely healed or clearly showed features of incomplete (scar) healing can be terminated after one year control. Very few cases will fail later -cases without radiographic signs of healing at the on year control should be recorded as failures -cases showing uncertain healing after one year will later and equally distributed as successes or failures

Gagliani

48 extracted teeth were endodontically treated and sealed by gutta-percha vertical compaction: 24 were resected with a 45 ° angle and 24 with a 90 ° one. An ultrasound source (P.M. 400 EMS) and a CT5 Scaler were used to make the retrograde cavity that was filled after- wards with EBA-zinc oxide-eugenol alumina- added cement. Apical leakage was determined us- ing fuchsin and assessed after the roots were sectioned longitudinally. Linear dye penetration in dentin and at the interface between dentin and cement was measured with a stereomicroscope -90 ° average infiltration of 0.2mm on side 1 and 0.2 mm on side 2. -45 ° angle, the average was 1.1 mm on side 2 and 1.0 mm on side 1. - difference between the sides is further demonstrated by the two different values: 1.0 mm for the 45 ° group and 0.1 or 0.2 mm on the two sides of the 90 ° group. -less specimens with no infiltration in the group sectioned at a 45 ° angle. - 90 ° angle showed an average infiltration of 0.41 mm on side 1 and 0.38 mm on side 2. - 45 ° angle, the average was 0.88 mm on side 1 and 0.69 mm on side 2. - depth of the preparation in the root ends resected at a 90 ° angle was 3.02 mm on side 1 and 3.1 mm on side 2, 45 ° angle, which were all measurable, the average length was 2.8 mm on side 1 and 3.12 mm on side 2. -less infiltration into the dentin and into the space between the filling and the root canal lumen in the root end 90 ° angle, the difference was statistically significant only for the dentin

Torabinejad

88 teeeth obturated with gutta-percha and sealer. Root-end resection and root-end cavities filled with amalgam, Super-EBA,l (IRM), or MTA. MTA had the smallest gaps (2.68 --- 1.35/xm), whereas IRM had the largest gaps (11.00 4- 7.9/xm) and poorest adaptation among the four materials. Super-EBA and amalgam were smaller than those with IRM,

Setzer

88% positive outcome for CRS and 94% for EMS -success for EMS was 1.07 times the probability of success for CRS. -difference in probability of success between the groups was statistically significant for molars, no significant difference was found for the premolar or anterior group

Lantz

A histologic study of the periodontal tissue reactions after surgical treatment of root perforation in dogs' teeth was carried out 1.If the perforation was immediately treated with endodontic-surgical technique, a favorable healing of the periodontal tissues occurred. In cases in which the perforation canal emerged close to the gingival crevice, proliferation of crevicular epithelium over the perforation exit was noted 2.If the perforation entrance was immediately sealed with phosphate cement, and some time elapsed before treatment with endodonic technique, healing of the periodontal tissues occurred with the following disadvantage. During the period before treatment, bone destruction had taken place, which resulted in a lowering of the interdental bone crest. This, in turn, facilitated proliferation of crevicular epithelium over the perforation exit. 3.The experiments were made in pairs on the same animal. In every pair of perforations, one perforation exit was sealed with gutta percha and the other with sliver amalgam. In all cases, it was found that gutta-percha had caused less irritation of the tissues than amalgam

Siqueira JF, Rocas IN.

A nested polymerase chain reaction (PCR)-based method was used to directly survey samples taken from primary endodontic infections for the occurrence of Pseudoramibacter alactolyticus. Identifi- cation by nested PCR was performed in root-canal samples from teeth associated with asymptomatic periradicular lesions or acute apical periodontitis, and in pus samples from acute periradicular ab- scesses. DNA was extracted from the samples and initially amplified using universal 16S rDNA prim- ers. A second round of amplification used the first PCR products to detect a specific fragment of P. alactolyticus 16S rDNA. P. alactolyticus was detected in 76% of root-canal samples from teeth showing asymptomatic periradicular lesions, in 60% of samples taken from root canals associated with acute apical periodontitis, and in 32% of pus samples aspirated from acute periradicular ab- scesses. No significant association of this species with clinical symptoms was observed (p > 0.01). In general, P. alactolyticus occurred in 56% of sam- ples taken from infections of endodontic origin. The high prevalence of P. alactolyticus in infections of endodontic origin as detected by nested PCR in this study, and its apparent pathogenicity, partic- ularly in mixed infections, indicate that this bacte- rial species is a candidate endodontic pathogen that can participate in the etiology of different forms of periradicular diseases.

Artzi

After inducing apical periodontitis in 9 cats, root canal and surgical endodontic treatment were performed on 72 roots of first and second maxillary premolars. Bone defects were treated with biomaterial particles + a membrane, biomaterial only, a membrane only, or left unfilled (control). Histomorphometry on nondecalcified sections were performed at 3 and 6 months after surgery. At each time period, bone formation was greater at the grafted membrane-protected sites than in the grafted- unprotected sites. At 6 months, the bone area fraction at membrane nongrafted sites was greater than in the grafted-protected sites. The new cementum was significantly greater at 6 months than at 3 months and greater at the grafted membrane-protected sites over the unprotected ones at 6 months. Statistically, the grafted bioma- terial, the membrane, and the time contributed significantly to the amount of new bone (P < .05) with no significant interaction. Biomaterial osteoconduction was significantly affected by the time. All 3 variables showed a significant interaction on new cementum. Conclusions: There was significantly more bone forma- tion after surgical endodontic treatment when membrane and bone grafts were used as compared with bone grafts only or unfilled control sites. However, it appears that the key factor to the enhanced tissue regeneration is the membrane and not the grafted biomaterial. (J Endod 2012;38:163-169)

