Borders:roof = palate (hard, soft)floor = tongue, mucosa, geniohyoid and mylohyoid mLat/ant

Outer fleshy wall = cheeks, gumsInner bony wall = teeth and inner aspect of gums

communicates posteriorly with oropharynxDivided into 2 areas: the oral vestibule, anterior to the teeth and buccal side of gingiva (gums) & oral cavity proper, which is the space behind the teeth and gums

ORAL HEALTH AND DENTISTRY The anatomy of the oral cavity and salivary glands.

Oral Vestibule = Cheeks, Lips, GingivaeLipsLips contain the orbicularis oris m, and sup/inf labial m, a/v/n.Covered externally by skin externally, and mucosa internally.Epithelium of skin transitions from normal skin –> red vermillion portion –> to inner mucosal layer. The border line b/w skin and red portion = transition zone.

Structures to identify in relation to the lips:upper lip = b/w nose & opening of oral cavitynasolabial grooves = seperate lips from cheeks, 1 cm lat to angle of mouthphiltrum = a shallow depression below the nose, bordered by 2 lateral crests – not everyone has onelower lip = b/w opening of oral cavity and labiomental groove, separating lower lip from chin.labial frenula = a mucosal membrane fold that attaches the lips to the ant surface of the vestibular gingiva (gums facing the oral vestibule) — NOTE diff from lingual frenula, that attaches the tongue to the floor of the mouth

Blood supply = sup/inf labial a (facial a)upper lip = br of facial/ infraorbital = sup labial brlower lip = br of facial/mental a = inf labial brInnervation upper lip = sup labial br of V2lower lip = inf labial br of mental n from V3 (mental n comes from inf alveloar n)Lymph Drainage = submandibular/submental lymph nodes

Cheeks over lie the zygomatic processcontain the buccinator m - that holds cheeks taught when exhaling forcefullycontains the buccal fat pad (of Bichat)Blood Supply = buccal br of maxillary a (terminal br of ext carotid), n = buccal br of mandibular n (V3)

Gumsare fibrous tissue covered with mucosahold teeth in placesupplied by many a/v/nBlood Supplyupper (maxillary) lingual gingiva of incisors, canines = nasopalatine n,a/v – most ant, this makes sense because nasopalatine structures go through incisive foramen at most ant part of hard palateupper (maxillary) lingual gingiva of premolars, molars = gr. palatine n, a/v – post, makes sense b/c gr. palatine structures go through gr palatine foramen at post/lat part of hard palatelower(mandibular) labial buccal gingiva of incisors, canines, premolars = inf alveolar n/a/vlower(mandibular) labial buccal gingiva of molars = buccal nlower(mandibular) lingual gingiva = lingual n/a/v

PalateMade up of hard and soft palateHard palateis bony and makes up the ant 4/5 of the palate = palatine process of the maxilla, and horizontal plate of palatine boneborder b/w nasal and oral cavity@ midline of hard palate, running back from incisive foramen = palatine raphe – where the 2 palatine shelves fused in embryonic life3 foramina:Incisive foramen (ant/med) = nasopalatine n/a/vIn the netter, it looks like sphenopalatine a goes through there, but do not say this in a test, it will be considered incorrect.NOTE – makes the location of the fusion b/w primary/secondary palate in embryonic lifeGreater and Lesser Palatine foramen (post/lat) – right next to 3rd molar (wisdom tooth) = the gr/lsr palatine n/a/v go through them.Gr palatine structures run ant and supply hard palateLsr palatine stuctures run post and supply soft palateThe a comes from desc palatine a, a br of maxillary a

Soft Palateis fibromuscular fold that makes up post 1/5 of palatemoves agains the pharyngeal wall to close oropharynx while swallowing or speakingas mentioned earlier, supplied a/v/n by lesser palatine structures.Laterally, is continuous with palatoglossal and palato pharyngeal folds

