Dentistry 2012 E.C

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Dentistry
For 3rd year public health students

By Dr. Daniel T.
1
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What is dentistry?
• Dentistry:-is a science & art of
preventing, diagnosing & treating of
disease, injuries & malformation of the
soft and hard tissues of the jaws, oral
cavity, maxillofacial area & replacing lost
or absent teeth & associated structures
• It is also called stomatology (Greek word)
Stoma=organ of oral cavity.
logy=study.
=study of oral cavity. 2
Historical background of dentistry
• Modern dentistry started in mid 19th c USA

• In 1840-baltimore college of dentistry was opened
• In 1844 discovery of L.A by well contribute a lot to
dentistry
• Pierre Fauchard (18th Century - 1728) - Father of
Scientific Dentistry.
• Harvard university was the first university
affiliated dental program
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For the first time dentistry was
practiced in Ethiopia in 1923 in
Diredawa by a Russian female doctor
In 1953 the first Ethiopian qualified
dentist started to work
In 1990 the first dental health service
& training center established in A.A
by NGO called medicus mundi in
collaboration with Italian government
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 It was started by training dental
therapists. But in1996 the center
upgraded to dental school & training
students in BDS
• In1997 J.U established dental school
& training students in DMD.
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Various fields of dentistry
Prosthodontics:-it is the study of dentures,
bridges, & restoration of implants
Endodontics:-it is the study of disease of the
dental pulp & root canal therapy (RCT)
Periodontics:-study of diseases of the
periodentium (non-surgical &surgical)
placement & maintenance of dental implant.
Oral & maxillofacial surgery:- the study of
extraction, implants & facial surgery.
Oral medicine:- it is the study of treatment
of oral & maxillofacial disease (infectious,
inflammatory other manifestation of
systemic disease…) 6
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Oral pathology:- study of disease of oral
cavity
Dental & maxillofacial radiology:- study
& radio logic interpretation of oral &
maxillofacial disease.
Operative dentistry
Community dentistry
Orthodontics:-it is the study of
straightening of the teeth &modification
of mid face & mandibular growth.
Pedodontics:- dentistry for children 7
Dental Anatomy and Physiology
Elements
A tooth is made up of three elements:
• Water
• Organic materials
• Inorganic materials
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Detinition (teeth): There are two detinitions

•Primary (deciduous)
•Secondary (permanent)
Primary (deciduous)
•Consist of 20 teeth
•Begin to form during the first trimester of
pregnancy
•Typically begin erupting around 6 months
•Most children have a complete primary
dentition by 3 years of age
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1. Oral Health for Children: Patient Education Insert. Compend Cont Educ Dent.
10
Incisors
Secondary (permanent) Canine (Cuspid

• Consist of 32 teeth in most
cases Premolars
• Begin to erupt around 6 years
Molars
of age Maxilla
• Most permanent teeth have
erupted by age 12
• Third molars (wisdom teeth)
are the exception; often do
not appear until late teens or
early 20s
• Mandibular molars=2 roots
• Maxilary molars =3 roots
Mandible
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Classification of Teeth:
according to function
•Incisors (central and
lateral)
•Canines (cuspids)
•Premolars (bicuspids)
•Molars
Incisor Canine
Premolar Molar
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•Incisors function as cutting
or shearing instruments for
food.
•Canines possess the longest
roots of all teeth and the
tearing of food
•Premolars act like the
canines in the tearing of food
and are similar to molars in
the grinding of food. Incisor Canine Premolar
Molar
•Molars are located nearest
the temporomandibular joint
(TMJ), which serves as the
fulcrum during function. 13
Tooth surfaces
Apical Apical
• Apical
• Labial
• Lingual
Mesial Distal
• Distal
• Mesial Labial
• Incisal
Lingual
Incisal Incisal
14
• Apical: Pertaining to the apex or
root of the tooth Apical Apical
• Labial: Pertaining to the lip;
describes the front surface of
anterior teeth
• Lingual: Pertaining to the tongue;
describes the back (interior) Mesial Distal
surface of all teeth
• Distal: The surface of the tooth Labial
that is away from the median line
• Mesial: The surface of the tooth
Lingual
that is toward the median line
15
Enamel
The Dental Tissues: Dentin
• Enamel (hard tissue)

Odontoblast Layer Gingiva
• Dentin (hard tissue)
• Pulp Chamber (soft tissue)
• Gingiva (soft tissue) Periodontal Ligament
• Periodontal Ligament (soft Pulp
Chamber
tissue) Cementum
• Cementum (hard tissue)
Alveolar Bone
• Alveolar Bone (hard tissue)
• Pulp Canals Apical Foramen
• Apical Foramen
Pulp Canals
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Anatomic Crown
The 3 parts of a tooth:
• Anatomic Crown
• Anatomic Root
• Pulp Chamber
Pulp
Chamber
Anatomic Root
17
Anatomic Crown
• The anatomic crown is
the portion of the tooth
covered by enamel.
• The anatomic root is the
lower two thirds of a
tooth. Pulp
• The pulp chamber Chamber
houses the dental pulp,
nerves, arteries, veins,
lymph channels,
connective tissue cells, Anatomic Root
and various other cells.
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Enamel
The 4 main dental tissues: Dental

Dentin Pulp
•Enamel
•Dentin
•Dental Pulp
•Cementum
Cementum
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Dental Tissues—
Enamel
• Structure
• Highly calcified and hardest
tissue in the body
• Crystalline in nature
• Insensitive—no nerves
• Acid-soluble—will
demineralize at a pH of 5.5
and lower
• Cannot be renewed
• Darkens with age as enamel is
lost
• Fluoride and saliva can help
with remineralization
20
Dental Tissues—
Dentin
•Softer than enamel

•Susceptible to tooth
wear (physical or
chemical)
•Does not have a nerve
supply but can be
sensitive
•Is produced throughout
life
•Will demineralize at a
pH of 6.5 and lower
21
Dental Tissue—
Cementum
• Thin layer of mineralized
tissue covering the dentin
• Softer than enamel and
dentin
• Anchors the tooth to the
alveolar bone along with the
periodontal ligament
• Not sensitive
22
Dental Tissue—Dental
Pulp
• Innermost part of the
tooth
• A soft tissue rich with
blood vessels and nerves
• Responsible for
nourishing the tooth
• The pulp in the crown of
the tooth is known as the
coronal pulp
• Pulp canals traverse the
root of the tooth
• Typically sensitive to
extreme thermal
stimulation (hot or cold)
23
Periodontal Tissues
•Gingiva
•Alveolar Bone
Gingiva
•Periodontal
Ligament
Periodontal Ligament
•Cementum
Alveolar bone
Cementum
24
•Gingiva: The part of the
oral mucosa overlying
the crowns of unerupted
teeth and encircling the Gingiva
necks of erupted teeth,
serving as support
structure for
subadjacent tissues.
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•Alveolar Bone: Also
called the “alveolar
process”; the thickened
ridge of bone containing
the tooth sockets in the
mandible and maxilla.
Alveolar bone
26
•Periodontal Ligament:
Connects the cementum
of the tooth root to the
alveolar bone of the
socket. Periodontal Ligament
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Dental Tissue—Dental
Tissue6
•Cementum: Bonelike,
rigid connective tissue
covering the root of a
tooth from the
cementoenamel junction
to the apex and lining
the apex of the root
canal. Cementum
•It also serves as an
attachment structure for
the periodontal
ligament, thus assisting 28
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Maxillae
• form the skeleton of the upper jaw
• Occur in pairs
• The two maxillae are united at the intermaxillary suture in
the median plane
• their alveolar processes include the tooth sockets (alveoli) and
house the maxillary teeth
• They articulate with the frontal bone anteriorly and zygomatic
bones laterally
• On the body of the maxilla is the infraorbital foramen for
passage of the infraorbital nerve and vessels
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Mandible
• is a U-shaped bone
• forms the skeleton of the lower jaw
• Its alveolar process supports the mandibular teeth.
 consists of:
a horizontal part (the body)
 and a vertical part (the ramus )
• Inferior to the second premolar teeth are the mental
foramina for the passage of the mental nerves and vessels
• Dense (compact) bone
• Less vascular supply.
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Tooth notation systems
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Introduction
Learning nomenclature is the first step in

understanding dental anatomy. Tooth
numbering or “shorthand” system of tooth
notation is necessary in clinical practice for
recording data and communication.
The various tooth notation systems are as follows:

1. Palmer notation system
2. Universal notation system
3. FDI system
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Palmer notation system
In 1861 Adolph Zsigmondy of Vienna introduced the
symbolic system for permanent dentition. He
then modified it for the primary dentition in 1874.
The symbolic system is now commonly referred to
as the Palmer notation system or Zsigmondy
system.
Primary teeth- EDCBA ABCDE

EDCBA ABCDE
Permanent teeth- 87654321 12345678

87654321 12345678
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Universal notation system
ADA officially recommended the Universal system in
1968. In this system for the permanent dentition the
maxillary teeth are numbered through 1 to 16
beginning with upper right third molar. The
mandibular teeth are numbered through 17 to 32
beginning with lower left third molar. The universal
system notation for primary dentition utilises upper
case alphabets.
Primary teeth- ABCDE FGHIJ

TSRQP ONMLK
Permanent teeth-
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17
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16
1
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32 17
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FDI system (Federation Dentaire
Internationale)
The FDI system is a two digit system that has been
adopted by WHO. In this system the first digit
indicates the quadrant and the second digit
indicates the tooth within the quadrant. 1 to 4
and 5 to 8 as the first digit indicates permanent
and primary dentition respectively. 1 to 8 and 1 to
5 as the second digit indicates permanent and
primary teeth respectively.
Primary teeth- 55 54 53 52 51 61 62 63 64 65
85 84 83 82 81 71 72 73 74 75 40
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Permanent teeth-
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27
28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37
38
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History taking and
physical examination
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Art of diagnosis
• The first step towards treating any
patient is making a correct diagnosis.
The diagnostic sequence can be divided
into five levels:
• 1. History taking
• 2. Clinical examination
• 3. Radiological analysis
• 4. Laboratory investigations
• 5. Interpretation and final diagnosis
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History Taking
• The aim of history taking is to obtain a
correct account of the patient’s problems,
taking into consideration his/her symptoms,
general condition, lifestyle, and socio-
economic background.
Steps in History Taking
1. Obtaining General Information
name, age, address, race occupation
sex,
marital status,
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2. Chief Complaint/s and HPI
• The chief complaint ascertains the
principal reason as to why the
patient is seeking medical attention.
• 1. All the symptoms, chronologically,
in the patient’s own words.
• 2. The onset, duration and progress
of each of these symptoms.
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3. Past/Present Medical
History
• A detailed picture of the general medical status of
the patient is obtained, which may or may not be
relevance to the chief complaint, the management
of the patient and outcome of the treatment.
• 1. Cardiovascular disorders
• 2.Diseases of the respiratory system.
• 3.Neurologic conditions
• 4. Haematological disorders
• 5.Infectious diseases
• 6.Reproductive system pregnancy, lactation
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• Renal pathologies
• Disorders of the liver like cirrhosis,
alcoholic liver disease, hepatitis
• Past/present history of radiation therapy.
4. Personal and Family History
A family history of epilepsy, cardiac
disorders, diabetes, bleeding disorders,
and tuberculosis is of particular
importance.
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Clinical Examination
• Extraoral Examination
The following structures are examined:
1. Face
2. Skin and soft tissue
3. Skull
4. Bony skeleton of the face
5. Temporomandibular joints
6. Lymphatic systems
7. Salivary glands
8. Eyes.
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Inspection
Face
At the onset of the examination, the face is
first observed for any signs of asymmetry,
swelling, etc.
Skin and soft tissue
The colour and texture of the
skin
Palpation
Palpation of the bony skeleton is begun from
the frontal bone and proceeds downward.
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Palpating lymph nodes and probable associated
conditions
Lymph nodes Condition
• Tender, mobile, enlarged Acute infection
• Nontender, mobile, enlarged Chronic infection
• Matted, nontender Tuberculosis
• Fixed, enlarged Squamous cell
Ca
• Rubbery, enlarged
Lymphomas
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• The preauricular, submandibular,
submental, and cervical lymph nodes
are palpated for enlargement,
tenderness, mobility and consistency.
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Interaoral examination.
• The structures to be examined during
intraoral examination are as follows:
1. Buccal, labial, and alveolar mucosa.
2. Hard and soft palate.
3. Floor of the mouth and tongue.
4. Retromolar region.
5. Posterior pharyngeal wall and faucial pillars.
6. Salivary glands and their orifices.
7. Dentition and occlusion.
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Clinical Diagnostic aids
• Radiological Examination
Radiological imaging is one of the most important
diagnostic aids available to the clinician.
• Intraoral Radiographs
Intraoral periapical view Areas best appreciated
are as follows:
1. Teeth
2. Periapical region
3. Lamina dura and periodontal ligament space
4. Supporting alveolar bone.
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Intra – oral radiographs
• There are three types of
commonly used intra – oral
radiographs. These are:
A.Periapical,
B.Bite wing and
C.Occlusal projection
Extraoral Radiograph
1. Orthopantomogram Areas best appreciated
are as follows
The temporomandibular joint,
the ramus,
the angle of the mandible
2. Lateral oblique view of mandible
mandibular ramus from the angle to the
condyle
Third molar regions of both the maxilla and
mandible
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3. PNS view
appreciate nasal bone and sinuses
4. Panoramic view; enable viewing of
both maxillary and the mandibular
arches with their supporting
structures
5. Submentovertex view; appreciate
zygomatic #
Specialized Imaging
• Computed tomography (CT)
• Magnetic Resonance Imaging (MRI) soft
tissue pathology
• Sialography
Sialography is a radiographic technique to
detect and monitor salivary gland disease.
 Arthrography
has immense importance in
temporomandibular joint imaging
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Anatomy of
orofacial structures
For 3rd year