Rud

A radiographic classification system is presented for healing assessment after periapical surgery. The use of the classifica- tion requires an observation period of at least one year. Radiographic- ally the following four groups are described: Group 1, Complete healing; Group 2, incomplete healing (scar tissue); Group 3, uncertain healing and Group 4, unsatisfactory healing (failures). Of 120 cases examined histologically, it was found that all cases in the unsatia'- factory healing group were severely inflamed. In the complete healing group inflammation was in some cases not depicted radiographically because of the projection. In Groups 2 and 3 inflammation was found in 61 and 86 %, respectively. Scar tissue was found in 91% of cases in Group 2. When the subjective and objective symptoms from 1,000 cases treated with endodontic surgery were correlated with the various healing groups, it appeared that these symptoms were concentrated mainly within the group unsatis/actory healing, and only a few cases showed symptoms within the groups complete and incomplete healing. When testing the precision of the radiographic classification it was found that the three authors agreed on cases with complete healing in more than 90 % of the cases. Most discrepancy was found regarding the uncertain healing group, where the authors were only 70- 76 % in agreement. Repeated readings of consecut]]ve cases by the authors showed discrepancies of 5-13 %. Two dent~l'surgeons, informed about the classification through the description and illustrations only, had a precision of 76- 79 % respectively, compared to the joint decisions of the present authors.

Kramper

A semilunar incision of alveolar mucosa, a submarginal incision of attached gingiva, and an intrasulcular incision of the attachment apparatus and papillae of the teeth were performed on beagles and observed at intervals of up to 60 days. 1. Inflammatory changes persist for longer time in the semilunar and intrasulcular incisions than in the submarginal incisions. This chronic inflammation retarded healing of the incisional wounds. 2. When compared with the submarginal incision, the semilunar and intrasulcular incisions demonstrated a delay in histologically observable mature collagen fibers and its realignment with adjacent tissues. Entrapped epithelial islands were observed in the intrasulcular incisions. 3. Loss of alveolar bone, accompanied by gingival recession or an increase in the length of the epithelial attachment, will occur with the intrasulcular incision. 4. Scar formation occurs with the submarginal and semilunar incisions, while very little, if any, visible scarring occurs with the intrasulcular incision. -the submarginal incision is the flap design of choice inperiapical surgery when not contraindicated by the anatomical location of the lesion or by insufficient attached gingival tissue.

Setzer

An intensive search of the literature was conducted to identify longitudinal studies evaluating the outcome of root-end surgery. -success rates calculated from extracted raw data showed 59% positive outcome for TRS and 94% for EMS. difference was statistically significant -success for EMS was 1.58 times the probability of success for TRS.

Morgan

Endodontic surgery was performed on 25 roots from 20 patients. In vivo vinyl polysiloxane impressions were made after root resection and again after ultrasonic root- end preparations. Epoxy resin casts were made from the impressions and scanning electron mi- crographic examination of the root-end replicas was performed. No cracks were evident alter root resection -Several root-ends demonstrated grooves (Fig. 2) probably caused by the skidding of the ultrasonic instrument across the root-end. -After root-end preparation, marginal chipping of dentin was frequently noted at the interface of the canal wall and the root surface

Harrison

Excisional wounds were made in the maxillas and mandibles of rhesus monkeys, and the osseous wound-healing responses at postsurgical intervals ranging from 1 to 28 days were evaluated by light microscopy. The excisional defects were initially filled with a coagulum which was subsequently replaced by granulation tissue emanating from the endosteal tissues. Cortical and trabecular bone forming the wound edges was devitalized, as evidenced by an absence of osteocytes in the peripheral lacunae. At 14 days postsurgery, woven bone trabeculae occu- pied most of the defect, with the more superficial trabeculae in direct contact with a thick band of dense fibrous connective tissue separating the os- seous defect from overlying mucosal tissues. Within the defect, new bone was deposited on devitalized bone without evidence of preceding osteoclastic activity. At 28 days, the woven bone trabeculae were more mature and a functioning periosteum was now active in repair of the cortical plate.

Vidana

Fifty consecutive patients with apical periodontitis in need of endodontic orthograde re-treatment were included. Samples were collected from root canals, saliva and faeces and subjected to microbiological cul- turing. The genetic relationship between Ent. faecalis from root canals and isolates from the different host sources was determined using pulsed-field gel electrophoresis. In 16% (8 ⁄ 50) of the patients, enterococci were collected from the root canal samples. The genetic analysis showed that the isolates from the root canals were not related to those from the normal gastrointestinal microflora. None of these patients had enterococci in their saliva samples. Conclusions: Endodontic infections with Ent. faecalis are probably not derived from the patient's own normal microflora, which indicates that these infections ent. faecalis are of exogenous origin.

Sundqvist et al. (1998)

Fifty-four root-filled teeth with persisting periapical lesions were selected for re-treatment. After removal of the root filling, canals were sampled by means of advanced microbiologic techniques. The teeth were then re-treated and followed for up to 5 years. Results. The microbial flora was mainly single species of predominantly gram-positive organisms. The isolates most commonly recovered were bacteria of the species Enterococcus faecalis. The overall success rate of re-treatment was 74%. Conclusions. The microbial flora in canals after failed endodontic therapy differed markedly from the flora in untreated teeth. Infection at the time of root filling and size of the periapical lesion were factors that had a negative influence on the prognosis. Three of four endodontic failures were successfully managed by re-treatment.

Curtis

For 68 retreatment and 57 EMS cases, preoperative and recall clinical data, periapical (PA) radio- graphs, and CBCT imaging were retrospectively obtained. - teeth with or without a preoperative PARL, EMS resulted in a statistically significant difference in complete healing (86.0%) versus retreatment (41.2%). EMS resulted statistically significant difference in combined complete healing and reductive healing (94.7%) versus retreatment (82.4%). Of 46 recalls in which CBCT imaging detected a PARL, PA radiography detected 30 (a 35% false-negative rate). Of the 79 recall studies in which CBCT imaging did not detect a PARL, PA radiography did detect PARL in 13(a 16.5% false-positiverate). Conclusions: In this CBCT and clinical data-based outcomes assessment, EMS resulted in a greater mean volumetric reduction and a higher healing rate compared with retreatment. Postoperative CBCT imaging is more sensitive and specific than PA radiography in assessing PARL and has demonstrable usefulness in outcomes assessment.