These folds are form the lateral border to the exit of oral cavity = Isthmus of Fauces, that leads to Oropharynx (More on that in pharynx)b/w them is the tonsillar bed = palatine tonsilsCLINCAL NOTE – are frequently inflamed and removed, along with pharyngeal tonsils (see pharyn) aka adenoids

CLINCAL NOTE = Since lingual gingiva is connected to mucosa of soft palate, can inject anasthetic there to numb soft palateHas numerous palatine glands, that secrete mucusBlood Supply: Gr and Lsr palatine a (more the 2nd one), Asc palatine a (Facial a), Palantine br of Asc Pharyngeal aInnervation : SS = lsr palatine n, SM = CN XVenous Drainage: hard and soft palate v drain in pterygoid venous plexusNOTE that Hard palate has no SM innervation – no musc there.

Muscles of Palate: all innervated by CN X via pharyngeal plexus – except Tensor Veli Palatini (V3)Tensor Veli Palatini - tenses soft palate, has a large tendon that strengthens the soft palate = palatine aponeurosisLevator Veli Palatini – elevate soft palatePalatoglossus - elevates tongus (Just uses palate as an origin site, doesn’t do anything to palate itself)Palatopharyngeus – elevates pharynx, to help close off nasopharynx from oropharynx in swallowingUvulus – @ termination of soft palate, no real function, but helps to identify issues with CN X, b/c if this doesn’t move when saying, “Ahhh”, then poss malfunction w. CN X

Tongue •is almost purely made of muscle •the ant 2/3 is called the oral part = originates from 1st pharyngeal arch •post 1/3 = pharyngeal part, orginates from 3rd arch, behind terminal sulcus of tongue •@ midline of terminal sulcus is foramen cecum, the remnant of thyroglossal duct •root = from 4th arch •Has midline sulcus on dosal surface = location of fusion of 1 lateral swellings of ant tongue over tuberculum impar. Function: aid in speaking, allow for movement of food toward oropharynx and within oral cavityParts:Body – most of the tongueApex – pointed ant partroot – part fixed to hyoid bone and mandible, is located behind palatoglossal fold, location of lingual tonsils.

Taste Buds: SEE HISTOThe inferior surface of tongue has a very thin mucus membrane, so can see many veins, and is attached to floor of mouth via another mucus membrane fold = lingual frenulum. – Basically keeps tongue in mouth while allowing apex to move aboutMuscle of Tongue = all innervated by CN XII, except palatoglossus, which we already said is innervated by Pharyngeal plexus, via CN XIntrinsic m - change the shape of tongue itselfSup/Inf Longitudinal, Transverse, VerticalExtrinsic m – change position of tongueGenioglossus – protrudes and depresses tongueHyoglossus – depresses and retracts tongueStyloglossus – retracts and elevate tonguePalatoglossus – elevates tongue

How to remember them? Gay Hats STYLe PerfectlyBasic Taste sensations:Sweetness = apexSaltiness = lateral sideSourness & bitterness = posterior partUmami = used to taste the unusual tastes in cheese, meat, asparagus, & tomatoesBlood Supply:Lingual a from Ext carotid a, emerges @ lever of gr. horn of hyoid bone in carotid trianglePathway: runs deep to hyoglossis (lateral lingual groove), and lies on middle pharyngeal constrictormBr = dorsal lingual, suprahyoid,sublingual a, terminates as deep lingual a ( on top of genioglossus m)Lymph Drainage:Post 1/3 = deep cervical lymph nodesMedial ant 2/3 = inf deep cervical lymph nodeslat ant 2/3 = submandibular l.napex = submental l.nInnervation of Tongue:Ant 2/3: SS = CN V3 via Lingual n, VS = CN VII via Chorda TympaniPost 1/3: SS/VS = CN IXRoot: SS = CN X, no taste buds here, so no VS

