Mary’s Swollen Face:

Body in Health:

 What are the muscles of mastication

The muscles involved with mastication are facial muscles found around the jaw area, and are
the muscles used to move the lower jaw around. These muscles are:

 Temporalis Muscles: (broad band of muscle that extends from the temporal to the
coronoid process of the mandible) this is the muscle that assists in raising and
lowering the jaw, as well as retracting the mandible too. This muscle is also involved
in crushing food between the molars and also contributes to the side-side grinding
motion.
 Pterygoid Muscles:
o Lateral: (this works in tandem with the masseter) this lowers the mandible
and assists in jaw rotation and
o Medial:
 Masseter Muscle: this is a thick muscle and it is the main muscle involved in chewing
– it elevates and retracts the mandible. This muscle is also involved in lateral
movements required for efficient chewing and grinding of the food. This muscle
consists of two parts (the deep and superficial part).

 Which muscles are involved in opening the mouth

 What other structures are involved in chewing

o TMJ
o Tongue,
o Buccinators,
o Hyoid muscles

 What are the natural movements for the muscles of mastication

 How do muscles function? Contraction and relaxation

 What are lymph nodes

Lymph glands are pea-sized lumps of tissue that contain white blood cells.

 What are the function of lymph nodes

Body in Disease:

 What does ‘grossly carious’ mean

 How does caries progress

 What bacteria are involved in caries

 Why is it difficult for Mary to open her mouth, why might muscles not work? Common
pathologies of muscles?

 What is the pathenogenesis of facial swelling/trismus

The harmful bacteria found in the caries (usually Staphylococcus aureus) can circulate
through the blood stream until it reaches the muscle, and once they have reached that area
they can multiply and infect that area. This means that there would an influx of white blood
cells to the infected area, thus causing inflammation. If this occurs for a long period of time,
muscle fatigue can occur and the muscles won’t be able to contract efficiently – causing
spasms.

 What do abnormal lymph nodes feel like

Abnormal lymph glands can be detected during an extra-oral examination (sometimes they
can be seen bulging out of the skin or can be felt during palpation), as they would be swollen
and inflamed. Abnormal lymph nodes tend to be firm, tender and noticeably warm.

 What is the purpose of raising the body temp

When leucocytes come into contact with exogenous pyrogens (e.g. microorganisms,
nonmicrobial antigens), they release endogenous pyrogen (proteins). When they are
released into the blood stream, they interact with the hypothalamus which raises the
thermoregulatory set point. By raising the body temperature, they cannot grow as fast and
can be destroyed. Also, fever activates the body’s acquired immune system to make more
white blood cells and antibodies
 What happens during inflammation

 What causes inflammation

 How does gingivitis develop into swelling

 What impact does trismus have on daily life

The patient may have:

 Difficulty Eating (malnutrition)

 Difficulty Tooth brushing and cleansing – this can lead to abscesses and caries
forming.
 Lots of pain and discomfort
 Difficulty speaking
 What is trismus
This is the inability to open the mouth/jaw completely; it is a symptom and indication of
another underlying disease. This could occur as a result of the infection of the teeth and
gums, which allow infection of the jaw.

 What are temperature, pus & swelling indicative – inflammation and innate immunity?
Why does Mary feel unwell?
The inflammatory response (inflammation) occurs when tissues are injured by bacteria,
trauma, toxins, heat, or any other cause. The damaged cells release chemicals including
histamines which trigger a number of chain reactions. These chemicals cause blood vessels
to become more permeable and release fluids which cause oedema (swelling). This helps
isolate the foreign substance from further contact with body tissues. The chemicals also
attract white blood cells called phagocytes that undergo phagocytosis (engulfing) of the
pathogens. The phagocytes eventually die. Eventually, pus is formed from a collection of
dead tissue, dead bacteria, and live and dead phagocytes.

