Table

of Contents

ENDODONTICS 2

OPERATIVE DENTISTRY 9

OMFS AND PAIN CONTROL 18

PERIODONTICS 30

PROSTHODONTICS 41

OCCLUSION 41
COMPLETE DENTURES 44
REMOVABLE PARTIAL DENTURES 47
FIXED PROSTHODONTICS 50

ORTHODONTICS & PEDIATRIC DENTISTRY 58

PEDIATRICS 58
ORTHODONTICS 64

ORAL DIAGNOSIS 73

ORAL PATHOLOGY 73

PHARMACOLOGY 78

PATIENT MANAGEMENT 79

MISCELLANEOUS TOPICS 88

Red: High Yield

Italicized: Low Yield


 Endodontics

Pulp Biology
- Contains loose fibrous CT with nerves, blood vessels, and lymphatics
- Contains fibroblasts
- Contains odontoblasts: form primary and secondary dentin
- Contains undifferentiated mesenchymal cells
- Surrounded by hard dentin which limits ability to expand
- Lacks collateral circulation which limits its ability to cope with infection

Dentin and Pulp Defense
- Sclerotic Dentin: calcification of tubules in response to slowly advancing caries or aging
- Reactionary dentin: reaction to minor damage
- Reparative dentin: repair for major damage

Endodontic Microbiology
- Vast majority of endodontic bacteria is anerobic
- Primary endodontic infection-> Bacteroides
- Failed endodontic treatment-> Enterococcus faecalis

Dentinal Pain (A-delta fibers)
- Large myelinated afferent nerve
- Course coronally through pulp
- Sharp, quick, momentary transient “first pain”
- Cold

Pulpitis Pain (C fibers)
- Small unmyelinated afferent nerve
- Course centrally in the pulp stroma
- Dull throbbing “second pain”
- Heat
- Surfaces with irreversible tissue pain

Referred Pain
- Preauricular pain often refers from mandibular molars since both share V3 (Mandibular
nerve of facial nerve) innervation

Pulpal Diagnosis
Description Radiographic Thermal EPT
Normal Pulp - Normal + +
Reversible Pulpitis Cold sensitivity; no Normal ++ +
spontaneous pain
Symptomatic Spontaneous intermittent Normal, widened PDL, ++ +
Irreversible Pulpitis or continuous pain— or PRL Lingering
postural changes— pain
referred pain
Asymptomatic Asymptomatic Widened PDL or PRL +
Irreversible Pulpitis
 Pulp Necrosis Usually asymptomatic but Normal, widened PDL, - -
not always or PRL (tenderness to
percussion & palpation)
Previously Treated Canals obturated Gutta percha - -
Pulp
Previously initiated Partial Therapy PO or PE - -
therapy
Hyperplastic pulpitis Growth of tissue through
and around caries

Cold Test: intensity and duration of response provide information about pulpal diagnosis
EPT: least reliable pulp vitality testing; indicates if there are vital sensory fibers present in the
pulp, but does not provide any information about vascular supply to the pulp
- False Readings: restorations, enamel thickness, trauma, recent erupted tooth

Apical Diagnosis
Description Radiographic Thermal/EPT Percussion Palpation
Normal Apical - Normal + - -
Tissue
Symptomatic Biting sensitivity—can Normal or +/- + +
Apical be caused by high Widened
Periodontitis occlusal restorations PDL
Asymptomatic Necrotic pulp PRL - - -
Apical
Periodontitis
Acute Apical Rapid swelling, Normal, - + +
Abscess spontaneous pain, pus Widened
PDL, or PRL
Chronic Draining sinus tract PRL - - -
Apical
Abscess
Condensing Diffuse RO lesion at RO +/- +/- +/-
osteitis apex

Percussion: tapping on teeth to check if PDL is inflamed
Palpation: spread of inflammation to mucoperiodontium

Contraindications of Endo Tx
- Adults/Permanent Teeth: uncontrolled diabetes or recent MI (within 6mos)
- Children: bacterial endocarditis, leukemia, nephritis, cancer, depressed PMN leukocyte and
granulocyte counts


- Furcation RL is a sign of necrosis of primary pulp
- Extraction of 1st primary molars with furcation involvement is done due to difficulty in
removal of diseased pulp for this tooth (looks of accessory canals)
- EXCEPTION: 2nd primary molar with mild to moderate root resorption of young patient
which could be saved by endo therapy as a space maintainer should not be extracted

SLOB rule: same lingual, opposite buccal in relation to an object and the cone head for making
radiographs

Non-surgical RCT
- Access Preparation: straight line access to orifice and apex
o Incisors: triangular; 1 canal
o Canines: ovoid/oval; 1 canal
o Premolars: oval; 2 canals (B, L)
§ 2 rooted PM? Maxillary 1st PM
o Maxillary Molars: triangle/rhomboid; 3 roots, 4 canals (MB1, MB2, D, L)
o Mandibular Molars: trapezoidal; 2 roots, 3 canals (DL1, DL2, M)
- Cleaning and Shaping
o Crown down: big to small
o Step back: small to big
- Irrigation and Medicaments
o Sodium hypochlorite (NaOCl): irritant, dissolves organic material
o Ethylenediamine tetraacetic acid (EDTA): 17% aqueous solution; lubricant,
dissolves inorganic material and smear layer—chelating agent
o Chloroform: dissolves GP in retreatment
- Obturation: seal canal system
o Gutta percha and sealer= Zinc Oxide Eugenol (ZOE)
o Techniques: warm vertical and cold lateral
- Seal Access Preparation

Instruments
- SS hand files= 0.02 taper
o K-file (Kerr): twisted square, watching winding method
o H-file (Hedstrom): spiral cone, only cuts in retraction
- NiTi rotatory instruments= 0.04 or 0.06 taper
o More flexible than SS but more likely to fracture; superelasticity
- D1= diameter at tip (i.e. Size 15 -> 0.15mm)
 - D2 or D16= diameter 16mm from tip where cutting flutes end (i.e. Size 15 -> 0.15+ (0.02*16)=
0.47mm)
- Gates-Glidden drills: to open orifice for straight-line access
- Barbed broaches: entangle and remove
- Reamer: twisted triangle

Surgical RCT: if RCT fails and infection is at the apex or just outside the apex
- Incision and Drainage: surgical opening in soft tissue to release exudate and pressure
o Best for localized & fluctuant swelling
- Trephination: surgical opening in hard tissue to release exudate and pressure
- Apicoectomy: removal of 3mm of root tip at a shallow bevel and retro-fill canal with 3mm
of MTA after non-surgical RCT unsuccessful or persistent PRL after RCT
- Hemisection: surgical division from crown into furcation with extraction of defective half;
Indications: Class III or IV furcation defect, vertical root fracture; mostly mandibular molars
- Bicuspidization: same as hemisection with no extraction
- Root resection
- Intentional reimplantation

Adjunctive Endodontic Treatment
- Calcium Hydroxide (CaOH2): best intracanal medicament available; stimulates secondary
odontoblasts to repair with dentinal bridge formation (tertiary dentin) form within 6 weeks
o High pH of 12.5 that cauterizes tissue and kills bacteria
- Mineral Trioxide Aggregate (MTA): stimulates cementoblasts to produce hard tissue
o 3 minerals: calcium, silicon, aluminum
o Bismuth oxide: opacifier
o Long 3 hour setting time
o Sets in the presence of moisture
o Antimicrobial
o Non-resorbable
- Indirect Pulp Cap: liner of CaOH or RMGI placed on dentin near pulp
- Direct Pulp Cap: CaOH on pulp exposure <2mm placed; avoid in primary teeth
- Cvek PO: removal of small portion of coronal diseased pulp >2mm; immature permanent
tooth or mature tooth with simple restoration
- PO: removal of coronal disease pulp filled with Formocresol or CaOH at canal orficies and
ZOE build-up; vital pulp in primary or immature teeth with carious, mechanical exposure or
traumatic exposures >72hrs
o Formocresol: only material used for primary teeth PO
- PE: removal of coronal and radicular pulp until RCT performed; only done on primary teeth
except primary first molars
- Apexogenesis: maintain pulp vitality in order to stimulate root development and allow the
body to make a stronger root in length, wall thickening, and apical closure
o CaOH or MTA is placed on healthy or diseased pulp
o Includes any vital treatment on immature permanent teeth with damaged coronal
pulp and healthy radicular pulp
- Apexification: disinfection of root canal followed by induction of an acceptable apical
barrier
o CaOH or MTA is placed at base of canal after pulp is removed—replace every 3mos;
MTA>CaOH
o PE performed on an immature tooth
 - Internal Bleaching: place oxidizing agent i.e. 30% Superoxol (hydrogen peroxide) or sodium
perborate & water; then apply heat
o Place GI or zinc phosphate 2mm apical to CE junction before Superoxol placement

Complications of Instrumentation
- Ledge Formation: artificial irregularity created on surface of root canal wall; use smaller
instrument to bypass ledge
- Instrument Separation: breakage of an instrument within the confines of a canal; use
smaller instrument to bypass instrument
- Perforation: immediate hemorrhage or sudden pain; avoid NaOCL
o Coronal
o Furcal
o Strip (furcation side of coronal surface): due to excessive coronal flaring—
common in mandibular molars
o Root: more apical has better prognosis—repair with MTA

Dental Trauma in Children: boy > girls, maxillary anterior most common, increased overjet
(>6mm) more often; prescribe mouth guards to prevent frequency and severity of injuries
Ellis Classification Trauma Description/Treatment
Class I Crown Fracture: Enamel Smooth
only
Class II Crown Fracture: Enamel, Perm: Restore
Dentin Prim: Smooth/Restore
Class III Crown Fracture: Enamel, <24hrs Perm: Direct pulp cap
Dentin, Pulp >24hrs Perm: Cvek PO
>72hrs Perm: PO
Vital prim: PO
Non-vital prim: PE
Prim with internal or external resorption: Ext
- Concussion Let the tooth rest
 Class IV Traumatized tooth has Open Apex Tx: allow to re-erupt; if >7mm
become non-vital—i.e reposition surgically or orthodontically
Intrusion Closed Apex Tx: Reposition, flexible splint
(4wks), RCT
<3mm: allow re-erupt
3-7mm: reposition surgically or
orthodontically
>7mm: reposition surgically
Primary Teeth: spontaneously re-erupt; can
cause hypoplasia, hypocalcification,
dilaceration
Class V Luxation Subluxation: Flexible splint 1-2wks
Lateral Luxation/ Extrusion:
Open Apex/Primary Tx: reposition, flexible
splint (7-14days), monitor; >3mm -> extract
Closed Apex Tx: reposition, flexible splint (7-
14days), RCT if needed
Class VI Avulsion (Extraalveolar Closed Apex EADT <60mins: reimplant, splint
dry time (EADT) is (7-10days), antibiotics, RCT (7-10 days later)
critical) Open Apex EADT <60mins: place the tooth in
doxycycline, reimplant, splint (7-10days),
antibiotics; no RCT but apexification at first
sign of infected pulp
Open Apex EADT >60mins: not usually
indicated but reimplant, splint (7-10days), RCT
out of mouth or apexification initiated
Closed Apex EADT >60mins: may or may not
reimplant, immerse tooth in 2.4% sodium
fluoride with pH of 5.5 for 5 minutes, splint (7-
10days), antibiotics, RCT (7-10 days later),
plan for implant
Not recommended to reimplant primary teeth
- Horizontal Root Fracture 3 PAs and 1 occlusal to ID fracture
(coronal displaced, apical Vital: Splint
not displaced) Coronal: rigid, 6-12 weeks
Midroot: flexible, 3 weeks
Apical: consider flexible, 2 weeks; not
necessary
Non-vital: RCT
- Vertical Root Fracture Extraction
(isolated probing depth & Multi-rooted tooth: Hemisection
RL in the apical region of
the middle root)
- Cracked Tooth Syndrome Transillumination
Vital: splint & observe or crown
Non-vital: RCT & crown

Cracked Tooth Syndrome
 - Sustained pain during biting, pain only on release of biting pressure; sensitive to thermal
changes
- Mostly occur on Mandibular 1st Molars

External Resorption:
- Primary: cementoblastic layer in PDL is damaged
- Permanent: margins ragged and poorly defined, lesions moves in radiographs
- Replacement: ankylosis, replaces PDL with bone; Tx: none
- Cervical: trauma or nonvital bleaching, biologic width area, pink spot; Tx: remove
granulation & repair with restoration
- Inflammatory root: bacteria, granulation tissue, RL; tx: RCT
- Apical Resorption: primary teeth only due to orthodontic forces
- Inflammatory & Replacement most commonly associated with Luxation

Internal Resorption:
- Primary: odontoblastic layer in pulp is damaged
- Permanent: Margins are sharp and well-defined, lesion doesn’t move in radiographs; tx:
RCT

Endodontic-Periodontic Lesions
- Endo -> Perio but Perio rarely leads to Endo
- Primary Endo: inflammation at or near apex; non-vital pulp with narrow deep pocket
- Primary Perio: inflammation starts at sulculs and moves down to apex; vital pulp with
broad-based pocket formation
- Primary Perio with Endo: deep pocketing; treat endo then perio
- True Combined lesion: indistinguishable; treat endo then perio

Success & Failure
- Principles of success: microbial disinfection, debridement, obturation
- Obturation most critical step & cause of most treatment failures


 Operative Dentistry

Apatite
- Apatite: mineral group Ca5(PO4)3(X)
o Hydroxyapatite (OH-): hexagonal, white
powder, low bioresorption rate
o Carbonate-substituted hydroxyapatite
(CHA): main component of enamel and
dentin
§ Enamel rod forms head & tail; tail
portion (more organic and more
mineral content) susceptible to
caries
§ Carbonate substitution increases solubility of hydroxyapatite (easier to
decay)
o Fluorapatite (F-)
o Chlorapatite (Cl-)

Stephan Curve
- X-axis: Time (minutes); Y-axis: Plaque & pH
- Mouth pH: 7; Dentin & Cementum pH: 6.2-6.7
- Critical pH of tooth enamel: 5.5; anything below leads to demineralization
- Demineralization occurs with addition of H+ molecule (sugar, acid, GERD, food/drinks)
o Frequency of sugar is more important than amount
- Remineralization occurs with addition of HCO3- molecule (saliva, MI paste)

How does Fluoride work?
- Remineralization of tooth structure with addition of F- molecule (fluoridated water,
toothpaste, etc)
- Decreasing enamel solubility (lowering critical pH to 4.5)
- Interfering with metabolic activity of cariogenic bacteria

Caries: multifactorial transmissible infectious dynamic oral disease
- Result of interaction of cariogenic oral flora (biofilm) with fermentable dietary
carbohydrates (sugar) on the tooth surface (host) over time-modeled by modified Keyes-
Jordan diagram
- Balance between demineralization and remineralization, pathologic and protective factors

Progress of Lesions
- Pit & Fissures lesions -> inverted V-shape
- Smooth-surface lesions -> V-shaped
- Root-surface lesions -> can progress rapidly,
- Infected dentin: superficial, wet/soft,
mushy, necrotic
- Affected dentin: deeper, dry, leather,
demineralized but not invaded by bacteria
- Intact surface is essential for remineralization
- Cavitation: irreversible process that requires restorative tx
- May take 1-2 years to form an actual enamel cavitation
 - Order: Enamel demineralization -> Dentin demineralization -> Enamel cavitation -> Dentin
cavitation

Caries Terms
- Extent
o Incipient/reversible: on smooth surface, appears opaque white when air-dried and
seems to disappear when wet
o Cavitated/irreversible: enamel surface is broken (not intact) and usually the lesion
has advanced into the dentin
- Location
o Simple: 1 surface
o Compound: 2 surfaces
o Complex: 3 or more surfaces
- Rate
o Acute/rampant: rapidly damages tooth structure, light-colored, soft, infectious
o Chronic/slow: demineralized tooth structure that is almost remineralized,
discolored, fairly hard
o Arrested: brown/black, hard, caries-resistant if exposed to fluoride (dentinal lesion
has sclerotic dentin)

Microbiology
- Streptococcus mutans -> enamel caries
o Gram (+) cocci
o Glucosyltransferase (GTF) converts sucrose to glucans and fructans, extracellular
polysaccharides that help stick it to tooth
o Acidogenic and aciduric: converts sucrose into lactic acid and tolerates acid well
o Bacteriocins: kill off competing microbes
- Lactobacillus -> dentinal caries
- Actinomyces -> root caries

Saliva
- Glycoproteins: large molecules that agglutinate bacteria together to help eliminate them
through swallowing
- Urea and other buffers: dilute bacterial acid byproducts
- Lysozyme: destroys cell walls
- Lactoferrin: actively binds iron which is important for bacterial enzymes
- Lactoperoxidase: inactivates some bacterial enzymes
- sIgA: salivary antibodies against bacteria
- Calcium, phosphate, and fluoride ions help with remineralization
- Statherin, cystatin, histatin, and proline- rich proteins promote remineralization

Clinical Exam for Caries
- Visual changes in tooth surface texture or color
o Dry, well-lit field
o Incipient caries partially or totally disappear from vision by wetting, while
hypocalcification does not
- Tactile sensation with careful use of explorer: careful not to cavitate an incipient lesion with
sharp explorer tip
- Radiographs
o White spot= hardly visible
 o Enamel cavitation= evident
o Dentinal lesion= clearly evident
o Lesions are always smaller radiographically
o Tooth needs 30-40% mineral loss to be detected radiographically
o PA for anterior; BW for posterior
- Transillumination
o Shine bright light through contact area of anterior teeth
o Shadows can indicate interproximal caries
o Also useful for distinguishing craze lines (whole tooth lit up) and fractures (part of
tooth lit up)

New technology: Laser fluorescence (DIAGNOdent), digital imaging fiberoptic transillumination
(DIFOTI), quantitative light-induced fluorescence (QLF), electrical conductance or impedance
measurement

Amalgam Exam
- Bluish hue due to corrosion products does not classify as defective
- Marginal gap or ditching >0.5mm is judge carious or caries-prone
- Proximal overhang, voids, fracture lines

Tooth Exam
- Erosion: caused by acidic foods/beverages or gastric acid
- Abrasion: loss of tooth structure by mechanical wear (i.e. toothbrushing, porcelain)
- Attrition: occlusal wear from functional contacts with opposing natural teeth
- Abfraction: due to tooth flexure
- Hypersensitivity: exposure of dentinal tubules in root surfaces
o Hydrodynamic theory: postulates that pain results from dentinal fluid movement
that stimulates mechanoreceptos near the pre-dentin
o Some causes of fluid shifts include temp change, air-drying, and osmotic pressure

Criteria for Restoring Teeth
- High caries risk: 2 or more active caries, large number of restorations, poor dietary habits,
low salivary flow, poor oral hygiene, low fluoride exposure, unusual tooth morphology
- Lesion extends to DEJ
- Cavitation

Dental Hand Instruments
- Non-cutting: mirrors, explorers (Shepherd’s hook 23, pigtail 2, back action 17), probes (UNC
15, Williams, marquis), condensers, ball burnisher; nib & face working end
- Cutting: blade & cutting edge working end
o Scalers -> Calculus; don’t follow cutting instrument formula
§ Universal: anywhere
§ Gracey’s: specific area
• 1-2, 3-4: anterior
• 5-6: anterior and PMs
• 7-8,9-10: posterior F/L
• 11-12: posterior, mesial
• 13-14: posterior, distal
§ Sickle scaler: supraG calculus
§ Curette: subG calculus
 o Excavators -> Dentin
§ Spoon: 11.5-7-14
§ Black Spoon: 15-8-14
o Chisels -> Enamel
§ Enamel hatchet (10-7-14): used for planing walls
§ Bin-Angle Chisel (10-7-8): used for planing walls
§ Gingival Margin Trimmer: used for planing enamel/beveling at gingival floor
of preparation
• Distal (10-95-7-14)
• Mesial (10-80-7-14)
o Other -> Restoration
§ Discoid-cleoid: carving and contouring amalgam
• Cleoid: claw-life end for craving grooves
• Discoid: round end for craving pits and fossas
§ Hollenback carver: placing, carving, and contouring amalgam

Instrument Design: handle, shank, working end

Cutting Instrument Formula
- 1st number: blade width (10=1mm)
- 2nd number: cutting edge angle (omitted if perpendicular to blade)
- 3rd number: blade length (7=7mm)
- 4th number: blade angle (14=14% of 360)

Instrument Grasp
- Pen versus modified pen grasp
- All grasps require firm finger rests (adjacent teeth, maxilla, mandible*)
- Use short working radius (more control, accuracy, protection)

Rotary Instruments
- Low speed handpiece (<12,000 rpm): large round bur for safe caries removal
- Medium-speed handpiece (12,000-200,000rpm)
- High-speed handpiece (>200,000 rpm)
- Rheostat: peddle

Burs: shank, neck, head (cutting part)
- Tungsten Carbide: better for end-cutting, produce lower heart (punch cuts, smooth walls,
remove amalgam, create retention)
- Diamond: better for side-cutting, produce higher heat, greater hardness (crown preps,
bevels, enameloplasty)
- Carbide: the greater the blades (flutes), the more smooth, but the less cutting efficiency
o Cutting= 6 blades
o Finishing= 12 blades
o Fine finishing= 18-24 blades
o Ultra fine finishing= 30-40 blades
- Diamond: the finer the grit, the less aggressive
- 245: 3mm x 0.8mm, pear-shaped
- 330: 1.5mm x 0.8mm, pear-shaped, smaller size is helpful for pediatric preps
- 169L: tapered fissure

Hazards
- Pulp: vibration, heat, desiccation
- Soft tissue, eyes, inhalation
- Ears: potential hearing loss depends on intensity of loudness, frequency, duration of noise,
and susceptibility of individual

GV Black’s Classification
- Class I, II, III, IV, V
- Class VI: only incisal edge of anterior or cusp tip of posterior

Cavity Preparation
- Cavosurface margin: where the cavity preparation
meets the original tooth surface
- External walls: contacts cavosurface margin
- Internal walls
- Line angle: junction of two walls
- Point angle: junction of three walls

