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Sara Sarraj
DDS MS MS FGD
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Dent 337
Clinic
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The clinician opinion resulted from the processof evaluating the patient
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Interview Patient
Gather data
Aanalyse Data
Developing Hypotheses Establish Diagnosis
Formulate Tx Paln
Consent form to begins treatment
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S:Subjective information
Objective: Physical findings of the clinician
Analysis : Clinical impression of the condition by
the clinician P:Plan ,recommended management for the
condition1. Specific treatment
2. Referral to specialist3. Dismissal as clinically insignificant
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For consultation with another dentist
To reevaluate current treatment
Only when diagnostic information is available
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Dental
History
AdjunctiveDiagnosticTools
PhysicalExam
Medical History
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Pt Identification
Systemic Disease
Family History
Social History
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Name
Age
Gender
Race Address
Phone# & Email
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Review:
of the medical conditions that have beendiagnosed.
Immunization Hospitalization
Allergies
Current Medications
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1.Is a dynamic document that should be updatedannually and for every new patient
2.Taking medical history makes the pt feel thatthe office provides an optimum treatment.
3.Early recognition of risk improves prognosis,and reduces complications
4.Dental team often first to identify silent
disease(silent killer)
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Standard review of past medical history
Hospitalization: Renal dialysis
Surgery: hip replacement, pace maker, bypass,
Prosthetic heart valve Illness:IE(infective Endocarditis)
Medications: Rx :bisphosphonates, chemotherapy,
anticoagulants,birthcontrol,steroids OTC,herbal,Diet control
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Highest risk People with the followingconditions are considered to be at the highest riskof developing infective endocarditis(IE).Preventive antibiotics are generally
recommended for people with the followingconditions before bleeding induced dentalprocedures A prosthetic heart valve
Valve repair with prosthetic material
A prior history of infective endocarditis
Many congenital (from birth) heart abnormalities
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antibiotic prophylaxismight be useful forpatients who also havecompromised immune
systems (due to, forinstance, diabetes,rheumatoid arthritis,cancer, chemotherapy,and chronic steroiduse), which increasesthe risk of orthopedicimplant infection.
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Chest pain, palpitation, breathlessness(CVD)
Cough, wheeze, breathlessness (RespT)
Bowel Habit: distention, pain, eating And
appetite(Gastrointestinal) Incontinence, straining or drippings
(Genitourinary)
Seizures ,fainting ,headache (central nervous
System)CNS
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Chief Complaint: CC
The statement of why the patient consulted thedentist
It should be in pt own words if possible To assess the dental awareness and the likelihood
of raising it
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Anxiety: How do they feel about dental TX
Florid intake: where do u live
Pt experience with GA and LA: if any complication
in the past Caries rate and erosion: what,s your favorite drink
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Assess motivation:How often to go to dentist
Provide clue about the nature of CC : When did ulast see dentist (RCT)
Motivation: how often do u brush. Gingivalcondition
TMJ: have had any pain or clicking from your jaw
Personality: do grind your teeth , bite nail
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Use introductory words:
What is the problem
When: onset and pattern
How: Frequency What: Exacerbating and relieving factors
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Location: Where
Commencement: When
Character & intensity:
Sharp , shooting ,aching .dull Frequency & Duration
Association : what make them worse or better
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Type
Size
Color
Location Surface Texture
consistency
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General
Extra oral Soft Tissue
Intra Oral Soft Tissue
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General Appearance
Gait
Mobility
Facial Asymmetry Lesion or Scar
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Asymmetry
Lymph Nodes
TMJ
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Visual screening
Palpation screening
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Exam
Extra Oral Exam
palpation
Bilateral
Bimanual
Bidigital
Visualscreening
symmetry
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Surgery Inflammation
Tumors Congenital
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Induration: fixation to the deeper tissues
Roughness or smooth textures of the lesion
Consistency: fluctuant, soft, hard,
Tenderness: if your palpation induces pain Presence of masses and size of them
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Bilateral
Bimanual
Bidigital
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using both hands toboth sides, like
submandibular lymphnodes, TMJ, muscles ofmastication, and thetwo lobes of thyroids
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using both hands toexamine one structurea one side, forsubmandibular
salivary glands to palpate the
buccinators muscleto feel anytenderness
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Using two fingers ofone hand to examineone side, for lips,tongue and for buccalmucosa
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Muscle of mastication Salivary glands
Lymph nodes
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The finger is insertedmedially to the muscleand the muscle ispressed laterally
against the innersurface of themandibular ramus, toelicit tenderness . .