public health students
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contents
• The skull and it’s foramina
• Neurovascular supply of the face
• Anatomy Temporomandiblar joint
• Parts of the oral cavity
• Tooth numbering systems
• References
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skull
• The skull, excluding the three pairs of
ossicles of the ear, is composed of 22
bones, some of which are paired, whereas
the others are single.
• Twenty-one of these bones are firmly
attached to each other via sutures and
are immovable. The only movable bone is
the tooth-bearing mandible, which
articulates with the paired temporal
bones by a combined hinge and gliding,
the temporomandibular joint.
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Bones of the Skull
• The cranium consists of the following

bones, two of which are paired
• Frontal bone: 1
• Parietal bones: 2
• Occipital bone: 1
• Temporal bones: 2
• Sphenoid bone: 1
• Ethmoid bone: 1
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cont’d
• The facial bones consist of the following, two of
which are single:
• Zygomatic bones: 2
• Maxillae: 2
• Nasal bones: 2
• Lacrimal bones: 2
• Vomer: 1
• Palatine bones: 2
• Inferior conchae: 2
• Mandible: 1
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MAXILLARY BONE
• Forms upper jaw and central portion of facial
skeleton
• Surround anterior nasal aperture and unite in medial
plane
• Articulates with all facial bones except mandible
• Forms upper dentition
• Surfaces - nasal, orbital, infratemporal, and anterior
• Parts – Body and Four processes - frontal, alveolar,
zygomatic and palatine
• Body – houses maxillary sinus
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Mandible
• Forms the lower jaw

• Largest, strongest bone of the face
• the only movable bone of the skull
• Houses lower dentition
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Foramina and Fissures of
the Skull
• Olfactory foramina
• Optic canal
• Superior orbital fissure
• Foramen rotundum
• Foramen ovale
• Foramen spinosum
• Foramen lacerum
• Carotid canal
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• Internal acoustic meatus
• Jugular foramen
• Hypoglossal canal
• Foramen magnum
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Cranial nerves
I: Olfactory nerve VII:
Facial nerve
II: Optic nerve VIII:
Vestibulocochlear nerve
III: Oculomotor nerve IX:
Glossopharyngeal nerve
IV: Trochlear nerve X:
Vagus nerve
V: Trigeminal nerve XI:
Spinal accessory nerve
VI: Abducens nerve
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SENSORY NERVES OF THE FACE
• Two sources
•Skin around the angle of the mandible –
greater auricular nerve (C 2, 3 )
•The rest of the face- trigeminal branches
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Trigeminal nerve
• The largest cranial nerve
• It is mixed nerve ( sensory and motor )
• Sensory to – Skin of face
-Mucosa of cranial viscera
Except base of tongue and pharynx
• Motor to – Muscles of Mastication
-Tensor ville palatini,Tensor
tympany
-Anterior belly of digastric
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-Mylohyoid 77
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Trigeminal nerve
• Motor root arises separately from sensory
root, originating
in main nucleus with pons and medulla
oblongata.
• Its fibers (as a small nerve root), travel
anteriorly along with, but separately, the
sensory root to the region of semilunar
ganglion.
• Sensory root fibers of trigeminal nerve
comprises of the central processes of
ganglion cells located in trigeminal
ganglion.
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Ophthalmic Nerve (V1)
• The ophthalmic nerve transmits sensory
innervation from eyeballs, skin of upper face and
anterior scalp, the lining of upper part of nasal
cavity and air cells and the meninges of anterior
cranial fossa.
• Its branches also convey parasympathetic fibers to
the ciliary and iris muscles for accommodation and
pupillary constriction and to the lacrimal gland.
• It passes anteriorly through lateral wall of
cavernous sinus. It divides into three branches:
• 1. Frontal
• 2. Nasociliary
• 3. Lacrimal.
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Maxillary Nerve (V2)
• The maxillary nerve transmits sensory
fibers from the skin of face between the
lower eyelid and the mouth from the
nasal cavity and sinuses, from the
maxillary teeth.
• it contains only sensory fibers some of its
branches receive postganglionic
parasympathetic fibers from
pterygopalatine ganglion which pass to
the lacrimal, nasal and palatine glands,
and others convey taste (visceral
sensory) fibers from the palate to the
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Cont’d
Maxillary nerve innervates:
1. Skin of:
i. Middle portion of face
ii. Lower eyelid
iii. Side of nose
iv. Upper lip.
2. Mucous membrane of:
i. Nasopharynx
ii. Maxillary sinus
iii. Soft palate
iv. Tonsil
v. Hard palate.
3. Maxillary teeth and periodontal tissues.
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Cont’d
Maxillary nerve gives off branches in four
regions:
1. Within the cranium; Middle Meningeal
Nerve
2. In the pterygopalatine ganglion;
Pterygopalatine, Zygomatic and
Posterosuperior alveolar nerves.
3. In the infraorbital canal; MSAN and ASAN
4. On the face; palpebral, nasal and labial
branch
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Mandibular Nerve (V3)
• It transmits sensory fibers from;
the skin over the mandible,
side of the cheek and temple,
the oral cavity and its contents,
external ear, tympanic membrane
Temporo mandibular joint
meninges of cranial vault.
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• It is motor supply to the muscles derived
from first branchial arch:
 muscles of mastication
 Mylohyoid and anterior belly of
digastric
 Tensor tympani and tensor palati.
• Some of its distal branches also convey
parasympathic secretomotor fibers to
salivary glands and taste fibers from
anterior portion of tongue.
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• In infratemporal fossa, it gives branches
in three areas:
1. From undivided nerve
2. From anterior trunk
3. From posterior trunk.
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Facial Nerve
• It is the nerve of second branchial arch
• Facial nerve possesses a motor and a sensory root.
• Secretomotor to submandibular and sublingual glands
• Emerge through stylomastoid foramen and enter
parotid and gives five branches
 Temporal
Zygomatic
Buccal
Mandibular
Cervical
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muscles of facial
expression
• THE FACE
• Lie in subcutaneous tissue
• May originate from bones
• Insert in to the skin
• Named as muscles of facial expression
• Arranged in groups around the orbit,
nose, mouth and auricles
• functionally considered as regulators of
openings
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Supplied from branches of facial nerve 93
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BLOOD VESSELS OF THE
FACE
1. From ophthalmic artery
Supratrochlear
Supraorbital
2. External carotid artery
Facial artery
Transverse facial
Infraorbital
Mental artery
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Veins
• Supratrochlear veins
• Supraorbital veins
• Facial vein
• Superficial temporal
• Retromandibular vein
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Temporomandibular joint
Articulating surfaces
•Head of mandible
•Mandibular fossa and articular tubercle of the
temporal bone
• Articular Capsule
•surround the joint
•thickened laterally to form ligaments
Articular disc
•dividing joint cavity into a lower compartment &
upper compartment
• Major supportive elements of the TMJ
•muscles of mastication
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 Ligaments of TMJ; Minor supportive of TMJ
Temporomandibular ligament - thickening of the
joint capsule
Stylomandibular ligament - behind and medial
Sphenomandibular ligament - medially attached to
the sphenoid and mandible
Synovial membrane – lines the capsule in the
upper and lower parts the joint cavity
Nerve supply – Auriclotemporal and nerve to
masseter
Arterial supply – from superficial temporal
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Musculature
• Muscles influencing mandibular motion
may be divided into two groups by
anatomic position.
• supramandibular muscle group
• inframandibular group
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Muscles of mastication
• The temporalis muscle
 elevate the mandible for closure
 retrusive movements of the mandible
 assists in deviation of the mandible to
the ipsilateral side.
• The masseter muscle
 most powerful elevator of the mandible
 protrusion and retrusion of the
mandible
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• The medial pterygoid muscle
 elevation of the mandible
 unilateral protrusion
The lateral pterygoid muscle
primary function of the inferior head is
protrusive and contralateral movement.
• it has also involved in closing
movements of the jaw and with retrusion
and ipsilateral movement.
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Medial pterygoid Closure, protrusion
Lateral pterygoid (inferior Protrusion, opening
head) contralateral
Lateral pterygoid Retrusion, closure,
(superior head) ipsilateral
Masseter, superficial layer Protrusion, closure
contralateral
Masseter, deep layer Retrusion, closure,
ipsilateral
Temporalis, anterior closure
portion
Temporalis, posterior Retrusion, closure
portion ipsilateral
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ORAL CAVITY
• Two parts ; vestibule and oral cavity

proper
• Vestibule
•Bounded by lips and cheeks and teeth and
gums
•The parotid duct opens in the superior
vestibule, opposite the 2nd upper molar
tooth
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• Oral cavity proper
•Boundaries
 Roof - hard and soft palates with the
midline uvula
 Floor - tongue and sub lingual region
 Anteriorly and laterally – the gums and the
teeth
The posterior border - oropharyngeal isthmus
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Muscles of the tongue
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The teeth
• The primary or deciduous dentition
consists of 20 teeth: 8 incisors, 4 canines,
and 8 molars.
• The normal adult dentition consists of 32
permanent teeth.
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Functions of Teeth
1- Mastication
2- Appearance
3- Speech
4- Growth of jaws
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References
• Neelima anil malik maxillofacial surgery
3rdedition
• Peterson’s Principles of Oral and
Maxillofacial Surgery 2ndedition
• Netter’s Head and Neck Anatomy for
Dentistry 2nd edition
• Art and science of operative dentistry 4th
edition
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DENTAL CARIOLOGY
BY Dr. Daniel T. (DMD)
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outlines
 Definition of dental caries