General Info:

covered by dense fibrous capsule from investing fascia of necksecretes serous salivalargest of the glands

secretion of gland

Salivary Glands:ParotidLocation: Retromandibular Space = Parotid BedBorders:ant = Masseter m, Ramus of mandiblepost = SCM, post digastric msup = zygomatic archinf = fascia b/w SCM and mandibleLat = open

Duct Pathway:From widest part of gland –> across masseter and deep to it –> lat/ant to Buccal fat pad –> peirces Buccinator m, and opens @ 2nd maxillary (upper) molarStructures Passing through It:Ext Carotid a - giving 2 terminal branches = Maxillary a, Superficial temporal aSuperficial Temporal v & Maxillary v combine to give Retromandibular vFacial n peirces it and gives 5 terminal branches – DOES NOT innervate the glandAuriculo temporal n – carries PNS post synaptic fibers with it to increase secretion of gland

Blood supply:from branches of external carotid and superficial temporal a = Transverse facial aVeins follow a and drain into Retromandibular vLymph Drainage:superficial and deep cervical lymph nodes

Innervation: Tympanic n arises from CN IX and emerges from jugular foramenn enters the middle ear via the tympanic canaliculus in petrous part of temporal bonetympanic n forms the tympanic plexus — and lesser petrosal n emerges from this plexuslesser petrosal leaves skull via foramen ovale

PNS fibers from it synapse in otic ganglionpost ggl fibers from ggl RUN W/ auriculotemporal n (from V3) to supply parotid gland*Parotid and Submandibular gland separated by stylomandibular lig b/w styloid process & angle of mandible

Submandibular GlandLocated: below mylohyoid & mandibleGeneral Info:Has Superficial and Deep part (deep part located b/w mylohyoid and styloglossus)secretes a mix of serous and mucus salivaDuct Pathway:ducts runs thru lat space of tongue w/ Hypoglossal n and lingual n = lateral lingual groove —> then eventually goes to and open lat to frenulum, b/w mylohyoid and styloglosseslingual n loops under duct in the lateral lingual grooveBlood Supply: sunmental a (Facial a), V run with a.Lymph Drainage: deep cervical l.n. –> jugulo-omohyoid nodesInnervation:Pre ggl PNS fibers from CN VII by chordatympani –> submandibular ggl –> post ggl fibers run w/ lingual nSNS post ggl fibers come from sup cervical ggl

Sublingual GlandsLocation: b/w mandible and genioglossus mGeneral info:smallest of the 3 glandssecretes both mucus and serous, but more mucusDuct Pathway: duct opens @ floor of oral cavity w/ submandibular duct, just below mucus membrane of tongue, lat to frenulumBlood Supply : Submental and sublingual a (from facial and lingual a)Innervation:Pre ggl PNS fibers from CN VII by chordatympani –> submandibular ggl –> post ggl fibers run w/ lingual nSNS post ggl fibers come from sup cervical ggl

Physical Examination of the Oral CavityLips

Inspect landmarks – vermilion zone, commissures, nasolabial foldInspect colorInspect surface for ulcerations, blisters, growths, thickness changesObserve patient with mouth closed and patient smiling to look for cranial nerve VII lesionsPalpate with gloved hands for surface irregularities not visible to the eye, submucosal nodules, and areas of tenderness

Labial mucosa – reflect lips with gloved handsInspect color and surface for nodules, ulcerations, thickeningsPalpate upper and lower surfaces with two fingers from commissure to commissure to detect submucosal changes

Evaluation and examination of oral cavity

Buccal mucosa – have patient open mouth wide in order to inspect and have good lighting.