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Similarly force isapplied to the subjectsleft jaw to stress theright lateral pterygoid
muscle
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Normal:Not palpabable,feel like a pea or lentil,non tender
Abnormal Lymph Nodes:
Larger,may be tender,inflammation or drainageof infection
Non-tender large lymph nodes:
Cancer
Lymphoma
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Preauricular Tonsilar
Submental
Submandibular Anterior & posterior cervical
suparcalvicular
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Methods of palpation of lymph nodes
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Palpate both joint simultaneously ,GentlePressure : Tenderness, swelling , Redness
Range of movement: open and close slowly manytimes .and from one side to another. Also feel forclicking ,locking ,& crepitus
Palpate the muscle of mastication for spasm &tenderness
Auscultation can be useful too
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There are 2 types of joint sound to look out for: Clicks - single explosive noise
Crepitus - continuos 'grating' noise
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A joint click probably represents the suddendistraction of 2 wet surfaces, symptomatic ofsome kind of disc displacement. The diagnosis ofa joint click, and therefore treatment, varies on
whether the click is left, right or bilateral, painfulor painless, consistent or intermittent. The timingof a click is also significant: a click heard later inthe opening cycle may represent a greater degree
of disc displacement.
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Crepitus is the continuous noise duringmovement of the joint, caused by the articulatorysurfaces of the joint being worn. This occurs mostcommonly in patients with degenerative joint
disease.
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Lateral Range of
Motion
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Temprature (35,5-37,5C)= (95,5-99,5F) post operative,infection,transfusion reaction Shock,hypothermia
Pulse:Adult(60-80 beat/min) Child(up to 140beat/min)
Blood Pressure BP :(120-140/60-90) BP =Age BP =Syncope,Hypovolemia Shock Respiratory Rate=12-18 breath/min, increases in the
following: Chest infection Pulmonary edema shock
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Oral Vestibule Oral cavity proper
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space bounded Laterally by cheek and
lips
Medially by the buccaland labial surfaces ofthe upper and lowerteeth
Posteriorly by theRetromolar area
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The oral
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cavityproper
Bounded
Laterallyby palatal andlingual surfaces of theupper and lower teeth
Superiorlyby the palate(hard & soft)
Inferiorlyby thetongue and or thefloor of the mouth
Posteriorlyby theisthmus of fauces
Superior boundary
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Superior boundary
Palate- PartsIncisive papilla
Palatine Rugae
Median
palatineraphe
Maxillarytuberosity
FoveaPalatina
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InferiorboundaryThe Floor of the mouth
Parts
Ventralsurface of thetongue
LingualFrenum
Sublingualfold
Sublingualcaruncle
Openning of sublingual duct
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Ventral side of the tongue
Plica Fimbriata
Sublingual fold
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D f Th T
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Dorsum of The TongueMedian fissure
fibrous septum
Sulcus terminalis:V-shaped ridge, separates?
Foramen cecum: (blind opening)
at apex of sulcus term.
marks the site of ?
Lingual papillae: 4 types
filiform
smallest & numerousfungiform
tip & marginsvallate
8-12, in front of ?
foliate
linear folds, on the sides
near terminal sulcus
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Exam of lateral side of the
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Exam of lateral side of thetongue(Oral Cancer Screening)
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Soft Tissue of the mouth Throat
Tongue
Gingiva
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Labial mucosa:I nside of the lip Buccal mucosa: Inside of the cheek
Hard Palate: Firm area of the roof of the mouth
Soft Palate: The soft area of the palate
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Linea alba The linea alba isusually presentbilaterally.