Initial Tooth Preparation
- Outline Form
o External outline of the tooth surface to be included in the preparation along the
cavosurface margin
o Defined by the extent of the carious lesion
o Extension to sound tooth structure at an initial depth of 0.2mm into dentin, 1.5mm
into tooth
o Extend gingival floor to get 0.5mm clearance always
o Extend facial and lingual proximal walls to get 0.5mm clearance UNLESS it would
require unreasonable removal of sound tooth structure to break the contact
o Remove all friable and unsupported enamel
§ Friable: demineralized; bonding agent is not as effective
§ Unsupported: undermined; there is no underlying dentin to support it under
cyclic loading, can be left if in non-stress bearing area
- Primary Resistance Form: prevention of tooth or restoration fracture from occlusal forces
o Flat pulpal and gingival floor
o If extension of prep is more than half the distance from primary groove to cusp tip
consider capping the cusp (i.e onlay, crown)
o Rounded internal line angles
- Primary Retention Form: prevention of displacement of restorative material
o Convergent walls prevent occlusal displacement
o Dovetail prevents proximal displacement
o Rely on bonding if using composite
- Convenience Form: improve access and visibility as needed

Final Tooth Preparation
- Remaining dentin caries removal: remove all infected dentin
- Pulp protection
- Secondary resistance and retention form
o Retentive grooves
o Beveled enamel margins
o Slots: at least 1mm deep and long, 0.5mm inside DEJ
 o Pins: self-threaded pin most common; usually where a vertical wall is missing
- Finishing external walls: establish design and smoothness of cavosurface margin

Sealer/Desensitizer
- Used for sensitivity for >2mm of dentin remaining
- Occludes dentinal tubules by cross-linking tubular proteins
- Gluma: 5% glutaraldehyde + 35% HEMA (hydroxyethyl methacrylate) + water

Liner (CaOH or RMGI)
- Used for direct or near pulp exposures
- Provides barrier to protect dentin from residual reactants of restoration and oral fluids
- Electrical insulation, thermal protection
- Pulpal treatment (formation of tertiary dentin)

Base (RMGI or GI cement)
- Used for metal restorations and when liner is used
- Thermal protection (especially under amalgam and gold)
- Distributes local stress across all underlying dentin

Remaining Dentin Thickness & How to Treat
- Amalgam
o >2mm -> sealer
o 0.5-2mm -> base, sealer
o <0.5mm -> liner, base, sealer
- Composite
o >0.5mm -> bond
o <0.5mm -> liner, base, bone
- Gold or Ceramic
o >2mm -> cement
o 0.5-2mm -> cement (2mm thick)
o <0.5mm -> liner, base, cement

Moisture Control: dry angle (cellulose wafer), local anesthetic

Amalgam Preparation
- Use carbide bur for smooth walls
- Retention: occlusal convergence, grooves, slots, pins
- Resistance for tooth: 90 cavosurface margin, maintain cusps and marginal ridges, remove
unsupported or weakened tooth structure, pins
- Resistance for amalgam: 90 amalgam margin, 1.5-2mm depth for adequate thickness of
amalgam

Composite Preparation
- Use a coarse diamond for rough walls
- Same as amalgam except no need for retentive features, occlusal convergence, and uniform
depth

Dental Amalgam: a mixture of 50% mercury and 50% metal alloy
- Silver -> strength
- Tin -> corrosion; helps to an extent seal the restoration
 - Copper -> strength
o <12%: results in all gamma phases
o >12%: results in only gamma and gamma-1 (less corrosion and creep)
- Zinc -> deoxidizer, but excess expansion if moisture contamination
- Spherical: microspheres of various sizes, easier to condense, stronger, sets faster
- Admixed: mixture of irregular and spherical pieces, require more condensation forces,
better proximal contacts
- Indications: mod to large lesions, heavy occlusal loading, hard to isolate, non-esthetic, lesion
extends onto root surface, foundation or abutment
- Contraindications: very small class VI lesion, high esthetic demands, allergy to metals

Trituration: alloy particle is coated by mercury
- Gamma: unreacted silver-tin
- Gamma-1: strong silver-mercury matrix
- Gamma-2: weak tin-mercury
- Normal mix: shiny, smooth
- Over: warm, wet, soft, sets too quickly
- Under: dry, dull, crumbly, sets too quickly

Carving: discoid-cleoid, Hollenbeck carver, explorer tip, amalgam knife (gingival excess on proximal
surfaces, gingival embrasure)

Marginal Ridge Fracture
- Axiopulpal line angle not rounded
- Marginal ridge left too high, occlusal embrasure form incorrect, improper removal of
matrix, overzealous carving

Class V Amalgam
- Prep walls diverge occlusally due to orientation of enamel rods
- Four corner coves, occlusal and gingival line angle grooves, or circumferential grooves are
all equally effective for retention

Mercury Toxicity
- Inhalation is biggest risk
- If spills occurs, use a special vacuum system and then apply sulfur powder on the floor
- Acute mercury toxicity: muscle weakness (hypotonia), loss of hair, weight loss/GI disorders,
exhaustion

Mercury Forms
- Methylmercury: organic, most toxic
- Elemental: liquid metallic, in dental amalgam
- Mercury salts: inorganic

Enamel Bonding: parallel enamel rods transform to high energy surface by increasing its surface
free energy and increasing wettability which allows phosphoric acid to flow into irregularities that
form interlock when polymerized

Dentin Bonding: equally as strong, but not as reliable or predictable
- Composition: has more organic matter and water
- Structure: collagen is a “bowl of spaghetti”
 - Depth: fluid-filled dentinal tubules are much larger and more numerous near pulp, so less
bond strength the deeper you are
- Smear layer: “sawdust” from cutting, decreases dentin permeability

Steps for Bonding:
1. Etch
o Etch for 15 seconds
o 30-40% phosphoric acid
o Removes smear layer
o Etched enamel -> chalky or frosty white, creates microporosities
o Etched dentin -> exposes layer of collagen, widens dentinal tubules
o Rinse for 10 seconds and leave moist
2. Primer
o HEMA (hydroxyethyl methacrylate): Enamel-Dentin Bonding Systems
monomer and solvent; can cause allergic Etch and Rinse Self-Etch systems-
contact dermatitis Systems leave smear layer
o Infiltrates enamel prisms and dentinal Acid Acid Acid Acid
tubules Primer Primer
Primer Primer
o Prevents collagen collapse Adhesive
o Lightly air dry after application Adhesive Adhesive Adhesive
3. Bond/Sealer/Adhesive Self-Etch least Effective!!
o Bis-GMA (bisphenol A-glycidyl
methacrylate)
o Light cure!
o Chemically bonds to underlying primer and overlying composite resin through MMA
bonds
o Hybrid Layer: mechanical interface between tooth and adhesive
§ Resin tags: adhesive resins lock into the microporosities of etched enamel
and intratubular dentin
§ Key= micromechanical bond!

Composite Composition
- Resin matrix (Bis-GMA): leaching of bisphenol A (BPA) can occur through wear of
composite or with uncured resin; adverse health effects is negligible
- Filler particles (Barium Silica): RO, affect properties of the composite
- Coupling agent (Silane): promote adhesion between the two
- Light cure or chemical polymerization/cross-linking from a liquid to a solid

Composite Types
- Macrofill (80%, 8): conventional, difficult to smooth
- Microfill (40%, 0.04): weak, good polish and wear resistance
- Hybrid (80%, 1): smooth surface
- Nanofill (0.005): most popular used today
 Self-Cure vs Light-Cure Composites
- Nanohybrid: nonfill plus other composites Self-Cure Light-Cure
- Flowable: very low filler amount, lower Two-paste system Single-paste system
wear resistance Benzoyl peroxide Camphorquinone is
- Packable: high filler amount, viscous is initiator photoinitiator
- Larger fillers -> more strength Tertiary amine is 468nm light needed
- Higher filler content -> less water activator to initiate
absorption polymerization

Polymerization Shrinkage
- Composite shrink as they polymerize (2-3%)
- Configuration factor (C-factor) is the ratio of bound to unbound surfaces
o Restoration Class (I-IV) is inversely related to C-factor
o Higher C-factor means more chance for shrinkage, microleakage, and post-operative
sensitivity

Spectrum of Tooth-Colored Restorations
Glass Ionomer Resin-Modified Compomer Ionomer- Composite Resin
Glass Ionomer (Polyacid- Modified
Modified Resin Composite
Composite)
Acid: polyacrylic acid Set by an acid- Anhydrous Set only by a Matrix
Base: base and free single pastes polymerization Filler
fluoroaluminosilicate radical addition that contain mechanism Light or self cure
glass polymerization major but contain Micromechanical
Self-adhesion to tooth (light and/or ingredients of ion-leachable bond
Rely on chemical bone chemical cure) both CR and GI glasses in an No fluoride
Fluoride release More rapid except water attempt to release
Weaker polymerization Attracted use in achieve Stronger
thanks to free Ortho fluoride
radical Slower release
initiation polymerization Least common
Fluoride allowing for hybrid
release more time to
clean up excess
Fluoride
release



 OMFS and Pain Control

Indications for Extraction: caries, endo, perio, ortho (1st PMs), cracked teeth, impacted teeth,
supernumerary, pathology, questionable teeth should be extracted before radiation therapy

Contraindications for Extraction: brittle (unstable) diabetes, end-stage renal disease (ESRD),
unstable angina, leukemia, lymphoma, hemophilia or platelet disorder
- Head and neck radiation- hyperbaric oxygen before (and after) extraction
- IV bisphosphonates- try to RCT or restore
- Pericoronitis- treat infection first

Impacted Teeth: fail to erupt into arch within expected time
- Mandibular third molars > maxillary third molars, maxillary canines
- Primary reason is inadequate arch length

Nature of Overlying Tissue
- For any impacted teeth
- Soft tissue impaction: height of contour is above bone level and gingiva is completely or
partially covering tooth, easiest
- Hard tissue impaction
o Partial: height of contour is below bone level
o Full: tooth is entirely encased in bone, most difficult

Winter’s Classification
- For impacted 3rd molars
- Based on position of long axis of the 3rd molar in relation to the long axis of the 2nd molar
- For lower molars:
o Mesioangular -> easiest
o Distoangular -> most difficult

Pell and Gregory Classification
- For impacted lower third molars only
- Class A: same plane as other molars
- Class B: halfway down other molars
- Class C: below the cervical line of 2nd molar, most difficult
- Class I: crown anterior to ramus
- Class II: half crown within ramus
- Class III: entire crown within ramus; most difficult

Subperiosteal Abscess
- Possible whenever a mucoperiosteal flap is elevated for surgical extraction
- Irrigate thoroughly to remove fractured tooth or bone spicules below the soft tissue

Oro-antral Communication
- Most common with maxillary 1st molars
- Prevent with good pre-op radiograph and avoid excessive apical pressure
- Tx: if <2mm do nothing, 2-6mm 4As (antibiotics, antihistamines, analgesics, Afrin nasal
spray) and figure-8 suture, >6mm flap surgery

Alveolar Osteitis (Dry socket)
- When blood clot dislodges or dissolves before wound heals following extraction
- Doesn’t require antibiotics
- Tx: irrigation and local pain control (Eugenol medicated paste)

Nerve Injury
- Most common with lower 3rd molars & IAN
- Tx: Medrol dosepak
- Patients with numbness lasting more than 4 weeks should be referred for
microneurosurgical evaluation

Tooth Displacement
- Maxillary 1st/2nd molar -> maxillary sinus
- Maxillary 3rd molar -> infratemporal fossa
- Mandibular 3rd molar -> submandibular space
- Tooth lost into oropharynx, send to ER for chest and abdominal x-rays

Instruments:
- Bite block: better visualization
- Suction tips: Yankauer (soft tissue), Frazier (hard and soft tissue)
- Towel clip
- Tissue retractors
o Austin: right angle, for small flaps
o Minnesota: offset curved and broad, for cheek/flap
o Weider (Sweetheart): broad heart-shaped to protect and retract tongue for
mandibular lingual surgery
o Seldin: long and flat for elevating down to FOM as in mandibular tori removal
- Periosteal elevator
o Woodson: small and delicate
o #9 Molt: larger
- Dental elevators
o Straight (#301): most commonly used, lever, blade has concave surface towards the
tooth to be elevated
o Triangular (Cryer): second most commonly used, wheel & axle, left and right pairs,
removing a broken root left in socket
o Pick: remove retained or broken root, wedge, crane is heavy version, root tip is
delicate version
- Extraction forceps
o #150: universal uppers
§ A: Premolars
§ S: Primary
o #151: universal lowers
§ A: Premolars
§ S: Primary
o Cowhorn #23: lower molars, two sharp beaks to engage bifurcation
o Cowhorn #88R/L: upper molars; two beaks -> palatal root, one beak -> buccal
bifurcation
o Ash #74: mandibular premolars
o Upper root #65
- Blades
 o #15: most common for intraoral surgery
o #11: stab incisions
o #10: large skin incisions
o #12: mucogingival surgery, curved shape enhances ease of access to the sulcus
- Irrigation: steady stream of sterile saline or water during bone removal, prevents heat
generation that can damage bone, increases efficiency of surgical bur
- Curettes: spoon-shaped end for scraping away soft tissue, always curette a socket once
you remove tooth
- Bone removers
o Rongeurs: double spring pliers, trim interradicular bone
o Osteotome (Bone Chisel): flat end tapped with surgical mallet
§ Monobevel -> remove torus
§ Bibevel -> section tooth
o Bone File: for final smoothing before suturing, removes bone with pull stroke
o Handpiece: do NOT use air-driven
§ Straight fissure burs -> section teeth
§ Round burs -> remove bone
- Hemostat: hemostatsis, blunt dissection for incision & drainage
- Needle holder: short stout beaks, crosshatched- allows for positive grasp of suture needle
- Suture
o Needle and thread
o Primary purpose is to immobilize a flap
o Suture should be placed from movable tissue to non-movable tissue
o Simple interrupted is the easiest and most common technique
o Silk has wicking property that allows bacteria to invade
- Forceps
o Adson Tissue Forceps: toothed -> periosteum, muscle, aponeurosis; non-toothed ->
fascia, mucosa, pathological tissue for biopsy
o Utility: used for picking up items from tray or preparing packing materials NOT for
handling soft tissues
- Scissors
o Dean: cutting sutures
o Mayo: for cutting fascia and dissecting soft tissue

Preparation for Extraction
- Remove the entire correct tooth
- Check tooth condition
- Check radiograph (Pano or PA)
- Informed consent
- Comfortable positioning
- Profound anesthesia
- Throat screen

Nitrous Oxide Sedation
- Minimum alveolar concentration (MAC): concentration required to render 50% of patient’s
immobile
- MAC of NO is 105%
- Protocol:
o Fill bad with oxygen and place hood on patient’s nose with flow rate of 4-6L/min
o Increase NO in 10% increments up to 30% for children, 50% for adults
 o Nausea is most common complication
o Diffusion hypoxia: lungs fill with NO after stopping it, so always give patient’s 100%
oxygen for 3-5mins after
o Contraindications: <2yo, uncooperative, wheezing episode (mild to moderate
asthma is okay)
- Four Plateaus for Stage I Anesthesia
o Paresthesia: tingling
o Vasomotor: warm
o Drift: floating, target analgesia for NO sedation
o Dream: eyes closed, jaw sag

Extraction Type
- Simple: usually no incisions or sutures needed
- Surgical: surgical access via mucoperiosteal flap, surgical handpiece to remove bone or
section tooth, suture usually needed

Simple Extraction
- Sever Soft Tissue Attachment: loosen gingival fibers and PDL fibers attached to tooth with
periosteal elevator
- Luxate Tooth with Elevator: lever- fulcrum is alveolar bone, not the adjacent tooth; causes
expansion of bone and tearing of PDL
- Deliver Tooth with Forceps: slow and deliberate force
o Outward (B/L) -> initial movement for most permanent teeth
o Inward (L/P) -> initial movement for most primary teeth
o Rotary -> initial movement used in conical-rooted teeth
o Apical -> applied to every tooth
o Upper Incisors/Canines: luxate labial 1st then lingually, rotate & remove labially
o Upper 1st PMs: same as above but don’t rotate
o Upper molars: start buccal than lingual (favor buccal movement)
o Lower incisors/canines: less rotation than uppers
o Lower premolars: easiest to extract
o Lower molars: hardest to extract; same as uppers
- After Tooth is Removed: bend back the bone unless ortho or implant in future; curettage,
smooth bone, irrigate

Surgical Extraction
- Types of Mucoperiosteal flaps: always full thickness
o Envelope: 0 vertical releases; most often used
o Three-cornered: 1 vertical release
o Trapezoidal: 2 vertical releases
o Semilunar incision: apical to the MGJ, for apicoectomy; apically displaced flap is
impossible in maxillary palatal
o Double Y incision: incision down the midline, two vertical releases at each end
(double Y), for palatal torus removal
- Factors Predicting Difficult Extraction: divergent roots, root dilacerations, endo-treated
tooth, root resorption, long roots, dense bone, root fracture, proximity to sinus/IAN, limited
opening, bruxism (stronger PDL), exostoses or tori, gross caries, severe crowding
- Handpiece Uses: remove buccal bone (ditch or trough), remove interradicular bone, section
tooth by amount of roots
 - Removal of root tip: gouge into adjacent bone with root tip pick, remove facial bone and
elevate facially, make a bone window at the apex and push the root out

Relative Contraindications for Implants: uncontrolled diabetes, immunocompromised patients,
volume and height of bone, bisphosphonate therapy, bruxism, smoking, hx of head/neck radiation,
cleft palate, adolescents; old age is not a contraindication

Implant Type & Components
- Subperiosteal, Transosteal, Endosteal
- Implant body (implant, fixture)
o Axisymmetric: symmetric around long axis of fixture
o Sequentially enlarge the osteotomy (reduce heat generated, helps to maintain
axis with freehand surgery)
o Inserted into tapped holes
- Abutment & Abutment Screw
o One-piece: abutment screw is actually a part of the abutment, no anti-rotation
component
o Two-Piece: abutment screw and abutment are separate components; has anti-
rotation component
- Implant crown
o Screw-retained: screw through crown abutment into implant with screw access
hole; better for restricted restorative space (Two-piece)
§ Retrievability
o Cement-retained: abutment is attached separately to implant; cement may be
trapped subgingivally and cause periimplantitis (One-piece or Two-piece)
§ Angle correction, more economical, easier for small teeth, more chair time
- One versus Two-Piece Implants
o One-piece: implant and abutment are attached together, drilled into bone as one
unit; cannot correct angle between the two components
o Two-piece: implant and abutment are separate components; implants drilled into
bone, then abutment attached next

Anti-rotation Component of Implants
- Prevents rotation and provides stabilization of abutment
- Internal Hex: abutment locks into implant body
- External Hex: implant body locks into abutment

Integration
- Osseointegration: direct histologic contact between bone and implant surface -> titanium
oxide layer
- Fibrousintegration: presence of fibrous tissue layer between implant and bone; failure of
osseointegration

Stability
- Primary: when you first place implant how well screw pattern holds
- Secondary: osseointegration, long-term healing of bone to the titanium alloy

Bone Quality
- Implant success rate goes from high to low
- Type I: anterior mandible, dense cortical bone
 - Type II: posterior mandible
- Type III: anterior maxilla
- Type IV: posterior maxilla, soft medullary bone

Implant Placement
- 1mm -> buccal plate, lingual plate, inferior border of mandible, maxillary sinus, nasal
cavity
- 1.5mm -> adjacent natural teeth
- 2mm -> IAN
- 3mm -> adjacent implant
- 5mm -> mental nerve (due to anterior loop)

One versus Two-Stage Surgery
- One stage: place the implant AND healing abutment in one visit -> remove healing
abutment and restore at next visit
- Two stage: place the implant with cover screw and cover it up with gums -> open gums
and place abutments at next visit; Indications: poor primary stability, placing graft, less
infection rate for medically compromised pts

Impression
- Once healing is complete, final impression is made so the crown and abutment are properly
oriented
- Impression coping: used to transfer location and angulation of implant to a master cast
o Open tray: hole in the tray
o Closed tray: no hole in the tray
- Analog: implant replica embedded in master cast

Socket Preservation
- Maintains height and width of alveolar ridge after extraction
- Need to have an atraumatic extraction
- Irrigate extraction site thoroughly, remove granulation tissue, place bone graft material,
cover with resorbable collagen membrane
- Primary closure is unnecessary

Biologic Width for Implants
- Roughened surface for bone, smooth surface for soft tissue
- Gingival fibers orient next to implant parallel with cuff

Surgical Stent
- Location, angulation, depth; make sure any and all implants being placed are aligned
properly

Implant Success & Failure
- Success: immobile, no peri-implant RL, peri-implant bone loss <0.2mm per year after 1st
year, absence of symptoms like pain
- Failure: gram (-) anaerobic rods and filaments, 47C for 1min or 40C for 7mins is enough to
compromise osseointegration

Mandibular Fractures
- Best evaluated with a panoramic
 - Condylar > Angle > Symphysis
o Angle: ipsilateral break from impact of blow
o Condylar: contralateral break from impact of blow
- Greenstick: not all the way through
- Comminuted: crushed into multiple fragments
- Simple: closed to oral cavity
- Compound: open to oral cavity, bone exposed through mucosa near teeth

Midface Fractures
- Best evaluated with a CBCT
- Le Fort I: horizontal across maxilla
- Le Fort II: pyramidal
- Le Fort III: complete craniofacial disjunction
- Zygomaticomaxillary complex fracture (Tripod fracture): caused by direct blow to the malar
eminence of zygomatic bone (lateral orbit, zygoma, maxilla), involves bleeding under
conjunctiva of the eye

Trauma Surgery
- Reduction: fracture fragments are returned to their normal position
- Open reduction: fracture fragments are exposed surgically by dissecting tissues
- Closed reduction: fracture fragments are manipulated without surgical exposure
- Internal fixation: using titanium bone plates to hold bone together
- Intermaxillary fixation (IMF): wiring jaws closed, archbars, elastics
- Mandible fractures are ideally treated with open reduction and internal fixation (ORIF)

Skeletal Discrepancies
- Retrognathic mandible: Class II
- Prognathic mandible: Class III
- Apertognathic: anterior open bite
- Vertical maxillary excess: maxilla too long, gummy smile
- Horizontal transverse discrepancy: posterior crossbite
- Macrogenia: chin too big
- Microgenia: chin too small

Orthognathic Surgery
- To correct severe skeletal discrepancies
- Lateral cephs are main images used in tx planning these cases
- Acrylic splint used intraoperatively
- Le Fort I osteotomy-> move maxilla
- Bilateral sagittal split osteotomy (BSSO) -> move mandible
o Most common post-op complication is nerve damage
o Condyle position should be unaltered
- Genioplasty -> move chin