Inspect color and surface for nodules, ulcerations, thickeningsIdentify normal landmarks: pterygomandibular raphe and parotid papilla. Identify parotid papilla on mucosal surface near upper molars. Palpate the parotid gland and observe for expression of fluid from Stensen’s ductPalpate surface with two fingers to identify submucosal lesions

Gingiva and alveolar mucosa

Gingiva and alveolar mucosainspect color of gingival and alveolar mucosa. Inspect texture of gingival and alveolar mucosa – look for atrophy, recession, hypertrophy or enlargement. Look for ulcerations.Palpate any areas of enlargement to determine if enlargement is due to edema, or an underlying bony or fibrous process

Palateidentify hard and soft palate landmarks – fovea palatinae, palatine raphe, alveolar tuberosity, hamular notch, pillars of the fauces, uvula. Inspect for any developmental abnormalities of these landmarksInspect color of hard and soft palate and inspect for ulcerations, thickenings, exudates. petechiaePalpate posterior hard palate and soft palate for subcutaneous nodules

1.Tongue – inspect in normal resting position and in a protruded position

1.Identify landmarks: terminal sulcus, median sulcus, foramen cecum, lingual frenulum2.Be familiar with normal appearance of filiform, fungiform and circumvallate papillae3.Inspect color and texture of dorsal, ventral and lateral surfaces. Look for plaques, ulcerations, thickenings, changes in papillae4.Palpate dorsal and ventral aspects of the tongue5.Evaluate movement of tongue

1.Floor of the Mouth – have patient open mouth touch tip of tongue to roof of mouth to inspect. Carefully retract tongue to inspect distal aspects of floor.

1.inspect normal landmarks – lingual frenulum, sublingual folds, caruncles2.inspect for color and texture changes3.palpate entire sublingual and submandibular fossa areas by bimanual palpation to detect nodules, differences in consistency of sublingual glands and tissues

2.Teeth1.Inspect for number and position of teeth – understand how the number of teeth change from childhood to adulthood, look for changes in teeth structure or number that indicate congenital/genetic syndromes2.Inspect color of teeth and look for surface changes indicative of early dental decay

Orlal examination

Diseases of the head & neckDiseases of the supporting hard & soft tissuesDiseases of the lips, tongue, salivary glands, oral mucosaDiseases of the oral tissues which are a component of systemic disease

Scope of responsibility

Many diseases (systemic or local) have signs that appear on the face, head & neck or intra-orallyMaking a complete examination can help you create a differential diagnosis in cases of abnormalities and make treatment recommendations based on accurate assessment of the signs & symptoms of disease

EquipmentAssure that you have all the supplies necessary to complete an oral examination

MirrorTissue retractor (tongue blade)Dry gauze

You must dry some of the tissues in order to observe the nuances of any color changes

Extra-oral examinationObserve: color of skinExamination area of head & neck

Determine: gross functioning of cranial nervesNormal vs. abnormal

ParalysisStroke, trauma, Bell’s Palsy

TMJPalpate upon opening

What is the maximum intermaxillary space?Is the opening symmetrical?Is there popping, clicking, grinding?

What do these sounds tell you about the anatomy of the joint?When do sounds occur?

Use your stethoscope to listen to sounds

Lymph node palpationRefer to handout

Thyroid Gland Evaluation

Thyroid Gland Palpation

Place hands over the tracheaHave the patient swallowThe thyroid gland moves upward

Exam: LipsObserve the color & its consistency-intra-orally and externallyIs the vermillion border distinct?Bi-digitally palpate the tissue around the lips. Check for nodules, bullae, abnormalities, mucocele, fibroma

Exam: Lips

Evert the lip and examine the tissueObserve frenum attachment/tissue tensionClear mucous filled pockets may be seen on the inner side of the lip (mucocele). This is a frequent, non-pathologic entity which represents a blocked minor salivary gland

Exam: Lips-palpationColor, consistencyArea for blocked minor salivary glands

Lesions, ulcers

Frenum:AttachmentLevel of attached gingiva

Exam: Lips-sun exposure

Palpate in the vestibule, observe color

Examination: Buccal Mucosa Observe color, character of the mucosa

Normal variations in color among ethnic groups

Amalgam tattoo Palpate tissue Observe Stenson’s duct opening for

inflammation or signs of blockage Visualize muscle attachments, hamular

notch, pterygomandibular folds

Linea albaStenson’s

duct

Lesions – white, red Lichen Planus, Leukedema

GingivaNote color, tone, texture, architecture & mucogingival relationships

How would you describe the gingiva?Marginal vs. generalized?Erythematous vs. fibrous