Matsuo

Forty extracted teeth with apical lesions were se- lected and divided into two groups: a group of untreated teeth and a group of canal-enlarged teeth. The bacteria in the specimens were detected by Brown-Brenn stain and the labeled-streptavi- din-biotin method with specific antisera for 16-bacteria. Seventy percent of the examined teeth showed bacteria invading the dentinal tubules of the roots. Fusobacterium nucleatum, Eubacterium alactolyticum, E. nodatum, Lactobacillus casei, and Peptostreptococcus micros were abundant. Even in the canal-enlarged group, invasion of bac- teria was observed in 65% of teeth. This study revealed the actual condition of bacteria in in- fected root dentin and suggested that the canal- enlargement procedure could not completely re- move all the bacteria in the infected dentinal tubules of the root.

Leubke

Indications A.Necessity for drainage 1.Elimination of toxic material 2.Alleviation of pain B.Postoperative failure of conventional therapy 1.obvious inadequate filling 2.apparent adequate filling 3.persistent postoperative filling c.Predictable failure with conventional therapy 1.flared apex 2.severely curved root end 3.internal, external, or apical resorption 4.fractures in the apical third 5.persistent infection 6.persistent suppuration or exudation 7.forecast of acute abscess 8.apical cyst D.Impracticality of conventional therapy 1.porcelain jacket crown 2.fixed partial denture attachment 3.dowel-retention crown 4.excessive calcification 5.assocciated periodontal lesion E.Procedural accidents 1.instrument fragmentation 2.perforation 3.overinstrumentation 4.gross overfilling Contraindications 1.highly emotional/apprehensive patient 2.too old/young, debilitating/terminal disease, first/third trimester, heat disease 3.surgically inaccessibility 4.short root length 5.poor bony support 6.missing cortical bone

Shah HN, Collins MD.

It was recently proposed that the genus Bacteroides should be restricted to Bacteroides fragilis (the type species) and closely related organisms (viz., B. caccae, B. distusonis, B. eggerthii, B. merdae, B. ovatus, B. stercoris, B. thetaiotaomicron, B. unifomtis, and B. vulgatus). By contrast, the moderately saccharolytic, predominantly oral Bacteroides species, which include B. melaninogenicus, B. oralis, and related species, form a phenotypically and phylogenetically coherent group of species which differ so significantly from the emended description of the genus Bacteroides that they should not be classified in the same genus. Therefore, we formally propose that these species be reclassified in a new genus, Prevotella. The type species is Prevotella melaninogenica.

Maiden MFJ, Cohee P, Tanner ACR.

With reference to the first Principle of the International Code of Nomenclature of Bacteria, which emphasizes stability of names, it is proposed that the original adjectival form of the specific epithet be conserved in the reclassification of Bacteroides forsythus to the new genus Tannerella. Thus, Tannerella forsythensis Sakamoto et al. 2002 should be Tannerella forsythia Sakamoto et al. 2002 corrig., gen. nov., comb. nov., and we put forward a Request for an Opinion to the Judicial Commission regarding this correction.

Rocas IN, Siqueira JF.

Members of the Dialister genus are asaccharolytic obligately anaerobic gram-negative coccobacilli that are culture-difficult or remain uncultivated. Their participation in endodontic infections has been only consistently demonstrated after advent of molecular biology approaches. This study was undertaken to characterize Dialister species in samples from primary endodontic infections using a devised 16S rRNA gene-based group-specific heminested PCR assay followed by sequencing of PCR products. Genomic DNA was isolated directly from clinical samples and used as template for PCR. Amplicons from positive specimens were sequenced and phylogenetically analyzed to determine species identity. Ten of 21 clinical samples yielded sequences with the highest percent similarities to oral Dialister species/phylotypes. Seven sequences were from Dialister invisus, and the other three sequences belonged to Dialister pneumosintes, Dialister oral clone BS095 and Dialister sp. clone IS013B24. Findings demonstrated that different Dialister species can take part in the microbiota associated with apical periodontitis lesions.

Mayrand D, Holt SC.

Recent developments in molecular biology and gene cloning and the use of specifically tailored microbial mutants will permit us to investigate the questions relevant to the role of BPBs and other microorganisms in mixed infections. Impor- tantly, these new technologies will allow the determination of the role of virulence factors of asaccharolytic BPBs in these infective processes. Once the mutants are available, we will then need to test and compare them in animal models so that definitive proof of their role as specific virulence factors in disease initiation and tissue destruction can be obtained. In recent years, a considerable body of research has focused on the expression of potential virulence factors in vitro. B. gingivalis, for example, has an extensive proteo- lytic activity which includes both natural and artificial substrates. However, it is not known whether these activities are the result of a limited number of enzymes or if this bacterium has a larger set of enzymes, each with a specific range of substrates. Also, very little is known of the involve- ment of these proteolytic enzymes in situ. This can be said for most, if not all, of the factors affecting virulence of these bacteria. Similarly, recently developed monoclonal antibodies (15.47, 117, 158) will contribute to our knowledge of the local- ization of specific bacteria both in plaque samples and within tissues. These new approaches will be central to investigations into the activities of cell surface molecules (i.e., LPS, pili, outer membrane proteins, etc.) as colonization factors, proteases, and hemagglutinins on the surface of the asaccharolytic BPBs. Structures such as vesicles produced by all three asaccharolytic BPB species also need to be thoroughly investigated. Studies are needed to determine whether these structures are important in disease, to biochemically characterize the vesicles, to determine whether they are a mechanism by which Bacteroides species can exchange genetic material as in Haeinophilits spp. (64) or whether they are a mechanism by which bacterial cells simply concentrate and secrete proteolytic enzymes. The results of these studies should help us to understand the role of these bacteria in mixed infections. Finally, we will need to gain more informaltion specifically on the ecological distribution of B. a(sa(lharolwti(ci.s and B. eniod(oontalis and the role that they play in mixed infections.