Distraction Osteogenesis (DO)
- Bone deposition between two bone surfaces that are separated by gradual traction
- For bone lengthening, but not for adding width
- 1st Phase Osteotomy: bone is cut
- 2nd Phase Latency Period: appliance is mounted to bone on each side of cut but is not
activated for 1 week
 - 3rd Phase Distraction Phase: appliance is used to gradually separate the two pieces allowing
new bone to fill in the gap

Biopsychosocial Model of Pain
- Axis I -> “bio,” nociceptive input from somatic tissue, acute pain
- Axis II -> “psychosocial,” influence of interaction between thalamus, cortex, and limbic
structures, chronic pain (4-6months)
- It is not just about the tooth (axis I), but also consider the person with the tooth (axis II)

Pain Pathway
- Transduction: pain information travels from PNS to CNS
- Transmission: pain information travels from CNS to thalamus and higher cortical centers
- Modulation: limitation of flow of pain information
- Perception: human experience of pain is the sum total of these physiologic processes and
the psychological factors of higher thought and emotion

Categories of Pain
- Somatic Pain: increased stimulus yields increased pain
o Musculoskeletal: TMJ, periodontal, muscles (myofascial)
o Visceral: salivary glands, pulpal
- Neuropathic Pain: pain independent of stimulus intensity; damage to pain pathways
o Trigeminal neuralgia (tic douloureux)
§ Postmenopausal woman (older than 50)
§ Affects CN V: V1, V2, V3
§ Trigger point sends electrical, sharp, shooting, and episodic pain
followed by refractory periods
§ Unilateral
§ Tx: Anticonvulsants, surgery
o Atypical Odontalgia: secondary to deafferentation (removal of part of the neural
pathway) as a result of endo therapy or extraction; phantom toothache
o Postherpetic Neuralgia (PHN): potential sequela of herpes zoster (VZV) infection;
burning, aching, or shock-like. Tx: anticonvulsants, antidepressants, or sympathetic
blocks
o Burning Mouth Syndrome (BMS): burning, pain, dryness, and maybe also altered
taste sensation; postmenopausal women associated with type II diabetes,
malnutrition, xerostomia
o Chronic Headache (neurovascular pain)
§ Migraine: unilateral, pulsating, nausea, vomiting, photophobia,
phonophobia
§ Tension: bilateral, non-pulsating, not aggravated by routine activity
§ Cluster: intense pain near one eye
§ Tx: triptans for migraine (selective serotonin receptor agonist)
o Trauma, stroke
- Psychogenic Pain: intrapsychic disturbance -> conversion reaction, psychotic delusion,
malingering
- Atypical pain: unknown cause/diagnosis pending

TMJ Anatomy:
- Condyle of mandibular bone
- Glenoid fossa & articular eminence of temporal bone
o Articulation between the condyle and the
glenoid fossa down the convex articular
eminence with articular disc in between
- Fibrous Articular disc: separates joint space
o Lower joint space -> rotation
§ During hinge movement from closed to
halfway open (<25mm)
o Upper joint space -> translation
§ Condyle slides down and forward along
the articular eminence during sliding
movement (>25mm)
§ Maximum opening (40-55mm), protrusive, lateral excursive movements
- Muscles: move the mandible
o Lateral pterygoid: open & protrusion by moving condyles
o Masseter: close & protrusion
o Temporalis: close & retrusion
o Medial pterygoid: close & excursion
- Ligaments: limit movement of the mandible
o Capsular: covers TMJ space
o Discal/collateral: attaches to the medial & lateral pulls of the condyle -> keeps disc
attached to condyle during movement
o Posterior: articular disc to the back of the condyle -> prevents anterior disc
displacement
o Lateral: wraps around condyle & attaches to disc -> prevents posterior disc
displacement
- Blood Supply (MADS): Maxillary, Ascending pharyngeal, Deep auricular, Superficial
temporal
- Innervated by CNV3

TMD
- Myofascial Pain Syndrome (MPS): chronic muscular pain disorder
o Most common cause of masticatory pain
o Trigger points in muscles of mastication
o Crepitus (clicking) in TMJ, limited opening or range of motion, pain at rest
o Diffuse pain in preauricular region
o Parafunctional habits and disc displacements can contribute
o Tx: PT, stress management, splint therapy, medications
- Disc Displacement/Internal Derangement
o With reduction: CLICK, condyle pops over anteriorly displaced disc and pops on
the way back to its fossa (ipsilateral movement of jaw)
o Without reduction: LOCK, condyle is stuck behind anteriorly displaced disc
resulting in limited range of motion and ipsilateral deviation on opening
- Opening Patterns
o Deflection: deflects toward side that is stuck at maximum opening
o Deviation: deviates toward on side then returns back to midline at maximum
opening
- Recurrent Dislocation
 o Mandibular condyle translates anterior to the articular eminence and requires
mechanical manipulation to achieve reduction; tx: Botox injection of lateral
pterygoid or surgery if chronic
- Ankylosis: union between condyle and skull can either be bony or fibrous
o Causes: trauma is the most common cause, surgery, radiation therapy, and infection
o Severely restricted range of motion
- Bruxism: clenching and/or grinding teeth diurnal and/or nocturnal usually caused or
exacerbated by stress; tx: occlusal guard (distribute occlusal forces more evenly and relax
musculature)
- Nonsurgical therapy (conservative -> aggressive)
o Counseling: address parafunctional habits like grinding, nail biting, stress
o Medical therapy: NSAIDs, steroids, analgesics, antidepressants, muscle relaxants
o PT: transcutaneous electrical nerve stimulation, massage, thermal tx, exercise
o Occlusion: splint therapy to reduce intraarticular pressure
o Arthrocentesis: two needles to flush out superior joint space
- Surgical therapy (conservative -> aggressive): nerve most damage in TMJ surgery ->
facial nerve (CN7)- temporal branch
o Arthroscopy: two cannulas, instrumentation within superior joint space
o Arthroplasty: disc repositioning surgery, for painful persistent clicking or closed
lock
o Discectomy: disc repair or removal when it is severely damaged
o Condylotomy: vertical ramus osteotomy and NOT fixated in order to allow soft
tissues to reposition condyle and disc into a better position
o Total joint replacement: for severely pathologic joints line in osteoarthritis or
rheumatoid arthritis

Biopsy: indicated after 2 weeks
- Types
o Cytology: repeatedly scrape with kit brush or tongue depressors -> cells smeared
on glass slide and immediately fixed
§ Monitoring large tissue area for dysplastic changes
§ Many false positives
o Aspiration: use of needle and syringe to suck up contents
§ For presence of fluid, ascertaining type of fluid, or exploration of
intraosseous lesion
§ RL lesion in bone that distinguishes between benign & malignant lesions
§ Fluid is expelled onto a slide and fixed
o Incisional: large >1cm lesion, suspicious of malignancy; deep, narrow wedge
containing lesion and normal tissue
o Excisional: small <1cm lesion, suspicious of benign lesion; 2-3mm margin of
uninvolved normal tissue with elliptical incision
- Techniques
o Block anesthesia is preferred because local infiltration can distort the architecture
of the lesion
o Direct handling will crush cells
o Sample in 10% formalin
- Clinical Examples
o Large white patch on buccal mucosa that wipes off with gauze presumed to be
candidiasis? Cytology
 o Firm rough 2x3cm white lesion on lateral tongue that does not wipe off with gauze?
Incisional
o Denture wearer presents with red swelling in buccal vestibule? Adjust denture and
bring back in 2 weeks

Surgical Management of Cysts and Tumors
- Enucleation: cyst & tumor; surgical removal of a mass without cutting into or rupturing it
- Curettage: cyst & tumor
- Marsupialization: only cyst; cut a slit into an abscess or cyst and suture the edges of the slit
to keep it open so it can drain freely (i.e. Incision and drainage)
- Resection: only tumor; surgical removal of cyst or tumor and normal tissue around it

Medical Emergencies
- “SPORT:” stop treatment, position patient, oxygen*, reassure, take vitals
- Syncope (Fainting): change in temp, decreased BP/HR, LOC
o Most common medical emergency in dental chair
o Vasovagal syncope: most common syncope, needle anxiety
o Trendelenburg
o Left lateral decubitus if pregnant to relieve inferior vena cava
o Orthostatic hypotension: 2nd most common cause of syncope; dizzy spell or head
rush; BP pressure suddenly falls when standing up
- Epinephrine Overdose: rapid, intravascular injections; BP & HR rise, thumping heart
- Angina: sable versus unstable (chest pain at rest)
o Ischemia without necrosis (not enough blood to heart)
o “ONA:” oxygen, nitroglycerin (NTG), aspirin
o NTG (0.4mg) -> 5mins -> NTG -> 5mins -> NTG, aspirin and call 911
- Myocardial Infarction (MI): sudden occlusion of major coronary vessel usually left anterior
descending artery (LAD)
o Ischemia with necrosis
o “MONA:” morphine, oxygen, NTG, aspirin
- Hypoglycemia/Diabetes
o Conscious -> glucose tab or orange juice
o Unconscious -> IV dextrose or IM glucagon
o Conscious IV sedation for diabetic pt: still have low calorie meal with decrease
insulin dose
o Symptoms of Hypoglycemia: sweating, pallor, irritability, hunger, sleepiness, lack of
coordination, mydriasis
o Symptoms of Hyperglycemia: dry mouth, increased thirst, weakness, headache,
blurred vision, frequent urination
- Hyperventilation: don’t give oxygen*, sit upright, brown paper bag; increase BP and
carpopedal spasms
- Asthma: constriction and inflammation of bronchioles
o Wheezing: high pitch on exhale
o 2 puffs from emergency inhaler—Albuterol
o Avoid NSAIDs and narcotics
- Airway Obstruction: hands around neck
o Clear the pharynx of any food, vomit, or foreign objects
o Check for breathing (rise and fall of chest, sound of mouth or nose)
o Chin tilt upwards to extend the neck
o Protrude tongue and mandible to open airway
 - Seizures/Convulsions
o Protect from injury, don’t restrain, IV or IM Benzo
o Most common seizure -> Grand mal seizure
o Grand mal (tonic-clonic)-> Dilantin(Phenytoin)
o Status epilepticus -> Valium(Diazepam)
- Stroke
o Transient ischemic accident (TIA): mini-stroke
o Cerebrovascular accident (CVA): stroke
o Oxygen and call 911
o Caused by hyponatremia (low sodium in the blood)
o Look for facial droop, arm drift, speech slur
- Anaphylactic Shock
o “AEIOU:” Albuterol, Epinephrine pen (0.3mg 1:1000), IM anti-histamine, oxygen,
you call 911
- Anticoagulation
o Check blood tests below:
§ CBC-> anemia, leukopenia, thrombocytopenia
§ Bleeding Time -> platelet function, Aspirin
§ PT (extrinsic) -> anticoagulants, liver damage, Vit K
§ INR (standardized PT exam)-> Warfarin (Coumadin) 2-3 (normal INR=1)
§ PTT (intrinsic) -> Heparin, renal dialysis, hemophilia
o Herbal anticoagulants: garlic, ginger, ginkgo, ginseng, saw palmetto

 Periodontics

Periodontium: alveolar bone, PDL, cementum, gingiva
- Free gingiva & attached gingiva: keratinized
- Alveolar mucosa: non-keratinized

Pathogenesis
- Microbial challenge (LPS, antigens) presented by
subgingival plaque bacteria
- Upregulated host immune-inflammatory response
(cytokines, prostaglandins, MMPs)
- Tissue destruction

Periodontal Exam & Classifications
- Probing pocket depth (PPD): from gingival margin to base of pocket
- Clinical attachment loss (CAL): from CEJ to base of pocket
o CAL= PPD + recession
- Bleeding on probing (BOP): best measure of inflammation in periodontal tissues
- Gingival recession: CEJ to gingival margin; determines likelihood of regaining root coverage,
Miller Classification
o Class I: marginal tissue recession not extending to the MGJ, no bone or tissue loss
o Class II: marginal tissue recession extends to or beyond MGJ, no bone or tissue loss
o Class III: marginal tissue recession extends to or beyond MGJ, bone or tissue loss or
tooth mal-positioning prevents total root coverage
o Class IV: marginal tissue recession extends to or beyond MGJ, bone or tissue loss or
tooth mal-positioning severe that total root coverage not possible
- Alveolar bone loss: radiographic measure with vertical BWs, not reliable
o Normal distance from CEJ to alveolar crest is 2mm
o Crest should be parallel to line connecting CEJs of adjacent teeth
o Horizontal: stays parallel
o Vertical/angular: classified by # of bony walls remaining-infrabony defects
§ 1 wall: hemi-septal
§ 2 wall: crater (most common)
§ 3 wall: trough
§ 4 wall: circumferential (extraction socket)
- Suppuration: indicates large number of neutrophils in pocket
- Mobility: due to loss of perio support, traumatic occlusion, or combo; Miller Classification
o Class 0: normal
o Class 1: slightly more than normal
o Class 2: <1mm
o Class 3: >1mm & vertically depressed in socket
- Furcation: bone loss at branching point of multi-rooted tooth (short root trunk, short roots,
narrow interradicular dimension, cervical enamel projection); Hamp & Glickman
Classification
Hamp Classification Glickman Classification
Class 0 Class 1: Incipient
Class 1: <3mm Class 2: Cul-de-sac
Class 2: >3mm Class 3: through-and-through
Class 3: through-and-through Class 4: visible through-and through
 - Fenestration: isolated area in which root is denuded of bone and root surface is covered by
gingiva and periosteum, where marginal bone is intact
- Dehiscence: when the denuded bone areas extend through the marginal bone

Oral Exam: measured by home care (plaque/calculus), inflammation (redness, swelling, BOP),
destruction of perio tissues (perio exam)

Healthy Gingiva Features
Features Children Adults
Color Reddish due to thinner epithelium, less keratinization, and Coral pink
greater vascularity
Contour Rounded and rolled margins due to edema that Knife-edge margins
accompanies eruption and prominent cervical ridges
Consistency Flabby due to less dense CT and lack of organized collagen Firm and resilient
Texture Lack of stippling due to shorter and flatter papilla Stippling present
Sulcus Deeper because soft tissue more easily splits up from tooth Less deep

Gingivitis: inflammation, no PDL or bone destruction measured by color, contour, consistency
(fibrosis overtime)
- Plaque-induced gingival disease
o Most common
o Plaque + Inflammatory cells of host -> Gingivitis
o Modified by systemic factors, medications, malnutrition: endocrine changes
(puberty, pregnancy, diabetes), blood dyscrasias (leukemia), drug induced
gingival enlargements with calcium-channel blockers, Dilantin, Cyclosporine,
oral contraceptives, Vitamin C deficiency (scurvy)
- Non-plaque-induced gingivitis
o In response to infections, allergy, trauma: bacterial (gonorrhea, syphilis), viral
(herpes), fungal (candidiasis), foods, restorative materials, toothpastes (sodium lauryl
sulfate), factitious (unintentional), iatrogenic (doctor), accidental
o Hereditary gingival fibromatosis: non-hemorrhagic and firm
o Reduced Attached Gingiva (RAG): in children, most common cause of inadequate
attached gingiva is labial eruption path; tx: Ortho, FGG or CT graft

Periodontitis: inflammation, PDL or bone destruction (CAL); most prevalent in males of African
descent; Chronic>LAP>GAP>Refractory
- Prepubertal Periodontitis: involves primary molars mostly in AA
- Necrotizing periodontal diseases (ANUG, ANUP): occurs in children and adults;
pseudomembranous, painful, fetid breath, blunted papillae, fever, predisposing factors are
stress, smoking, and immunosuppression
o Tx: debride & Chlorhexidine & antibiotics (for fever)
- Periodontitis
- Periodontitis as a Manifestation of Systemic Disease & Acquired Conditions
o Systemic disease or conditions affecting periodontal supporting tissues
o Mucogingival deformities and conditions
o Traumatic occlusal force
o Tooth- and prosthesis-related factors
- Periodontal abscesses and Endo-Perio lesions
- Peri-implant disease and conditions
 o Peri-implant health: pseudomonas, staphylococcus
o Peri-implant mucositis: gingivitis of implants
o Peri-implantitis: periodontitis of implants
o Peri-implant soft and hard tissue deficiencies

Steps to Staging and Grading a Periodontal Case
Step 1: Initial Case Screen:
Overview to Access - Full mouth probing depths
Diseases - FMX
- Missing teeth
Mild to mod periodontitis will typically stage I or II
Severe to very severe periodontitis will typically be either stage III or IV
Step 2: Establish Stage I or II (Mild to Moderate Periodontitis):
Stage - Confirm CAL
- Rule out non-periodontitis cause of CAL (i.e. root fractures, NCCL,
trauma)
- Determine max CAL or RBL
- Confirm RBL patterns

Stage III or IV (Moderate to Severe Periodontitis):
- Determine max CAL or RBL
- Confirm RBL patterns
- Assess tooth loss due to periodontitis
- Evaluate case complexity factors (i.e. severe CAL frequency,
surgical challenges)
Step 3: Establish - Calculate RBL (% of root length x 100) divided by age
Grade - Assess risk factors (i.e. smoking, diabetes)
- Measure response to SRP and plaque control
- Assess expected rate of bone loss
- Conduct detailed risk assessment
- Account for medical and systemic inflammatory considerations
Step 4: Treatment Stage I or II, Grade A or B: Standard non-surgical periodontal therapy
Plan Stage III or IV- complex and/or multidisciplinary therapy


Periodontal Staging: intends to classify the severity and extent of a patient’s disease based on the
measurable amount of destroyed and/or damaged tissue as a result of periodontitis and to access
the specific factors that may attribute to the complexity of long-term care management
- Initial stage determined by CAL. If CAL not available, RBL. Tooth loss due to periodontitis
may modify stage definition. One or more complexity factors may shift the stage to a higher
level
Staging
Periodontitis Stage I Stage II Stage III Stage IV
Interdental 1-2mm 3-4mm >5mm >5mm
CAL
Coronal Coronal Extending to middle third of root or
Severity
RBL third third (15- beyond
(15%) 33%)
Tooth loss No tooth loss < 4 teeth >5 teeth
 Max PDD Max PDD Stage II plus: Stage III plus need for
<4mm <5mm PDD >6mm rehab due to:
Mostly Mostly Vertical BL masticatory
Horizontal Horizontal >3mm dysfunction, 2nd
bone loss bone loss Furca II or III occlusal trauma
Complexity Local Moderate (mobility >2), severe
ridge defects ridge defects, bite
collapse, drifting,
flaring, <20 teeth
remaining (10
opposing pairs)
For each stage, describe extent as:
Extent and Add to stage - Localized (<30%)
distribution as descriptor - Generalized (>30%)
- Molar/incisor pattern

Periodontal Grading: aims to indicate the rate of periodontitis progression, responsiveness to
standard therapy, and potential impact on systemic health
- Always assume grade B and seek evidence to shift to A or C
Grading
Progression Grade A: Slow Grade B: Mod Grade C: Rapid
Direct No loss over 5 <2mm over 5 >2mm over 5
evidence of RBL or CAL years years years
progression
% bone <0.25 0.25-1 >1
loss/age
Heavy biofilm Destruction Destruction
deposits with commensurate exceeds
Primary low levels of with biofilm expectations
criteria Indirect destruction deposits given biofilm
evidence of deposits; specific
Case
progression clinical patterns
phenotype
suggestive of
periods of rapid
progression
and/or early
onset disease
Grade Smoking Non-smoker <10 cigs/day >10 cigs/day
Risk factors
modifiers Diabetes Normoglycemic HbA1c <7% HbA1c >7%

Plaque
- Microbial plaque considered initiating factor of disease (both caries and periodontal)
- in health, bacterial composition is from gram(+) cocci and rods from Streptococcus and
Actinomyces
- Hypotheses
o Non-specific: more plaque means more disease no matter what bacterial species
o Specific: only specific bugs cause disease
o Ecological: mouth is an ecosystem just like a rainforest, so certain bacteria and host
factors (smoking, diabetes) change the environment to favor pathogenic bacteria
 - SupraG: aerobic
o Tooth: gram(+); outer surface of plaque: gram(-)
- SubG: anaerobic
o Tooth: gram(+) coronal, gram (-) apical; epithelium: gram(-)
- Composition
o Organic: polysaccharides, proteins, glycoproteins, lipids
o Inorganic: calcium, phosphorous, sodium, potassium fluoride
o SupraG derive from saliva, subG derive from GCF
- Formation
o Pellicle Formation: within secs consists of glycoproteins, proline-rich proteins, and
other molecules that serve as attachment sites for bacteria
o Adhesion & Attachment of Bacteria: within minutes; initial adhesion is due to weak
irreversible van der Waals and electrostatic forces -> firm attachment is due to
strong irreversible interactions between specific bacterial adhesin molecules and
host pellicle receptors
o Colonization & Plaque Maturation: within 24-48 hours; firmly attached primary
colonizers provide new receptors for attachment of other bacteria in a process
called coadhesion; as bacteria grow and the biofilm matures, there is a shift from
facultative gram(+) to anaerobic gram(-)
§ Primary Colonizers: Streptococcus
§ Secondary Colonizers
§ Fusobacterium nucleatum: non-motile, gram (-) rod, induces apoptosis of
leukocytes and release of tissue-damaging substances from leukocytes;
bridge that attaches to both primary and secondary colonizers
- Biofilm
o Fluid channels run through the plaque mass permitting the passage of nutrients
o Quorum sensing: communication among bacteria in biofilm to encourage growth of
beneficial species and discourage growth of competing species
o Biofilm bacteria is more resistant to antimicrobials than planktonic or free-
swimming bacteria
- Microbial Complexes
o Red complex: associated with BOP and deep PDD; P. gingivalis, T. denticola, T.
forsythia
o Orange complex: precedes presence of red complex supporting sequential nature
of plaque maturation; Fusobacterium, Prevotella intermedia, Campylobacter rectus
- A.actinomycetemcomitans: causes aggressive periodontitis (old classification), non-motile,
gram(-) rod, capnophilic, leukotoxin, lipopolysaccharide, collagenase, protease that cleaves
IgG
- P. gingivalis: chronic periodontitis (old classification), non-motile, gram(-), fimbriae,
capsule, gingipain, collagenase, hemolysin
- T. denticola: ANUG/ANUP, motile, gram(-) spirochete, penetrates epithelium and CT,
protease that can degrade collagen, immunoglobulins, and complement factors
- T. forsythia: non-motile, gram(-) rod, protease that cleaves immunoglobulins and
complement factors
- P. intermedia: pregnancy gingivitis, non-motile, gram(-) rod, become darkly pigmented
when grown on blood agar plates
- S. salivarius: most common oral bacteria, residues on tongue