It is restricted to
dentulous areas. It presents an
asymptomatic, linearelevation, with awhitish colour, at thelevel of the occlusalline of the teeth.
l
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Oral Exam
a proper oral exam from your dentist (DDS or DMD) iswarranted at least yearly and should be performed when yourteeth are cleaned during routine visits - the dentist orhygienist should be visually and physically evaluating thetongue's dorsal (top), ventral (bottom), and lateral (side)surfaces through palpations and observations.
A "larger tongue" is termed hyperglossia and the "corrugated"sides of the tongue are termed scalloped tongue, wherethere are indeed what appears to be indents from theadjacent teeth on the lateral borders of the tongue. Both ofthese are common variations of normal that are seen quitefrequently and usually appear together.
Other things that could cause hyperglossia besides beingcongenital (from birth) or medication-induced would be adietary/nutrient insufficiency. Do not hesitate to contact yourdentist or physician, both would be happy to give you anymore information.
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MorsciatioBuccarum
Morsciatio(labiorum)
Morsciatio (linguarum),
Morsciatio labium
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Intraoral:PA,BW,Occlusal Extraoral:Panoramic,Posterior
anterior,cephalometry
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Documenting Periodontal and
periapical disease
Tooth orientation
Root shapes
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X ray
Detects interproximalcaries in both arches
simultaneously Level of crestal bone
Intermediatescreening tools before
taking PA.
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Upper Occlusal
Detecting Palatallesions
Reveal impacted orextra teeth
Document expansionof mandible
Salivary stones in theduct of submandibularduct
Lower occlusal
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Maxillary Occlusal
x ray
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Mandibular Occlusal X ray
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Cover both Jaws Detect developmental abnormalities
Pathological lesion of teeth and bones
Evaluation of edentulous pt before prostheses
Third molar position
Less valuable diagnostic evaluation due to lowerresolution and superimposition of the structures
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Soft tissue Palpation Alveolar hard tissue palpation
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Indicates infalmmation in the periodontalligament.
Cause: could beTrauma,Occlusalprematurities,periodontal disease,extension of
pulpal disease to PDL. Discriminates the affected tooth from its
neighbors, due to the proprioceptive nervereceptors
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Prelude(inform Patient) for the test for moreaccurate results.
The test should be repeated to make sure itsreproducible
This test reflects an advance stage of pulp disease.
It doesnt reflect the tooth vitality
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Simple & reliable methods to indentify individualtooth when group of teeth are involved
Abrupt pressure to the periapical area
Increased intensity of discomfort indicates
inflammation is present Light tap is adequate
Tap normal and suspected teeth
Ankylosed teeth produce different sound than
normalteeth(Trauma,deciduous,ortho,inflammation,reimplantation)
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This test detects the inflammation in the PDL,which results in pain, and the tooth is then calledtender to percussion (TTP)
TTP could be the result of
Toxins from a necrotic pulp reaching PDL
Trauma
Periodontal abscess
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It s an indication of acompromisedperiodontalattachment when
+1>mm . Its a relative exam
Trauma Occlusal trauma
Parafunctional habits
Periodontitis
Root fracture
Rapid orthodonticmovement
PDL Infection ofpulpal origin
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Pulp vitality is defined by the retention of blood supply. Thisshould be differentiated from sensibility Thermal tests Cold test Heat tests
Electric pulp tests Selective anesthesia Test cavity Pulse oximeter Laser doppler flowmetry
Other signs of vitality Color Sinus tract
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Test the suspected tooth Similar tooth controls should be used
Replicate patients symptoms
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To detects incipient cracks Test involved tooth in centric and lateral
occlusion.
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Patients who complain from pain during masticationmay be actually suffering from the wedging force Cracked tooth syndrome Patients usually complain of sharp sporadic pain
while chewing, along with occasional pain from cold
food or drink. Sometimes the patient may indicatethat the pain occurs minutes after chewing or uponreleasing from clenching
Wedging is a test where the patient is asked to bite ona Tooth Slooth on successive cusps until the offending
cusp is located Staining is done by the application of methylene blueor erythrosine dye (cottonwood stick or IRM)
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Flurorescence procedures are based
on illustrating certain fluorescencesubstances like porphyrins, whichgrow in bacterial populated areas.When the area is stimulated withlight of a certain wavelength, themolecules absorb the light energyand release part of the light energywith a different wavelength.