Drug reactions: Anti-epileptic, calcium channel blockers, immunosuppressant

Exam: Hard palate Minor salivary glands, attached gingiva Note presence of tori: tx plan any pre-

prosthetic surgery

Exam: Soft palate How does soft palate raise upon “aah”? Vibrating line, tonsilar pillars, tonsils,

oropharynx

Exam: Oropharanyx

Color, consistency of tissueLook to the back, beyond the soft

palateNote occasional small globlets of

transparent or pink opaque tissue which are normal and may include lymphoid tissue

Exam: TonsilsTucked in at base of anterior &

posterior tonsilar pillarsGlobular tissue that has “punched

out” appearing areasRegresses after adulthoodMay see white “orzo rice like” or

“torpedo” shaped white concretions within the tissue

Exam: Tongue

The tongue and the floor of the mouth are the most common places for oral cancer to occurIt can occur other places; so visualize all areasYou may observe:

Circumvalate papillae, epiglottis

You may observe lingual varicosities

You may observe geographic tongue (erythema migrans)

You may observe drug reaction

Observe signs of nutritional deficiencies, immune dysfunction

You may observe oral cancer

Palpation of the floor of the mouth

Exam: Floor of mouth Visualize, palpate - bimanually Wharton’s duct Must dry to observe

Does “lesion” wipe off? Where are the two most likely areas for oral cancer?

lateral border of the tongueFloor of mouth

Squamous Cell Carcinoma

Squamous Cell Carcinoma

Exam: Leukoplakic area

Edentulous Mandibular Ridge

Oral Cancer:RedWhiteRed and White

Does the patient have important risk factors for oral cancer?Counseling for smoking and alcohol

Cessation

Squamous Cell Carcinoma

Triaging Lesions *Describe it’s characteristics

Size, shape, color, consistency, locationHow long has it been present?Is it related to a trauma?

Fractured cusp, occlusal traumaHas it occurred before?Can you wipe it off? Does the patient have specific risk factors for neoplastic lesions?

Any lesion that is suspicious should be re-evaluated in 2 weeks

Lesions due to infectious processes would have healed in that time frameIf it remains, the lesions should be biopsied

Exam: Maxilla & Mandible• size, shape, contour

• pre-prosthetic treatment

•Tori removal

• tuberosity reduction

•Soft or hard tissue or both

Evaluate for Epulis fissuratum

If you make a new denture will the excess tissue resolve?

OcclusionOrthodontic classificationInterferences

BreathOral odors can indicate:

Infection: caries, periodontal dxURT infectionsChronic G.I. disturbancesLung abscessDiabetic acidosisUremia, kidney problemLiver failure: mousy, musty odorSelf-medication with alcohol

Visualize all areas

Oral odors can indicate:Infection: caries, periodontal dxURT infectionsChronic G.I. disturbancesLung abscessDiabetic acidosisUremia, kidney problemLiver failure: mousy, musty odorSelf-medication with alcohol

Disease of the hard tissue of teeth

Dental cariesDental caries, also known as tooth decay or a cavity, is an irreversible infection usually bacterial in origin that causes demineralization of the hard tissues (enamel, dentin and cementum) and destruction of the organic matter of the tooth, usually by production of acid by hydrolysis of the food debris accumulated on the tooth surface .

If demineralization exceeds saliva and other remineralization factors like from calcium, fluoridated tooth pastes, these tissues progressively break down, producing dental caries (cavities, holes in the teeth). Two groups of bacteria are responsible for initiating caries: Streptococcus mutans and Lactobacillus. If left untreated, the disease can lead to pain, tooth loss and infection.