Local Factors: in relation to leading to periodontal disease
- Calculus: lingual surfaces of mand anterior teeth and buccal surfaces of max molars
 o Mineralized dental plaque—precipitation of mineral salts into plaque usually occurs
within 1-14 days
o Calculus does not by itself serve as a mechanical irritant to gingival tissues but is
always covered with a layer of bacterial plaque which serves as the primary
irritant
o SupraG: white/yellow, mineralization via saliva, occurs near salivary duct openings
o SubG: dark, mineralization via GCF
- Materia Alba: soft white cheese-like unorganized accumulation of bacteria, salivary
proteins, desquamated epithelial cells, and occasional food debris; easily displaced with
water spray
- Extrinsic Stains: don’t contribute to gingival inflammation and are primarily an esthetic
concern
o Orange: anterior teeth, poor OH
o Brown: drinking dark-colored beverages, poor OH
o Dark brown and back: tobacco
o Yellow-brown: CHX and stannous fluoride
o Black: thin lines on cervical third found in healthy mouth, consumption of iron
o Green and yellow: anterior teeth, poor OH and chromogenic bacteria
o Bluish-green: occupational exposure of metallic dust
- Malocclusion: prominent roots and teeth associated with high frena often experience
gingival recession; crowding, mesial drift or extrusion can lead to food impaction and
plaque retention
- Faulty Restorations: overhangs, open margins, rough surfaces, open contacts; over-
contoured restorations are worse for gingival health than under-contoured
- SubG margins
- Appliances: RPDs, ortho therapy, oral jewelry
- Self-inflicted injury: aggressive horizontal brushing, toothpicks, fingernail biting

Pathogenesis
- Neutrophils (PMNs): 1st line defense
o Most important cells involved in controlling the bacterial challenge and destroying
periodontal tissue via release of destructive molecules
o Migrate via chemotaxis from blood vessels to pocket
o Kill via phagocytosis with myeloperoxidase and oxygen radicals
o MMP-8 (neutrophil collagenase): most important proteinase involved in destruction
of periodontal tissue
o Defective neutrophil chemotaxis leads to aggressive periodontitis (Neutropenia,
Chediak-Higashi syndrome, Papillon-Lefevre syndrome, LAD-1/2)
- Macrophages: antigen-presenting cells like monocytes and dendritic cells; regulate immune
response via cytokine release like IL-8
- Mast cells: vascular permeability and dilation; IgE
- Lymphocytes:
o B cells become plasma cells and make antibodies
o T helper cells (CD4) help in communication
o T cytotoxic cells (CD8) kill intracellular antigens
o NK cells are T cells that recognize and kill tumor and virally-infected cells
- Proinflammatory cells: “body destructs itself to help itself”
o IL-1: bone resorption
o IL-6
o PGE2
 o TNFa: macrophage activation
o MMPs: collagen destruction (Protein-ase -> eats proteins)
- Anti-inflammatory mediators: IL-4, IL-10, TIMPs
- Gingivitis
o Stage 1: 2-4 days, neutrophils (PMNs), increased GCF
o Stage 2: 4-7 days, T lymphocyte, increased collagen loss, BOP
o Stage 3: 14-21 days, B lymphocyte (plasma cells), collagen loss, clinical changes in
color, contour, consistency
o Stage 4: transition to irreversible damage of periodontitis

Treatment Planning
- Short-term goals: reduce gingival inflammation by correcting conditions causing it
- Long-term goals: eliminate pain, arrest CAL, establish occlusal stability and function, reduce
tooth loss, prevent disease recurrence
- Preliminary Phase (0): treat emergencies, extract hopeless teeth
- Non-surgical Phase (I): plaque control and patient education
- Periodontal re-evaluation: 4-8 weeks after to allow formation of JE (epithelium contacts
enamel directly via hemidesmosomes)
- Surgical Phase (II): reduce or eliminate periodontal pockets, correct defects, regenerate
tissue, implants, endo tx
- Restorative Phase (III)
- Maintenance Phase (IV): maintenance performed in a continuum with phase II and III
therapy every 3mos for the first year
- Risk Elements
o Risk factor: casually associated with the disease (i.e. smoking, diabetes, plaque)
o Risk determinant: unchangeable background characteristics, increase likelihood of
disease (gender, genetics, age, socioeconomic status)
o Risk indicator: not casually associated with the disease (i.e. stress, osteoporosis,
HIV/AIDS)
o Risk marker or predictor: quantitative association with disease (previous history,
BOP, CAL)

Prognosis: CAL is the most important factor in determining the prognosis!
Bone Level Clinical Local Factors Systemic Patient
Factors Factors Cooperation
Excellent - - Health - Good
Good Adequate - Maintain - Good
Fair Inadequate Mobility, Maintain Limited Adequate
furcation I
Poor Moderate Mobility, Difficult to Yes Questionable
furcation I/II maintain
Questionable Advanced Mobility, Inaccessible Yes Inadequate
furcation areas
II/III
Hopeless Advanced Extract Unable Uncontrolled Inadequate

Non-surgical therapy
- Scaling Root Planing
o Scaling: removal of both supraG and subG plaque and calculus
 o Root planing: removal of embedded calculus and rough cementum
- Ultrasonic scalers: 20,000-45,000 cycles/sec to remove tenacious calculus; lavage,
cavitation, vibration, acoustic turbulence
o Magnetostrictive: Cavitron; elliptical pattern
o Piezoelectric: linear pattern
o Contraindications: pacemakers, aerosol diseases, implants
- Strokes:
o Exploratory: light; probes and explorers
o Scaling: short, strong pull
o Root planning: light to mod pull stroke
o Ultrasonic: light intermittent stroke with tip
parallel to the tooth surface and in constant motion
o Insertion: 0 degrees (closed-angle) -> scaling and
root planing: 45-90 degrees (open-angle) with
lower apical third of curette at the line angle
- Prophy with Gritty Paste
o Cup: extrinsic stain removal and pocket access
o Brush: occlusal grooves and interproximal areas
o Jet: slurry water and sodium bicarbonate to remove stains and soft deposits

General Concepts of Surgery
- Wider base to ensure adequate blood supply
- Incisions over intact bone, not over bony defects or eminences
- Rounded corners
- Vertical releases at line angles
- Avoid vital structures
- Post op plaque control is most important procedure after surgery

Flap Thickness
- Split or partial thickness (mucosal) flap: gingiva/ mucosa and submucosa
o Indicated for gingival graft, periosteal sutures, prominent fenestration or dehiscence
- Full thickness (mucoperiosteal) flap- includes periosteum; expect ~1mm of thin
periradicular bone resorption and remodeling
o Completed with 3 horizontal incisions
§ Internal or reverse bevel incision-
• 0.5-1mm from the gingival margin (Apically Displaced Flap)
• 1-2mm from the free gingival margin (Modified Widman Flap)
• Coronal to the base of the pocket (Undisplaced Flap)
§ Sulcular or crevicular incision- base of pocket to alveolar crest
§ Interdental or interproximal incision- removes collar of tissue around the
tooth created by first 2 incisions
o Modified Widman Flap: includes incisions of full thickness flap but not reflected
beyond MGJ—access subG for debridement with new attachment
o Apically repositioned flap: full thickness flap that requires additional vertical
releasing incisions made beyond MGJ in order to attain pocket reduction

Periodontal Pack: ZOE for 1 week; doesn’t enhance healing but protects surgical sight

Papilla Preservation
- Conventional Flap= split the papilla
 - Papilla preservation flap: cuts made at these line angles
o Lingual to facial line angle
o Lingual to lingual line angle
o Facial to facial line angle

Gingival Surgery—secondary healing
- Gingivectomy: excision of gingiva to eliminate pockets or enlargements via external bevel
incision (perpendicular to long axis of tooth)
- Gingivoplasty: excision of gingiva to reshape
- Distal Wedge: pocket reduction distal to terminal molars with a band of attached
keratinized gingiva required
o Max: full thickness flap with parallel incisions; tuberosity
o Mand: full thickness flap with V-shaped incisions; retromolar triangle area

Mucogingial Surgery—partial thickness flaps
- Free gingival graft: widen band of keratinized tissue; happens below or apical to gingival
margin
o Ideal thickness: 1-1.5mm
o Needs to undergo revascularization at the site of implantation
o Donor site most likely to suffer greater palatine nerve injury
- CT graft: root coverage; donor site is usually palate; happens above or coronal to gingival
margin
- Laterally Positioned Flap (Pedicle): edge remains attached to gum & is pulled over or down
to cover exposed root and sewn in place
- Frenectomy: complete removal of frenum; Labial > Buccal > Lingual
- Frenotomy: incision of frenum
- Vestibuloplasty: deepen the vestibule by apically repositioning the alveolar mucosa,
buccinator, mentalis, and mylohyoid muscles

Osseous Surgery
- General Considerations
o (+) architecture: interproximal bone is coronal to radicular bone
o Flat architecture: interproximal and radicular bone at the same height
o (-)/reverse architecture: interproximal bone is apical to radicular bone
- Ostectomy: removal of supporting alveolar bone—from bone contacting tooth
- Osteotomy: removal of non-supporting alveolar bone—away from tooth

Crown Lengthening: combing ostectomy with gingivectomy (need 2mm of keratinized tissue) or
apically repositioned flap (preserve keratinized tissue present)

Periodontal Regeneration
- GTR: regenerate bone, cementum and PDL
o Barrier membrane: prevents soft tissue down growth and permits hard tissue
ingrowth
o Bone graft: osteoconductive, osteoinductive, and/or osteogenic
o Biological agent: creates an environment conducive to tissue formation

Root Surface Treatment: chelating agents like EDTA and citric acid can expose the collagen fibrils
through demineralization and may improve new attachment

Bone Graft Materials:
- Autograft: self; osteoconductive, osteoinductive, osteogenic
- Allograft: other human undecalcified/decalcified freeze-dried bone with bone morphogenic
proteins (BMPs); osteoconductive, osteoinductive
- Xenografts: animal; osteoconductive
- Alloplast: synthetic or inorganic; osteoconductive
- Osteoconductive: scaffold
- Osteoinductive: convert neighboring progenitor cells into osteoblasts
- Osteogenic: make bone

KEY THINGS TO KNOW FOR BOARDS
- Additive: periodontal regeneration, FGG, CTG, coronally advanced flap
- Subtractive: resective osseous surgery, gingivectomy, apically positioned flap
- 1 and 2 wall defects- resection, recontour bone to restore (+) architecture
- 3 and 4 wall defects- regeneration, better blood supply and cell source proximity
- Deep narrow 3-wall is ideal for regenerating infrabony defects
- Hamp Class II (buccal upper or either buccal or lingual lower) is ideal for regenerating
furcation defects
- Miller Class I with thick gingival biotype and wide band of keratinized tissue is ideal for
regenerating recession defects

Healing After Surgery
- Regeneration: complete restore architecture and function
- Repair: not complete restore, involve healing by scar or formation of long JE
- Reattachment: reunion of epithelial and CT with root surface after incision or injury
- New attachment: embedding of new PDL fibers into new cementum that has been
previously deprived of its original attachment

Wound Healing
- Cells arrive fastest to slowest; epithelial cells -> CT cells -> PDL cells -> bone cells
- Primary Healing
- Secondary Healing
o Hemostasis and fibrin clot cover wound
o Cell proliferation of epithelium at wound margin
o Epithelium migrate across cut CT surface under fibrin clot—proliferation of vascular
tissue (0.5-1mm per day)
o Complete surface epithelization
o Epithelial growth proceeds until new JE attachment established

Adjunctive Therapies
- Antibiotics: aims to decrease the number of bacteria in pocket
o Only used as adjunct in debridement during non-surgical phase
o Aggressive and refractory periodontitis
o Tetracyclines: concentrate in GCF, doxycycline only requires one dose per day
o Amoxicillin (500mg TID) & Metronidazole (250mg TID) for 14 days= best combo!
§ Duration is more important than dose—the longer the better
§ Avoid alcohol with MTZ
o Amoxicillin + Clavulante potassium= Augmentin: resistant to penicillinases
o Local Antibiotics: localized recurrent and/or residual PPD >5mm with inflammation
are still present following conventional therapy
 § Arrestin=Minocycline
§ Atridox=Doxycycline
§ PerioChip=Chlorhexidine gluconate
- Host Modulation Therapy: aims to downregulate the destructive aspects of the host
response
o Only used as adjunct in debridement during non-surgical phase
o Chronic periodontitis
o NSAIDs, Bisphosphonates
o Subantimicrobial Dose Doxycycline (SDD): inhibits MMPs; 20mg twice daily for 3-
9mos Periostat both systemic and local
o Emdogain: enamel matrix proteins, local
o PDGF: GEM 21S
o These surgical adjuncts may also influence periodontal regeneration
- Occlusion Correction from traumatic occlusion
o Primary occlusal trauma: excessive forces on normal periodontium
o Secondary occlusal trauma: normal occlusal forces on reduced periodontium
o Fremitus: vibration of teeth upon closing
o Therapy: delayed until after inflammation is resolved; coronoplasty or bite guard
o Splinting: improve patient comfort and function by immobilizing excessively mobile
teeth
- Furcation Correction
o Furcation plasty/Odontoplasty: open furcation area and smooth it to allow access
o Tunneling: remove bone and move tissue apically to create Class IV to keep it clean
o Class I- Initial therapy, Odontoplasty, Barrel in crowns
o Class II- GTR, Odontoplasty, Root resection
o Class III & IV: root resection (DB root of max molars), hemisection (mand molars),
extraction

Maintenance:
- Toothbrushing- Bass method: sulcular brushing where bristles are placed at gingival
margin at a 45 degree angle to the tooth, the bristles extend about 0.5mm subG to
effectively disrupt plaque buildup in the cervical area; soft nylon bristle brushes replaced
every 3mos
- Flossing- C-shape
- Waterpik: home water irrigation systems are designed to flush out gross food debris and
reduce bacterial load on the gingiva, NOT biofilm on the tooth surface
- Parental participation in oral hygiene until age 8 due to manual dexterity

 Prosthodontics

General considerations of Pros
- Crown-to-Root ratio: 1:2 ideal, 1:1 minimum
- Abutment: tooth to which bridge attaches; don’t used compromised endodontic or
periodontal teeth
o Divergent, multiple, curved, and broad roots preferred
- Retainer: crown that attaches to abutment
- Pontic: fake tooth
- Connector: connects retainer to pontic
- Poor Prognosis: single retainer cantilever, multiple-splinted abutment teeth, nonrigid
connectors, intermediate abutments (pier)
- Ante’s Law: PDL surface area of the abutment teeth should be equal to or greater than the
imaginary PDL surface area of missing teeth
- Splinting: distributes occlusal forces, recommended where the periodontal surface of an
abutment tooth is not sufficient to support the bridge
o When replacing a canine, central and lateral should be splinted together to
prevent lateral drifting of the bridge

Support, Stability, Retention in Removable
Definitions Maxillary Mandibular CD RPD Tooth
Resistance to Palate Buccal Shelf Base Rest Occlusal
Support vertical Alveolar Retromolar Altered Third
seating Ridge Pad Cast DE
Resistance to Ridge Ridge height Flange Major & Middle
horizontal height Depth of Minor Third
Stability dislodging Depth of vestibule Connector,
forces vestibule Reciprocal
Clasp Arm
Resistance to Alveolar Alveolar Peripheral Direct & Gingival
vertical Ridge Ridge Seal by Indirect Third
Retention dislodging Adhesion of Retainer,
forces Salvia Retentive
Clasp Arm

Occlusion
MMR: Maxillo-Mandibular Relations
- Centric Relation (CR): position in which condyles articulate with thinnest avascular portion
of their respective discs in the most anterior-superior position against articular eminence;
CD, multiple teeth being restored or replaced
o Achieved by Bimanual manipulation, deprogram with leaf gauge or acrylic resin jig
o For edentulous patient, provides the ability to increase or decrease the VDO more
accurately in the articulator by establishing a radius of the mandible’s arc of
closure
- Centric Occlusion (CO)/ Maximum Intercuspation (MICP): complete interdigitation of teeth;
single fixed procedure
- VDO: distance between nose and chin when biting together
 - VDR: VDO + Interocclusal Rest Space; distance between nose and chin at rest; take
measurement when patient is sitting up
- Interocclusal Rest Space: ideally 2-4mm of space between upper and lower premolars

Compensating Curves
- Curve of Spee: anteroposterior curve to ensure loading into long axis of each tooth; more
mesial inclination as you move distally
- Curve of Wilson: mediolateral curve along posterior cusp tips to ensure loading into long
axis of each tooth; more lingual inclination as you move distally

Plane of Occlusion
- Camper’s line: imaginary line from ala of nose to tragus of ear
- Interpupillary line: imaginary line between pupils of the eyes

Facebow: maxillary arch to the skull and mandible to the rotational center of the TMJs;
transfers relationship between the hinge axis and maxilla from the patient to the articulator
- Arbitrary: orients maxilla to skull via external auditory meatus
- Kinematic: placed on hinge axis of mandible

Articulator
- Non-adjustable
- Semi-adjustable: Bennet Angle (15) and horizontal condylar inclination (HCI 30)
o Arcon: condyles are lower and fossa are upper
o Non-arcon: upper and lower membranes are rigidly attached
- Fully adjustable

Mounting Casts
- Alginate cast -> wax records
- Elastomeric materials -> elastomeric materials (PVS)

Disclusion
- Condylar Guidance: posterior determinant by slope of articulator eminence—HCI on
articulator
- Incisal Guidance: anterior determinant; incisal edges of mandibular incisors against L
slopes of maxillary incisors—pin and guide table on articulator
- Canine Guidance: contact occurs only on upper and lower canines on working side in
lateral movements
- Anterior Guidance: Incisal Guidance + Canine Guidance
- Protrusive: registers anterior-inferior condyle path in the translation movement of the
condyles; incisal and condylar guidance disclude posterior teeth
o Christensen’s phenomenon: refers to the distal space created between the
maxillary and mandibular occlusal surfaces when the mandible is protruded, due to
downward and forward movement of condyles down their articular eminences
- Lateral: canines on working side and condyle on balancing side disclude posterior teeth on
balancing side
o Balancing side: side jaw is moving away from
o Working side: side jaw is moving towards

Guide Table: made to preserve anterior guidance; mechanical can be used for all except restoring
maxillary anterior teeth because cannot reproduce lingual contours of maxillary anterior
teeth—need custom incisal guide made of acrylic resin

Mutual Protection: front teeth disclude posterior teeth during protrusive and lateral movement
while back teeth have flat occlusal surfaces and strong roots to help protect anterior teeth from bite
forces

Balanced Occlusion: simultaneous anterior and bilateral posterior contacts (tripodization) in
centric & eccentric movement; increasing condylar guidance, need to increase compensating curves
- Balancing Side: Max L cusps contact L incline of mand B cusps
- Working Side: Max L cusps contact B incline of mand L cusps AND mand B cusps contact L
incline of max B cusps

Lingualized Occlusion: only the palatal cusps of the maxillary posterior teeth contact the
mandibular posterior teeth

Bennett
- Bennett Angle: angle obtained after nonworking side condyle has moved anteriorly and
medially relative to the sagittal plane
- Bennett Shift: lateral movement of mandible toward the working side during lateral
excursions
- Bennett Movement: lateral movement of both condyles toward the working side, basically
“TMJ looseness”

Occlusal Determinants Favoring Disclusion (Opposite for Eccentric Occlusion)
Horizontal: Steep Incisal Guidance
Anterior Guidance
Lateral: Steep Canine Guidance
Horizontal: Steep Horizontal Condylar Inclination
Posterior Guidance
Lateral: Less Bennet Movement
Cuspal Anatomy Short with shallow inclines
Tooth Arrangement Less Curve of Spee & Curve of Wilson
Orientation of Occlusal Plane Less parallel to orientation of condylar path



Static Occlusion
Functional/Holding/Supporting Cusps: lingual
uppers, buccal lowers
Non-function/non-holding/non-supporting: buccal
uppers, lingual lowers
Centric Stops: where functioning cusps are
contacting opposing teeth

Ideal: mandible offset by ½ to mesial




Dynamic Occlusion
Working Contacts: contact made in working movement
Non-working contacts: contact made in NW movement
Centric Stop Facial Range: B cusps of lowers contacting in
central fossa/marginal ridges in uppers
Centric Stop Lingual Range: L cusps of uppers contacting in
central fossa/marginal ridges in lowers


Right Side of Mouth
Working movement: side matches movement
Protrusive movement
Non-working movement: side doesn’t match movement

ID Cusps Asking
1. ID color on other arch
2. Determine movement
3. Do movement accordingly

Working Interferences: 1st contact on tooth on the
working side

Non-working interferences: any tooth on opposite side
makes 1st contact

Complete Dentures
Maxillary Edentulous Anatomy
- Alveolar Ridge
- Labial & Buccal Frenum: restrict or secure mobile tissue
- Labial Vestibule: space between lips and ridge; from buccal frenum to buccal frenum
- Buccal Vestibule: space between cheeks and ridge; posterior to buccal frenums
- Hamular Notch: posterior boundary marker; junction of maxilla with sphenoid bone distal
to alveolar ridge
- Vibrating Line: from hamular notch to hamular notch; 2mm away from Fovea palatini
- “Butterfly Line:” junction between soft and hard palate; vibrating line is posterior to this
- Posterior Palatal Seal: in between “butterfly line” and vibrating line; compensates for
polymerization and shrinkage of processing
 - Coronoid Notch: DB area of impression/denture to avoid interference from coronoid
process in mandible; captured in border molding by moving left and right (masseter)
- Pterygomandibular Raphe: connects buccinator and superior pharyngeal constrictor;
captured in border molding by asking patient to open wide