 What causes trismus

o Trauma to the jaw
o Problems with the TMJ
o Local muscle soreness from bruxism
o Tetanus
o Infection
o A tumour in the jaw area
o The extraction of the 3rd molar can lead to lockjaw

 What does a broken down molar look like (clinically and radiographically)

 How does caries cause a tooth to be broken down

 What are the difference between gram positive and gram negative

Gram Negative Bacteria Gram Positive Bacteria

Gram reaction Can be decolourized to
accept counter stain
(Safranin or Fuchsine); stain
red or pink, they don't retain
the Gram stain when
washed with absolute
alcohol and acetone.
Peptidoglycan layer Thin (single-layered)
Outer Membrane Present
Lipopolysaccharide content High
Toxins Produced Primarily Endotoxins
Retain crystal violet dye and
stain dark violet or purple,
they remain coloured blue
or purple with gram stain
when washed with absolute
alcohol and water.
Thick (multi-layered)
Absent
Virtually none
Primarily Exotoxins
  Why is swelling on the buccal side

 What is pus
This is a thick discharge that is formed in inflamed tissue as an end-result of suppuration (the
process of forming and discharging pus). It can vary in colour; from yellow to green or
brownish blue (this all depends on the causative agent of infection). It consists of leukocytes,
dead bacteria, and cellular debris or tissue elements.

 How is pus produced

Treatments and Procedures:

 What extent of caries is required for extraction

1. Extent of caries
2. Presence of abscess, swelling
3. Severe bone loss, that makes the tooth not functional
4. Pain
5. Unrestorable
6. Affecting daily life (eating, sleeping)
 Why would massaging muscles help

It removes some of the pressure from the area (due to the build-up of pus); this may relieve
the pain in the surrounding area.

The mechanical response behind massaging is the increased blood and lymph circulation in
that area. This means more waste products are removed and there is a higher flow of
 oxygen to the infected area. Overuse of the muscle can increase the amount of muscular
knots are in the area, which can cut off the blood supply to that area.

 Which lymph nodes are palpated during extra oral examination

o Postauricular nodes
o Perauricular
o Superficial cervical node
o Supraclavicular lymph nodes
o Submental lymph nodes

 Consequence of dental caries and what are the different treatments for different stages of
caries
o Early enamel caries – fluoride varnish and oral hygiene regime
o Dentinal caries – restoration and oral hygiene regime
o Pulpitis – reversible then pulp treatment, irreversible then extraction/root canal

 How can bacterial culture help in treatment/ prescribing medication

 How do you take a bacterial culture

Oral swabs are usually taken to confirm the infectious bacteria that are causing the problem
in the mouth, so the antibiotic prescribed is tailored to problematic pathogen. The swabs are
contained and are taken to a lab for analysis. The substances on the swab are spread across
a petri-dish containing nutritious agar-gel. This is then left in an incubator, so that the
bacterial colonies can accumulate. After this the bacteria can be tested (to identify the
species) using Gram staining, tests that identify their respiration process (fermentation or
oxidative respiration), which antibiotic they react to, lipid hydrolysis test, catalase and
oxidase test, etc.

 How does each antibiotic work – explain their selectivity

Penicillin is a group of antibiotics that is used to assist the body’s immune system in fighting
against bacterial infection. This is a naturally occurring substance found in Penicillium fungi,
however in present times it is made synthetically. This group of drugs is usually used to treat
skin infections, chest infections and urinary tract infections.

Metronidazole this is a synthetic drug used to treat oral, intestinal, genital tracts and
infections in the bone.

 How does a dentist prescribe and administrate antibiotics

 What are the differences between the antibiotic taken orally & intravenously
 Drugs that are taken orally are taken through the mouth, whereas drugs taken intravenously
are delivered straight into the veins via an injection. The oral route is more convenient,
safest and least expensive, so most drugs are administered that way. When the oral route
cannot be used, other methods of administration are used. For example, when the drug can
irritate the digestive tract (e.g. NSAIDs), when the drug is absorbed poorly in the digestive
tract, when the person cannot take anything orally or when the drug must be administered
in high dosage.

 Pros/cons of oral vs. intravenous antibiotics

Why is it hard to adhere/comply with treatment