 Etiology of dental caries
 Characteristics of SM
 Dental caries process
 Important factors for caries occurrence
 Stages of dental caries development
 Dental caries classification
 Transmission of dental caries
 Roles of saliva in caries prevention
 Diagnosis of dental caries
 Prevention of dental caries
 G.V Black’s dental cavities.
01/29/2022 118
Dental caries
Definition
 Is an infectious bacterial disease
 Is a dietary carbohydrate-modified bacterial infectious
disease with saliva as a critical regulator.
 It can be stated as dental or tooth decay.
 It is the most common chronic infectious disease of tooth.
 is localized progressive disease, whose character consists
in the destruction of tooth structures mainly under the
influence of metabolic products of the oral microflora; in
which each level of decomposition is clinically
differentiated.
 Caries is an infectious disease that is actually transmissible,
usually when the mother infected with S. mutans, infects
her infant when the child’s first teeth appear in the oral
cavity
01/29/2022 119
Cont’d…
• Dental caries does not occur in a sterile mouth.
(no mouth can ever be made sterile)
• The conditions in the oral cavity are ideal for the
growth of bacteria that metabolize sugar to acids
• The oral cavity is generally a warm place, at body
temperature (37°C) encouraging the growth of
bacteria.
01/29/2022 120
Etiology
• Microorganisms in dental caries first observed by van
Leeuwenhoek in 1683
• W.D. Miller – University of Berlin 1890 – considered all
bacteria in mouth were potentially cariogenic
• Acid production by bacteria considered responsible for
breakdown of tooth.
• 1924 – Clarke isolated a streptococcus species from a
cavity in a child
• The bacteria underwent some changes as the culture aged
• Clarke named it Streptococcus mutans for “mutation”
• He demonstrated that specific microorganisms were
responsible for caries and caries was transmissible
• Later, the responsible bacteria were found to comprise
seven distinct species in which only mutans and sobrinus
are associated with caries in humans
01/29/2022 121
Cont’d,…
• Two specific groups of bacteria found in the mouth that
are responsible for dental caries are Mutans
streptococci (Streptococcus mutans) and
Lactobacilli
• They are found in relatively large numbers in the dental
plaque.
• The presence of lactobacilli in the mouth indicates a
high sugar intake.
• MS is responsible for initiation of caries in the sufficient
other factors for dental caries occurrence
• Lactobacilli sp.found in large numbers in oral cavity
considered as opportunistic, not initiators.
• Numbers in cavity increase after DEJ invaded
• lactobacilli are good indicators of total carbohydrate
intake
01/29/2022 122
Characteristics of SM
Ecological niche
 human oral cavity
 “Intentionally designed to be a cariogenic
organism”
Cariogenic properties
 ability to produce acid (acidogenicity)
 ability to withstand acid conditions (aciduricity)
 ability to adhere to teeth
Metabolism yields
 acids, primarily lactic, from a variety of sugars
 extracellular polyglucose, called glucan, which
creates irreversible attachment (from sucrose
metabolism only)
01/29/2022 123
Dental caries process
For caries to develop, three factors must
occur at the same time:
 A susceptible tooth
 Diet rich in fermentable carbohydrates
 Specific bacteria (regardless of other factors,
caries cannot occur without bacteria)
 In the absence of one of these
Factors no dental caries at all.
01/29/2022 124
01/29/2022 125
Cont’d…
• Must have a tooth, plaque bacteria, fermentable
carbohydrate, saliva, and enough time in order for
a carious lesion to develop
• Caries results when all of the factors that
contribute to caries overlap
• Several factors influencing each component, affect
the rate and severity of the caries.
Dental plaque is a colorless, soft, sticky coating that
adheres to the teeth.
• Plaque remains attached to the tooth despite
movements of the tongue, water rinsing, water
spray, or less than thorough brushing.
• Formation of plaque on a tooth concentrates
millions of microorganisms on that tooth.
01/29/2022 126
Dental biofilm(plaque)
01/29/2022 127
Cont’d…
Enamel structure
 Enamel is the most highly mineralized tissue in the body.
• Enamel consists of microscopic crystals of hydroxapatit
arranged in structural layers or rods, also known as prisms.
• The enamel crystals are surrounded by water.
• The water and protein components in the tooth are important
because that is how the acids travel into the tooth and the
minerals travel out and the tooth structure dissolves.
• Caries process takes place in the biofilm on the tooth surface .
• Carious lesion is the result of carious process developing
between the microbial biofilm and tooth structure
• If the quality of enamel is poor in the case such as

presence/depth of pits and fissures, hypoplasia, less fluoride,
the occurrence of dental caries enhanced more.
01/29/2022 128
Cont’d…
Cariogenic dietary
• The sugars with the most cariogenicity are sucrose and
glucose.
• Other carbohydrates (maltose, lactose, fructose, and
starch) are less cariogenic.
• The sugar alcohols, such as sorbitol and mannitol, are
the least cariogenic
• Xylitol has even been shown to be anticariogenic
01/29/2022 129
Cont’d…
• The disaccharide sucrose and the
monosaccharide glucose ( a component of
sucrose), are most cariogenic.
• Frequent ingestion, can cause severe damage to
the tooth.
• Not only does their conversion to acid result in
enamel dissolution, but they also encourage the
growth of more virulent cariogenic bacteria.
• Glucan is water soluble extracellular “glue”
which enables adhesion to tooth and reduced
susceptibility to mechanical disruption.
• It inhibits diffusion properties of plaque
• It reduces buffering capacity of saliva
• Inhibits transport of acid away from tooth
01/29/2022 130
Cont’d…
Cariologenic bacterial species
 streptococci and lactobacilli are two bacteria
species responsible for caries
 These bacteria continue to break down the
fermentable sugar and lead to pH drops
 If the plaque is not removed, eventually, the
enamel starts to decalcify and an incipient ‘white
spot’ lesion ensues
 These all event need more time to happen since
dental caries is the most chronic disease.
01/29/2022 131
Stages of Caries Development
• It takes a period of time, from months to years, for a
dental carious lesion to develop.
• It is an ongoing process, characterized by alternating
periods of demineralization and remineralization.
Demineralization is the dissolving of the calcium and
phosphate from the hydroxyapatite crystals of dental
enamel by acid formed from sugar break down by
cariogenic bacterial
Remineralization is the calcium and phosphate being
redeposited in previously demineralized areas from
saliva
• It is possible to have the processes of
demineralization and remineralization occur without
any loss of tooth structure.
01/29/2022 132
Cont’d…
• If the plaque thickness dominated by cariogenic

bacteria, it effectively keep the saliva from
reaching the enamel surface and enhance the
demineralization of the enamel calcium and
phosphate mineral and inhibit remineralization and
lead to dental caries
• In addition, the more plaque there is, the more
acid is produced which have a longer time to
penetrate into the enamel under thick biofilm and
allows the tooth to demineralize.
• If the saliva reaches the acids they are washed
away and neutralized by the salivary buffers and
allows the tooth to remineralize.
01/29/2022 133
Cont’d…
• The pH of dental plaque in response to glucose has
been studied using the classic Stephan curve
• The diagram illustrates the plaque pH response
curves that have been obtained from patients with
different risks for caries.
01/29/2022 134
Cont’d…
• A high-risk individual, • The area under the pH-
when given a glucose time
rinse , will experience curve(AUC)representing
a dramatic drop in the the time spend at pH
plaque pH well below lower than the critical
the critical pH of 5.5. pH.
• The recovery to • The AUC for a high risk
neutral pH in the high individual will be very
risk individual will be large.
slow. • AUC is a better
measure of total caries
risk.
01/29/2022 135
 The person with a high risk for caries snacks
frequently during the day, and the total AUCs
clearly are excessive and will not allow
remineralization to occur and if that daily trend
continues, the person will experience dental
decay.
01/29/2022 136
• For a moderate risk • For caries-resistant person
individual(yellow), the initial (green),the initial pH drop
pH drop may only be a little of that person’s plaque
lower than the critical pH, and may not even reach the
the AUC will be much less. critical pH, and the
recovery will be very quick.
01/29/2022 137
 The person with moderate caries risk might have
three meals and one snack of moderate cariogenic
potential on a daily basis,
and the AUCs below the critical pH might result in
a net loss of mineral and at this stage,
remineralization strategies might work.
01/29/2022 138
 Тhe person at low risk may not snack at all he person at low risk may not snack at all
and has three meals of low cariogenicity
spread apart during the day.
 This allow remineralization to occur
01/29/2022 139
Sequence of dental caries development
01/29/2022 140
Mechanism of acid demineralization
01/29/2022 141
Condition in which dental caries
inhibited
01/29/2022 142
Dental caries classification
Based on stage of development dental caries can
be classified;
 Incipient lesion develops in the earliest stages when
caries begins to demineralize the enamel.
 Overt, or frank, lesion is characterized by cavitation
(the development of a cavity or hole in the tooth).
 Rampant: The time between the onset of the incipient
lesion and the development of the cavity is rapid and
there are multiple lesions throughout the mouth.
 Secondary, or recurrent, caries starts to form in the
small spaces or gaps between the tooth and the
margins of a restoration.
 Restorative materials that slowly release fluoride help
to prevent secondary caries.
01/29/2022 143
Cont’d…
Based on the surface it occur dental caries can be

classified into:
 Pit and fissure caries; occurs primarily on the
occlusal surfaces and buccal and lingual grooves
of posterior teeth, as well as in lingual pits of the
maxillary incisors.
 Smooth surface caries; occurs on intact
enamel other than pits and fissures.
 Root surface caries ;occurs on any surface of
the root
 Root caries is more prevalent in elderly
population who often have gingival recession
exposing the root surfaces.
 Older people are often taking medications known
01/29/2022 144
Cont’d…
• Carious lesions form more quickly on root
surfaces than coronal caries because the
cementum on the root surface is softer than
enamel and dentin
• Like coronal caries, root caries has periods of
demineralization and remineralization
01/29/2022 145
Black classification of dental caries
 G.V. Black classified dental caries based on the
anatomy of surface involved
 Class I which AKA pit and fissures caries and it
occur on occlusal surface of posterior teeth and
lingual fossa of maxillary incisors.
 Class II which is known as smooth surface dental
caries
 It occur on smooth surface of anatomical crown on
the surface which are not accessible to the natural
cleaning action of the lips, cheeks, and tongue.
 A class II lesion is the extension of a class I lesion
into the proximal surfaces of premolars and
molars.
01/29/2022 146
Cont’d…
Class III lesion
• Affects the interproximal surface of incisors and
canines
Class IV lesion
• Involves a larger surface area, including the
incisal edges and interproximal surface of incisors
and canines .
Class V lesion
• Classified as a smooth-surface lesion affects
cervical one third of both anterior and posterior
tooth.
01/29/2022 147
Transmission of dental caries
Vertical transmission
 Mutans streptococci are transmitted through saliva,
most frequently from mother, to the infant which
account 70%
 Transmission may occur at birth, but MS reside in
low numbers in reservoirs such as tonsils or dorsum
of tongue
 When mothers have high counts of mutans
streptococci in their mouths, the babies also have
high counts of the same bacteria in their mouth.
 When the number of caries causing bacteria in the
mouth increases, the risk for developing dental
caries also increases.
Horizontal transmission
 Among individual who share tooth brushes and kids
who share some instruments at the age of pre
school.
01/29/2022 148
Role of saliva in dental caries
• Saliva to teeth is similar to what blood is to cells
of the body
Composition
• Supersaturated with Ca, P bicarbonate principal
buffer, proteins, immunologic/antibacterial
components and fluoride.
• Viscosity depends on gland, nervous control of
secretion
• It is pH normally around 7.0 that varies from ~5.5-
8.0
• Saliva in the oral cavity has the most important
roles in prevention of dental caries.
• The major roles are the followings.
01/29/2022 149
Cont’d…
• Physical protection provides a cleansing effect.
• Thick, or viscous, saliva is less effective than a more
watery saliva in clearing carbohydrates.
• Chemical protection contains calcium, phosphate, and
fluoride. It keeps calcium there ready to be used during
remineralization.
• It includes buffers, bicarbonate, phosphate, and small
proteins that neutralize the acids after we ingest
fermentable carbohydrates.
• Antibacterial substances in saliva work against the
bacteria.
 Amylase, lipase,protease,pyrophosphatase,lysozyme IgA
• If salivary function is reduced for any reason, such as from
illness or medications or due to radiation therapy, the
teeth are at increased risk for decay.
01/29/2022 150
Cont’d…
 Because of its buffering capacity and ability to
neutralize acids, a simple intervention such as
stimulating the saliva with chewing gum can arrest
white spot lesions and prevent cavities formation
Saliva flow rate can be increased by:
 Gustatory stimulants (sugar-free candy)
 Masticatory stimulants (sugar free chewing gum)
Can be reduced/decreased by:
 Medications (antihistamines, antiasthmatics, others)
 Diseases (degenerative, metaplastic)
 Dehydration
 Radiation
 Age
01/29/2022 151
Diagnosis of Dental Caries
• Detectable explorer “stick”
• Radiographs
• Visual
• Laser caries detector
• The laser caries detector is used to diagnose caries
and reveal bacterial activity under the enamel
surface.
• Carious tooth structure is less dense and gives off
a higher reading than non- carious tooth structure.
01/29/2022 152
Prevention
Neutralize the plaque acids;
 This can be done by adding base or adding buffers such as sodium
bicarbonate (baking soda) to the saliva to boost its ability to
neutralize acids.
Improve hygiene:
 With bacterial levels low, less acid is produced.
 Plaque layers don’t have a chance to grow thick;
 Saliva can penetrate better to the
 Enamel surface through thin layers of plaque.
Introduce antimicrobials:
Since caries is a disease caused by bacteria, simply
eliminating the bacteria or controlling their growth
will reduce the caries incidence.
 Chlorhexidine, xylitol, even experimental antibodies,
have been used to control bacterial growth.
01/29/2022 153
Cont’d…
Stimulate saliva:
 Saliva contains numerous components that fight
tooth decay
 By buffers, remineralizing minerals, antimicrobial
enzymes, antibodies.
Topical fluorides
 Fluoride added to the remineralizing incipient
lesion increases the enamel crystals’resistance to
dissolution by plaque acids.
Remineralizing strategies
 Remineralization can be promoted with the use of
calcium-phosphate complexes.
01/29/2022 154
G.V. BLACK CAVITIES CLASSIFICATION
01/29/2022 155
G.V BLACK CAVIES
• Greene Vardiman Black (1836 - 1915), commonly
known as G.V. Black, is known as one of the
founders of modern dentistry in the USA.
• He was born near Winchester, Illinois on, 1836 and
began studying medicine with the help of his
brother, Dr. Thomas G. Black.
• He researched many important topics to dentistry,
including the best composition for dental
amalgams and the cause of dental fluorosis .
• One of his many inventions was a foot-driven
dental drill.
• Black was the first to use nitrous-oxide for
"extracting teeth without pain.
01/29/2022 156
Cont’d…
• " He is also known for his principles of tooth
preparations,
• The phrase, "extension for prevention," is still
famous in the dental community today and
represents Black's idea that dentists should follow
preventive measures to aid patients from
developing tooth decay.
• He organized a classification system with five
categories for different patterns of tooth decay
which is still in use today.
• Since that time, only one more category has been
added to his classification system.
01/29/2022 157
G.V Black’s class I cavity
 Class (I) lesions occur in pits and fissures on the
facial , lingual , and occlusal surfaces of molar and
premolar and the lingual pits of incisors.
01/29/2022 158
G.V.Black’s class II cavity
• Class (II) lesions occur on the proximal surfaces