Alhadainy

Root perforations may be due to iatrogenic causes, internal or exlternal resorptions, or caries. Iatrogenic perforations are often due to inadequate access preparation, misdirection of a bur, overinstrumentation of root canals, or the misuse of a rotary instrument in preparing post or dowel. Diagnlosis of root perforation is possible with diagnostic aids that include direct observation of bleeding, indirect bleeding assessment using a paper point, radiography, and an apex loca tor. The prognosis of an endodontically treated tooth with a small perforation is fair when the perforation occurs away from the gingival sulcus or the furcation site and when the perforation is sealed immediately after it is encountered. The prognosis becomes worse when the perforation occurs in the pulp chamber floor or the furcation area. The treatment plan for root perforations depends on several factors. These perforations can be repaired nonsurgically by conventional filling, orthodontic-en- dodontic technique, as an additional canal, or by stimulation of callcification in the same way as apex- ification of the incompletely formed root end. Perfo- rations of the pulp chamber floor can be filled nonsurgically whlen access is available through the pulp chamber. The major difficulty with such a method of repair is the extrusion of the filling mate- rial into the periodontal space. Repair material ex- trusion can be controlled by using of bioinert matri- ces such as indium foil, dentin chips, calcium hydrox- ide, Teflon disks, hydroxyapatite, or plaster of Paris. Plaster of Paris proved to be a good barrier against the extrusion of the repair materials with favorable biologic properties. Surgical repair of a root perforation has been attempted by reflecting a flap at the perforation site and packing a relpair material into the defect through the surgical access. Surgical approach is usually limited to the defects that are not amenable to other treatment modalities. Large perforations in the furcation area can be treated by bicuspidization, hemisection, or root amputation. Surgically inaccessible perforations of tlhe midroot or perforating internal or external resorption can be treated by intentional replantation whereas apical perforations may be treated by apicoectomy.

Murdoch DA, Shah HN

Several lines of evidence, notably 16S rRNA sequence analysis, indicate that the genus Peptostreptococcus is phylogenetically incoherent. Two of the most well studied species, Peptostreptococcus magnus and Peptostreptococcus micros, differ significantly in both genetic and phenotypic characteristics from each other and from the type species of the genus, Peptostreptococcus anaerobius. Therefore, we propose that Peptostreptococcus magnus be reclassified in a new genus, Finegoldia, as Finegoldia magna; we propose that Peptostreptococcus micros be reclassified in new genus, Micromonas, as Micromonas micros.

Author: Winkler

Streptococci form 61 per cent of the isolated organisms. Among these, the group of hemolytic, indifferent, and indifferent anaerobic streptococci, mainly belonging to serologic groups F, G, and C, seem the most serious possible pathogens. D streptococci (especially Streptococcus liquefaciens) are difficult to eliminate from the root canal and are also potential pathogens. Streptococcus rnitis seems of much less importance, and all other organisms are to be considered as chance contaminants.

Gilheany

Teeth were divided into groups corresponding to the angle of apical resection (0, 30, and 45 degrees to the long axis of the root) and apical leakage was determined following incremental increases in the depth of the retrograde filling (Ketac Silver). -significant differences in leakage between retrograde fillings in teeth resected at 0, 30, and 45 degrees to the long axis of the tooth. -increasing the depth of the retrograde filling significantly decreased apical leakage and that there was a significant increase in apical leakage as the amount of the bevel increased -Statistical differences were found be- tween the 0-degree group and both the 30-degree -No statistically significant differences were found between the 45- and 30-degree groups -No significant difference was found between the slopes of each group, Conclusion Increasing the depth of the retrograde filling significantly decreased apical leakage; there was also a significant increase in leakage as the amount of bevel increased. Both the permeability of resected apical dentin and microleakage around the retrograde filling material had a significant influence on apical leakage.

Stevens

Ten E. faecalis strains were isolated from root canals of teeth undergoing retreatment following unsuccessful endodontic therapy. Mitomycin C was used to induce any prophages present in the bacterial isolates. The induced phages were purified and examined using electron microscopy. The DNA extracted from one of the phage isolates was subjected to restriction endonuclease digestion and agarose electrophoresis analysis. Results: Lysogeny was demonstrated in 4 of the 10 E. faecalis strains. Three of the lysogenic strains yielded phages exhibiting a Siphoviridae morphology, with long, noncontractile tails 130 nm in length, and spherical/icosahedral heads 41 nm in diameter. The virus induced from the fourth lysogenic E. faecalis strain had a contractile tail characteristic of Myoviridae. Restriction endonuclease analysis of NsiI and NdeI DNA fragments from one of the Siphoviridae phage isolates (phage /Ef11) indicated a genome size of approximately 41 kbp. Conclusion: This is the first report of lysogenic bacteria and their inducible viruses in infected root canals.

Barone

The 4- to 10-year outcome of apical surgery was prospectively assessed by a blinded, independent, calibrated examiner and dichotomized as ''healed'' (periapical index score #2 or scar; no signs or symptoms) or ''diseased.'' Teeth presenting without signs or symptoms were classified as ''functional.'' 99 teeth (74%) were healed, and 126 teeth (94%) were functional. Three significant outcome predictors were identified: (age >45 years, 84%, <45 years, 68%), preoperative root-filling length (healed: inadequate, 84%; adequate, 68%), and size of the surgical crypt (healed: <10 mm, 80%; > 10 mm, 53%). Conclusions: In this 4- to 10-year cohort study, the outcome was better in subjects >45 years old, teeth with inadequate root-filling length, and crypt size of #10 mm.