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Treat with Confidence Laser Fluorescence technology
Small lesions can be detected reliably withoutexposure to ionizing radiation
No damage to enamel by sharp-edged probes
Optional Perio-Probe detects calculusconcrements 9mm in periodontal pockets
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DIAGNOdent uses laser technology to detect and quantify hidden orsub-surface caries by measuring laser fluorescence within the toothstructure.
The device operates at a wavelength of 655 nm. At this specificwavelength, clean healthy tooth structure exhibits little or nofluorescence, resulting in very low scale readings on the display.
Altered tooth substances and bacteria, including caries, willfluoresce.
The DIAGNOdent will react with elevated scale readings on thedisplay.
An audio tone allows the operator to hear changes in the scale values.This enables the user to focus on the patient not solely on the
device. The DIAGNOdent is an extremely accurate, reliable and non-
invasive method to aid in caries detection. The device has beensuccessfully used by more than 20,000 dental professionals in theUnited States and is integrated into the curriculum by a growingnumber of dental schools.
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Generally, conventional handinstruments may not be used to probe
within drop-shaped fissures.
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The DIAGNOdent pen offers the
advantage of measuring fluorescencedeep within the fissure pattern, sinceLASER light easily penetrates the enameland is reflected by even the smallestlesion. Measurement is indicated withan acoustic signal and numerical value.
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ionic change across the neural membrane, The circuit is completed via the patient wearing
a lip clip or by touching the probe handle withhis/her hand
individual age, pain perception, tooth surfaceconduction, and resistance
Tip of EPT placed labially within the incisal orocclusal two-thirds of the crown gave moreconsistent results .
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False positive Patient anxiety Saliva conducting the
stimulus to the gingiva Metallic restorations
conducting the stimulus tothe adjacent teeth Liqueficative necrosis
conducting the stimulus tothe attachment apparatus
False negative Premedication with drugs
or alcohol Immature teeth Trauma
Poor contact with the tooth Inadequate media Partial necrosis with vital
pulp remaining in theapical portion of the root
Individual patients withatrophied pulps or highpain thresholds
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unreliable in many instances, producing falseresults in healthy immature teeth . Newly eruptedteeth may take five years before the maximumnumber of myelinated fibres reaches the pulp-dentine border at the plexus of Rashkow. This isalso when apical root maturation occurs
Teeth with pulp canal calcification (PCC) andpatients suffering from primary hyperthyroidismfrequently have an increased sensory response
threshold to EPT. False response healthy pulps undergoing
orthodontic treatment
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Also traumatized teeth when two adjacent teeth have contacting
proximal metallic restorations
Periodontal tissues, breakdown products from
pulps undergoing necrosis, and remnants ofinflamed pulp tissues
Cause false response
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is a last resort in a toothwhere no other meanscan ascertain the pulpstatus .
Cutting into dentine
using a high or low speedbur without localanesthetic
nonetheless consideredinvasive andirreversible,and wouldbe rejected byapprehensive patients
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Mixed responses to vitality tests indicate falsenegative or false positive results
A test cavity is done in a concealed area of thetooth, without anesthesia, where the patient fully
understands the test and knows what to expect Crowned teeth
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This technique has been used to detect vascularintegrity in the tooth.
Relates the absorption of light by a solute to itsconcentration and optical properties at a given lightwavelength. It also depends on the absorbance
characteristics of hemoglobin in the red and infra-redrange. the red region, oxyhemoglobin absorbs lesslight than deoxyhemoglobin and vice versa in theinfrared region].
Oxygenated hemoglobin and deoxygenatedhemoglobin are different in color and thereforeabsorb different amounts of red and infrared light.
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(a) LED-emitting redlight at 660 nm. (b) LEDemitting infrared light at940 nm. (c)Photodetector. (d) Pulseoximeter monitor. (e)
Pulse oximeter sensor.(f) Custom-made pulseoximeter sensor holder.HbO2, oxygenatedhemoglobin; HbR,
deoxygenatedhemoglobin; SpO2,oxygen saturation ofarterial blood
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1.Effective and objective method of evaluating dentalpulp vitality.