Mandibular Edentulous Anatomy
- Alveolar Ridge: smaller than maxillary
- Labial Frenum: attaches to orbicularis oris
- Buccal Frenum: attaches to orbicularis oris, buccinator
- Lingual Frenum: attaches to genioglossus
- Labial Vestibule: determined by superior border of mentalis
- Buccal Vestibule: determined by superior border of buccinator
- Retromolar Pad: marks distal extension of ridge; ideally covered for support and retention
since the integrity of the bone in this area is maintained; contains attachments to
temporalis, buccinator, superior pharyngeal constrictor, and pterygomandibular
raphe
- Masseteric Notch: refers to the DB area on the impression/denture; masseter contracts
when mouth closes against resistance
- Avelolingual Sulcus: between mandibular alveolar ridge and tongue
o Anterior Region: from lingual frenum to premylohyoid fossa; sublingual gland sits
above mylohyoid in this region so the flange is shorter anteriorly and should tough
the mucosa of FOM
o Middle Region: from premylohyoid fossa to distal end of mylohyoid region; flange is
deflected medially away from mandible due to prominence of mylohyoid ridge in
this area and contraction of mylohyoid medially
o Posterior Region: extends into retromylohyoid fossa; although mylohyoid attaches
higher posteriorly, the posterior fibers are directed more vertically so the denture
seats deeper and the lingual flange is longer; flange is deflected laterally toward
the ramus of the mandible to form typical S-form of lingual sulcus; denture
extension in this area is limited by palatoglossus and superior constrictor
- Buccal Shelf: lies perpendicular to occlusal forces, buccinator attaches here, provides
support for denture

Pre-Prosthetic Surgery
- Frenectomy, FGG for OD teeth
- Hypermobile Ridge: flabby edentulous ridges are common in anterior maxilla—treat with
tissue conditioner. If that doesn’t work, electrosurgery but can eliminate vestibule. Use
large relief in try or perforate custom tray when taking impression
- Epulis Fissuratum: treat with tissue conditioner and adjust flange
- Fibrous (Pendulous) Tuberosity: large tuberosities touch retromolar pads; treat by excise
tissue/bone
- Papillary Hyperplasia: multiple papillary projections of palate caused by local irritation,
ill-fitting denture, poor OHI, and leaving dentures in; candidiasis is the main cause; treat
with OHI, leave out & soak dentures overnight in 1% bleach, tissue conditioner, brush area
- Combination Syndrome: specific pattern of bone resorption in the anterior edentulous
maxilla when it is opposing mandibular anterior teeth only; overgrowth of tuberosities,
papillary hyperplasia, extrusion, loss of bone in posterior mandible
- Retained Root Tips: non-RCT tips can be infection risks; may be left if they have an intact
lamina dura and no RL
- Paget’s Disease: dentures not fitting, will need to be remade periodically
 - Alveoloplasty, Vestibuloplasty, tori removal
- Bone Augmentation: bone grafts with hydroxyapatite, easy for horizontal than vertical
augmentation

Occlusion related to CD
- VDO & Dentures
Excessive versus Insufficient VDO
Excessive VDO Insufficient VDO
Display of Mandibular Excessive -
Teeth
Posterior Teeth Clicking Diminished occlusal force
Muscles of Mastication Fatigue -
Lips Appear Strained Thin Appearance
Supporting Tissue Excessive trauma Aging appearance: wrinkles,
chin too near nose,
overlapping corners of mouth
Miscellaneous Unable to wear dentures, Angular cheilitis
discomfort, gagging
- The maxillary occlusal wax rim should be parallel Camper’s line and Interpupillary line,
which can be measured with a Fox plane
- Balanced Occlusion without anterior guidance
- Lingualized Occlusion can be used to eliminate destabilizing buccal force vectors
- Phonetics:
o Fricative or Labiodental Sounds (F, V, PH): contact between maxillary incisors
and wet/dry line of lower lip; help determine position of incisal edges of maxillary
anterior teeth
o Sibilant or Linguoalveolar Sounds (S, Z, SH, CH, J): contact between tip of tongue
and the anterior palate of lingual surface of the teeth; help determine vertical length
and overlap of anterior teeth
§ Whistling: too narrow arch form
§ Lisp where S become SH: too wide arch form
§ Closest speaking space: evaluate VDO during pronunciation of S sound, the
interincisal separation should be 1-1.5mm
o Linguodental Sounds (TH): contact between tip of tongue and upper and lower
teeth; determine labiolingual position of anterior teeth
§ Tongue not visible: teeth too far forward
§ Tongue sticks out: teeth are set too far back
o Bilabial Sounds (B, P, M): contact between both lips; insufficient lip support by the
teeth or labial flange can affect production of these sounds
o Guttural Sounds (G, K): contact between back of tongue and throat
- Stability, Support, and Retention
o Retention= Surface Tension
§ Adhesion: attraction of unlike molecules; intimate contact between
denture base to tissues creates best seal; occlusal prematurities may break
retention
§ Cohesion: clinging of like molecules; thick and ropy saliva is unfavorable
§ Surface Tension: combination of adhesion and cohesion to maintain film
integrity; water are more attracted to each other than air
- Ridge: best indicator for success because has all 3 things, stability, retention, support!

Problems with Dentures
- Overextension: flange is too long -> get sore spot or ulcer -> tx: relieve denture; extends
too far back -> occlusal forces would dislodge denture
- Underextension: flange is too short -> lack of retention
- Cheek biting: insufficient horizontal overlap between maxillary and mandibular teeth; tx:
reduce buccal of posterior mandibular teeth

Denture Materials
- Heat-Cured Acrylic
o Powder
§ Polymethyl methacrylate (PMMA): polymer
§ Benzoyl peroxide: initiator
§ Salts of iron, cadmium, or organic dyes: pigment
o Liquid
§ Methyl methacrylate (MMA): monomer
§ Hydroquinone: inhibitor
§ Glycol dimethacrylate: cross-linking agent,
§ Dimethyl-p-toluidine as activator

Denture Processing: shrinkage always occurs but more shrinkage if excessive monomer; ideal
ratio of monomer to polymer is 1:3;
- Porosity: due to underpacking with resin at time of processing or being heated too
rapidly

Denture Teeth
- Acrylic: better retention because can bond to acrylic resin of base
- Porcelain: more esthetic, more stain and wear resistant, brittle, mechanical retention is
achieved with pins (anterior) or diatorics (posterior)

Removable Partial Dentures
Indications: distal extension, long span, bone loss around potential abutments, finances

Kennedy Classification and Applegate’s Rules

Bilateral distal Unilateral distal Unilateral bounded Bilateral bounded
extension extension edentulous space edentulous space which
means it crosses the
midline
Applegate’s Rules:
1. Classification should be assigned after any extractions
 2. Missing 3rd molars not considered
3. Abutment third molars are considered
4. Missing 2nd molars are not considered
5. Most posterior edentulous area determines the classification
6. Other edentulous areas are referred to as modifications
7. Extent of modification does not matter (# of missing teeth), only the number (# of
missing spaces)
8. Class IV cannot have any modifications by definition

Major Connectors: provides rigidity, unites all other components and not placed on movable
tissue
Connector Type Characteristics Indications
Complete Palatal Most rigid Distal extension,
Plate periodontally
compromised teeth,
shallow vault, small
mouth, flat or flabby
ridges
Maxillary Horseshoe Least rigid Large palatal torus
Palatal Strap Should cross the -
midline at a right
angle
Beading: involves scribing a 0.5mm rounded groove in the cast at the
borders of the major connector -> add strength and maintain tissue
contact to prevent food impaction
Lingual Bar Simplest and most Depth of lingual
common vestibule is >7mm
Lingual Plate Distal extension,
depth of lingual
vestibule is <7mm,
additional tooth loss
Mandibular
anticipated, lingual
tori
Labial bar Unfavorable soft Missing canine,
(swinglock) tissue contour questionable
periodontal
prognosis

- Minor Connectors: connects major connector to rests, indirect retainers, and clasps
- Rest: rigid extension of an RPD framework that contacts the O, L, or I surface of an
abutment tooth; directs forces through long axis providing support
- Rest Seat: prepared into O, L, or I surface of an abutment tooth in order to receive and
support a rest
o Occlusal: rounded semicircular one-third MD width, one-half intercuspal width,
1.5mm deep for base metal; floor inclines apically towards center -> angle formed
with vertical minor connector is <90
o Cingulum: inverted V or U shape; 2.5-3mm MD width, 2mm labiolingual width
(ledge), 1.5mm deep; benefits include good distribution of occlusal load, esthetics,
strength from closeness to major connector, CI: mandibular incisors
 o Incisal: rounded notch at incisal angle; 2.5mm MD width, 1.5mm deep, indirect
retainer; less favorable leverage not often used because of esthetics
- Proximal Plate: minor connector metal plate that contacts proximal surface of abutment
tooth
- Guide Planes: flat parallel surface of abutment teeth that provide path of insertion and
removal; one-third buccolingual width, extends 2-3mm vertically down from marginal
ridge
- Indirect Retainer
o Distal extension area of a partial is “loose” and not anchored posteriorly
o Rotational movement centered around an imaginary line drawn through the most
distal rests
o Indirect retainer is directly perpendicular and anterior to the fulcrum line which
provides bracing to resist rotational movement of distal extension area
- Direct Retainer (Clasp Assembly): Rest + Minor Connector + Clasp Arms (Retentive (RA) &
Reciprocal (RBA))
o Extracoronal retainer: common, conventional “clasp” design; encircle a tooth at
least 180 to prevent movement away from clasp
o Intracoronal retainer: precision attachment with key and keyway pattern; no clasps
-> more esthetic
o Retentive Clasp (Buccal usually): originates from minor connector and rest; contacts
tooth below HOC/survey line
§ Shoulder and middle should be above HOC, only the tip should be under HOC
§ Tip is designed to engage in undercut and resist dislodging forces—only
active when dislodging forces are applied to them, otherwise seat passively
o Reciprocal/Stabilizing Clasp (Lingual usually): originates from minor connector and
rest; contact tooth above HOC/survey line
§ Braces abutment tooth so it is not torqued by retentive clasp
o Clasp Designs
§ Suprabulge: originate above survey class
• Circumferential (Akers): most common clasp!
• Ring: undercut adjacent to bounded edentulous space
• Embrasure: 2 Akers clasps that go between two teeth and encircle
them; 2 rests next to each other
• Combination: retentive arm is made of wrought wire
§ Infrabulge: originate below survey line; need vestibule depth
• T bar: T-shape
• I bar: I-shape
• Bar type
• Y type

Clasp Assemblies & Selection
Type Design Indications
RPI Rest (away from proximal plate), Ideal Class II lever system, Distal
Proximal Plate, I bar Extension (1)
RPA/RPC Rest, Proximal Plate, Aker’s BES with rests adjacent to edentulous
clasp/circumferential clasp space, Distal Extension (2)
Wrought Wire Flexible clasp resulting in less Periodontally compromised/endo-
torque; soldered in position treated teeth, Distal Extension (3)
 - Distal Extension RPDs: rotate when a force is directed on the denture base because of
displacement of the sot tissue of the residual ridge and the ligament of the abutment teeth.
o Altered Cast Technique: records the form of the edentulous segment by means of
the metal RDP framework, which holds the custom tray material -> improves
adaptation of base, equalize stress to ridge and abutments
- Framework Material: Cobalt-Chromium
o 2.3% shrinkage which causes irregularities and porosity
o Chromium prevents corrosion of
o Cold-working/ plastic deformation: involves manipulating the metal while at
ambient temperature -> clasp assembly is cold-worked every time it is seated and
dislodged -> main reason why clasps break; yield strength=cold-working! & high
modulus of elasticity

Fixed Prosthodontics
Inlay: within cusps; less than 1/3 of isthmus is prepared, low caries risk patients

Onlay: covers cusps
- Collar: beveled shoulder around capped cusp for bracing
- Skirt: feather-edge margin
- Provide secondary retention & resistance form
- Beveled Margins: good fit of gold to tooth, strong margin, burnished gold to margin

¾ and 7/8 crowns: hybrid gold restorations between onlay and full crown that conserves tooth
structure, less restorative margin in close proximity to gingival tissues, and more easily seated
during cementation

Crown Tooth Preparation
Occlusal Reduction within occlusal table (cusp
tip to cusp tip along marginal ridges)
Functional Cusp Bevel: 2 planes of reduction on
functional cusps for posterior

#1 lab complaint= tooth is undereduced!!

Three Principles of Tooth Preparation:
Biologic: health of oral tissues
Mechanical: integrity and durability of
restoration
Esthetic: appearance of restoration

- Biologic Concerns
o Mechanical injury: thinnest gingival tissue is lingual molars and facial premolars
o Thermal injury: proximity to pulp; water spray, sharp cutting instruments,
intermittent light pressure
o Chemical injury: soaked retraction cord, certain cements
o Bacterial injury: leakage under crown
o Don’t impinge on Biologic Width!!! BW= 1mm CT + 1mm JE
- Mechanical Concerns
 o Retention form: those features that prevent removal of crown along long axis of the
tooth prep
§ Most important Taper/Parallelism
§ Geometry/surface area of tooth preparation, roughness of fitting surface,
materials being cemented, film thickness of luting agent, grooves
o Resistance Form: features that prevent removal of crown by apical, horizontal, or
oblique forces (occlusal forces)
§ Grooves, cement
o Taper or Parallelism: angle of convergence formed between two opposite
prepared axial surfaces, most operator control, ideal 6-10 degrees
o Height or Length: 3mm minimum for incisors and premolars and 4mm for molars
o Width: MD or FL dimension of base
o Height to Base Ratio: minimum ratio is 0.4; height is more important than width
o Short clinical crown-> buccal grooves for retention, proximal grooves for
resistance
o Reduction vs. Clearance: not always the same i.e. tilted tooth
- Esthetics Concerns: gold>PFM>all ceramic

Crown/Veneer Preparation Measurement
Margin Type Occlusal/Incisal Axial TOC
Reduction Reduction
Metal Light Chamfer Functional: 1.5mm 10-20
0.5mm Non-functional: 1mm degrees
Porcelain/Metal Heavy Chamfer Functional: 2.0mm 1.2-1.5mm 10-20
Labial: 1.2-1.3mm Non-functional: 1.5mm degrees
Lingual: 0.5-0.7mm
All Ceramic Shoulder Anterior: 1.5-2mm 1.2-1.5mm 10-20
Labial: > 1-1.2mm Posterior: 2mm degrees
Lingual: > 1-1.2mm
360 degrees
Zirconia Shoulder 1.0 Functional: 1.5-2mm 1-1.5mm 10-20
360 degrees Non-functional: 1-1.5mm degrees
Central Groove: 1.5mm
Porcelain Gingival: 0.3mm Incisal 1-2mm - -
Veneer Facial: 0.5mm

- 2 Margins: edge of crown and edge of tooth prep
- Margin Types: SupraG>ParaG>SubG
o Featheredge: very acute, thin margin that is less invasive and provides best
marginal seal; insufficient clearance for most materials, difficult to visualize
o Light chamfer: 0.3-0.5mm thick, gold crowns; wide gold collars of PFM crowns
o Heavy chamfer: 1-1.5mm thick, PFM crowns and some all ceramic crowns; if not
given enough room, lab will overcontour crown
o Shoulder: 1-1.5mm thick, porcelain for PFM and all-ceramic crowns; potential for
pulpal embarrassment from aggressive preparation

Pontic Designs


Design Sanitary/ Saddle/ Conical Modified Ridge Ovate
Hygienic Ridge-Lap Lap
Location Posterior NEVER USE Molar Anteriors Anteriors
Mandible
Advantages Good hygiene - Good hygiene, Good esthetics Superior
better Esthetics
esthetics
Disadvantages Poor esthetics, Bad Hygiene - - Requires
Requires VDO surgery
& good
ridge

Connector Design
- Rigid: either cast in one piece or soldered
- Nonrigid: indicated when it is impossible to obtain a common path of insertion between
abutments i.e. male/female
- Connectors for PFM bridges should have a minimum of 3mm height (occlusogingivally)

Occlusal Schemes to Use
- Occlusal point contacts preferred to be broad and flat to prevent wear
- Cusp-marginal ridge: seen in Class I occlusion and with unworn teeth
- Cusp-fossa: seen in Class II malocclusion

Tissue Management of Impressions
- Fluid control: cotton rolls, suction, antisialagogues (Atropine)
- Tissue displacement
o Retraction Cords: stretch circumferential periodontal fibers
o Impregnated cords: AlCl (Hemodent), FeSO4 (Viscostat), Epinephrine
o Electrosurgery: electrode must not contact tooth

Impression Materials
Types Description Precautions
Reversible Changes between sol Pour immediately
Hydrocolloid (Agar) and gel based on temp Use only with stone
with equipment
High accuracy
Problems with
Aqueous*/** moisture
Irreversible Most inaccurate -> Setting time: 3-4mins
Hydrocolloid Diagnostic Casts P->W
(Alginate) Ingredients: Pour within gypsum
diatomaceous earth, in 10mins
potassium alginate
 Polysulfide polymer** Water byproduct Pour within 30-45
mins
Moisture tolerant
(hydrophobic)
Condensation Silicone Alcohol byproduct -> Pour within 30 mins
shrinkage

Non-aqueous Addition Silicone No byproducts, Inhibited by the

(Polyvinyl Siloxane) Best fine detail, elastic sulfur in latex gloves
recovery, dimensional and rubber dam
stability
Polyether* Very stable, very stiff Easily influenced by
-> break teeth off water and humidity
cast (Hydrophilic)
60 mins to pour
*Imbibition: absorption of water
**Syneresis: loss of water

Setting/Working Time for Alginate & Gypsum
- Decrease: hot water, less water, use of slurry water, increased spatulation time
- Increase: cold water, more water, decrease spatulation time
- Burgundy only applies to Gypsum

Gypsum Materials
- Mined as calcium-sulfate dihydrate (CaSO4 * 2H2O)
- Manufactured with heat to get rid of some water to become calcium-sulfate hemihydrate
(CaSO4 * ½H2O)
- All gypsum products are chemically same, but differ in size and shape of particles
- Gauging water: extra water needed to obtain a workable mix of material, does not
chemically react with gypsum
o Increase water: less strength, more porosity, less expansion, increased setting time
o Decrease water: more strength, more porosity, more expansion, decreased setting
time
- Type I: Impression Plaster -> Mounting Stone
o Low expansion, sets quickly
- Type II: Model Plaster: mouth guards and essex retainers
- Type III: Dental Stone: diagnostic casts, removable prostheses
- Type IV: Dental Stone, high strength, low expansion -> best Type!
o Best abrasion resistant, least gauging water, least amount of expansion, used
for fabrication of dies
- Type V: Dental Stone, high strength, high expansion: used for fabrication of dies
- Pouring Gypsum:
o 20 second vacuum mix or 30sec hand spatulate
o Setting time is 45-60mins
o Disinfect with 1:10 bleach solution, glutaraldehyde or iodophor spray
- Gypsum Trend: the greater the type, increase in strength, decrease in porosity

Metal Alloys
- Noble Metals:
o Gold: tarnish resistant
 o Platinum: strength, increases melting temperature
o Palladium: strength
o Silver is not a noble metal (in dentistry) and causes greening of porcelain
- Metal Alloys
o High noble alloys: >60% noble, of which at least 40% gold
o Noble alloys are >25% noble
o Base metal alloys are <25% noble (Ni-Cr, Ni-Cr-Be, Co-Cr, Ti)
- Gold Alloys: the greater the type, increase strength, decrease % gold
o Type I (98-99%): soft, class V restoration , inlay
o Type II (77%): medium, inlays, onlays
o Type III (72%): hard, crowns
o Type IV (69%): extra hard, RPD castings, bridges, post and cores, clasps

Mechanical Properties
- Compressive Strength: ability to resist fracture during compression
- Tensile Strength: ability to resist fracture during pulling
- Flexural Strength: ability to resist fracture during bending
- Fracture Toughness: ability to resist the propagation of a crack; zirconia is the best
(transformation toughening)
- Modulus of Elasticity/Elastic Modulus: measure of stiffness or rigidity
o Stress divided by strain
o Sustain deformation without permanent change in size or shape
- Brittle: fractures easily without substantial dimensional changes i.e. Porcelain
- Ductility (Plastic Deformation): deforms easily under tensile strength i.e. Ortho Wires, Gold
- Malleability: deforms easily under compressive stress i.e. Gold
- Percentage Elongation: ability to be burnished—contact stress locally exceeds the yield
strength of the material i.e. Gold
- Coefficient of Thermal Expansion (CTE): measures the fractional change in size per degree
change in temperature
o So higher CTE means more tendency to change
o Possible break in marginal seal of any restoration becomes imminent when there is
a marked difference between the tooth and restorative material
o High to Low: Composite > Amalgam > Gold (14, best!) > Tooth (11.4) > Ceramic
- Desirable Mechanical Properties:
o High yield strength
o High elastic modulus
o Casting accuracy: gold > base metal
o CTE close to that of tooth
o Biologic compatibility—Nickel and Beryllium allergies
o Corrosion resistance: the more noble, the more resistant
o Minimal wear of opposing dentition

Provisional Crown
- Biologic: protects tooth, maintain periodontal health
- Mechanical: maintain occlusal stability and tooth function
- Esthetics
- Method
o Direct: made in patient’s mouth
o Indirect: made in lab setting on a cast
- Mold
 o Prefabricated crown: polycarbonate, aluminum, stainless steel
o Cellulose acetate crown form (clear crown)
o Putty or shim
- Material
o PMMA (Acrylic): indirect, exothermic
o PEMA
o Bis-acyrl Composite (LuxaTemp): direct
- Remove Provisional Crown & Clean the Prep: provisional cements have Eugenol which
inhibits polymerization of resin

Metal-Ceramic Crowns (PFM)
- Bonding of Porcelain to Metal: monomolecular oxidative layer must be present for
porcelain to bone to the alloy
- Opaque Porcelain: masks dark oxide color, provides porcelain-metal bond, masking must
be accomplished with minimum thickness (0.1mm)
- Body or dentin Porcelain: contains most of the shade, builds up most of the crown
- Incisal/Occlusal or enamel Porcelain: most translucent layer
- Metal-porcelain junction should be rounded right angle to avoid porcelain fracture.
- Occlusal contacts must be >1.5mm away from porcelain-metal junction
- PFM Failures
o Adhesive: oxide layer not formed, contaminated
o Cohesive: voids in porcelain, too thick of oxide layer
o Long span PFM bridges: fracture under flexure due to porcelain’s low ductility

All Ceramic Crown
- Esthetics
- Glass infiltrated ceramics are etched with HF acid and treated with silane coupling agent
(enhance bonding to tooth surface) and bonded to the tooth
- Ceramics with no glass content are luted to the tooth with cement (Zirconia, Alumina)

Porcelain Veneer: intra-enamel preparation

Maryland Bridge (Resin-Bonded Bridge): requires less removal of tooth structure than other FPD,
can experience debonding