: Liljestrand

The aim of this cross-sectional study was to delineate the associations between EL and CAD. Subgingival P. endodontalis, its immune response, and serum lipopolysaccharide were examined as potential mediators between these 2 diseases. The Finnish Parogene study consists of 508 patients (mean age, 62 y) who underwent coronary angiography and extensive clinical and radiographic oral examination. The cardiovascular outcomes included no significant CAD (n = 123), stable CAD (n = 184), and acute coronary syndrome (ACS; n = 169). EL was determined from a panoramic tomography. We combined data of widened periapical spaces (WPSs) and apical rarefactions to a score of EL: 1, no EL (n = 210); 2, ≥1 WPS per 1 apical rarefaction (n = 222); 3, ≥2 apical rarefactions (n = 76). Subgingival P. endodontalis was defined by checkerboard DNA-DNA hybridization analysis, and corresponding serum antibodies were determined by ELISA. In our population, 50.4% had WPSs, and 22.8% apical rarefactions. A total of 51.2% of all teeth with apical rarefactions had received endodontic procedures. Subgingival P. endodontalis levels and serum immunoglobulin G were associated with a higher EL score. In the multiadjusted model (age, sex, smoking, diabetes, body mass index, alveolar bone loss, and number of teeth), having WPSs associated with stable CAD (odds ratio [OR] = 1.94, 95% confidence interval [95% CI] = 1.13 to 3.32, P = 0.016) and highest EL score were associated with ACS (OR = 2.46, 95% CI = 1.09 to 5.54, P = 0.030). This association was especially notable in subjects with untreated teeth with apical rarefactions (n =59, OR = 2.72, 95% CI = 1.16 to 6.40, P = 0.022). Our findings support the hypothesis that ELs are independently associated with CAD and in particular with ACS. This is of high interest from a public health perspective, considering the high prevalence of ELs and CAD.

Verma

The aim of this study was to determine, radiographically and histologically, the effect of residual bacteria on the outcome of pulp regeneration mediated by a tissue-engineered construct as compared with traditional revascularization. Periapical lesions were induced in 24 canine teeth of 6 ferrets. After disinfection with 1.25% NaOCl and triple antibiotic paste, ferret dental pulp stem cells, encapsulated in a hydrogel scaffold, were injected into half the experimental teeth. The other half were treated with the traditional revascularization protocol with a blood clot scaffold. After 3 mo, block sections of the canine teeth were imaged radiographically and processed for histologic and histobacteriologic analyses. Associations between variables of interest were evaluated through mixed effects regression models. There were no significant differences between the 2 experimental groups in radiographic root development (P > 0.05). There was a significant association between the presence of persistent periapical radiolucency and root wall thickness (P = 0.02). There was also no significant difference in histologic findings between the 2 experimental groups (P > 0.05). The presence of residual bacteria was significantly associated with lack of radiographic growth (P < 0.001). The amount of dentin-associated mineralized tissue formed in teeth with residual bacteria was significantly less than in teeth with no residual bacteria (P < 0.001). Residual bacteria have a critical negative effect on the outcome of regenerative endodontic procedures.

Shah HN, Collins MD.

The asaccharolytic, pigmented Bacteroides, Bacteroides asaccharolyticus, Bacteroides gingivalis, and Bacteroides endodontalis, form a group of relatively homogeneous species which differ markedly in biochemical and chemical properties from the type species of Bacteroides, Bacteroides fragilis (Castellani and Chalmers), such that they should not be retained within this genus. Therefore, we propose that Bacteroides asaccharolyticus (Holdeman and Moore) Finegold and Barnes, Bacteroides gingivalis Coykendhll, Kaczmarek and Slots, and Bacteroides endodontalis van Steenbergen, van Winkelhoff, Mayrand, Grenier and de Graaff be reclassified in a new genus, Porphyromonas, as Porphyromonas asaccharolytica comb. nov., Porphyromonas gingivalis comb. nov., and Porphyromonas endodontalis comb. nov., respectively

Sakamoto M, Suzuki M, Umeda M, Ishikawa I, Benno Y.

The characteristics of the fusiform species Bacteroides forsythus, isolated from human periodontal pockets, were examined. 16S rDNA sequence analysis confirmed that B. forsythus was not a species within the genus Bacteroides sensu stricto. Although B. forsythus was phylogenetically related to Bacteroides distasonis and Bacteroides merdae in the phylogenetic tree, the ratio of anteiso-15:0 to iso-15:0 in whole-cell methanolysates of B. forsythus was different from those of B. distasonis, B. merdae and other Bacteroides species. B. forsythus did not grow on medium containing 20% bile, but members of the Bacteroides fragilis group did. B. forsythus was the only species tested that was trypsin-positive in API ZYM tests. The dehydrogenase enzyme pattern was of no use for the differentiation of B. forsythus and the B. fragilis group. On the basis of these data, a new genus, Tannerella, is proposed for Bacteroides forsythus, with one species, Tannerella forsythensis corrig., gen. nov., comb. nov. The type strain of Tannerella forsythensis is JCM 10827T ( ̄ATCC 43037T ).

Rud

The course of healing with observation periods of from one to fifteen years was examined for 1,000 teeth treated by surgical endodontics. This analysis showed that the groups complete healing and unsuccess]ul healing constitute stable groups without significant changes into other healing groups irrespective of the observation period. Conversely, the two groups incomplete healing and uncertain healing showed a number of changes into other healing groups, especially during the first post-operative years. With observation periods exceeding four years, only minor changes occur. Consequently a four- year observation period was proposed as the final follow-up in cases showing uncertain healing. The results obtained in the present study were compared with those from the literature after endodontic surgery and also after conservative endodontic treatment of cases with peri- apical rarefaction. It is stressed that such comparisons should be made with caution, because of the many differences between the various studies.