2.Useful in cases of impact injury where the blood
supply remains intact but the nerve supply isdamaged. 3.Pulpal circulation can be detected independent of
gingival circulation. 4.Pulp pulse readings are reproducible.
5.Smaller and cheaper commercial oximeters are nowavailable for routine clinical use in an average dentaloffice
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1.Background absorption associated with venousblood and tissue constituents is notdifferentiated.
2.Probes should be specific for the anatomy of a
tooth as the oxygen saturation values from theteeth routinely register lower than the readingsfrom the patient's finger.
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(LDF) is a noninvasive, painless, electro opticaltechnique, which It measures blood flow even inthe very small blood vessels of themicrovasculature.
estimates the velocity of red blood cells incapillaries
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Red light is emitted from a light source; if thelight beam is scattered-off of stationary tissue orcells, there is no shift in the light spectrum. If,however, the light hits a moving cell in a blood
vessel there is a shift in the light spectrum of thescattered light according to the Dopplerflowmetry
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Accurate Reliable
Reproducible
Non painful
Luxation injuries
Useful in young children whose responses areunreliable and its noninvasive nature helps to
promote patient cooperation and acceptance
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Too expensive The sensor should be maintained motionless and in
constant contact with the tooth for accurate readings.
The laser beam must interact with the moving cells withinthe pulpal vasculature It is generally agreed that LDF assessment for human teeth
should be performed at 4 weeks following the initialtrauma and repeated at regular intervals until 3 months.
Blood pigments within a discolored tooth crown can also
interfere with laser light transmission. Care must be takento ensure that the false positive results are not obtainedfrom the stimulation of supporting tissues.
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Cold Test Hot test
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Simple ,does not need armamentarium, exceptrubber dam to avoid + response
Can be used on Crowned teeth
Has 86%accuracy ,compared with,81%Electric pulp
test,71%heat test. Vital teeth respond quickly, wherase false
postive reading respond more slowly
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Ice Frozen Carbon Dioxide (CO2 )
Refrigerant Spray: tetrafluoroethane which haszero ozone depletion potential
The last two methods are superior to other coldtest
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Utilizes a strong light source which identifiescolour changes that may indicate pulp pathosisand caries.
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It can help to identify cracks in teeth. Limited result in teeth with large restoration
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Detects endodontically involved teeth Should be conducted buccally, labially , and
lingually , palatally.
Reveal s fistulas and swelling
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Used when other test are inconclusive When pain is referred
Start at posterior teeth toward the anterior
PDL injection applied
Mobility test
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y
Handles of mirrors
Other Vitality Test
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y
Color Non-vital teeth may become darker
and less translucent Sinus tract Its presence is a strong evidence of
having a necrotic pulp in a nearbytooth
It usually discharges close to theapex of the offending tooth
Insertion of a gutta percha cone intothe sinus and exposing a radiographtraces the sinus to its origin
Sinus Tract
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Satining
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g
Staining is done by the applicationof methylene blue or erythrosinedye (cottonwood stick or IRM
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Ability of the test to identify diseased tooth 83%Cold test,86% heat test,72% EPT
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The ability of the test to identify healthy tooth 93% cold and EPT
41% heat test
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Periodontal charting: plaque index Probing depth bleeding points
gingival level tooth mobility
charting caries &existingrestorations
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existingrestorations
Palmer 8-1 1-88-1 1-8Letter code UR1-8 UL1-8
LR1-8 LL1-8FDI 1(1-8) 2(1-8)
4(1-8) 3(1-8)Universal 1 16
32 17
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FDI World Dental Federation notation(International System)
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Universal Numbering Systemfor Permanent Dentition Phase
Universal Numbering System
for Primary Dentition Phase
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Contract between Patient & Dentist
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The Art and Science of Operative Dentistry Clifford & John Sturdevant
Oxford Handbook of clinical dentistry
Pickard,s Manual of Operative Dentistry
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20 of July 40 /100
All previous lectures are required
Thank You for Your Attention
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