of the posterior teeth (molars and premolars)
01/29/2022 159
G.V Black’s class III Cavity
• Class (III) lesions occur on the proximal
surfaces of anterior teeth (1, 2, 3,teeth)
• Class 3 cavities do not involve an incisal angle.
01/29/2022 160
G.V Black’s class IV cavity
• Class (IV) lesions occur on the proximal surfaces
of anterior teeth when the incisal angle requires
restoration.
• The angle may have to be removed because of its
fragility or for proper placement of the restoration.
01/29/2022 161
G.V Black’s class V cavity
• Class (V) lesions occur on smooth facial and
lingual surfaces in gingival third of any teeth.
• It begin close to gingiva and may involve a
cementum or dentinal surface as well as enamel.
01/29/2022 162
Class VI dental cavity
• Class (VI) lesions are pit or wear defects on
the incisal edges of anterior teeth or the cusp
tips of posterior teeth.
• This was not developed by G.V Blacks.
01/29/2022 163
Cont’d…
• The names of surfaces are often abbreviated
(distal D, lingual L, mesial M,occlusal O, buccal
B...etc MO,DO,BO,….
01/29/2022 164
DISEASE OF THE PULP
IT IS CLASSIFIED INTO TWO PARTS -SOFT TISSUE

CHANGES AND HARD TISSUE CHANGES
PULPITIS
• The dental pulp is the loose C.T.,
containing blood vessels, lymphatic,
nerves & undifferentiated C.T. cells.
• Pulpitis: an inflammation of the
pulpal tissue that may be reversible
or irreversible.
• Like any another C.T. is characterized
by redness, swelling, fever, pain.
• *However, is a unique one ,why
• 1-surrounded by hard tissue
• 2-small apical foramen
ETIOLOGY
• 1-bacterial cause: caries, fracture,

bacteremia, periodontal pocket
• 2-physical cause: severe thermal
change (cavity preparation), large
metallic restoration
• 3-trauma: from occlusion, like attrition
or accident
• 4-chemical cause: filling (amalgam,
composite), bases, disinfectant, eugenol
01/29/2022 167
Clinical classification
 Reversible pulpitis
 Irreversible pulpitis
 Pulp necrosis
Reversible pulpitis (Hyperemia)
 not a disease, but a symptom
 pulp state: vasodilator/hyperaemia
 asymptomatic
 thermal stimuli (usually cold)
• quick, sharp, hypersensitive response
• subsides as soon as the stimulus removed
Reversible pulpitis
• Anamnesis:
– pain stimulated by cold and
sweet, tooth can be fixed
• Clinical examination:
– vitality test: positive, „short”
respond
• Treatment:
– removing of the exciting agent
– making a filling (or pulp capping)
Reversible pulpitis
Prognosis
• irritant removed
further appropriately treated
—pulp will revert to an asymptomatic
uninflamed state
• irritant remains
—symtoms pesist /more widespread
—irreversible pulpitis
IRREVERSIBLE PULPITIS
• Acute pulpitis(early stage IP)
• Chronic pulpitis(late stage IP)
chronic pulpitis with a closed pulp chamber
hyperplastic pulpitis
residual pulpitis
Acute Pulpitis
• mainly occurs in children teeth and
adolescent
• pain is more pronounced than in
chronic
Symptoms and Signs of acute pulpitis
• The pain not localized in the affected tooth

is constant and throbbing worse by
reclining or lying down
• The tooth becomes painful with hot or cold
stimuli
• The pain may be sharp and stabbing
• Change of color is obvious in the affected
tooth
• swelling of the gum or face in the
area of the affected tooth
Acute pulpitis (characteristics ）
• intermittent/continuous paroxysms
 Postural change-- a fitful night
 Temperature change
• pain that lingers after the thermal
stimulus is removed
 Non localization
ACUTE PULPITIS CHARCTERISTIC
Referred pain
-- The maxillary canine may refer to the
maxillary first or second premolars and/or
the first or second molars, as well as to the
mandibular first or second premolar.
Maxillary premolars may refer pain to the
mandibular premolars. The reverse is also
true. The mandibular first molar pain
referred to ear.
ACUTE PULPITIS (EXAMINATION)
Oral/visual examination
-- deep caries, deep wedge-shaped defect,
extensive restorations, severe abrasion,
crack, deep peridontal pocket,…
-- detection: severe pain
-- percussion: (-)/(+)
CONTD.
radiograph examination
-- help to provide some information of the
tooth: deep caries, extensive restorations
pins, evidence of previous pulp capping,…
-- a thickened periodontal membrane
space at the apex ， the inflammation
spreads out of the pulp
CONTD.
Local anesthesia
--Diagnosis
--pain relief
Local anesthesia gives blessed relief, and the
dentist has, from that moment, made a
friend for life. The friendship will be more
lasting if the tooth is saved by endodontic
therapy rather than extracted.
CHRONIC PULPITIS
Complains/“grumble”
---discomfortable
---mild pain
---vague pain
---weeks, months, or years
---easy control with analgesic tablets
1.CHRONIC PULPITIS WITH A
CLOSED PULP CHAMBER
• ---deep caries/recurrent caries

• extensive restorations (near the chamber)
• ---detection: bluntness/inaction
• ---percussion: (+)
• ---pulp test: no-reaction/slow-reaction
• ---radiograph:“thicken” periodontal
membrane
2.Hyperplastic pulpitis
- in young people, chronically inflammed pulp
• Anamnesis:
– asymptomatic
• Clinical examination:
– vitality test: positive
– open pulp chamber
– Appearance of the polypoid tissue
– Reddish pulpal mass fills
most of the pulp chamber
• Treatment:
– root canal treatment or
extraction
CONTD.
• It is a form of irreversible pulpitis also
known as pulp polyp
• It occurs as a result of proliferation of
chronical inflamed young pulp
tissue.
it is a rare condition that is confined to the molars
of children. It result from acute caries in young
teeth that rapidly reaches the pulp before it
becomes completely necrotic
3.RESIDUAL PULPITIS
• treated tooth (uncomfortable treatment)
• missing canal, residual pulp,…
• ---percussion: (+)
• ---pulp test(strong): slow-reaction
• ---radiograph:“thicken” periodontal
membrane
• ---final decision: painful when canal
detection
PULP NECROSIS
 coronal discoloration with
• no true symptoms
 an accident of years ago
 percussion: (-~±)
 pulp test: no reaction
 radiograph: normal
 distinguish from chronic periapical
periodontitis
CONTD.
– Also referred to as non-vital. Used to

describe a pulp that does not respond to
sensory stimulus
– Tooth is usually discoloured
Symptoms and diagnosis of
periapical disease
• Acute （ symptomatic ）
periapical periodontitis
• Chronic （ asymptomatic ）
periapical periodontitis
Etiology
• Pulpal inflammation into
the periapical tissue
• Mechanical or chemical trauma by
endodontic instruments or materials
• Occlusal trauma cause by
hyperocclusion or bruxism
Acute periapical periodontitis
Periradicular pain
---may be almost as excruciating as
pulp pain and may often continue
for a longer period of time
---the severity and the rapidity
of the course of the lesion
---is by far the most distressing
periradicular lesion
CONTD.
Periradicular pain
---described as constant, gnawing,
throbbing, and pounding
---many patients beg to have
the tooth extracted
---swelling involved
---painful tooth elevated slightly in its socket
fear to touch the suffered tooth
CONTD.
Examination
---deep caries, deep wedge-shaped defect,
extensive restorations, severe abrasion,
crack, deep peridontal pocket,…
---coronal discoloration
---percussion:(+)~(++)~(+++)
CONTD.
Distinguish from periodontal abscess
---swelling extension
---degree of loose
---percussion
---radiograph
---cause of disease
Chronic periapical periodontitis
• almost invariably a sequel to pulp necrosis with
low-grade pathogenicity
• The pathosis is a long-standing “smoldering”
without any subjective signs and symptoms
usually accompanied by radio-graphically visible
periradicular bone resorption
• Radiographic findings are the diagnostic key
• Also known as chronic alveolar abscess
• Presence of sinus tract
CONTD.
• Anamnesis:
– asymptomatic or slight discomfort
• Clinical examintaion:
– little or no pain on percussion
• X-ray:
– interruption of lamina dura or apical radiolucency
• Treatment:
– root canal treatment
Radiogram of healthy periodontium
and chronic apical periodontitis
periradicular lesions
59.3% Granulomas
22% cysts
12% apical scars
6.7% other pathoses
Nobuhara and del Rio

Basic principles of Endodontic Treatment(RCT)
1- Endodontic Diagnosis
2- Case Selection and Patient Education
3- Local Anesthesia
4- Rubber Dam Isolation (single isolation)
5- Access Cavity
6- Working length
7- Instrumentation
8- Obturation
9- Final restoration
01/29/2022 203
Contraindications for RCT
• Caries extending beyond bone level
• Rubberdam cannot be placed
• Crown of tooth cannot be restored in
restorative dentistry nor prosthodontics
• Patient is physically/mentally handicapped
and therefore cannot follow instructions
• Unmotivated patient
• Severe root resorption
• Vertical root fractures
• Cost factor
Thank you for your attention
Oral malodor
 Is a symptom in which a noticeably
unpleasant odor is present on the
exhaled breath.
 It is the most frequent reason for people
to seek dental care,following tooth decay
and gum disease.
 Not all who think they have halitosis have
a genuine problem.
Cont...
 Of those who have genuine halitosis,often
the odor is caused by bacteria present
subgingivally and on the dorsum of the
tongue
 The remaining 10% is accounted for by
many different conditions including
disorders in the nasal
cavity,sinuses,throat,lungs,esophagus,sto
mach or elsewhere.
Cont...
 Genuine halitosis can sometimes trigger
social anxiety and depression.
 If the origin of the odor is not in the
mouth,halitosis can be more difficult to
diagnose and to manage.
classification
 Intraoral halitosis
 Extraoral halitosis:
A. blood borne halitosis like
-systemic diseases,metabolic
diseases,food and medication.
Cont...
B. Non blood borne halitosis
-upper respiratory tract (ozostomia)
-lower respiratory tract
(stomatodysodia)
 halitosis is generally classified as:
i) Physiological
ii) Pathological
iii) Psychological
OZOSTOMIA…
 Obstruction, Nasal- discharge, Tonsillitis,