Shade & Shade Selection
- Hue: color family (i.e. Red, Blue)
- Chroma: saturation or intensity of color (i.e. Dull Blue or Vibrant Blue)
- Value: lightness or darkness, most important; measured from 0 (black) to 100 (white)
- Effect of Light Source
o Metamerism: color appears different under different lighting; 5500K and 100% CRI
is ideal light
o Fluorescence: object emits visible light when exposed to UV light
o Opalescence: light effect of a translucent material appearing blue in reflected light
and red-orange in transmitted light (Incisal edge)
- Shade Selection
o (1) Value -> Middle Third
o (2) Chroma -> Cervical Third
o (3) Hue -> Incisal Third
- Characterization
 o Staining: decreases value; loss of fluorescence and increases metamerism
o Glazing: surface layers of porcelain melt slightly coalescing particle and filling in
defects
o You can always add more color (lower chroma) and make something darker
(higher value), but not the reverse

Steps of Crown Delivery
1. Shade (esthetics)
2. Proximal contacts (Open -> send back, heavy -> adjust)
3. Margins
4. Fit
5. Retention & Resistance Form
6. Occlusion
7. Contour
8. Cement

Dental Cements (Luting Agents)
Types Advantages Disadvantages Uses
Zinc Oxide Eugenol Soothes pulp - TempBond
(ZOE)

Zinc Phosphate History of use Phosphoric Acid Mix on chilled glass

irritates the pulp slab due to
exothermic reaction
Zinc Polycarboxylate - Minimal pulpal Chelation to calcium
irritation
Glass Ionomer (GI) Releases fluoride - Adheres to enamel
and dentin
Resin Modified Glass Higher strength and Can’t be used with -
Ionomer (RMGI) lower solubility than Ceramic crowns due
GI to expansion from
water absorption
(Zirconia is exception)
Resin: Composite & Most compressive - Light-cure cement is
Adhesive strength more color stable
Bonds to dentin than dual cure
cement, Light,
Chemical, Dual
Cement Trend: Going down the list, increase technique sensitivity, decrease solubility, increase
strength

Crown & Cement Armamentarium
1. Zirconia (Ceramic but no Silica)
2. Metal (PFM or Full Gold)
3. Lithium Disilicate (E-max)
4. Feldspathic Porcelain (Veneers)
- Resin cement: 3&4, chemical bond dentin – bond – resin – silane – silica (HF) (for repair,
do reverse order)
o Lithium Disilicate -> dual-cure resin cement
 o Feldspathic Porcelain -> light-cure resin cement
- Luting Cement (GI or RMGI): 1 &2, fluoride release and less post-op sensitivity

Lab Processing
- Die: exposes the margin
- Die Spacer: room for cement
- Positive (Tooth, Cast)
- Negative Reproduction (Impression)
- Waxing the Crown on Die: positive
- Spruing: making a path with wax for metal to go into the prosthesis as it is being casted;
attach to crown in area of biggest bulk
- Investing: make negative by covering wax with investment material
o Gypsum-bonded investments -> Gold
o Phosphate-bonded investments -> PFM
o Silica-bonded investments -> Base Metal
- Burnout: melt out wax to leave room for the metal to take its place
- Casting: positive; melt metal into investment
- Recovery: positive; retrieving cast framework by breaking open the investment
- Quenching: very hot cast metal immediately placed in cool water to make more malleable
for finishing
- Porosity Issues:
o Porcelain -> inadequate condensing
o Acrylic -> too fast heating
o Shrinkage of Metal -> too thin sprue prevents molten metal from flowing effectively
into mold
o Back-pressure of metal -> too short sprue prevents venting of gas, gas will still
present in an area prohibiting fluid from flowing in


 Orthodontics & Pediatric Dentistry

Pediatrics
Odontogenesis
- Initiation: 6 weeks in utero; defects -> congenitally missing, supernumerary
o Oral epithelium: outer layer
o Dental lamina: first evidence of forming, budding teeth
o Ectomesenchyme: signals overlying oral epithelium to proliferate into dental lamina
- Bud Stage: 8 weeks in utero; defects -> congenitally missing, supernumerary
o Dental placode: proliferating bud
§ Primary and permanent molars arise from dental lamina
§ Permanent incisors, canines, and premolars arise from their primary
predecessor
§ Condensing mesenchyme
- Cap Stage (Proliferation): 9 weeks in utero; defects -> cyst, odontoma, gemination,
fusion, dens in dente, fusion
o Enamel organ (enamel): outer cell layer (OEE), inner cell layer (IEE), Stellate
reticulum (between layers), enamel knot (cusps tips)
o Dental papilla (dentin and pulp)
o Dental follicle: surrounding sac
- Bell Stage11 weeks in utero
o Histodifferention:; defects -> amelogenesis imperfecta, dentinogenesis
§ Transformation into distinct cell types: IEE -> ameloblasts, dental papilla ->
odontoblasts
o Morphodifferentiation: defects-> peg laterals, mirco/macrodontia, etc
§ Shape and size of eventual crown is determined during this process
- Apposition: 14 weeks in utero; defects -> enamel hypoplasia, enamel pearls,
concrescence
o Odontoblasts deposit dentin matrix (collagen)
o Ameloblasts deposit enamel matrix (amelogenin)
o Cervical loop: where IEE and OEE join
§ Hertwig’s epithelial root sheath (HERS)
§ Epithelial rests of Malassez
o IEE + OEE= REE (junctional epithelium)
- Maturation/Calcification: 14+ weeks in utero; defects -> enamel hypomineralization,
fluorosis, tetracycline staining
o Deposition of enamel and dentin
o Calcification begins at cusp tips/incisal edges and proceeds cervically
o Takes 2 years to complete for primary tooth crown
o Takes 4-5 years to complete for permanent tooth crown
- Summary
o Enamel -> Ameloblasts
o Dental Papilla: Odontoblasts -> dentin, Central cells -> pulp
o Dental Follicle
§ Cementoblasts -> cementum
§ Osteoblasts -> alveolar bone
§ Fibroblasts -> PDL


Important Trends to Memorize Charts:
- Calcification Start Times for Primary Teeth: ADBCE -> 14, 15, 16, 17, 18
- Calcification Start Times for Permanent Teeth: Eruption Sequence by time intervals of 6
months (6,1, L2,3,U2,4,5,5,7 -> 0,6,12,18,24,30)
- Eruption of Primary Teeth: A-B-D-C-E
- Eruption of Permanent Maxilla: 6-1-2-4-5-3-7
- Eruption of Permanent Mandible: 6-1-2-3-4-5-7
- Eruption Times of Permanent Teeth:
o Mandible before Maxilla
o Female before Male
o 2-3 Rule: Tooth will erupt once crown is completely calcified, through bone
when 2/3s of the root has formed & through gingiva when ¾ formed & takes
2-3 years for it to be complete after eruption

Development Disturbances of Teeth
Number Size Shape Structure
Supernumerary Microdontia Dens Evaginatus Enamel Hypoplasia
Congenitally Missing Macrodontia Dens in Dente Enamel Hypocalcification
Fusion (Invaginatus) Amelogenesis Imperfecta
Gemination Taurodontism Dentinogenesis Imperfecta
Dilaceration Dentin dysplasia
Regional odontodysplasia
G=Generalized Concrescence
L=Localized Enamel Pearl

- Supernumerary Teeth: most common is mesiodens
- Congenitally Missing Teeth
 o Permanent: Third Molars> Mandibular 2nd PMs > Maxillary Laterals> Maxillary
2nd PMS
o Primary: Maxillary Lateral Incisor is the most common
- Microdontia: small teeth; associated with down syndrome (G), pituitary dwarfism (G),
ectodermal dysplasia (G), peg-shaped laterals (L)
- Macrodontia: big teeth; associated with pituitary gigantism (G), pineal hyperplasia with
hyperinsulinism (G), hemifacial hyperplasia (L)
- Fusion: two buds merge into one tooth (1 crown, 2 roots); more common in primary
anterior teeth
- Gemination: one root buds into two crowns
- Dens Evaginatus: extra cusp called talon cusp in anterior teeth containing all dental tissues
- Dens Invaginatus/Dens in Dente: invagination of IEE; caries progress very quickly through
tunnel; most common in permanent maxillary lateral -> radiograph to confirm
- Taurodontism: vertically elongated pulp chamber and short roots; associated to type IV
amelogenesis imperfecta
- Dilaceration: abnormal bend in root; due to trauma injury to primary tooth
- Enamel hypoplasia
o Turner’s: PA infection or trauma to primary tooth causes inflammatory response
that messes up ameloblasts of developing permanent tooth
o Congenital Syphilis: Hutchinson’s incisors (hypoplastic notch) & Mulberry molars
(globular enamel)
- Enamel hypocalcification: abnormal mineralization resulting in white spots
- Amelogenesis imperfecta
o Autosomal dominant, recessive, or X-linked
o Intrinsic alteration of enamel
o All teeth from both dentitions are affected
o Thin to no enamel, but dentin and pulp are normal
o Tx: crowns for esthetics
- Dentinogenesis imperfecta
o Autosomal dominant
o Intrinsic alteration of dentin
o All teeth from both dentitions are affected
o Short roots, bell-shaped crowns, and obliterated pulps
o Bulbous crowns in radiographs due to constricted DEJ
o Blue sclera
o Tx: crowns for esthetics
- Dentin dysplasia: autosomal dominant, intrinsic alteration of dentin
o All teeth from both dentitions are affected
o Short roots (Type I) and chevron pulps (Type II)
o Teeth are not good candidates for restorations
- Regional odontodysplasia: ghost teeth
o Quadrant of teeth exhibits short roots, open apices, and enlarged pulp chambers
o All teeth from both dentitions are affected
o Tx: support eruption, extract affected teeth
- Concrescence: union of two adjacent teeth by cementum only -> most common with
maxillary molars; linked with hypercementosis
- Enamel pearl: chunk of enamel blocking attachment of Sharpey’s fibers only in molars;
patient will automatically have a periodontal pocket -> not come off with scaling

Primary Tooth Anatomy
 - Thinner enamel/dentin
- Bigger pulp
- Whiter
- Occlusally directed enamel rods
- Cervical bulge
- More divergent roots
- Small or absent root trunk
- Wider mesio-distally and shorted inciso-gingivally
- Specifics for each Tooth:
o Max Central: widest anterior MD, only anterior that width > height
o Max Canine: widest anterior FL, longer and sharper cusp
o Max 1st Molar: prominent MF cervical ridge -> CEJ dips more on mesial; resembles
permanent 1st premolar
o Max 2nd Molar: widest FL, resembles permanent max 1st molar
o Man Central: smallest FL
o Man 1st Molar: most unique tooth, CEJ dips more on mesial, ML ice cream cone cusp,
MB cusp is largest
o Man 2nd Molar: widest MD, resembles mand 1st molar

Local Anesthesia
- 4.4mg/kg is maximum recommended dose of anesthetic
- IAN -> lower teeth
- PSA -> molars
- ASA -> anteriors

Treatment Options
- Amalgam: 1.5mm deep, extend into pits and fissures, isthmus width is 1/3 intercuspal
dimension
- Composite: area of failure is at gingival margin
- Stainless Steel Crown: teeth affected by extensive caries especially past the axial line
angles
o 1mm occlusal reduction, break axial contacts mesio-distally
o Seat from lingual to buccal
o Cervical bulge provides retention
o Allows primary tooth to function until exfoliation (never use as permanent
restoration)
- Strip Crown: primary incisors with proximal caries that approximates of involves incisal
edge
o Good choice if adequate tooth remaining for bonding and esthetics
o Celluloid crown form
o 1mm incisal reduction
o Caries dictates preparation design
- Endodontic Treatment: treatment: refer to pgs. 4-5

Space Management
- Interdental Space: most frequently caused by growth of dental arches
- Arch Length: distance from the contact point from central incisors to mesial contact from
permanent 6s
- Space maintenance not necessary if no bone remaining between primary and permanent
tooth (months left for eruption of permanent tooth)
 - Loss of Teeth & Treatment: Cs and Es most important to maintain space
o As,Bs: kiddie partial for speech or esthetics but not necessary
o Cs: causes lingual collapse of incisors -> loss of arch length
§ Tx: Lower lingual holding arch (LLHA, Man) or Nance holding arch
(Max) from 6; LLHA need to wait for 1,2s to erupt so they aren’t trapped by
appliance
o Ds: tx with band and loop, LLHA, or Nance
o Es: tx with distal shoe from Ds to unerupted 6 or LLHA or Nance if 6s present; band
and loop will not work because Ds erupt first so won’t hold space when exfoliates
first
- Eruption Timing Variations
o Lower 7s ahead of 5s -> loss of leeway space for 5s and may result in impaction, use
space maintainer to hold molars back
o Upper 3s ahead of or alongside 4s -> 3s forced labially, vampire fang
o Asymmetries between R & L -> about 6 month is normal, extract contralateral
primary if there is early exfoliation to keep midline
- Rule of 7
o Primary molar lost before 7 -> eruption of premolar is delayed
o Primary molar lost after 7 -> eruption of premolar is accelerated
- Space Closure: occurs within first 6 months after tooth loss
o Tipping not bodily movement
o Active eruption of a neighboring tooth tends to increase amount of space loss
- Ectopic Eruption: permanent tooth erupting along the wrong path
o 1s, 2s
§ Lingual -> double row of teeth, will resolve on their own unless over-
retained As
§ Lateral -> due to early exfoliation of Bs, extract contralateral B ASAP to avoid
midline deviation
o 3s
§ Can lead to canine impaction, resorb lateral incisor
§ Tx: extract primary canine
o 4s, 5s
§ Distal -> most common in man 5s where it resorbs only distal root of Es
§ Buccal/Lingual -> very common, extract D/E if it is not ready to exfoliate
within a few weeks
o 6s
§ Mesial -> get impacted underneath the distal of Es
§ Tx: upright erupting molar, Spacer, Halterman appliance
§ Most common in max
- Ankylosed Ds, Es
o Prevalence: 1% AA, 4% Caucasian, more common in mandible, Es > Ds
o Diagnosis: out of occlusion since other teeth continue normal eruption, no mobility,
hollow sound when tapped, radiographic loss of PDL space
o Usually no tx required, but if adjacent teeth are drifting resulting in space loss,
extract and use space maintainer

Soft Tissue Specific to Just Children
- Eruption cyst: most common around incisors and mandibular first molars; presents as
bump on crest of alveolar ridge where tooth should be; tx: incision if symptomatic

Child Abuse and Neglect
- Ages 0-3 are most commonly abused or neglected
o Physical: intentional injuries
o Emotional: denial of affection, isolation
o Neglect: willful negligence to provide basic needs of a child
- Dentists are required by law to report suspected child abuse and neglect, even if there
is no proof

Child Behavior
- Cooperative: communicative, comprehending, willing with minimal apprehension
- Potentially Cooperative: capable of appropriate behavior but are disruptive in dental setting
o Defiant: any age, spoiled and stubborn, do not like to be advised by adults
o Uncontrolled: 3-6yo, tantrums
o Timid: 3-6yo, may hide behind parents (shielding), may deteriorate into
uncontrolled
o Tense-cooperative: 7yo or older, white knuckler, want to behave but very nervous
o Whining: continuous, usually no tears
- Uncooperative: not communicative, comprehending or willing i.e. infant, disabled
- Frankly Rating Scale
o 1: Definitely negative -> refusal/distress
o 2: Negative resistance -> uncooperative/reluctant
o 3: Positive acceptance -> cooperative/reserved
o 4: Definitely positive -> interested/enjoyed
- Anticipatory Guidance: age-appropriate counseling for patients and their parents focused
on prevention; first visit should be by 1yo
o Child <6yo supervised when brushing with fluoride toothpaste
- Familiarization: no tx dental visit with an emphasis on introducing the dental setting and
common instruments
- Knee-to-Knee Exam: for infants (<2yo); clinician and parent in a knee-to-knee position
with the child’s head in the dentist’s lap
- Five Domains of Pediatric Patient Management
o Physical: papoose board, belt, tape
o Pharmacological: anesthetics, sedatives, nitrous oxide
o Reward-oriented: reinforcement
o Aversive: punishment
o Linguistic: communication
- ADHD
o More common in boys, most commonly appears 3-6yos
o Medications: Methylphenidate (Ritalin), Atomoxetine (Strattera),
Amphetamine (Adderall)
- Autism Spectrum Disorder: condition related to brain development that impacts how a
person perceives and socializes with others; wide range of symptoms -> repetitive
behavior, heightened sense of light and sound

Digit sucking
- Very common up to 3yo
- Depends on time per day, duration, and intensity
- Effects are increased overjet, anterior open bite, maxillary constriction, and posterior
crossbite
- Intervention with appliance therapy recommended by 5-6yo
 - Crib: stainless steel fixed reminder appliance in anterior palate region
- Bluegrass: fixed reminder appliance with roller in anterior palate region

Natal and Neonatal Teeth
- Natal teeth: present at birth
- Neonatal teeth: erupt within first 30 days
- most common are As
- Riga-Fede disease: baby tooth causing ulceration on ventral tongue, smooth or extract it
- May cause nursing difficulties

Early Childhood Caries (ECC)/Baby Bottle Syndrome
- Any dmft on patient younger than 6yo (birth and 71mos)
- Mostly involves maxillary incisors and molars
- 5% of US infant and toddler population
- Breastfeeding/bottle before bed should be stopped after first tooth erupts
- Other causes: fruit juice consumption, chronic antibiotic use with high sucrose content
- Recommendations
o Infants should drink from a cup as they approach 1yo
o First visit by 1yo
o Smear of toothpaste before 2yo
o Pea of toothpaste between 2-5yo

Orthodontics
Prevalence of Malocclusion
- Class I Normal Occlusion: 30%
- Class I Malocclusion: 50-55%
- Class II Malocculsion: 15%
- Class III Malocculsion: ~1%

Growth: Bone Formation and Sites of Growth
- Endochondral bone formation: cranial base (ethmoid, sphenoid, occipital), mandible;
cartilage -> bone
- Intramembranous bone formation: cranial vault, maxilla, mandible; secretion of bone
matrix within CT
- Cranial Vault: bones are separate by loose CT at fontanelles -> apposition of bone along
edges of fontanelles -> bone separated by cranial sutures
- Cranial Base: ossification of CT -> 3 bands of cartilage that act as growth centers remain ->
intersphenoid, sphenoethmoid, and sphenooccipital synchondroses -> inactive at 3,7, and
later respectively
- Maxilla: growth occurs posterior and superior to suture and grows downward and forward
away from cranial base through surface remodeling and adds bone posteriorly at the
tuberosity for posterior teeth eruption
- Mandible: most growth of the mandible occurs by new bone forming at the condyle and by
resorption of the anterior part of the ramus with apposition posteriorly
- Nearly all tissue from head and neck derive from ectoderm

Timing of Growth
- Cephalocaudal gradient of growth: the further from the brain -> more growth
- Scammon’s growth curves
 o Neural tissue: stop growing by 6-7yos
o Lymphoid Tissue: stop growing by 10yos, involute during puberty
o Genital: grow at puberty spurt
o General: grow fast during birth and puberty
o Maxilla & Mandible: maxilla grows earlier/faster and follows a pattern closer to that
of neural tissue while the mandible parallels the puberty spurt
- Growth velocity curve: growth is rapid after birth and during puberty
- Sex differences: girls reach their peak 12yos, boys at 14yos; the earlier the peak -> shorter
the duration of spurt and less growth occurs
- Physical growth predicated through skeletal age -> hand-wrist radiograph revealing
ossification is standard for assessing skeletal development

Development of Occlusion
- Gum Pad Stage: birth-6/7mos
- Primary Dentition: 6mos-6yrs;
o Overbite: vertical overlap develops as teeth
erupt; normal is 10-40%
o Open bite: lack of overbite
o Overjet: horizontal distance between
maxillary and mandibular teeth; normal is
0-4mm
o Spacing: extra space helps accommodate
larger sized permanent teeth as they erupt
o Primate spaces: between 1.5mm space
between lateral incisor and canine in
maxilla and between canine and 1st molar in
mandible -> account for space in permanent
incisors
o Know primary molar relationship chart! Normal is light grey arrow
o Molar relationship: about 90% of children have a flush terminal plane or 1mm or
greater mesial step
- Mixed dentition stage: >6yos
o Ugly duckling stage: centrals erupt, move labially, and temporary diastema of 1-
2mm -> permanent canines fix this
o Proximal contacts are tight
o Leeway space: difference in MD size between primary canine, 1st and 2nd molar and
their permanent replacement; 1.5mm per side in maxillary, 2.5mm per side in
mandible
o Early Mesial Shift: spaced dentition with flush terminal plane; when permanent
molar erupts -> primate space closes -> decrease in arch length
o Late Mesial Shift: no space exist; when permanent molar erupts -> not able to close
space -> uses Leeway space
o Mixed Dentition Analysis: predicts amount of crowding or tooth size-arch length
deficiency in permanent dentition
o Moyer’s Mixed Dentition Analysis: combined MD widths of mandibular
permanent incisors used to predict combined MD widths of patient’s 3, 4, 5
o Tanaka-Johnson analysis: same as Moyer’s -> divide the total tooth size of incisors
by 2 and add 10.5mm
- Permanent dentition: curve of Spee and Wilson present, overbite, overjet

Dimensional changes in arch:
- Maxillary Intercanine Width: increases
- Mandible Intercanine Width: increases than decreases from 13-45yos
- Maxillary & Mandibular Intermolar Width: increases than decreases by 1mm form 13-45yo
- Maxillary & Mandibular Arch Length: small decrease in arch length -> incisors more upright
and lost of leeway space
- Circumference: in mandible decreases significantly, maxillary increases a little bit