Vickers

The hemostatic agents used were epinephrine pellets (Racellet pellets) or 20% ferric sulfate (Vis- costat). Patients were assigned to one of two experimental groups. Blood pressure and pulse rate were recorded pre- and postoperatively and at three additional times during the surgery (root-end resection, root-end preparation, and filling). no signif- icant change in cardiovascular effects when using either of these hemostatic agents. Except in one case where ferric sulfate was the agent, both agents produced surgical hemostasis that allowed for a dry field for root-end filling.

Pecora

The lesions had a radiographic diameter of at least 10 mm, were removed by periradicular surgery, before retrofilling the apices with either super EBA or dessicated zinc oxide-eugenol. In 10 test sites large e-PTFE membranes (Gortex) were placed to cover the lesions, while at the control sites the lesions were not covered before resuturing. Radio-graphic analysis of the lesions at 3, 6, 9 and 12 months lesions covered with the membranes healed quicker than the control lesions, and that the quality and quantity of the regenerated bone was superior when membranes were used. Results of the study indicate that guided tissue regeneration (GTR) principles can be etfectively applied to the healing of large periapical lesions, especially in through-and- through lesions.

Ebeerhardt

The mean distance between the apices of the maxillary posterior teeth and the floor of the maxillary sinus was measured from computed tomographic display data from 12 autopsy specimens and 38 human subjects - distance from the maxillary molars and premolars to the floor of the maxillary sinus ranged from 0.83 mm for the mesiobuccal root of the second molar to 7.05 mm for the lingual root of the first premolar. -The thickness of buccal bone covering the apices ranged from 1.63 mm over the buccal root of the first premolar to 4.45 mm over the mesiobuccal root of the second molar. -The thickness of palatal bone covering the palatal roots of the first and second molars and the first premolar was 7.01, 2.16, and 5.42 mm, respectively. -Two of the 38 subjects (5%) had roots that protruded into the sinus cavity.

Waltimo

The occurrence of yeasts in 967 microbiological endo- dontic samples taken from root canals in persistent endodontic infections was studied. The sampling was done by general practitioners in various parts of Finland from root canal infections which did not respond favour- ably to standard conservative therapy. The samples were cultivated aerobically on a non-selective enriched horse blood agar medium, on TSBV agar medium in 5% CO2 and anaerobically on horse blood agar medium. Micro-organisms were found in 692 of the samples while 275 showed no growth. Forty-eight fungi were isolated from 47 samples which is 7% of the culture- positive samples. Twenty yeast strains were identified further by their colony morphology, growth and cellular characteristics and patterns of carbohydrate assimilation. All isolates except one belonged to the genus Candida. Candida albicans was the most common species. C. glabrata was found together with C. albicans in one sample. C. guilliermondii, C. inconspicua and Geotrichum candidum were each isolated once. Yeasts were found in pure culture in six samples and together with bacteria in 41 samples. In all the samples except two, the accompanying facultative bacteria were Gram positive. The most frequent of them were a- and non-haemolytic Streptococcus species which were found in 31 samples. Anaerobic bacteria were isolated together with yeasts from 12 root canals. They included both Gram positive species such as Peptostreptococcus micros and Gram negative species such as Fusobac- terium nucleatum. The regular isolation of yeasts, also in pure culture, indicates that yeasts may have an important role in cases of apical periodontitis persisting after conventional treatment.

Molander

The present study examined the microbiological status of 100 root-filled teeth with radiographically verified apical periodontitis - the pathology (P) group - and of 20 teeth without signs of periapical pathosis - the technical (T) group. In the P group 117 strains of bacteria were recovered in 68 teeth. In most of the cases examined one or two strains were found. Facultative anaerobic species predominated among these isolates (69% of identified strains). Growth was classified as 'sparse' or 'very sparse' in 53%, and as 'heavy' or 'very heavy' in 42%. Enterococci were the most frequently isolated genera, showing 'heavy' or 'very heavy' growth in 25 out of 32 cases (78%). In 11 teeth of the T group no bacteria were recovered, whilst the remaining nine yielded 13 microbial strains. Eight of these grew 'very sparsely'. It is concluded that the microflora of the obturated canal differs from that found normally in the untreated necrotic dental pulp, quantitatively as well as qualitatively. Nonsurgical retreatment strategies should be reconsidered.

Sedgley

The root canals of 150 extracted single canal teeth were instrumented to apical size 60 and divided into six groups of 25. Within each group 10 canals were inoculated with either gelatinase-producing E. faecalis OG1-S and the other 10 with its gelatinase-defective mutant E. faecalis OG1-X. Five canals per group were kept as uninoculated controls. The root canals in groups 1 and 2 were inoculated with 106 bacteria, incubated for 48 h at 37 !C then filled with gutta-percha and zinc-oxide eugenol sealer. Root canals were inoculated with 106, 105, 104 and 103 bacteria in groups 3-6, respectively, and left unfilled. All teeth were sealed coronally with glass-ionomer cement. After 6- (groups 1, 3-6) and 12-month (group 2) incubation at 37 !C in 100% humidity, root fragments were analysed for presence of E. faecalis, using culture, polymerase chain reaction and histolog- ical methods. Results Viable E. faecalis was recovered from all root filled teeth and from 95-100% of unfilled inoculated teeth. Initial cell density and gelatinase production did not influence the recovery of viable E. faecalis (P > 0.05; chi-square test). Enterococcus faecalis 16S rRNA gene products were present in all inoculated teeth and absent in all noninoculated controls. Dentinal tubule infection was evident under light microscopy in sections from inoculated teeth after 48-h, 6- and 12-month incubation. Conclusions Enterococcus faecalis inoculated into root canals maintained viability for 12-months ex vivo. The clinical implications are that viable E. faecalis entombed at the time of root filling could provide a long-term nidus for subsequent infection.