Tonsiloliths, Laryngitis,
 Dysphagia, Voice problems
 Previous ENT pathology
 Sinusitis, Rhinitis, Pharyngitis, Foreign
Bodies
 Infection
 Malignancies
STOMATODYSODIA
 Tobacco Smokers
 Bronchitis
 Bronchiectasis
 Lung Abscess
 Pleuritis
 Pneumonia
HALITOSIS physiological
 Poor hydration
 Menstruation
 Diet
 Starvation, Morning breath
 Habits (Mouth breathing, thumb sucking)
HALITOSIS pathological
 Lungs release blood-borne catabolic
products
 Stomach--Gastritis, Liver hepatitis,
Kidney nephritis
 Pancreas--Diabetes mellitus (Ketosis)
 Anorexia/Bulimia nervosa
 IgA deficiency
 Xerostomia (Sjogrens, Radiation therapy,
Stress)
HALITOSIS psychological
 “Halitophobia” not very accurate term
 Delusional cacosmia
 Psychogenic dysosmia
 Symptomatic schizophrenia
 Temporal lobe epilepsy (Aura)
 Cerebral tumors
Fetor ex Ore/ Fetor Oris
 From Mouth: Gums &Teeth
 Gingivitis/Periodontitis
 Percoronitis/Peri-implantitis
 Dorsum of tongue
 Interdental areas
 ANUG/NUG
 Post-extraction, Dry socket
 Plaque & Calculus Oral Hygiene, Stagnation
areas
 Caries: Tooth decay
 Brushing and Flossing
 Reduced salivary flow
Cont...
 Faulty fillings, Overhangs
 Dental materials
 Cements: Eugenol,
 Fixed bridgework, Pontics
 Appliances– Orthodontic, Prosthodontic
 Denture hygiene
 Oral medicine conditions
 Ulcerations, Abrasions, Wounds
 Neoplasias
 Hemorrhagic diatheses
Cont...
 The intensity of bad breath may differ
during the day,due to eating certain
foods such as garlic ,onions,meat,fish and
cheese,smoking,and alcohol
consumption.
Diagnostic approach
 Self diagnosis:patients often self-
diagnose by asking a close friend.
 A better way of self-diagnosing would be
to lightly scrape the posterior back of the
tongue with a plastic disposable spoon
and to smell the drying residue,
Cont...
 Professional diagnosis: if bad breath is
persistent,and all other medical and
dental factors have been ruled
out,specialized testing and treatment is
required.
 Some of the several laboratory methods
for diagnosis of bad breath includes:
Cont...
 Halimeter: a portable sulfide monitor
used to test for levels of sulfur emissions
in the mouth air.
management
The following strategies may be suggested:
1. Gently cleaning the tongue surface using
a tooth brush,tongue cleaner or tongue
brush/scraper to wipe off the bacterial
biofilm,debris,and mucus.
2. Eating a healthy breakfast like rough
foods which helps clean the very back of
the tongue.
Cont...
3. Chewing gum which can help in the
production of saliva and thereby help to
reduce bad breath.
4. Gargling right before bedtime with an
effective mouthwash.
5. Maintaining proper oral hygiene,including
daily tongue cleaning,brushing,flossing
and periodic visits to dentists.
Cont...
6. treat URT and LRT
7. Treat systemic disease Diabetes,
Hypertension,
8. Oral Health: Teeth and Gum problems
cause >90% cases of oral malodor
9. Educate the patient
Periodontal Disease
By; Dr. Daniel T.
2021 G.C
Overview of Periodontal Disease:
Causes, Pathogenesis, and
Characteristics
• Periodontal diseases are serious
chronic infections that involve
destruction of the tooth-supporting
apparatus,
• Although plaque is essential for the
initiation of periodontal diseases, the
majority of the destructive processes
associated with these diseases are
due to an excessive host response to
the bacterial challenge.
TYPES OF PERIODONTAL
DISEASE
• Periodontal diseases include two
general categories based on whether
there is attachment or bone loss:
gingivitis and periodontitis.
AAP Classification of Periodontal
Diseases and Conditions (1999)
• The classification of periodontal diseases
now includes eight general types:
• Gingival Diseases
– Dental plaque-induced gingival diseases
– Non-plaque induced gingival lesions
• Chronic Periodontitis (Slight: 1-2mm CAL; moderate:
3-4mm CAL; severe: >5mm CAL)
– Localized
– Generalized (>30% of sites are involved)
• Aggressive Periodontitis
– Localized
– Generalized
Cont...
• Periodontitis as a Manifestation of Systemic
Diseases
– Associated with hematological disorders
– Associated with genetic disorders
– Not otherwise specified
• Necrotizing Periodontal Diseases
– Necrotizing ulcerative gingivitis
– Necrotizing ulcerative periodontitis
• Abscesses of the Periodontium
– Gingival abscess
– Periodontal abscess
Cont...
• Periodontitis Associated with Endodontic Lesions
– Combined periodontic-endodontic lesions
• Developmental or Acquired Deformities and
Conditions
– Localized tooth-related factors that modify or
predispose to plaque-induced gingival diseases
periodontitis
– Mucogingical deformities and conditions
around teeth
– Mucogingival deformities and conditions on
edentulous ridges
– Occlusal trauma
Plaque-Induced Gingival
Diseases
• Gingivitis is gingival inflammation
associated with plaque and calculus
accumulation.
• It is the most common form of gingival
disease.
• Gingivitis can occur on teeth with no
attachment loss; it also occurs in the
gingiva of teeth previously treated for
periodontitis with no further attachment
loss.
Cont...
• Dental Plaque Only:The bacterial
antigens and their metabolic
products (e.g., endotoxin) stimulate
epithelial and connective tissue cells
to produce inflammatory mediators
that result in a localized
inflammatory response recruiting
polymorphonuclear leukocytes
(PMNLs or neutrophils) to the site.
Cont...
• the clinical signs of gingivitis
develop are redness, swelling, and
bleeding.
• The plaque host interaction can be
altered by the effects of local factors,
systemic factors, or both.
Cont...
• Systemic Factors: Systemic hormonal
changes associated with puberty,
menstrual cycle, or pregnancy, as well as
with chronic diseases such as diabetes,
can alter the host response to dental
plaque.
• Hormonal changes and certain diseases
can upregulate systemic cellular and
immunologic function resulting in local
severe gingival inflammation,
Cont...
• Medications: Medications such as
anticonvulsant drugs (e.g., dilantin),
immunosuppressive drugs (e.g.,
cyclosporine), and calcium channel
blockers (e.g., diltiazem) can cause
severe gingival enlargement and
pseudo-periodontal pocketing (i.e.,
increased probing depths with no
associated attachment or bone loss).
Cont...
• Malnutrition: The host immune system can be
diminished when malnutrition develops, resulting
in excessive gingival inflammation.
• Severe ascorbic acid (vitamin C) deficiencies
(i.e., scurvy) can produce bright red, swollen,
and bleeding gingival tissues.
• In the case of vitamin C deficiency, gingivitis is
associated with a suppressed synthesis of both
connective tissue collagens
• treatment with vitamin C supplements can
reverse this condition.
Nonplaque-Induced Gingival
Lesions
• These types of lesions usually are rare and
mainly due to systemic conditions.
• Bacteria,viruses, or fungi can cause these
types of gingival lesions.
• It is associated with pain and fever, as well
as red swollen gingival tissues with
bleeding or abscess formation, and can be
treated with routine periodontal scaling
and root planing in addition to antibiotic
therapy.
Cont...
• Some of the clinical signs include
bleeding on probing, deep
pockets,recession, and tooth mobility.
• Often, this destructive process is
silent and continues for long periods
of time without being identified.
Chronic periodontitis
Chronic periodontitis is a common disease of
the oral cavity consisting of chronic
inflammation of the periodontal tissues
that is caused by accumulation of profuse
amounts of dental plaque.
Cont...
Cont...
• Most prevalent in adults, but can
occur in children and
adolescents
• Amount of destruction is
consistent with presence of
local factors
• Subgingival calculus is a
frequent finding
• Associated with a variable
microbial pattern
• Slow to moderate rate of
Cont...
• Can be associated with local
predisposing factors
(e.g. tooth-related or iatrogenic
factors)
• May be modified by and /or
associated with systemic
diseases (e.g. diabetes mellitus,
HIV infection)
• Can be modified by factors other
than systemic disease such as
smoking and emotional stress
Extent and severity
• Extent:
– Localized: <30% of sites affected
– Generalized: > 30% of sites affected
• Severity: entire dentition or individual

teeth/site
– Slight = 1-2 mm CAL
– Moderate = 3-4 mm CAL
– Severe = 5 mm CAL
Clinical Characteristics
• Gingival inflammation (color and texture
alteration)
• Bleeding on probing (BOP)
• Periodontal pocketing
• Loss of clinical attachment and or loss of
alveolar bone
• Variable pocket depths
• Horizontal/vertical bone loss
Cont...
Microbiology
• Strong evidence for etiology
Porphyromonas gingivalis, Bacteriodes forsythus
and treponema denticola
• Moderate evidence
Campylobacter rectus, Eubacterium nodatum,
Fusobacterium nucleatum, Prevotella intermedia/
nigrescens, Peptostreptococcus micros,
Streptococcus intermedius-complex and
Treponema denticola.
CP diagnosis
• Radiographic features:
• horizontal bone loss

CP
• Treatment and prognosis:
• Remove local etiologic factors (scaling and
root planning), education, control of
associated factors
Aggressive Periodontitis
• This form of periodontitis was previously
categorized as Juvenile Periodontitis.
• Common features include rapid attachment loss
and bone destruction in the absence of
significant accumulations of plaque and calculus.
• These forms of periodontitis usually affect young
individuals, often during puberty,from 10 to 30
years of age, with a genetic predisposition.
• The bacteria most often associated with
aggressive periodontitis are Actinobacillus
actinomycetemcomitans.
Cont...
• Aggressive periodontitis can be
further characterized as localized
and generalized forms.
• The localized form usually affects
first molar and incisor sites.
• The generalized form usually
involves at least three teeth other
than first molars and incisors.
LOCALIZED AGGRESSIVE
PERIODONTITIS
• age of onset around puberty.
• interproximal attachment loss on at
least two permanent teeth, one of
which is a first molar, and involving
no more than two teeth other than
first molars and incisors.
Cont...
• lack of clinical inflammation despite the
presence of deep periodontal pockets
• Furthermore, in many cases the
amount of plaque on the affected teeth
is minimal,
• the quantity of plaque may be limited, it
often contains elevated levels of A.
actinomycetemcomitans, and in some
patients, Porphyromonas gingivalis.
Cont...
• progresses rapidly.
• Evidence suggests that the rate of
bone loss is about three to four times
faster than in chronic periodontitis.
• robust antibody response to the
pathogens present.
GENERALIZED AGGRESSIVE
PERIODONTITIS
• usually affects individuals under the age of
30, but older patients also may be affected.
• In contrast to localized aggressive
periodontitis, a poor antibody response to
the pathogens present.
• is characterized by "generalized
interproximal attachment loss affecting at
least three permanent teeth other than first
molars and incisors"
Cont...
• often have small amounts of bacterial plaque
associated with the affected teeth .
• P. gingivalis, A. actinomycetemcomitans, and
Bacteriodes forsythus frequently are detected
in the plaque that is present.
• a severe, acutely inflamed tissue, often
proliferating, ulcerated,and bleeding may
occur spontaneously or with slight stimulation.
• deep pockets can be demonstrated by probing.
treatment
• Mechanical therapy(non surgical or surgical
debridement) in conjunction with antibiotics.
• Tetracycline seems affecting A.a better
(250mg 3 times daily for 2wks). Or
• Some studies suggest the use of
metrondazole 400mg and amoxicillin 250mg
4 times daily for 1wk in severe cases.
• Root planning and maintaining good oral
hygiene is required and periodontal surgery
to gain more access to the roots.
Necrotizing Periodontal Diseases
• The most severe inflammatory

disorders caused by plaque bacteria
• Usually run an acute course,
therefore it included in diagnoses
• They are rapidly destructive and
debilitating
• Appear to represent various stages of
the same disease process
Cont...
A. Necrotizing ulcerative gingivitis
(NUG)
B. Necrotizing ulcerative
periodontitis (NUP)
C. Necrotizing ulcerative
stomatitis (NUS)
Cont...
• In NUG there is a rapid destruction of
gums tissue
• In NUP there is rapid destruction of
hard (alveolar bone) tissues.
• It has not been determined whether
or not NUG and NUP are the same or
unique entities, and both are
classified as NUP diseases.
• Both have similarities in the microbial
profile
• NUP is a marker of severe immune
suppression.
Clinical characteristics of NUG
• NUG is an inflammatory gingival