Orthodontic Diagnosis:
- Anterior Posterior—Angle’s Classification:
o Class I Normal: MB cusp of max 1st molar in buccal groove of man 1st molar
o Class I Malocclusion: same as normal but intraarch relationships abnormal
o Class II: MB cusp anterior/mesial to buccal groove
§ Division 1: Max incisors flared
§ Division 2: max incisors upright (laterals flared) and deep overbite
o Class III: MB cusp posterior/distal to buccal groove
o Overjet: normal, (1-3mm), excess (II), reverse (anterior crossbite, III)
- Vertical (Overbite): normal (20-30%), deep (>50%), or open
- Width (Transverse, Posterior Crossbite)
o Normal: maxillary L cusp in mandibular fossa
o Crossbite or lingual crossbite: maxillary B cusp in mandibular fossa
o Complete lingual crossbite: whole maxillary lingual to mandibular
o Complete buccal crossbite: whole maxillary buccal to mandibular
- Frontal Esthetics: R/L symmetry and proportions, vertical proportions, lip
posture/competence (touching), incisor show at rest (2-4mm), gingival show on smile (1-
2mm)
- Profile Examination
o Convex: retrognathic, II, full lip, acute nasolabial angle
o Straight: average, I, perpendicular nasolabial angle
o Concave: prognathic, midface deficient, III, flat lip, obtuse nasolabial angle
o Brachycephalic: broad-head
o Mesocephalic: medium-head
o Dolichocephalic: long-head
- Skeletal: Cephalometric reference planes & Measures
o S-H: anterior cranial base
o Frankfort Horizontal: Po-Or; porion (midpoint of upper contour of external
auditory meatus) to Orbitale (point between orbits)
o Occlusal Plane
o Mandibular Plane: Go-Me or Go-Gn
o SNA (82 +3): anterior-posterior position of maxilla—bigger -> excessive maxilla
(II)
o SNB (79 +3): anterior-posterior position of mandible—bigger -> mandible
prognathic (III)
o ANB (3 +2): SNA-SNB—more positive -> II, convex; more negative -> III, concave
o MP-SN: mandibular plane angle—bigger -> long face and anterior open bite
o Y-axis: S-N to S-Gn—bigger ->long face and anterior open bite
o 1/-Sn: upper incisor angulation; bigger -> more flared
o /1-MP: lower incisor angulation; bigger -> more flared
o Interincisal angle

Treatment Planning: impacted teeth are high priority, esthetic and occlusal are next; interarch
problems > intraarch problems

Biology of Tooth Movement
- Force system is applied on crown -> transmit through bone & PDL -> continuous force
applied for minimally acceptable period of time to elicit biologic response
- Heavy or light force determines pathway of tooth movement and formation of hyalinized
zone undermining resorption
- PDL remodels significantly during orthodontic tooth movement
- Pressure or compression side: side tooth is moving towards, side of resorption of bone
- Tension side: side opposite tooth is moving towards; apposition of bone and widen PDL
occurs
- Areas of resorption may also undergo appositional remodeling if tooth movement changes
direction and pressure side of the alveolus undergoes tension
- Different type of movements -> different stress distribution in PDL and
resorption/apposition areas
o Intrusion: compression PDL is concentrate at apex of tooth
o Tipping: crown and apex move in opposite directions -> 2 compression sites
(cervical area on side towards movement and apical on side opposite) & 2 tension
areas (opposite of compression)
o Translation or bodily movement: 1 side of PDL experiences compression
(towards) and other tension (opposite)
- Heavy Force: delays tooth movement by creating lag period after initial movement of tooth
within PDL—significant hyalinized area
- Light Force: causes smooth, continuous tooth movement without formation of significant
hyalinized zone in PDL; move earlier
- Give patients Acetaminophen for pain!!
- Root resorption: heavy forces> light forces
- Rapid Acceleratory Phenomenon: trephinations in bone to allow movement of teeth faster

Mechanical Principles in Tooth Movement
- Forces: vectors acting anywhere on line of action (pulling is the same as pushing)
o Force acting through center of resistance of tooth -> Pure Translation
o Healthy Tooth Center of Resistance: one half the distance from alveolar crest to
root apex -> about 10mm from where a bracket would be located
o Periodontal Compromised Center of Resistance: more apical due to loss of
attachment
- Moments: tendency to rotate, force applied to any point other than center of resistance
o 1st order -> rotation, 2nd order -> tipping, 3rd -> torque
o Center of rotation: point which tooth appears to have rotated after movement
complete
o M=Fd; M for Moment, F for magnitude of applied force, d for distance
- Couples: 2 equal and opposite, noncollinear forces -> Pure Rotation
o Tooth rotates about its center of resistance regardless of point of application of
couple
o Engaging wire in edgewise bracket slot
- Equivalent force systems: what tooth will feel at center of resistance secondary to force
systems applied at bracket
- Types of tooth movement:
 o Pure rotation: couple -> rotates around center of resistance; center of rotation =
center of resistance
o Tipping (uncontrolled): crown tips in direction of force, apex opposite; center of
rotation is apical to center of resistance
o Crown movement (controlled tipping): tipping plus small couple; center of
rotation at root apex; difficult and slow
o Pure translation: force plus large couple; center of rotation so far apical translates
without tipping; difficult and slow
o Root movement: force plus even larger couple; center of rotation at the crown;
most difficult and slowest
- Static Equilibrium: for every action, equal and opposite reaction (Newtons 3rd Law);
Appliances: Forces + Moments = Zero
o Equal and Opposite forces: elastic band, coil spring stretched between brackets
o One-couple appliances: couple produced at engaged end of bracket
o Two-couple appliances: bracket at both ends; couple largest at end closer to bend in
wire or more angled bracket in straight wire
- Anchorage: resistance to movement; anchorage value is equivalent to root surface area
o Reciprocal tooth movement: two equal value teeth or groups of teeth moved
against each other and move the same amount toward or away from each other
o Reinforced anchorage: additional teeth to a unit to distribute force over greater
area and slowing movement
o Stationary anchorage: anchor teeth undergo translation or root movement while
reactive area undergoes tipping
o Cortical anchorage: anchor teeth moved into cortical bone
o Implants for anchorage: provide absolute anchorage; palatal, miniscrews,
temporary anchorage devices (TADs)

Orthodontic Materials
- Edgewise Brackets: 0.018 inch x 0.025 inch, 0.022 inch x 0.028 inch
- Stainless Steel Wire material proprieties: ductile
o Stress-strain relationship: response of a wire to force per cross-sectional area
(stress =F/A) -> deformation of wire due to stress (strain= change/original)
- Ideal: high strength, low stiffness, high working range, high formability
- Wire: doubling length -> decrease strength by half, 8x less stiff, 4x range; doubling diameter
-> 8x stronger, 16x stiffer, working range decreased by half
- Wire selection: large movements: low load/deflection rate; minimal movements: high
load/deflection rate
o Wire material: Load/deflection rate is proportional to modulus of elasticity
§ Stainless steel -> highest modulus of elasticity, excellent corrosion
resistance, lowest springback
§ Nickel titanium -> lowest load/defection rate, wide working range
§ Beta Titanium (TMA): intermediate modulus of elasticity, wide working
range, high formability; con: high coefficient of friction
o Wire cross section: load/deflection rate varies directly with the fourth power of the
diameter of round wire and third power of width of rectangular wire
o Wire length: load/deflection rate inversely with third power of length
§ Increasing interbracket distance by loops or helices into archwire decreases
load/deflection rate

Orthodontic Appliances
- Straightwire/Preadjusted edgewise appliances
o Rotational control: bracket wings, rotational arms in single wings
o Horizontal control: varying thickness of bracket base for teeth of different thickness
o Mesiodistal tip control: slot of the bracket is angulated relative to base of bracket for
tipping
o Torque: slot is angulated labiolingually to provide root & crown movements
§ Metal, ceramic, self-ligating brackets
§ Bands in molars
§ Bonding
- Appliances to modify the growth of the maxilla and the mandible; growth modification is
most successful in pre-adolescent children with good compliance and growth potential
o Headgear: modify growth of maxilla, distalize maxillary teeth, reinforce anchorage
§ High-pull: restrict growth of maxilla, distal movement of molars, intrusion,
control maxillary molar eruption for class II
§ Cervical-pull: restrict anterior growth of maxilla and distalize and erupt
maxillary molars for class II
§ J-hook: used to retract canine and incisors
§ Protraction/reverse pull/ facemask: exert downward and forward pull on
maxilla to correct class III
§ Chin cup/cap: restrain mandibular growth to correct class III
- Functional Appliances: correct class II by restraining maxilla and displace mandible and
allowing mandible growth continue
o Herbst: fixed/removable; can cause mandibular incisors to flare
o Activator: removable; tip anterior teeth and control eruption of teeth vertically
o Bionator: removable
o Twin block: removable/fixed
o Mandibular anterior repositioning appliance (MARA)
- Noncompliant appliances: correct class II malocclusions in full or end-on occlusion,
crowding (0-6mm), profile or other characteristics that do not support extraction
o Pendulum: can expand palate if needed
o Forsus Fatigue Resistant Device
- Aligners
- Appliances to correct posterior crossbites: maxillary or palatal expansion; rapid
(0.5mm/day) or slow (1mm/week) expansion
o Hyrax appliance: banded; most commonly used rapid expansion with retention for
3-6mos
o Haas, Hawley type removable with jackscrew
o Quad-helix/W-arch: symmetrical or asymmetrical expansion and correcting
rotated molars
o Transpalatal arch: expansion or constriction of intermolar width, root movement
of 1st molars, derotation of teeth, anchorage reinforcement
- Appliances in Mixed Dentition
o Nance: space maintainer
o Lower lingual arch: anchorage reinforcement, space maintainer, expansion,
increasing dental arch length
o Lip bumper: control or increase mandibular arch length, to upright mesially or
lingually tipped mandibular molars, prevent interposition of lower lip between
maxillary and mandibular incisors
- Appliances used to control vertical incisor position
o Intrusion arch: correct deep bite; extrude molars, intrude incisors
 o Extrusion arch: correct open bite; intrude molars, extrude incisors
- Elastics: force for tooth movement
o Class I: same arch sliding mechanics
o Class II: cross arch anterior maxillary to posterior mandible to correct class II,
reduce overbite by extruding molar, retract anterior teeth, minimize anchorage loss
in maxilla
o Class III: cross arch posterior maxillary to anterior mandible to protract posterior,
improve overjet in edge-to-edge or anterior crossbite, anchorage for retraction of
mandibular incisors
o Crossbite: palatal of maxillary to buccal of mandible; cause extrusion
o Anterior diagonal elastics: one side of max teeth to cross midline mandibular teeth
to fix noncoinciding midlines

Early Treatment
- Crowded/irregular teeth
o Space maintenance
o Space regaining (<3mm): removable appliance with finger springs to tip teeth
distally, headgear (maxillary), activated lingual arch (mandibular), lip bumper
(mandibular)
o Moderate (<4mm): arch expansion, extract primary canines, flare incisors
o Severe (>4mm): arch expansion,
§ Serial extraction: timed extraction of primary and permanent teeth
reserved for large space discrepancies (>10mm); A -> C -> D -> 4
- Anterior spacing
o Diastema <2mm: self corrects
o Diastema >2mm: fixed appliances; wait until permanent canines to erupt -> close
space -> then remove frenum
o Generalized: postpone tx
- Eruption problems
o Overretained primary teeth: extract
o Ankylosed primary teeth: resorbs or extract
o Ectopic eruption -> refer to Pediatric section
- Missing teeth: for mandibular 5s -> retain E; for max 2s -> substitute with 3s or restore
- Occlusal relationship
o Posterior crossbite: unilateral due to mandibular shift (midline deficiency
reflected on affected side)-> equilibration or maxillary expansion
o Anterior crossbite: skeletal -> protrude maxilla or retrude mandible; dental
(mostly 2s)-> create space with appliances
o Maxillary dental protrusion with spacing: skeletal, digit sucking -> removable
appliance
o Deep bites: bite plates to open posteriorly but if need intrusion delay tx
o Oral habits and open bites: cease before permanent tooth eruption

Growth Modification
- Successful growth modification can occur only during periods of growth; early modification
often requires retreatment
- Mandibular deficiency (II): headgear, functional appliances to accelerate mandible
- Vertical deficiency (Short Face): cervical headgear, functional appliances erupt upper and
lower posterior teeth
 - Vertical excess (Long Face): high-pull headgear, functional appliances block posterior
eruption
- Maxillary deficiency: before puberty!; transverse -> expansion, anterior-posterior (II)->
facemask headgear
- Mandibular excess: chin cup/cap headgear restrain mandibular growth
- Facial asymmetry: functional appliances, early surgery

Comprehensive Treatment
- Extraction vs Non-extraction:
o >10mm crowding, overbite, flared incisors, full lips, acute nasolabial angle, anterior
recession
o Camouflage class II or III by extracting in only 1 arch -> extract upper 4s for II, upper
4s for III
- Stages: Alignment, Overbite Correction- Leveling, Correct Molar Relationship, Space
Closure, Root Correction, Detailing and Finishing, Retention
- Special Considerations: IPR for large teeth, buildup for small teeth, headgear at night for
skeletal II or III
o Supracrestal Fiberotomy: cutting supercrestal, transseptal, gingival fibers to
reduce exertion of some elastic force that may move teeth after treatment,
especially rotation

Retention
- Allow time for reorganization of gingival and periodontal factors; full time first 3-4mos, part
time for 4mos-12mos
- Prevent soft tissue pressure alter tooth position
- Hold new position until growth completed
- Removable retainers: Hawley, wraparound, positioner
- Fixed retainers: lingual wire
- Active retainers: realignment of irregular teeth

Combined Surgical and Orthodontic Treatment
- Orthodontics is performed to align the teeth within each arch and remove compensations
in the dentition that may mask the underlying skeletal discrepancy
- Remove third molars 6->9 months before surgery
- Anterior-Posterior Corrections
o Maxillary Surgery:
§ Advancement -> Le Fort I -> correct Class III
§ Setback -> Segmental Osteotomy with 4s extracted -> correct Class II
o Mandibular Surgery:
§ Advancement -> BSSO -> correct Class II
§ Setback -> BSSO -> correct Class III -> limited use, advance maxilla instead
- Vertical Corrections
o Maxillary Surgery
§ Superior repositioning -> Le Fort I -> correct Open Bite
§ Inferior repositioning -> Le Fort I -> correct Deep Bite -> least stable!
o Mandibular Surgery
§ Rotate closed -> correct Open Bite -> not recommended
§ Anterior and Downward rotation -> BSSO -> correct Deep Bite
- Transverse corrections
o Maxillary expansion -> Le Fort I
 o Maxillary constriction -> Remove Bone
- Genioplasty: chin can be augmented to improve esthetic outcome using osteotomy or by
adding implant material
- Surgery performed with orthodontic appliances and rigid wires on
- Reposition jaws and hold with rigid internal fixation
- Continue orthodontic for about 6 months to detail occlusion and finish
- Maximize skeletal movements by extracts upper 4s to correct class III and lower 4s to
correct class II (opposite of camouflaging technique extractions!!)



 Oral Diagnosis
Oral Pathology
Developmental Conditions Connective Tissue Tumors
Lymphoid Neoplasms
Cleft lip/palate Benign Malignant
Non-Hodgkin’s lymphoma
Lip pits Peripheral fibroma Fibrosarcoma
Multiple myeloma
Fordyce granules Generalized gingival hyperplasia Malignant peripheral
Leukemias
Leukoedema Focal fibrous hyperplasia nerve sheath tumor
Macroglossia Denture-induced fibrous (Neurosarcoma)
Lingual thyroid Hereditary Conditions hyperplasia Kaposi’s sarcoma
Thyroglossal tract cyst White sponge nevus Traumatic neuroma Leiomyosarcoma
Geographic tongue Epidermolysis bullosa Pyogenic granuloma Rhabdomyosarcoma
Fissured tongue Hereditary hemorrhagic Nodular fasciitis Liposarcoma
Hemangioma telangiectasia Fibromatosis
Lyphangioma Cleidocranial dysplasia Granular cell tumor
Exostoses Hereditary ectodermal dysplasia Schwannoma/Neurofibroma
Dermoid cyst Gardner’s syndrome Mucosal Neuromas of multiple
Branchial cyst Osteopetrosis endocrine neoplasia 2B
Oral lymphoepithelial cyst Amelogenesis imperfecta Leiomyoma
Stafne bone defect Dentinogenesis imperfecta Rhabdomyoma
Nasopalatine duct cyst Dentin dysplasia Lipoma
Globulomaxillary lesion Regional odontodysplasia
Traumatic bone cyst
Odontogenic Lesions
Focal osteoporotic bone marrow defect
Cysts Tumors
Periapical cyst Ameloblastoma
Salivary Gland Diseases Dentigerous cyst Calcifying epithelial odontogenic tumor
Reactive Benign Malignant Lateral periodontal cyst Adenomatoid odontogenic tumor
Gingival cysts of newborn Odontogenic myxoma
Odontogenic keratocyst Central odontogenic fibroma
Calcifying odontogenic cyst Cementifying fibroma
Cementoblastoma
Periapical cemento-osseous dysplasia
Ameloblastic fibroma/fibroodontoma
Odontoma
 Mucous extravasation Pleomorphic adenoma Mucoepidermoid
phenomenon Monomorphic adenoma carcinoma Mucosal Lesions
Physical-Chemical Warthin’s tumor
Mucous retention cyst Infections Immunologic Disease
Polymorphous low- Premalignant Disease Malignancies
Focal (frictional)
Necrotizing HSV Apthous ulcers
grade adenocarcinoma Idiopathic leukoplakia Verrucous carcinoma
hyperkeratosis
sialometaplasia Varicella- Chickenpox Adenoid cystic
Bechet’s sundrome Proliferative verrucous Squamous cell carcinoma
Linea alba
Maxillary sinus Herpes Zoster Erythema multiforme
carcinoma leukoplakia Basal cell carcinoma
Traumatic ulcer
retention cyst Coxsackievirus Drug reactions and Erythroplakia Oral melanoma
Chemical burn
Infectious sialadenitis Measles (Rubeola) contact allergies Actinic cheilitis
Nicotine stomatitis
Sarcoidosis HPV Wegener’s Oral submucous fibrosis
Amalgam tattoo
Metabolic EBV granulomatosis Smokeless tobacco
Smoking-associated
enlargement of major Syphilis Midline granuloma
melanosis
salivary glands Tuberculosis Lichen planus
Melanotic macule
Sjogren’s syndrome Gonorrhea Lupus erythematosus
Drug-induced Actinomycosis Scleroderma
pigmentation Scarlet Fever Pemphigus vulgaris
Hairy tongue Deep fungi Mucous membrane
Dentifrice-associated Candidiasis pemphigoid
slough Aspergillosis
Mucormycosis
Rhizopus


Bone (Nonodontogenic Lesions
Fibro-osseous Lesions Giant Cell Lesions Inflammatory Diseases Malignancies
Ossifying fibroma Peripheral giant cell Acute osteomyelitis Osteosarcoma
Fibrous dysplasia granuloma Chronic osteomyelitis Chondrosarcoma
Osteoblastoma Central giant cell Chronic osteomyelitis Ewing’s sarcoma
granuloma with proliferative Burkitt’s lymphoma
Aneurysmal bone cyst periosteitis Metastatic carcinoma
Hyperparathyroidism Focal sclerosing Multiple myeloma
(von Recklinghausen’s osteomyelitis
disease of bone) Diffuse sclerosing
Cherubism osteomyelitis
Langerhans’s cell disease BRONJ
Paget’s disease




Developmental Conditions
- Cleft Lip: lack of fusion between medial nasal process and maxillary process; 1 in 1000 births; Unilateral (80%) or bilateral
(20%)
- Cleft Palate: lack of fusion between palatal shelves; 1 in 2000 births
- Lip Pits: invaginations at comissures or near midline
o Van de Woude Syndrome= cleft lip/palate + pits
- Fordyce Granules: ectopic sebaceous glands
- Leukoedema: white or whitish-gray edematous lesion of buccal mucosa; dissipates when cheek is stretched
- Lingual Thyroid: thyroid tissue mass at midline base of tongue located along embryonic path of thyroid descent
- Thyroglossal duct cyst: midline neck swelling located along embryonic path of thyroid descent
- Geographic tongue (migratory glossitis & erythema migrans): white annular (ringed) lesions surrounding central red islands that
migrate over time; occasionally hurt and burn
- Fissured tongue: folds & furrows of tongue dorsum
o Melkersson-Rosenthal Syndrome= fissured tongue + granulomatous cheilitis (lip inflammation) + facial paralysis (bells
palsy)
§ i.e. “Mels Bells Rosy Red”
- Angioma: tumors composed of blood vessels or lymph vessels
o Cherry Angioma: red mole
o Hemangioma: congenital focal proliferation of capillaries; most undergo involution but persistent lesions are excised
o Lymphangioma: rare congenital focal proliferation of lymph vessels
§ Purple Spots: Tongue
§ Cystic hygroma: Neck
§ Sturge-Weber Syndrome: angiomas of leptomeninges (arachnoid and pia mater) + angiomas on skin along the
distribution of the trigeminal nerve
- Exostoses/tori: excessive cortical bone growth; on buccal, exostoses; on palate, tori
- Dermoid Cyst: mass in midline floor of mouth if above mylohyoid; mass in upper neck if below mylohyoid; contains adnexal
structures like hair and sebaceous glands; doughy consistency
- Branchial cyst: lateral neck swelling; epithelial cyst within lymph node of neck
- Oral Lymphoepithelial cysts: epithelial cyst within lymphoid tissue of oral mucosa; palatine and lingual tonsils are common
regions
- Stafne Bone defect: RL in posterior mandible below mandibular canal due to lingual concavity of jaw
- Nasopalatine duct cyst: heart-shaped RL in nasopalatine canal caused by cystification of canal remnants. Tx: excision
 - Globulomaxillary lesion: clinical term denoting any RL between max canine and lateral incisor
- Traumatic bone cyst (simple bone cyst & idiopathic bone cavity): large RL scalloped around roots with no epithelial lining
(dead space) in mandible of teenagers; usually associated with jaw trauma. Tx: aspirate to diagnosis, just monitor

Mucosal Lesions- Reactive
Mucosal Lesions- Infections

Mucosal Lesions- Immunologic Diseases
- Aphthous ulcer (“canker sore”): recurrent nonkeratinized painful ulcers, minor heals without scarring, major heals with scarring
o Sutton Disease: major form
o Behcet’s syndrome: multisystem vasculitis that causes aphthous-type ulcers of oral and genital, and inflammation of eye;
Tx: corticosteroids
- Erythema multiforme: often on lips; minor due to herpes simplex hypersensitivity, major due to drug sensitivity
o Stevens-Johnson syndrome: major form
- Angioedema: allergic reaction to drug or food contact; diffuse swelling of lips, neck, or face; mediated by mast cell release of
IgE and histamines
- Wegener’s Granulomatosis: allergic reaction to inhaled antigen; strawberry gingivitis; Tx: corticosteroids and cyclophosphamide
- Lichen planus: T lymphocytes target and destroy basal keratinocytes, basal zone vacuolization and sawtooth rete pegs
secondary to this destruction is observed histologically; Tx: corticosteroids
o Reticular-> Wickham striae, more common
o Erosive-> Wickham striae with red ulceration
- Lupus erythematosus: tx: corticosteroids
o Discoid chronic type: disc-like lesions on facial skin, oral lesions mimic erosive lichen planus
o Systemic acute type: multiple organ involvement, butterfly rash over bridge of nose, autoantibodies (ANA test)
- Scleroderma: hardening of skin and CT; restricted opening and uniform widening of PDL space
- Pemphigus vulgaris: suprabasilar; autoantibodies against desmosomes; multiple painful ulcers preceded by bullae; (+) Nikolsky’s
sign; tx: corticosteroids
- Mucous membrane Pemphigoid: subasilar; autoantibodies against basement membrane