Tooth decay is caused by specific types of acid-producing bacteria that cause damage in the presence of fermentable carbohydrates such as sucrose, fructose, and glucoseThe mineral content of teeth is sensitive to increases in acidity from the production of lactic acid. To be specific, a tooth (which is primarily mineral in content) is in a constant state of back-and-forth demineralization and remineralization between the tooth and surrounding saliva. For people with little saliva, especially due to radiation therapies that may destroy the salivary glands, there also exists remineralization gel

These patients are particularly susceptible to dental caries. When the pH at the surface of the tooth drops below 5.5, demineralization proceeds faster than remineralization (meaning that there is a net loss of mineral structure on the tooth's surface). Most foods are in this acidic range and without remineralization, this results in the ensuing decay. Depending on the extent of tooth destruction, various treatments can be used to restore teeth to proper form, function, and aesthetics, but there is no known method to regenerate large amounts of tooth structur

ClassificationCaries can be classified by location, etiology, rate of progression, and affected hard tissues. These forms of classification can be used to characterize a particular case of tooth decay in order to more accurately represent the condition to others and also indicate the severity of tooth destruction.

Rampant caries.In some instances, caries are described in other ways that might indicate the cause. "Baby bottle caries," "early childhood caries," "baby bottle tooth decay," or "Bottle Rot" is a pattern of decay found in young children with their deciduous (baby) teeth. The teeth most likely affected are the maxillary anterior teeth, but all teeth can be affectedThe name for this type of caries comes from the fact that the decay usually is a result of allowing children to fall asleep with sweetened liquids in their bottles or feeding children sweetened liquids multiple times during the day. Another pattern of decay is "rampant caries", which signifies advanced or severe decay on multiple surfaces of many teeth

Etiology

. Rampant caries may be seen in individuals with xerostomia, poor oral hygiene, stimulant use (due to drug-induced dry mouth and/or large sugar intake. If rampant caries is a result of previous radiation to the head and neck, it may be described as radiation-induced caries. Problems can also be caused by the self destruction of roots and whole tooth resorption when new teeth erupt or later from unknown causes

1 Carbohydrate substrate2 Acid that caused dissolution of tooth minerals3 Oral micro-organisms that produce acid and also cause proteolysis.

Three factors for dental caries

Rate of progression These descriptions can be applied to caries to indicate the progression rate and previous history. "Acute" signifies a quickly developing condition, whereas "chronic" describes a condition that has taken an extended time to develop, in which thousands of meals and snacks, many causing some acid demineralization that is not remineralized, eventually results in cavities. Fluoride treatment can help recalcification of tooth enamel.

Recurrent caries, also described as secondary, are caries that appears at a location with a previous history of caries. This is frequently found on the margins of fillings and other dental restorations. On the other hand, incipient caries describes decay at a location that has not experienced previous decay. Arrested caries describes a lesion on a tooth that was previously demineralized but was remineralized before causing a cavitation. Using fluoride treatments can help with recalcification.

Affected hard tissueDepending on which hard tissues are affected, it is possible to describe caries as involving enamel, dentin, or cementum. Early in its development, caries may affect only enamel. Once the extent of decay reaches the deeper layer of dentin, "dentinal caries" is used. Since cementum is the hard tissue that covers the roots of teeth, it is not often affected by decay unless the roots of teeth are exposed to the mouth. Although the term "cementum caries" may be used to describe the decay on roots of teeth, very rarely does caries affect the cementum alone. Roots have a very thin layer of cementum over a large layer of dentin, and thus most caries affecting cementum also affects dentin.

Signs and symptomsA person experiencing caries may not be aware of the diseaseThe earliest sign of a new carious lesion is the appearance of a chalky white spot on the surface of the tooth, indicating an area of demineralization of enamel. This is referred to as an incipient carious lesion or "microcavity". As the lesion continues to demineralize, it can turn brown but will eventually turn into a cavitation ("cavity"). Before the cavity forms, the process is reversible, but once a cavity forms, the lost tooth structure cannot be regenerated A lesion that appears brown and shiny suggests dental caries were once present but the demineralization process has stopped, leaving a stain. A brown spot that is dull in appearance is probably a sign of active caries.