condition characterized by ulcerated
and necrotic gingival papillae
(punched-out appearance)
• Ulcers are covered by yellowish-
white or grayish slough
(pseudomembrane)
• Removal of pseudomembrane leads
to bleeding
NUP
• Interproximal ulceration,
necrosis and cratering
• Foetor ex ore is often present
• Pain (severe, deep, localized in
jaw)
• Spontaneous bleeding
• Soft tissue necrosis and rapid perio-
destruction
Cont...
Prominent changes in gingival contour
are associated with tissue necrosis
and loss of periodontal attachment
and bone
Microbiology of necrotizing
lesions
• Treponema sp.,
• Selenomonas sp.,
• Fusobactrum sp.,
• Provetella melaninogenicus
• Provetella intermedia
Management of NUG
• Local debridement, scaling and root
planing, and irrigation of affected areas
with either povidine iodine 10% or
chlorhexidine gluconate 0.12-0.2%.
– Povidine iodine provides some
analgesic properties.
• Daily rinses with antimicrobial
– Chlorhexidine gluconate mouth 0.12%
1
– Listerine Antiseptic 2
Cont...
• Frequent (daily or every-other-day)
follow up for 7-10 days, repeating
scaling and debridement as necessary
• Reevaluation 1 mo following
resolution of acute symptoms
Cont...
• Systemic antibiotics
– Metronidazole (250mg tid, 7-10 days)
– When necessary, should administered
concurrently with topical clotrimazole
troches or nystatin vaginal tablets and,
in severe immunosuppression, systemic
antifungal medication fluconazole
• Reevaluation 1 mo following resolution of
acute symptoms
Management of NUP
Local debridement, scaling and root planing,
and irrigation of affected areas with either
povidine iodine 10% or chlorhexidine
gluconate 0.12-0.2%.
Cont...
– Chlorhexidine gluconate mouth
0.12%
– Listerine Antiseptic
• Frequent (daily or every-other-
day) follow up for 7-10 days,
repeating scaling and
debridement as necessary
Cont...
• Systemic antibiotics
– Metronidazole (250mg tid, 7-10
days; (Robinson et al.,1998)
– Consideration should also be
given to the prophylactic
administration
Cont...
– Topical application of
clotrimazole troches or
nystatin vaginal tablets
– In severe
immunosuppression,
systemic antifungal
medication fluconazole
100mg, 7 to 10 days
Cont...
• 3 mo supportive periodontal
maintenance
– 30% of patients experience
recurrence in 2 years
– History of NUP predisposes to
Necrotizing Ulcerative Stomatitis
(Robinson, 2002)
Management of NUS
• Debridement of affected areas
– Chlorhexidine gluconate mouth
rinse 0.12%
– Listerine Antiseptic
Cont...
• Daily (or every-other-day) follow up
for the first week, repeating
debridement at each visit
• Systemic antibiotics (e.g.,
metronidazole 250 tid, 7-10 days).
Cont...
– Consideration should also be
given to the prophylactic
administration of an antifungal
medication (fluconazole
100mg,or Itraconazole 200mg;
for 7 to 10 days)
Periodontal abscess
Classification of Periodontal abscess
• Periodontal abscess can be:
1. Chronic or acute
2. Single or multiple
3. Gingival abscess or periodontal
abscess
Multiple periodontal abscess
Periodontal abscess
• Gingival abscess is a localized
purulent infection that involves the
marginal gingiva or interdental
papilla.
• Periodontal abscess is a localized
purulent infection within the tissues
adjacent to the periodontal pocket
that may lead to the destruction of
periodontal ligament and alveolar
bone.
Periodontal abscess
Classification of periodontal abscess
• Depending on the cause of

infection:
1. Periodontitis-related abscess
(subgingival biofilm)
2. Non-periodontitis-related abscess
(foreign body)
Clinical features of GA
• Clinical features may include

combinations of the following signs
and symptoms:
1. A localized area of swelling in the
marginal gingiva or interdental
papillae, with a red, smooth, shiny
surface.
2. The lesion may be painful and
appear pointed.
3. A purulent exudate may be present.
Gingival abscess
Clinical features of PA
• Clinical features may include
combinations of the following signs
and symptoms: a
1. Smooth, shiny swelling of the
gingiva;
2. pain, in the area of swelling
3. Tender to touch; a purulent
exudate;
Periodontal abscess
Acute Periodontal Abscess
Clinical features of PA
4. Increase in probing depth. The tooth
may be sensitive to horizontal
percussion and may be mobile.
5. Rapid loss of periodontal
attachment may occur.
6. A periodontal abscess may be
associated with Endodontics pathosis
Signs and symptoms
• Swelling that usually occurs at sites
with
pre-existing periodontitis
• Pain is more continuous, less intense
and
easier to localize than an endo
abscess
• May not respond to percussion, heat,
cold
• Rule out contribution from non-vital
Microbiology PA
• Approximately 60% of bacteria are
strict
anaerobes
• Bacterial isolates similar to chronic
periodontitis
Steps in Treatment of Periodontal
Abscesses
• Establish drainage
• Debride the pocket and root plane
the
affected tooth
• Rx antibiotics for aggressive
infections
• Evaluate resolution of the abscess
within 1
week
Cont...
Thank you for your attention
Maxillofacial
trauma
MAXILLOFACIAL TRAUMA
• Maxillofacial injuries are

commonly encountered
in the practice of
emergency medicine.
• More than 50% of
patients with these
injuries have
multisystem trauma that
requires coordinated
management
INTRODUCTION
• The facial skeleton is divided
into 3 parts:
I. The upper 1/3: formed by frontal
bone.
II. The middle 1/3: from frontal
bone to the level of upper teeth.
III. The lower 1/3: the mandible.
293
ETIOLOGY
• Fights
• Domestic injuries and falls
• RTA
• Occupational hazards- athletic
injury, industrial mishaps
• Iatrogenic
• Human and animal bite
• Pathologic
294
Emergency Department
Care
 Airway maintenance with cervical
spine
protection
 Breathing and ventilation with
maximum
flow oxygen
 Maintenance of Circulation &
bleeding control
 Disability; neurological status
assessment
 Exposure: Completely undress the
patient but prevent hypothermia
295
Cont…
 Control airway:
 Maxillofacial bleeding:
• Chin lift, Jaw thrust
• Oropharyngeal toileting and • Direct pressure.
suctioning.
• Avoid blind clamping
• Move the tongue forward.
• Immediate restoration of the  Nasal bleeding:
position of the soft palate
• Cervical immobilization • Direct pressure.
 Avoid nasotracheal • Anterior and posterior packing.

intubation:
 Pharyngeal bleeding:
• Nasocranial intubation
• Nasal hemorrhage • Packing of the pharynx
• Consider an awake around ET tube.
intubation with Sedation.
Causes of Respiratory
Obstructions Related to
Maxillofacial Injuries
• Inhalation of blood clot, vomit, saliva,
thick mucus or portions of teeth, bone
and dentures
• Inability to protrude the tongue
• Occlusion of the oropharynx by the soft
palate after retroposition of the maxilla
Basic principles of mgt
of facial bone #
1. Reduction
2. Fixation
3. Immobilization
1.Reduction :
. Restoration fragments to their original position
Open reduction
Closed reduction • Surgical reduction
• Can be carried out that allows visual
by manipulation or identification of
traction fractured
fragments
• Occlusion of the
teeth is used as a
guide line
• It could be by
manipulation or
traction
Cont…
2) Fixation
• Fractured fragments are fixed to
prevent displacement and for
achieving proper approximation
• Direct skeletal fixation: by plates or
intraosseous wiring
• Indirect skeletal fixation: by arch bar or
intermaxillary fixation
300
Cont…
3) Immobilization
The fixation device is retained
to stabilize the reduced
fragments until a bony union
takes place.
For maxillary # 3 to 4 weeks
For mandibular # 4 to 6 weeks
immobilization.
Condylar # 2 to 3 weeks
301
Diagnosis of facial
fractures
• Midface fractures
• Zygomatic
complex fractures
• Nasal fractures
• Mandibular
fractures
Fracture of the middle 1/3
of the face
• Boundaries :
• Superiorly : line
from FZ suture,
across frontonasal
suture,
frontomaxillary
suture.
• Inferiorly : occulusal
plane
• Posteriorly :
sphenoethmoidal
junction
Cont…
Classification
I. Le Fort I
II. Le Fort II
III. Le Fort III
304
Le Fort I #...
Horizontal fracture of the
maxilla ,Guerin's fracture or
floating fracture
 Usually bilateral
 Floating of the palate
 Hematoma within the
maxillary antrum
 Bilateral hematoma of the
cheek
 Deranged occlusion with
anterior open bite
306
Treatment
Zygomatic maxillary buttress
Nasomaxillary buttresses
Le Fort II #
• Pyramidal or Subzygomatic fracture
• Results from a force delivered at a
level of the nasal bones in superior
direction.
• The fracture line occurs along the
nasofrontal
suture  lacrimal bone  across the
infraorbital rim in the region of the
zygomaticomaxillary suture  above
the canine eminence  inferiorly and
distally along the lateral antral
wall, but at a higher level than Le Fort
CLINICAL FEATURE
 Extraorally
 Ballooning of the face
Lengthening of the face
Bilateral circumorbital edema and ecchymosis
(Black eye)
Sub conjunctival Hemorrhage
Enophthalmos
Diplopia
Epistaxis
CSF rhinorrhea
Step deformity in the lower border of the orbit
Cont..
 Intraorally
Malocclusion
Gagging of the posterior teeth and anterior
open bite
Mobility of the maxilla
Ecchymosis of the sulcus
Treatment
• Intermaxillary
fixation
• Interosseous
wiring
• Plating of
infraorbital rims,
nasal-frontal area,
& zm buttress
312
Le Fort III fractures
(transverse)
• Results when horizontal forces are
applied at a level superior enough (at
orbital level) to separate the NOE
complex, the zygomas, and the maxilla
from the cranial base (Craniofacial
separation/ dysjunction)
• The fracture line courses through the
zygomaticotemporal and
zygomaticofrontal sutures lateral orbital
wall inferior orbital
fissure medially to the naso-frontal
suture  fractures the pterygoid plate at
Clinical findings
 Extraorally
Severe edema of the face “ballooning”
Lengthening of the face
Flattening of the cheek
Circumorbital ecchymosis
Subconjunctival Haemorrhage
Epistaxis
Enophthalmos
CSF rhinorrhoea
Cont…
 Intraorally
Gagging of the posterior teeth and anterior
open bite
Ecchymosis and Haemorrhage of the buccal
sulcus
Mobility of the maxilla
Mandibular interference
Cont…
Treatment
• Intraosseous wiring at zygomatico-frontal
sutures
• Bilateral fronto-zygomatic suspension
after the application of arch bars.
• Intraosseous wiring may be done at the
infraorbital margin, if step deformity
exists
• Plating
Fractures of Zygoma
• The zygoma has 2 major
components:
• Zygomatic arch
• Zygomatic body
• Blunt trauma is the most
common cause
• Two types of fractures can
occur:
• Isolated arch fracture
• Zygomatic complex fracture
Zygoma Arch Fractures
• Can fracture 2 to 3
places along the
arch
• Lateral to each end
of the arch
• Fracture in the
middle of the arch
• Patients usually
present with pain
on opening their
mouth or unable to
open (Trismus)
Clinical Findings
• Palpable bony
defect over
the arch
• Depressed
cheek with
tenderness
• Pain in cheek
and jaw
movement
• Limited
mandibular
movement
Cont…
• Radiographic
imaging:
• Submentovertex
view (bucket
handle view)
Closed reduction
Open reduction without
fixation
• Reduction using • Reduction through
the transoral the temporal
(Keen) approach (Gillies) approach
Zygomatic complex fracture/ ZMC #
• Consist of
fractures
through:
• Zygomatico
temporal
• Zygomaticofr
ontal suture
• Inferior
orbital rim
and
• Floor of orbit
Clinical Features
• Periorbital
edema and
ecchymosis
• Paresthesia
of the
infraorbital
nerve
• Palpation
may reveal
step off
• Concomitant
globe injuries
are common
Imaging Studies
• Radiographic
imaging:
• Waters,
Submental
and Caldwell
views
• Coronal CT of
the facial
bones:
• 3-D
reconstructio
n
Nasal bone fracture
• High Incidence because of

its prominence in nature
• Usually due to direct injury
• can occur as an isolated #
or with other facial fractures
• Result in cosmetic deformity
and functional disturbance.
• Force could be from anterior
or lateral
Anterior injuries
• Anterior force may result in smash #
• Comminuted fragments may be driven
laterally into the orbit or upward into the
ethmoid region
• May be associated with damage to the
nasolacrimal ducts, the perpendicular
plate of the ethmoid, the ethmoid
sinuses, the cribriform plate and the
orbital parts of the frontal bone.
• Widening of the
intercanthal
distance
(traumatic
telecanthus)
• Buckling of the
nasal septum may
be seen.
Lateral injuries
• Force applied from the side
• May involve only one nasal bone with
medial displacement
• Most commonly in adults a violent blow
from the side results in # of both nasal
bones and septum with lateral shifting of
the entire bony framework which is called
‘open book’ fracture
Clinical findings
• Nasal
deformity
• Edema and
tenderness
• Nasal
obstruction
• Epistaxis
• Crepitus and
mobility
Nasal Fractures
• Diagnosis:
• History and
P/E
• Imaging :Late
ral , Waters
view or CT
Nasal Fractures
• Treatment:
• Control
epistaxis.
• Drain septal
hematomas.
• Observation,
closed or
open
reduction
Treatment
• Observation: Non-
displaced #
without nasal
deformities or
airway obstruction
Cont…
• Closed reduction:
Displaced,
unilateral/bilateral
nasal bone #
• Closed reduction
should be
performed as soon
as the deformity is
identified
preferably 10-14
days post injury
• Splinting for 5-10
• Open
reduction :Unstabl
e or dislocated
nasal bone
fractures.
Fracture of the mandible
• Largest ,strongest and heaviest bone