Ozok

The roots of 23 extracted teeth with apical periodontitis were sectioned in half, horizontally, and cryo-pulverized. Bacterial communities were profiled using tagged 454 pyrosequencing of the 16S rDNA hypervariable V5-V6 region. Results—The sequences were classified into 606 taxa (species or higher taxon), representing 24 bacterial phyla or candidate divisions and one archaeal phylum. Proteobacteria were more abundant in the apical samples (p<0.05), while Actinobacteria were in significantly higher proportions in the coronal samples. The apical samples harbored statistically significantly more taxa than the coronal samples (p=0.01), and showed a higher microbial diversity. Several taxa belonging to fastidious obligate anaerobes were significantly more abundant in the apical segments of the roots compared to their coronal counterparts. Conclusions—Endodontic infections are more complex than reported previously. The apical part of the root canal system drives the selection of a more diverse and more anaerobe community than the coronal part. The presence of a distinct ecological niche in the apical region explains the difficulty of eradication of the infection, and emphasizes the need that new treatment approaches should be developed.

Selim

The volume of blood lost during endodontic surgery was measured for 60 patients undergoing routine surgical pro- cedures using local anesthesia. patients lost an average of 9.5 ml of blood Mean operating time was 47 min, highest mean blood loss was 38.3 ml associated with the palatal surgery of maxillary molars, while the lowest mean was 2.4 ml from the mandibular incisors. The mean duration of surgery was also greatest for palatal surgery, and was least for the maxillary canine and mandibular incisors. Other than palatalsurgery, the maxillary first premoiar showed the greatest blood loss, almost double the average for all teeth. The rate of blood loss showed a strong correlation with duration of surgery (r = 0.86) (Fig. 1). The highest mean rate of blood loss occurred in cotijunction with palatal surgery (0.46 ml/min) and the maxillary first premoiar (0.23 ml/min), and the lowest with tbe mandibular incisor (0.09 ml/min). The rate of blood loss tended to parallel duration of surgery for all individual teeth (Table 2). Tbe mean blood loss for males (n= 19) was 12.8 + 3.4 ml (mean± S.E.M.), while mean blood loss for females (n = 41) was 8.1 + 1.3 ml (Table 1). These values are not significantly difierent (p > 0.05, Student's unpaired t test). The four different types of fiap design used are shown in Table 3. The triangular flap was most commonly used. No strong relationship was ob- served between flap design and amount of blood loss. Palatal surgery led to the greatest blood loss, with almost 4 times the mean for all teeth

Sukawat et al. (2002)

This study compared the antibacterial efficacy of three different formulations of calcium hydroxide by using human dentin specimens that were in- fected with Enterococcus faecalis. After exposure to three forms of calcium hydroxide (calcium hy- droxide mixed with distilled water, calcium hydrox- ide mixed with 0.2% chlorhexidine, and calcium hydroxide mixed with camphorated paramono- chlorophenol) for 7 days, dentin powder from the infected specimens was obtained and assessed for bacterial quantity by spectrophotometry. It was found that calcium hydroxide mixed with camphorated paramonochlorophenol killed all of the Enterococcus faecalis inside the dentinal tubules. This result was better than that obtained with cal- cium hydroxide mixed with distilled water or with 0.2% chlorhexidine (p < 0.05). Calcium hydroxide mixed with distilled water and calcium hydroxide mixed with 0.2% chlorhexidine were ineffective against these bacteria.

Gutmann

Three groups of 20 extracted teeth each were prepared as follows; I, a size 010 round bur was used to prepare an apical cavity 2-3 mm down the long axis of the root; II, treatment as per group I followed by a 60-s rinse with a solution of 10:3 (10% citric acid, 3% Fe2a3); and III, an ultrasonic retrotip was used to prepare a 2-3 mm deep apical cavity. 1. There were significant differences (P<0.05) in the amount of superficial debris remaining in root-end preparations in both the bur-prepared cavities and the bur-prepared cavities rinsed with a solution of 10% citric acid and 3% ferric chloride. 2. There were no significant differences at all levels in the amount of smear layer produced with tbe bur preparation only. All levels showed a thick layering of adherent debris. 3. There were significant differences (P<0.05) at all levels in the amount of smear layer with the bur preparations which were rinsed with the solution of 10% citric acid and 3% ferric chloride. The apical one-third demonstrated the least amount of smear layer of all techniques and areas evaluated. 4. There were no significant differences at all levels of root-end preparations made with the ultra- sonic retrotip for either superficial debris or smear layer. 5. There were significant diflerences (P<0.05) between the three methods of cavity preparation with regard to both superficial debris and smear layer. The least amount of superficial debris was observed in the ultrasonic group; the least amount of smear layer was observed in the bur preparation rinsed with a solution of 10% citric acid and 3% ferric chloride. 6. No technique effectively removed the smear layer in the coronal one-third ofthe preparation.

Vianna

We analyzed 20 necrotic uniradicular teeth with radiographic evidence of apical periodontitis and with no previous endodontic treatment. Using real-time quantitative PCR based on the functional gene mcrA (encoding the methyl coenzyme M reductase, specific to methanogenic archaea) and on archaeal 16S rRNA genes, we found five cases to be positive. Direct sequencing of PCR products from both genes showed that the archaeal community was dominated by a Methanobrevibacter oralis-like phylotype. The size of the archaeal population at the diseased sites ranged from 1.3 X 10^5 to 6.8 X 10^5 16S rRNA gene target molecule numbers and accounted for up to 2.5% of the total prokaryotic community (i.e., bacteria plus archaea). Our findings show that archaea can be intimately connected with infectious diseases and thus support the hypothesis that members of the domain Archaea may have a role as human pathogens.