As the enamel and dentin are destroyed, the cavity becomes more noticeable. The affected areas of the tooth change color and become soft to the touch. Once the decay passes through enamel, the dentinal tubules, which have passages to the nerve of the tooth, become exposed and causes a toothache. The pain may worsen with exposure to heat, cold, or sweet foods and drinks Dental caries can also cause bad breath and foul tastes In highly progressed cases, infection can spread from the tooth to the surrounding soft tissues. Complications such as cavernous sinus thrombosis and Ludwig's angina can be life-threatening.

CausesThere are four main criteria required for caries formation: a tooth surface (enamel or dentin); caries-causing bacteria; fermentable carbohydrates (such as sucrose); and time The caries process does not have an inevitable outcome, and different individuals will be susceptible to different degrees depending on the shape of their teeth, oral hygiene habits, and the buffering capacity of their saliva. Dental caries can occur on any surface of a tooth that is exposed to the oral cavity, but not the structures that are retained within the bone All caries occurs from acid demineralization that exceeds saliva and fluoride remineralization, and almost all acid demineralization occurs where food (containing carbohydrate like sugar) is left on teeth. Though most trapped food is left between teeth, over 80% of cavities occur inside pits and fissures on chewing surfaces where brushing, fluoride, and saliva cannot reach to remineralize the tooth as they do on easy-to-reach surfaces that develop few cavities.

A build-up of plaque and calculus can lead to inflamed and infected gums. Mild gum disease is called gingivitis and is not usually serious. More severe gum disease, called periodontitis, can lead to teeth falling out. Good oral hygiene which includes regular tooth brushing and cleaning between teeth (eg by flossing) can usually prevent gum disease, and treat mild-to-moderate gum disease. Specialist dental treatments may be needed for severe gum disease.

Dental Plaque and Gum Disease

Dental plaque is a soft deposit that forms on the surface of teeth. It contains many types of bacteria (germs). You can usually remove plaque quite easily by tooth brushing and cleaning between teeth.Calculus is hardened calcified plaque. It is sometimes called tartar. It sticks firmly to teeth. Generally, it can only be removed by a dentist or dental hygienist, with special instruments.

Gum disease (periodontal disease) means infection or inflammation of the tissues that surround the teeth. Depending on the severity, gum disease is generally divided into two types - gingivitis and periodontitis.

GingivitisGingivitis means inflammation of the gums. Most cases of gingivitis are caused by plaque. This is then called plaque-associated gingivitis.PeriodontitisPeriodontitis literally means 'inflammation around the tooth'. It occurs if gingivitis becomes worse and progresses to involve the tissue that joins the teeth to the gums (the periodontium), and/or the supporting bone.

As a consequence of periodontitis, a gap (pocket) develops between the tooth and gum. If left untreated, the tooth may slowly loosen and eventually fall out.

Dentists assess the severity of periodontitis by measuring the depth of the pockets that form between the gum and tooth.

Plaque can be removed from shallow pockets (up to about 3 mm deep) by brushing and cleaning teeth in a normal way. However, deeper pockets need to be treated by a dentist, as normal brushing and cleaning will not reach the bottom of the pocket.

Dental Pulp DiseasesPoor dental hygiene is the main reason for tooth decay, tooth pain, and other oral health conditions. If you don't maintain good oral health habits, including brushing and flossing regularly, plaque can develop and lead to cavities. Left untreated, a cavity can eventually affect the soft center (or pulp) of your tooth, which contains sensitive nerves and delicate blood vessels. And if pulp diseases aren't properly managed, you can lose your teeth.