of the face
• Classification:
1. Condylar # 35%
2. Angle #20%
3. Body #20%
4. Parasymphysis # 13%
5. Symphysis # 11%
6. Coronoid # 1%
341
Signs and symptoms
• Malocclusion
• >50 % are multiple
• Decreased jaw range of motion
• Trismus
• Chin numbness
• Ecchymosis in floor of mouth
• Palpable step deformity
• Airway obstruction from loss of attachment
at base of tongue
Management
1. Closed reduction
 Dental wiring or arch bar is used to get the occlusion
 IMF for 4- 6 wks
Indication
 Nondisplaced #
 Lack of soft tissue over the # area
 # of children with developing tooth bud
 Coronoid process #
Cont…
2) Open reduction
Indications
 Displaced fracture
 Multiple fracture
 Associated mid face fracture
 Associated condylar fracture
Contraindicated: if GA is not
advisable, sever comminution
or loss of soft tissue & severe
infection to the site
344
Complication of
maxillofacial fracture
• Paresthesia
• Malunion and deformity
• Infection
• Derangement of occlusion
• Ankylosis of TMJ
• Diplopia
345
Mandibular Dislocation
• The mandible
can be
dislocated:
• Anterior ~
70%
• Posterior
• Lateral
• Superior
• Dislocations
are mostly
bilateral
• Clinical
features:
• Inability to
close mouth
• Pain
• Facial
swelling
• Physical
exam:
• Palpable
depression
• Jaw will
deviate away
• Closed
reduction:
• Muscle
relaxant
• Analgesic
• Closed
reduction in
the
emergency
room
• Disposition:
• Avoid excessive mouth opening
• Soft diet
• Analgesics
• Follow up
Injury to the tooth and the
periodontium
• Tooth fracture ; Ellis classification
• Concussion
• Subluxation
• Intrusive luxation
• Extrusion luxation
• Lateral luxation
• avulsion
Facial Soft Tissue Injuries
• Before repair, rule out injury to:
• Facial nerve
• Trigeminal nerve
• Parotid duct
• Lacrimal duct
• Medial canthal ligament
Facial Soft Tissue Injuries
• Remove embedded foreign material
• For lip lacerations, place first suture at vermillion
border
• Never shave an eyebrow: may not grow back
• Most face bite wounds can be sutured primarily
• Clean facial wounds can be repaired up to 24
hours after injury
• Place incisions or debridement lines parallel to
the lines of least skin tension (Lines of Langer)
• Remove sutures in 3 to 5 days to prevent cross-
marks(rail way marks)
References
• Neelima anil malik maxillofacial surgery
3rdedition
• Peterson’s Principles of Oral and
Maxillofacial Surgery 3rd edition
Thank you for your
attention
356
Diseases of
salivary
glands
Instructor – Dr. Daniel
T (DMD)
Introduction
357
 The salivary glands classified as major &

minor glands
 Major glands are paired glands they are
 Parotid glands
 Submandibular glands
 Sublingual glands
 The numerous minor salivary glands , widely
distributed in the oral cavity
 Salivary gland secretion contain water,
electrolytes , urea , ammonia , glucose , fats
&proteins
Parotid gland
358
 Largest salivary gland

 Pyramidal in shape
 Two lobes superficial , & deep connected by an
isthmus at posterior part of gland
 Apex is toward angle of mandible
 Base at the external acoustic meatus
 Anteriorly gland extends up to buccal pad of fat
 Posteriorly encircles posterior border of mandible
 Parotid gland secretion is serous in nature
Parotid duct (Stenson's
359
duct )
 Stenson`s duct emerges at anterior part
of gland
 Stenson`s duct opening is seen as a
papilla in the buccal mucosa opposite
maxillary second molar
Submandibular gland
360
 The gland is located submandibular

space
 Extending inferiorly up to digastric
muscle
 Superiorly mylohyoid muscle
 Posteriorly up to angle of mandible
 Anteriorly mid portion of body of the
mandible
 Submandibular gland secretion is
mixed
Submandibular duct (Wharton's
duct)
361
 The duct starts from deep part of gland

 Turns sharply at the posterior border of
mylohyoid muscle anteriorly & superiorly
, crosses hyoglossus muscle
Sublingual gland
362
 This gland is located in sublingual space

it is present in association with
sublingual fold below tongue , & divided
into anterior & posterior part
 Sublingual gland secretes both serous &
mucous
 Bartholin’ s duct
 The ducts of anterior part may join to
form a large main duct called Bartholin’ s
duct
Minor salivary glands
363
 More than 800 minor salivary glands

may be present in oral cavity
 Secrete mucous secretions
Functions of saliva
364
 Digestive function
 Protective function
 Cleansing
 Lubrication
 Antibacterial action
Classification of salivary gland
diseases
365
 Salivary gland dysfunction

 Xerostomia
 Sialorrhea
 Developmental
 Aplasia - absence of the gland
 Atresia - absence of the duct
 Aberrancy - ectopic gland
Cont.
366
 Enlargement of the gland

 Inflammatory
 Viral ; mumps
 Bacterial
 Non – inflammatory
 Autoimmune; Sjogren’s syndrome
 Alcoholic cirrhosis
 Diabetes mellitus
 Sialolithiasis
CONT.
367
 Cysts
 Retention cysts
 Extravasation cyst
 Ranula
 Tumours of salivary glands
 Benign tumours
 Pleomorphic adenoma
 Warthin’s tumour
CONT.
368
 Malignant tumours
 Mucoepidermoid carcinoma
 Acinic
cell carcinoma
 Adenoid cystic carcinoma
 Necrotizing sialometaplasia
Xerostomia
 Xerostomia is a subjective sensation of a
dry mouth
 It affects women more than men , are
commonly in older people
 Antihistamines , decongestants ,
antidepressants , antipsychotics,
antihypertensives, & anticholinergics are
known to cause xerostomia
 Other cause of xerostomia -- salivary
gland aplasia, aging , excessive
smoking , mouth breathing , local
36
9 radiation therapy , Sjogren’s syndrome &
Cont.
 Clinical features
 Dry mouth with foamy , thick , & ropy
saliva
 Gloves stick to the mucosa
 Difficulty in mastication & swallowing
 More chance for candidiasis & caries
 Treatment
 Removal of the cause
 Maintenance oral hygiene
 Use of sialagogues
37
0
Cont.
371
 Systemic pylocarpine 5- 10 mg 3-4 times

daily
 Frequent dental visits
 Topical fluoride application
Sialorrhoea
 Sialorrhoea is excessive salivation
 Minor sialorrhea can be seen due to local
irritation like aphthous ulcers or ill- fitting
dentures
 Profuse salivation is seen in rabies, heavy metal
poisoning, gastro esophageal reflux disease or
after certain medication like lithium & cholinergic
agonists
 Mentally retarded children also excessive
salivation – not by excessive production of saliva
 Treatment
 Removal of the cause
37
2
Cont.
 Anticholinergic medication
 Submandibular gland resection
 Parotid duct ligation.
37
3
Sialadenitis
374
 Inflammation of the salivary glands is

known as sialadenitis
 Causes
 Viral infections
 Bacterial infections
 Allergic reactions
 Systemic diseases
Mumps
375
 It is also called as epidemic parotitis.

 It is caused by paramyxo virus and
affects major salivary glands,

especially the parotid salivary gland.
 Clinical Features:
 The mumps virus can be transmitted

through urine, saliva or respiratory
droplets.
 Incubation period-16 to 18 days.
Cont.
376
 Patients are contagious 1 day before & 14

days after the resolution
 Usually subclinical
 If symptomatic prodromal symptoms of Low-
grade fever, Headache, malaise & Myalgia
 Discomfort & swelling over the lower ½ of
external ear down to posterior & inferior
border of mandible
 Either one or both the parotid gland are
enlarged and become tender.
Cont.
377
 Enlargement & pain are maximum in 2-3

days
 Chewing movements or saliva
stimulating foods increases pain
 Enlargement begins on one side & then
extends to other side
 There many also be and edema & erythema
involving the ductal orifice.
 If sublingual gland is involved – bilateral
enlargement of floor of mouth
Cont.
378
 Complications
 Pancreatitis
 Orchitis
 Oophoritis
 Meningio encephalitis
 Diagnosis:
 Urine, saliva & cerebrospinal fluid for
culture.
Cont.
379
 Treatment:
 Analgesics and antipyretics
 Bed rest
 Avoidance of sour foods
 Prior vaccination
Bacterial infection
380
 Bacterial infection can inflammation of

major salivary glands
 Bacterial sialadenitis affects parotid
gland more commonly
 Submandibular glands are rarely
affected
Acute bacterial
sialadenitis
 Organisms - staph ;aureus , strep ;
pyogenes, strep; viridans etc
 Some drugs like tranquilizers;
antiparkinson drug ; diuretics; &
antihistamines drugs etc decrease
salivary flow with increased chance of
infection of salivary glands
 Sudden onset of pain at angle of the jaw
which is unilateral
38
1
Cont.
 Affected gland is enlarged & tender &
extremely painful
 Inflammatory swelling is very tense & does
not show much fluctuation
 Skin is warm & red
 Associated fever & trismus may be there
 Purulent discharge from the affected duct
orifice
 Histopathologic features
 Accumulation of neutrophils is observed
with in ductal system & acini
38
2
Cont.
 Treatment
 Antibiotics
 Hydrating the pt
 Stimulate the salivation by chewing
sialagogues
 Improve oral hygiene by debridement &
irrigation
 Surgical drainage if abscess is there
38
3
Chronic bacterial
siladenitis
 It may be idiopathic or with factors like
 Duct obstruction ,
 Congenital stenosis,
 Sjogren ’s syndrome
 The microorganisms may be strep; viridans,
e- coli
 Unilateral periodic pain & swelling at the
angle of jaw usually during mealtime
 Gland may undergo atrophy , which results
in decreased salivary flow
38
4
Cont.
 Patchy infiltration of salivary
parenchyma by lympocytes & plasma
cells
 Atrophy of acini & ductal dialatation &
sometimes fibrosis
 Sialography – ductal dialatation
proximal to area of obstruction
 Treatment
 Antibiotics
38
5
Cont.
386
 Intra ductal infusion of erythromycin or

tetracycline
 Excision of the gland
38
7
Sjogren syndrome
 Characterized by dry eyes , xerostomia
& rheumatoid arthritis
 Occurs predominantly in women
 Dry eyes & dry mouth
 Pain & burning sensation
 Red & tender mucosa with Ulceration
 Difficulty in swallowing
 Altered taste sensation
 Denture sore mouth
38
8
Cont.
 Angular cheilitis
 There may have diffuse firm enlargement
of major salivary glands usually bilateral
 Sialography - demonstrates cavitary
defects are filled with radiopaque
contrast media producing ‘ branchless
fruit laden tree’ or “cherry blossom
appearance”
 Lymphocytic infiltration with destruction
38
of acinar cells
9
Cont.
390
 Treatment
 Xerostomia - artificial saliva,sugarless
gums,pilocarpine
 Flouride application to prevent caries
39
1
Sialadenosis
 It is non- inflammatory , non - neoplastic
swelling of the salivary gland
 Sialadenosis can occur in the following
conditions;
 Hormonal disorders(pregnancy,
hypothyroidism)
 Diabetes mellitus
 Alcoholic cirrhosis
 Malnutrition
 Caused by dysregulation of autonomic
innervation of salivary acini causing
39
2 aberrent intracellular secretory cycle
Cont.
 Enlargement is usually painless
 Usually bilateral
 More common in women
 Commonly affects parotid
 Hypertrophy of acinar cells
 Nuclei are displaced to the base
 Cytoplasm is engorged with zymogen
granules
39
3
Cont.
 In DM & alcoholism – acinar atrophy &
fatty infiltration
 Treatment
 Control underlying cause
 Pilocarpine
39
4
Sialolithiasis
 Sialolithiasis is the formation of sialolith
( salivary calculi, salivary stone ) in the
salivary duct or gland resulting in the
obstruction of the salivary flow
 Sialolith
 Sialolith is a calcified mass with
laminated layers of inorganic material
from crystallization of salivary solutes
 The sialolith is yellowish white in colour ;
 Single or multiple, may be round & ovoid
39
or elongated having size of 2cm or
5
more diameter
Cont.
 The minerals are various forms of calcium
phosphate like hydroxyapatite, octacalcium
phosphate etc
 Calcium & phosphorus ions are deposited on
the organic nidus, may be desquamated
epithelial cell, bacteria, foreign particle or
product of bacterial decomposition
 It may be related to sialadenitis or ductal
obstruction
 Commonly seen in middle -age persons
39
6
39
7
Cont.
 More common in submandibular salivary ductal
system
 Pain & swelling during & after eating food
 Stone can be palpated if it is in the peripheral
aspect of the duct
 Minor salivary stones are seen as asymptomayic
hard nodule commonly in upper lip
 Sialoliths appear as round , & oval calcified
mass exhibits concentric laminations surround
a nidus of amorphous debris
39
8
Cont.
 Investigations
 Radiographs –PA view , lateral oblique or
occlusal view – shows radiopaque mass
 Sialography
 Treatment
 Smaller sialoliths, are located
peripherally near ductal opening may be
removed by manipulation called milking
the gland
 Larger sialoliths are surgically removed
39
9
Cont.
400
 Stones which are not impacted , may be

extracted through the intubation of the duct with
fine soft plastic catheter& application of the
suction to the tube
 Piezoelectric shock wave lithotripsy
 Multiple stones or stone in gland require
removal of the gland
 Transoral sialolithotomy of the
submandibular duct
 Local anaesthesia
 Position of the stone is located by x-rays & palpation
Cont.
401
 Suture is placed behind the stone