Tidmarsh

Two groups of teeth were examined by SEM to ascertain the presence of a potential pathway for leakage at the root ends of apieected teeth. Teeth of unknown age: all teeth have dentinal tubules exposed to communicate between root canal and external surface. Varied number, size, and orientation Teeth of known age: 3 mm from apex and halfway between root canal and DCJ, mean number of tubules: 27,000, Older teeth have larger number of tubules: 25,000 Close to root canal, exposed tubules: 28,000 Inside DCJ: 13,000

Lin

Two hundred and thirty-six cases of endodontic treatment failures, none of which had advanced periodontal disease, postperforations, or root or crown fractures were analyzed clinically, radiographically, and histobacteriologically to determine the major factor(s) for treatment failures. there was a correlation between bacterial infection in the canal system and the presence of periradicular rarefaction in endodontic failures. This report provides evidence indicating that the major factors associated with endodontic failures are the persistence of bacterial infection in the canal space and/or the periradicular area and the presence of preoperative periradicular rarefaction. The apical extent of root canal fillings, i.e underfiUed, flush-filled, or overfilled, seems to have no correlation to treatment failures.

Alhadainy

Two light-cured materials, Vitrebond and Prisma WC Dycal, were compared with two chemically cured materials, Ketac fil and Dycal, for ability to seal furcation perforations. Access openings and furcation perforations were prepared in 60 teeth and randomly divided into four equal groups. - The chemically cured Dycal (group IV) showed the highest percentage of dye penetration (93.01%) followed by Ketac Fil ( 67.94%), Light-cured Prisma VLC Dycal (33.19% dye penetration), Vitrebond (lowest dye penetration, 26.48% of the perforation wall) significant difference between all tested groups except for the difference between Vitrebond and Prisma VLC Dycal.

: Peters

Two sets of teeth with apical periodontitis were collected at different geographic locations to study the identity of bacteria left in the root dentinal tubules. Root dentin of 20 of these teeth was cultured from three locations between pulp and cementum (A, B, and C). In addition dentin from eight teeth was examined histologically. Using the culturing technique bacteria were found in 77% of the dentin samples from set 1 (Amsterdam) and in 87.5% of the dentin samples from set 2 (Glasgow). At greater distance, in layer C, from the pulp bacteria were found in 62% (13 of 21) of the dentin samples. Twenty-three percent (3 of 13) of set 1 and 25% (2 of 8) of set 2 contained >50,000 colony-forming units/mg of dentin in layer C. In layers closer to the pulp higher numbers of anaerobic bacteria and Gram-positive rods were found, as well as a larger number of bacterial species. Histological sections showed bacterial penetration in dentinal tubules in 5 of 8 teeth. In the other three teeth where the colony-forming units/mg recovered was <10,000, no histological signs of tubule penetration was seen. It seems clear that, in more than half of the infected roots, bacteria are present in the deep dentin close to the cementum and that anaerobic culturing of dentin is more sensitive than histology to detect these bacteria.

Tsesis

literature search combined with strict inclusion and exclusion criteria was undertaken to identify clinical studies that assessed the added benefit of GTR in endodontic surgery. A trend of better outcome was found when GTR was used compared to control cases, but the results were not statistically significant. Lesion size, lesion type, and membrane type were identified as factors significantly affecting the outcome of GTR versus control cases. GTR techniques favorably affected the outcome of surgical endodontic treatments in cases of large periapical lesions and through-and-through lesions. A favorable outcome was found when using a resorbable membrane over using a nonresorb-able membrane or graft alone. Conclusions: GTR tech-niques may improve the outcome of bone regeneration after surgical endodontic treatments of teeth with certain lesions. Additional large-scale prospective clin-ical studies are needed to further evaluate possible benefits of GTR techniques in endodontic surgery.

Von Arx

six rabbits. Standardized bone defects (diameter 4 mm) were trephined, and different haemo- static agents were applied and compared with control defects: bone wax (left for 10 min), Stasis (ferric sulphate, left for 5 s), ExpasylTM (aluminium chloride, left for 2 min and left permanently in situ), and a combination of ExpasylTM (2 min) and Stasis (5 s). The sites were photographed before the application and after the removal of the haemostatic agents. most efficient haemorrhage control was provided by ExpasylTM in combination with Stasis and by ExpasylTM alone, whereas bone wax had the weakest bleeding reduction effect. an inflammatory and foreign body tissue response towards all haemostatic agents. At 12 weeks, this tissue response was less pronounced but still present in sites treated with bone wax or ExpasylTM. the inflammatory tissue reactions were limited to the bone defects, and never extended into the surrounding tissues. Conclusions ExpasylTM alone or in combination with Stasis appeared to be the most efficient of tested agents to control the bleeding within the bony defects created in a rabbit calvarium model.

Torabinejad

systematic review was to compare the clinical and radiographic outcomes of nonsurgical retreatment with those of endodontic surgery -higher success rate was found for endodontic surgery at 2-4 years (77.8%) - nonsurgical retreatment for the same follow-up period (70.9%; P < .05). At 4-6 years, however, this relationship was reversed, with nonsurgical retreatment showing a higher success rate of 83.0% compared with 71.8% for endodontic surgery -Insufficient numbers of articles were available to make comparisons after 6 years of follow-up period. Conclusions: endodontic surgery offers more favorable initial success, but nonsurgical retreatment offers a more favorable long-term outcome.

Von Arx

this meta-analysis was to review clinical articles on apical surgery with root-end filling in order to assess potential prognostic factors. -the following categories were significantly associated with higher healed rates: cases without preoperative pain or signs, cases with good density of root canal filling, and cases with absence or size #5 mm of periapical lesion. -treatment-related factors, cases treated with endoscope have higher healed rates Conclusions: Although the clinician may be able to control treatment-related factors, patient-and tooth-related factors should be considered as important prognostic determinants when planning or weighing apical surgery against treatment alternatives.