Mucosal Lesions- Premalignant
Mucosal Lesions- Malignant
CT Tumors- Benign
CT Tumors- Malignant
Salivary Gland Diseases- Reactive
Salivary Gland Diseases- Benign
Salivary Gland Diseases- Malignant
Lymphoid Neoplasms
Odontogenic Cysts
Odontogenic Tumors
Bone Lesions- Fibro-Osseous
Bone Lesions- Giant Cell
Bone Lesions- Inflammatory
Bone Lesions- Malignant
Hereditary Conditions




 Pharmacology




 Patient Management
ADA Principles of Ethics
1. Autonomy: self-governance
o Respect patient’s right to self-determination and privacy
o Treat patient according to the patient’s desires within the bounds of acceptable
treatment
o HIPPA Privacy Rule: safeguard the confidentially of patient records
o Informed Consent: dentist must share information with and obtain consent from the
patient; must inform patient about nature of procedure, benefits, risks, and
alternative treatment option including no treatment—not cost of treatment;
otherwise held accountable for assault and battery
§ Required: voluntary, language patient understands, ability to ask questions,
only patient or guardian can authorize tx
o Minors
§ 1-7yo: infant, not responsible for actions
§ 8-14yo: competent
§ 15-17: responsible
§ Minors <18 can give implied consent or assent but not actual consent ->
exception if they are emancipated (married, parent, pregnant, military) or
in an emergency situation
o Patient Records: OG charts you keep, copies of chart may be provided to patient or
attorney with signed authorization from patient; keep all documents for as long as
possible
o Risk Management: constantly weigh risk and benefits of your practice ->
documentation is the most essential component (specific, objective, complete,
timely, never make or sign an entry for someone else, never delete or change
anything you wrote—instead provide an addendum)
2. Nonmaleficence: do no harm
o Keep skills and knowledge up-to-date through CE
o Know your limitations and refer difficult cases to a specialist
3. Beneficence: do good
o Duty to act for the benefit of others
o Provide service to the patient and the public at large, patient’s welfare
o Same ethical standard exists no matter the financial arrangement
4. Justice: fairness
o Be fair in dealings with patients, colleagues, society
o Deal with people justly and deliver dental care without prejudice
o Never slander another dental professional
5. Veracity: truthfulness
o Be honest and trustworthy in dealings with public
o Respect the position of trust inherent in the dentist-patient relationship
o Must not represent care being rendered, fees being charged, or any form of
advertising in a false or misleading manner

Statue of Limitations
- Laws that set the maximum time after an event within which legal proceedings may be
initiated
 - Occurrence rule: statue of limitations starts to run after the injury or malpractice occurred
- Discovery rule: statue of limitations starts to run after the injury or malpractice is
discovered

Witnesses
- Expert testimony: an expert who has expertise in dentistry and can testify to the existing
standard of care and how it was breached by defendant
- Fact witness: someone who was there

Good Samaritan Act: offers legal protection to health professionals and others who provide
“reasonable assistance” to individuals who are injured, ill, in-peril, incapacitated

Communication and Interpersonal Skills
- Active Listening: setting time aside free from distraction, paraphrase, lean forward,
maintain good eye contact, face patient, ask questions, nod, smile maintain close proximity
(tapping shoulder is as close as you should get)
- Rapport: mutual sense of trust and openness, ask about patient’s interest, disclose some
personal info as appropriate; best established with empathy
- Sympathy: feelings of pity and sorrow for someone else
- Empathy: reflection and showing understanding, acknowledge concerns, open-mind, NOT
share personal experience
- Nonverbal communication: most common reaction of discomfort is eye and eyebrow
movement
- Verbal Communication: simple, specific, direct , don’t just give advice, help reach informed
decision, do not falsely reassure and make expectation clear
- Clinical Interviewing: open-ended questions, close questions, don’t use leading questions,
probing, laundry list (MC questions)
- Treatment Planning: present treatment alternatives to patient in descending order of
desirability, verify understanding (teach-back method)

Behavior Change (ABC): health behavior involves a complex interplay of a person’s thoughts,
feelings, and behaviors
1. Antecedent: factor that facilitates behavior
2. Behavior: the behavior itself
3. Consequences: consequences of the behavior

Stages of Change
1. Precontemplation: not considering behavior change
2. Contemplation: begins to consider behavior change
3. Preparation: preparing to take steps to change, often expresses a desire to change
4. Action: engaged in taking action towards behavior change, often requires support
5. Maintenance: attempts to maintain a changed behavior

Social Cognitive Therapy: motivation to change behavior is influenced by several factors
1. Self-efficacy: cognitive perception that you can execute behaviors necessary for a given
situation
2. Behavioral modeling
3. Social reinforcement: positive social consequences

Health Belief Model: motivation to change behavior is influenced by several factors
 1. Perceived susceptibility: to given disease or problem
2. Perceived cost and benefits: severity of consequences
3. Cues to action: prompts to engage or not engage in certain behavior

Behavioral Learning
- Classical conditioning (Stimuli): a neutral stimulus is associated with a natural response
o Unconditioned Stimulus (UR) -> Unconditioned Reaction (UR)
o When you introduce Neutral Stimulus (NS) to US -> UR
o Becomes Conditioned Stimulus (CR previously NS) -> Conditioned Reaction (CR
previously UR)
o Classical Extinction: discontinue CS->CR link
- Operant conditioning (Consequences): a response is increased or decreased due to
reinforcement > punishment
o Positive reinforcement: do good -> reward
o Negative reinforcement: do good -> remove bad stimulus
o Positive punishment/ Aversive conditioning: do bag thing -> get punished
§ Not for timid and tense-cooperative
§ Voice control: speak in firm tones
§ Hand-over-mouth (HOM): gently place hand over patient’s mouth to gain
attention of uncontrolled
o Negative punishment: do bag thing -> remove good stimulus
o Operant Extinction: discontinue connections
- Observational Learning (Modeling): learning occurs through observation and imitation of
others; i.e. asking an anxious or uncooperative child to observe cooperative sibling

Behavioral strategies
- Altering antecedents, consequences
- Shaping: slowly develop behavior by reinforcing successive approximations to a desired
goal; reinforcement should always be immediate and specific to the desirable behavior
- Premack Principle: making a behavior that has a higher probability of being performed
contingent on a behavior that has a lower probability of being performed
- Ability to change depends on locus of control (Internal > External motivation)

Motivational Interviewing: change patient from ambivalence to change
- OARS: open questions, affirmations, reflective listening, summarizing
1. Engaging: form relationship
2. Focusing: exploring motivation, goals, values
3. Evoking: eliciting their own motivations
4. Planning: exploring how one might move toward change (Sustain, change, commitment)

Anxiety & Plan Control
- Biggest issue in practice -> fearful patients
- Dental Anxiety
o Stress: perceived threat to one’s well being
o Anxiety: subjective experience involving cognitive, emotional, behavioral,
psychological factors; sit still and not say much, require more interpersonal
distance
- Stress Management
o Trust: provide patients with sense of control by providing information, hand signals
to break, and time structuring
 o Comfort: acknowledge the patient’s experience -> empathy
o Coping: use cognitive-behavioral interventions
§ Diaphragmatic breathing: deep breathing -> relaxation response
§ Progressive muscle relaxation: tensing and relaxing certain muscles
focusing on the difference between tension and relaxation
§ Guided imagery, hypnosis, rehearsals
o Systemic desensitization/graded exposure: exposing a patient to items from a
collaboratively constructed hierarchy of slowly increasing anxiety-provoking
stimuli (related to the target fear) while using relaxation skills
o Distraction: least effective in hypervigilant anxious patient
o Tell-Show-Do
o Rational response/reframing/cognitive coping: more adaptive thought or
statement
o Habituation: decrease in response that occurs as a result of repeated or prolonged
exposure to a conditioned stimulus
- Cognitive Appraisal of a Threat: less controllable, less familiar, less predictable, more
imminent -> more stressful no matter if it is a positive or negative event
- Child Behavior Management: create child-oriented environment, ask them to be a helper,
tell-show-do, ask about fears, count!

Dental Pain
- Pain: cognition and emotion
- Anxious patients are more likely to report pain and discomfort
- Behavioral Management of Pain: start simple -> invasive, give choices when possible, hand
signals, respond immediately to discomfort
- Pharmacologic Management of Pain:
o Rx: Mild (Ibuprofen or Acetaminophen), Moderate (Ibuprofen and Acetaminophen),
Severe (Ibuprofen and/or Acetaminophen and Opioid)
o Nitrous Oxide, IV sedation

Public Health: science and art of preventing disease, prolonging life, promoting physical health and
efficiency through organized community efforts

Epidemiology: study of distribution and determinants of disease
- DMFT: only irreversible epidemiologic measure; conventional method of defining caries
in population
o DMFT: decayed, missing, filled permanent teeth
o DMFS: decayed, missing, filled surfaces of permanent teeth
o DEFT: decayed, extracted, filled teeth of permanent teeth
o dmft: decayed, missing, or filled primary teeth
- Gingival index: 4-6 surfaces on six indicator teeth
o Normal (0), Mild Inflammation (1), Moderate Inflammation (2), Severe
inflammation, ulcerated tissue with tendency toward spontaneous bleeding (3)
- Community Periodontal Index of Treatment Needs: combines gingivitis and periodontitis,
doesn’t consider recession or attachment loss
o Healthy (0), Bleeding (1), Calculus (2), Shallow Pockets (3), Deep Pockets (4)
- Simplified oral hygiene index (OHI-S): quantified amount of debris (DI-S) and calculus (CI-S)
o Oral Hygiene: Good > Fair > Poor

Oral Cancer: tongue is most common site for cancers in the oral cavity

Prevention
- Primary: prevent disease before it occurs
- Secondary: eliminate or reduce disease after it occurs
- Tertiary: rehabilitates patient after disease has taken place

Fluoride
Topical Fluoride: incorporates into teeth present in mouth
Systemic Fluoride: ingested and incorporated into teeth actively forming + topical effect

Community Water Fluoridation: most cost effective and most practical preventive measure to
prevent tooth decay; caries decline from 70s
- 1ppm (1mg fluoride per liter of water) is optimal amount
- Odorless, colorless, tasteless when in range of 0.7-1.2ppm
- 210 million people live in fluoridated communities

School Water Fluoridation: 4.5x concentration of community water, fluoride mouth rinses

Salt Fluoridation: developing countries with no safe public water supply, 200-350mg/kg of salt;
combine both water and salt fluoridation not recommended

Fluoride Supplements Fluoride Supplement Dosage Schedule
- Prescription only Age <0.3ppm 0.3-0.6ppm >0.6ppm
- For children at risk for caries Birth-6mos None None None
who live in non-fluoridated areas 6mos-3yos 0.25mg F None None
- <3yo -> fluoride drops 3-6 0.5mg F 0.25mg None
- >3yo -> fluoride tablets/
6-16 1mg F 0.5mg None
lozenges
- >6yo -> fluoride mouth rinse (0.2% NaF solution weekly or 0.05% NaF solution daily)

Topical Fluoride: best for smooth surfaces, root caries, ECC
- Varnish is adhesive and maximizes fluoride-tooth contact with 5% fluoride
- Acidulated Phosphate Fluoride (APF) gel has pH 3 and 1.23% fluoride
- Stannous fluoride: benefit of antimicrobial, astringent taste, extrinsic tooth staining

Fluoride Toxicity: toxic dose is 5mg/kg; lethal dose is 5g for an adult

Sealants: best for occlusal surfaces; recommended for 1st and 2nd permanent molars for children at
risk for caries

Education alone cannot function as a method to prevent disease!

Evidence-Based Dentistry
- Prevalence: proportion of a given population that is affected by a condition at a given time
- Descriptive/Epidemiological studies: quantify disease status in community
- Analytical/Observational studies: determine etiology of a disease
o Cross-sectional study: survey or measurement taken to represent a snapshot in
time, prevalence; limited causation result
o Case-control: people with a condition (cases) are compared to people without it
(controls) in the past, odds ratio
 o Prospective cohort study: cohort followed through time to see who develops a
disease, incidence and relative risk
o Retrospective cohort study: look back after following the cohort and decide what
disease you want to look for, incidence and relative risk
- Experimental Studies: determine effectiveness of a therapy
o Clinical Trial: aim to isolate one factor and examine its contribution to a patient’s
health by holding all other factors as constant as possible
o Community Trial: group as a whole is studied rather than individuals in it

Frequency Distributions
- Normal distribution: bell-shaped
- Skewed distribution: tail to the right or left
- Bimodal distribution: two peaks
- Central Tendency
o Mean: average value
o Median: middle value
o Mode: most frequent measurement in a set of data
- Dispersion
o Range: max #-min #
o Variance: how spread out individual values are from the mean; shown on
Histogram
o Standard deviation: square root of variance
- Quality
o Reliability: precision
o Validity: accuracy
o Sensitivity: correctly diagnosed with disease
§ True Positive: have disease
§ False Negative: incorrectly diagnosed with disease
o Specificity: correctly diagnosed with health
§ True Negative: don’t have disease
§ False Positive: diagnosed with disease but are healthy
- Inferential Statistics
o Statistical significance (p-value): probability that two variables are unrelated
§ P<0.05 reject null -> statistically significant
§ P >0.05 accept null -> not significant
o Null hypothesis (H0): hypothesis tries to disprove, reject, or nullify
o Correlation coefficient (r): statistical measure that represents the strength of
relationship between two quantitative variables (between -1 to +1, 0 means no
linear relationship)
o Multiple regression: a multiple regression provides a mathematical model of
linear relationship between a dependent and two or more independent
variables
o Chi-squared test (X2): measures the association between two categorical values
o T-test: measures the statistical difference between two means, small sample size
o Z-test: measures the statistical difference between two means, large sample size,
variance is known
o ANOVA (analysis of variance): used to test differences between two or more
means
- Operational Variables
o Qualitative: descriptive
 § Nominal: names or labels
§ Ordinal: ranking
o Quantitative: numbers
§ Ordinal: ranking
§ Interval: range of values
§ Ratio: range of values with clear definition of 0
o Independent variable (X): explanatory, predictor
o Dependent variable (Y): outcome, predicted
o Confounding variable: covariate

Components of Scientific Paper
- Title
- Abstract: quick summary
- Introduction: background, purpose, aims, hypothesis
- Methods: validity and reliability, variable
- Results: outcomes
- Discussion: interprets outcomes
- Conclusion: tie it all together
- References

Infection Control
- Hand Wash -> 15 seconds minimum
- Flush Ultrasonic -> 20-30 seconds minimum
- Routes of Transmission: direct, indirect (fomite), droplets/aerosols, parenteral
- Hepatitis
o A/E: fecal-oral
o B/C: blood, semen
§ B: 30% risk, DNA virus, vaccine, postexposure prophylaxis includes vaccine
and immunoglobulin
§ C: 1.8% risk, RNA virus, has postexposure prophylaxis
o D: direct contact, prior infection with HBV
- HIV: 0.3% risk, RNA virus, detected by ELISA test, has postexposure prophylaxis
- TB: inhalation, worker should be have skin test once per year
- PPE: gloves, utility gloves, masks per patient, glasses (dentist most at risk for injury),
gowns per day
- OSHA: offer free HBV vaccines; report, evaluate and follow-up needle stick injury; clothing
at work cannot be washed at home; HazCom
- Environmental Protection Agency (EPA): maximum exposure levels of Hg vapor at
0.1ug/kg, regulates transportation of dental waste
- Sterilization: destruction of bacteria, viruses, spores
o Glutaraldehyde: cold solution used for heat-sensitive items, long time
o Pressure sterilization/Autoclave: 121C at 15psi for 20mins; moist heat denatures
protein of bacteria; monitor via biologic and process indicators (strips)
o Dry heat sterilization: 160C for 60min, only glass or metal, destroys bacteria by
coagulation of proteins; best preserves cutting edges
o Ethylene oxide: PSP plates, lengthy aeration
- Disinfection: used on inanimate objects, no spores destroyed but Mycobacterium
tuberculosis; let it sit for 10 minutes
- Antispesis: used on living tissue; i.e. Alcohol, Chlorohexidine, Detergents, Quaternary
ammonium compounds (quats)
 - Disposal of Wastes: sharps -> sharps bin, infectious -> separate waste bin, non-infectious ->
trash
o Highest chance of get needle stick injury -> clean-up
- Spaulding Classification System
o Critical: contacts sterile tissue or vascular system -> sterilization
o Semi-critical: contacts mucosa -> disinfection/sterilization
o Non-critical: contacts skin -> disinfection

Materials and Instrument Safety
- Mercury: inhalation is biggest risk, if spill -> vacuum and apply sulfur powder; acute
toxicity: hypotonia, alopecia, weight loss/GI disorders, exhaustion
- Airborne Particles
o Splatter: visible, fall within 3 feet of patient’s mouth
o Aerosols: invisible, remain floating in air for hours, carry only respiratory infections
- Noise Control: hearing loss develops slowly over time and can be caused by >90dB
- Water Lines: EPA requires <500 CFU of heterotrophic bacteria per mL of water; anti-
retraction valves prevent retraction of fluid from a patient back into instrument
- Material Safety Data Sheet (MSDS): manual made by the manufacturer of hazards
required by OSHA to have readily available
o Blue: Health Hazard
o Red: Fire
o Yellow: Reactivity of chemical
o White: Require PPE
o 0-4 least to most dangerous

Insurance Terms & Healthcare Systems
- Beneficiary: person with the insurance plan
- Benefactor: insurance company
- Benefits: insurance pays for dental services covered under contract
- Premium: monthly amount you pay to have insurance
- Copayment: predetermined rate you pay at time of care
- Deductible: what you need to pay before insurance starts kicking in
- Coinsurance: percentage of charge that you pay
- Out-of-pocket maximum: most you have to pay before insurance covers 100% of bill
- Third Party Payer: negotiates payment between provider and patients for services
o Usual, customary, and reasonable (UCR): based on geographic location
o Table of allowances: lists maximum amount a plan will pay for each procedure but
allows dentists to charge more if they want
o Fee schedule: list of fees the dentist has agreed upon for dental services and the
insurance will cover in full
- Payment Plan
o Fee-for-service: dentist is paid per procedure, leading payer for tx
o Capitation plan (HMO): per capita -> dentist is paid flat fee for each patient seen,
cap on how dentist is paid
§ Value of service > payment -> dentist loss
§ Payment > value of service -> dentist gain
o Sliding scale fee: cost of treatment is adjusted based on patient income and ability
to pay
o Balance billing: dentist charges the remaining balance between total fee and what
the insurance company covered
 o Prospective reimbursement (FQHC): dentist is paid predetermined fixed amount
before treatment is provided
- Fraud Terms
o Unbundling: separating dental procedure into component parts
o Bundling: combining distinct dental procedures
o Upcoding: reporting a more complex or higher cost procedure than was
performed
o Downcoding: code changed to less complex or lower cost than was performed
o Overbilling: charging more than legally or ethically acceptable
- US Health Care
o Private Health Coverage
§ Consumer-driven: private fee-for-service, flexible spending account (FSA),
health savings account (HSA)
§ Managed care: HMO, PPO
o Government Health Programs: Medicare, Medicaid, Children’s Health Insurance
Program (CHIP), Indian Health Service (HIS), Veterans Health Administration (VHA)
- Managed Care
o Health Maintenance Organization (HMO): insurance option that limits coverage to
medical care provided through specific providers who are under contract; low
premium, limited choice of providers
o Preferred Provider Organization (PPO): panel of providers agree to accept less
than usual fees in exchange for higher volume of patients, since subscribers to
this plan have a financial incentive to use providers from this panel; high premium,
more choice of providers
o Open Panel: participating dentist can see any patient
o Closed Panel: participating dentist is contracted and can only see patients who are
members of the managed care organization
- Department of Health and Human Services (HHS): suspected elder abuse must be reported
to this agency
o Administration for Children and Families (ACF): head start which provides
comprehensive education, health, nutrition, and parent involvement to low-income
families
o Centers for Medicare and Medicaid Services (CMS)
§ Medicare: does not cover dental care EXCEPT when related to medical
care
§ Medicaid: Early Periodic Screening and Diagnostic and Treatment (EPSDT)
requires states to take action to ensure children <21yo access care; ACA
expanded Medicaid
§ CHIP: children whose family’s income are too high for Medicaid but too low
to afford private insurance
o Health Resources and Services Administration (HRSA): National Health Service
Corps (NHSC) -> loan repayment for providers who work in underserved
communities & Ryan White CARE Act -> HIV/AIDS
o CDC: oral health surveillance
o FDA: efficacy and safety
o IHS: improves health of American Indians and Alaska Natives
o NIH: biomedical and public health research
o Agency for Healthcare Research and Quality (AHRQ): quality and access to care
research through quality assessment and assurance
 Miscellaneous Topics

Vital Bleaching
- Office-Based- Chairside & Supervised
o 35-50% Hydrogen Peroxide with or without light source (i.e. Opalescence Xtra,
Opalescence Boost)- Chairside
§ Requires isolation: 4-6mm of Opal Dam barrier that is lightcured, apply
1mm layer of bleach material, light cure 30secs per tooth, suction excess,
rinse and suction, remove Opal Dam
o 35-45% Carbamide Peroxide gel with bleaching tray for 30mins-2 hours (i.e
Opalescence Quick PF); supervised
- Home Bleaching
o 10-35% Carbamide Peroxide with bleaching tray overnight or 2-4 hours during the
day (i.e. Opalescence, Opalescence PF)
o 16-22% Carbamide Peroxide for 7-8 hours(i.e Nite White)
o 6-14% Hydrogen Peroxide for 30mins 2x a day (i.e. Day White)
- If bonding to bleached enamel, wait at least 1 week after termination of bleaching to allow
oxygen and residual peroxide to exit the tooth
- Shade change is determined usually right after treatment. Teeth are dehydrated, usually a
relapse so its better to wait one week for shade selection!