 Tongue is lifted & held with help of a gauze
 Incision is made in the mucosa parallel to the duct
 Duct is located by blunt dissection
 Longitudinal incision is made over the stone
 Stone removed using small forceps, in case the
stone is large, it is crushed with help of the
forceps
 Cannula may be passed to aspirate the pieces of
stone, mucin etc
 Sutures are placed at the level of the mucosa
Mucocele
 Lower lip is commonly affected
 Other common sites are buccal mucosa,
ventral tongue, floor of mouth
 It can be superficial or deep
 Superficial – elevated well circumscribed
vesicle with bluish hue
 Deep – nodule with no change in color
 Cystic contents – thick mucous material
 Usually covered by mucous membrane
 There may have periodic rupture of the
40
2 swelling releasing the contents
40
3
Cont.
 After rupture it may leave shallow
painful ulcers
 Some lesions resolve by itself
 Area of spilled mucin surrounded by
granulation tissue
 Adjacent minor salivary glands contain c/c
inflammatory infiltrate
 Treated by excision along with adjacent
minor salivary glands to prevent
recurrence
40
4
Salivary duct cyst
 Mucus retention cyst or sialocyst
 Epithelium lined cavity that arises from
salivary gland tissue
 True cyst
 May be caused by ductal dilatation or
secondary to ductal obstruction
 It can be seen in major or minor salivary
glands
 Cysts of major glands are common in
parotid gland
40
 Intraoral cyst are common in buccal
5
mucosa, floor of mouth & lips
Cont.
 They are soft, fluctuant, asymptomatic
swelling & may appear bluish depending
on the depth
 Histopathologically – cyst may be lined
by cuboidal, columnar or squamous
epithelium surrounding the mucoid
secretion in lumen
 Treated by local excision for minor
salivary gland ducts
 For major salivary glands total or partial
removal of gland can be done
40
 Sialgogues can stimulate salivation &
6
40
7
Ranula
 Extravasation cyst usually arises from
ducts of sublingual gland
 Bluish, dome shaped, fluctuant swelling
in floor of mouth
 May enlarge raise the tongue
 Usually seen lateral to midline
 May extend to the neck behind the
posterior border of mylohyoid (plunging
ranula)
 Histopathologically similar to mucocele
40
8
 Treated by marsupialization or removal of
40
9
Pleomorphic adenoma
 It can affect both major & minor salivary
gland
 It commonly affects the parotid gland
 More commonly in females
 Small painless nodule at the angle of
mandible or beneath the ear lobe
 Well circumscribed , encapsulated , firm
in consistency & may show area of cystic
degeneration
41
0
 Difficulties in mastication & talking
Cont.
 If deep lobe is affected , a swelling in the
lateral pharyngeal wall or soft palate
 Minor salivary gland involvement is
common in palate & lip as smooth
surfaced dome shaped swelling
 Well - circumscribed , encapsulated
tumor
 Tumor is composed of a mixture of
glandular epithelium & myoepithlial cells
41
with in a mesenchyme like
1
background may be myxoid or
41
2
Cont.
413
 Treatment - surgical excision

Warthin tumor
 Papillary cystadenoma lymphamatosum
 Affects the parotid glands
 Males are affected more
 Firm or fluctuant, nontender ,
circumscrided mass in the region of
angle or ramus of the mandible or
beneath ear lobe
 Common in the tail of the gland
 Both side parotid gland affected
41
4
41
5
Cont.
 Tumour composed of mixture of ductal
epithelium & lymphoid tissue
 Treatment
 Surgical excision
41
6
Mucoepidermoid carcinoma
 The low grade tumour behaves almost
like a benign tumour with very good
prognosis
 High grade tumour behaves very
aggressively
 It occurs with equal distribution between
males& females
 More common in parotid gland
 It may grow slowly or rapidly
41
7
 Painless swelling
Cont.
 Facial paralysis
 Minor salivary gland tumors are common
in palate & may have bluish hue
 Local destruction & metastasis to
regional lymph nodes & distant
metastasis to the lung
 Mucus producing cells & squamous cells
 High grade tumors have cellular atypia

41
8
41
9
Cont.
 Treatment
 For minor salivary glands excision with
surrounding normal tissues
 For tumors with metastasis radical
resection with radiation
42
0
Acinic cell carcinoma
 A low grade malignancy
 Commonly occurs in parotid gland
 Common in females
 Usually asymptomatic
 Commonly affects serous acini
 In minor salivary glands it is common in
buccal mucosa, lip & palate
 It may be a slow growing swelling
 Sometimes pain, tenderness may be
42
1 there
42
2
Cont.
 Acinar cell has abundant granular
basophilic cytoplasm & round, darkly
stained eccentric nucleus
 Treatment
 Tumour confined to the superficial lobe
is treated by lobectomy
 Tumour involving deep lobe -
parotidectomy
 Radiotherapy for severe cases
42
3
Adenoid cystic carcinoma
 It is also called cylindroma
 Slow growing swelling
 Commonly occurs in palatal minor
salivary glands
 Commonly occurs in middle aged
individuals
 Constant , low grade, dull aching pain
 Facial nerve paralysis in parotid tumours
42
4  Islands of basaloid epithelial cells that
42
5
Cont.
 Perinueral invasion
 Treatment
42
6
Necrotizing sialometaplasia
 It is a locally destructive inflammatory
lesion affecting minor salivary glands
 Cause is ischemia of salivary tissues
 Commonly occurs in men
 Minor salivary glands of the palate, lip or
retromolar pad affected
 The lesion occurs as a swelling with
paresthesia then it sloughs leaving large
ulcer or ulcerated nodule
42
7
 Edge of lesion presents with an
42
8
Cont.
 Acinar necrosis
 Squamous metaplasia of salivary ducts
 Treatment
 Debridement by hydrogen peroxide or
saline
 Application of gentian violet
 The lesion is self - limiting one & heals in
6 to 8 weeks
42
9
Sialography
430
 It is a specialized radiographic procedure

performed for detection of disorders of
major salivary glands
 Mercury is used as contrast agent
 It involves cannulation & filling with a
radiopaque or contrast agent to make
them visible on a radiograph
 Indications
 Detection of calculi or foreign bodies
Cont.
431
 Determination of the extent of

destruction of salivary gland tissue
secondary to obstruction such as calculi
or foreign bodies
 Detection of fistulae , diverticuli &
strictures
 Detection & diagnosis of recurrent
swelling & Inflammatory processes
 Demonstration of tumour ; its size
location & origin
 Selection of the site for biopsy
Cont.
432
 Contraindications
 Pt with allergy or hypersensitivity to
contrast media
 Acute inflammation of the salivary
glands
 Pt scheduled for thyroid function test
 Technique
 Identification of the location of duct
orifices
 Exploration of the duct with lacrimal
Cont.
433
 Radiographic projections
 Lateral oblique projection
 Lateral projection
 Occlusal projection
 Antero- posterior projection
 OPG projection
Surgical management
434
 Superficial parotidectomy
 Complete excision of parotid gland
 Biopsy or excision of submandibular
gland
Superficial
435
parotidectomy
 Indications
 Tumour ; common is pleomorphic
adenoma
 Massive enlargement secondary to
 Sjogren’s syndrome
 Calculus in the hilum of gland - calculus is
removed without removal of the gland
 Chronic infection
Cont.
436
 Approaches
 Preauricular
 Submandibular
 Combination of the two
 Preauricular incision
 Incision is taken in the skin
 Platysma & superficial fascia dissected
 Duct is identified at anterior border of
gland
Cont.
437
 Duct is followed backward through

substance of gland until calculus
identified & recovered
 Fascial sheath encasing the gland is
closed completely
 Wound is closed in layers
 Pressure dressing given
Complete excision of
438
parotid gland
 In this procedure facial nerve
preservation is difficult so this should be
explained to the pt
 Y-shaped incision is planned, starting
from the superior attachment of the
pinna downward & anteriorly toward
angle of the mandible & anteriorly ,
forward till hyoid bone
 The second arm of incision is made
posterior to the pinna
 Ear lobe is retracted upward & skin flap
Cont.
439
 Superficial lobe is freed from its

attachments
 Stenson’s duct is located , ligated & cut
 Deep lobe is approached
 Ligation of external carotid artery &
posterior facial vein is carried out
 Facial nerve is then carefully elevated
from the deep portion
 Deep portion is gently dissected out of
the retromandibular space
Excision of
440
submandibular gland
 An incision , 4to5 cm in length , is taken
in the skin in the submandibular region
 Incision is placed in, or parallel to the
skin creases , about 2cm below
submandibular border
 Wound is deepened through platysma &
deep fascia
 Branches of facial nerve in the field are
identified , mobilized & retracted
 Facial vein is identified & ligated
Cont.
441
 Lower pole of the gland is exposed,

grasped with tissue holding forceps
 Facial artery is ligated & divided
 Gland is separated from lower border of
mandible
 Lingual nerve is dissected
 Ligature is passed anterior to ductal
pathosis
 Second ligature is passed posterior to
the first one , but still anterior to the
Cont.
442
 Deep part of the gland is excised

 Wound sutured in layers
Complications of surgery
443
of salivary glands
 Damage to lingual nerve
 Damage to Wharton's duct
 Damage to Auriculotemporal nerve
 Facial nerve paralysis
444
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01/29/2022

For 3rd year public health students

• Modern dentistry started in mid 19th c USA

A tooth is made up of three elements:

Detinition (teeth): There are two detinitions

Secondary (permanent) Canine (Cuspid

• Enamel (hard tissue)

The 4 main dental tissues: Dental

•Softer than enamel

Learning nomenclature is the first step in

The various tooth notation systems are as follows:

Primary teeth- EDCBA ABCDE

Permanent teeth- 87654321 12345678

Primary teeth- ABCDE FGHIJ

For 3rd year

• The cranium consists of the following

• Forms the lower jaw

• Two parts ; vestibule and oral cavity

BY Dr. Daniel T. (DMD)

 Definition of dental caries

• If the quality of enamel is poor in the case such as

• If the plaque thickness dominated by cariogenic

Based on the surface it occur dental caries can be

• Class (II) lesions occur on the proximal surfaces

IT IS CLASSIFIED INTO TWO PARTS -SOFT TISSUE

• 1-bacterial cause: caries, fracture,

• The pain not localized in the affected tooth

• ---deep caries/recurrent caries

– Also referred to as non-vital. Used to

Nobuhara and del Rio

 Obstruction, Nasal- discharge, Tonsillitis,

• Severity: entire dentition or individual

• horizontal bone loss

• The most severe inflammatory

• NUG is an inflammatory gingival

• Depending on the cause of

• Clinical features may include

• Maxillofacial injuries are

 Avoid nasotracheal • Anterior and posterior packing.

• High Incidence because of

• Largest ,strongest and heaviest bone

 The salivary glands classified as major &

 Largest salivary gland

 The gland is located submandibular

 The duct starts from deep part of gland

 This gland is located in sublingual space

 More than 800 minor salivary glands

 Salivary gland dysfunction

 Enlargement of the gland

 Systemic pylocarpine 5- 10 mg 3-4 times

 Inflammation of the salivary glands is

 It is also called as epidemic parotitis.

affects major salivary glands,

 The mumps virus can be transmitted

 Patients are contagious 1 day before & 14

 Enlargement & pain are maximum in 2-3

 Bacterial infection can inflammation of

 Intra ductal infusion of erythromycin or