Symptoms of Pulp Diseases Depending on the type of pulp disease, symptoms may vary in intensity and can include: Pain in a tooth or teeth when you eat something very sweet, hot, or coldSudden, intense pain in the mouthInfection in the mouth

Types of Pulp Diseases There are several different pulp diseases, including: Reversible pulpitis, or mild inflammation of the pulp. Symptoms typically include pain upon eating or drinking something very sweet, hot, or cold. Without treatment, the inflammation can progress to a dental abscess, a collection of bacteria and pus. Good oral health habits can help offset reversible pulpitis, but in many cases, a filling is eventually needed. Pulpitis can also occur if you crack or break a tooth.Irreversible pulpitis, or severe inflammation of the pulp that can't be cured. Symptoms include sudden intense pain. Left untreated, it can result in a widespread gum and connective tissue infection. Irreversible pulpitis is generally treated with a root canal procedure. If that doesn't work, your dentist may have to remove the tooth.

Dental pulp calcification (also known as dental pulp stones). This is a condition in which hardening, or calcification, of pulp tissue results in hypersensitivity and extreme pain because the dental nerves become compressed. A root canal is usually necessary to clear away hardened tissue.

Dental pulp exposure. This condition comes on when damage to the external covering of a tooth, such as a cavity or crack in the tooth, exposes the normally protected pulp to bacteria and irritating food particles. Pain is the most frequent symptom and without proper dental care, a mild infection can progress into a serious abscess. Depending on the degree of pulp exposure, a filling, root-canal procedure, or even tooth extraction may be required.

Pulp Diseases Treatment: Root Canal Therapy If damaged pulp in your tooth isn't taken out, a severe infection can spread to surrounding tissue, including your jaw bone. A root canal procedure to remove the pulp tissue is usually performed over several visits by a regular dentist or a pulp specialist, called an endodontist. The root canal therapy may spare you from having to get the infected tooth removed.

Here's what you can expect from root canal therapy: First visit. The diseased pulp is removed and the empty space, the root canal, is cleaned out and enlarged. Special medications may be placed in the canal to disinfect the area. A temporary filling may be placed as well, or your dentist may choose to leave the canal open and let the tooth drain for a few days. An oral antibiotic may also be recommended to treat infection in the tissues surrounding your tooth.Second visit. The temporary filling is removed and a permanent filling is placed.Final visit. A crown is placed over the tooth to reinforce the tooth and make it stronger. Some pulp diseases may be caused by an injury that broke a tooth. But many other pulp diseases are simply caused by poor oral health habits. If you brush and floss regularly and seek out regular dental care, you are less likely to develop pulp diseases.

Tooth extraction Definition Tooth extraction is the removal of a tooth from its socket in the bone.

Indcations And Contra-Indications Of Extractions

Dental Extraction:Dental Extraction is defined as :

“The removal of a tooth from oral cavity by means of elevators and forceps”.

Also referred as “Exodontia”.

Indications Of Extraction:Indications advocated for dental extraction:

-Unrestorable carious tooth.

-Pulp necrosis and irreversible pulpitis;untreatable by endodontic therapy,calcified root canal,patient refusal.

-Severe periodontal disease; Bone loss,grade 3 mobility,furaction involvement.

-Impacted teeth ;Mal-alligned,resorption of roots of adjacent teeth.

Orthodontic treatment ; Crowding,Space creation.Maxillary and Mandibular 1st Pre-molar.

-Mal-alligned teeth ; Tissue trauma,mal-positioning,esthetics.

Esthetics ; Stained teeth, excessively protruded teeth,mal-alligned.

-Cracked and fractured tooth ;Tooth in fracture line,pain,Dialceration,healing, infection.

Pre-prosthetic extraction ; Unsuitable abutments,interference with appliance

-Supre-numerary teeth ; Impacted,resorption, displacement,failure for erruption.

-Pre-radiation therapy ; Osteoradionecrosis.

-Economical reason ; Unaffording patient.

-Lack of time ; Unavailability of time for other options.

Contraindications for Dental Extraction

Systemic Local

Systemic Contraindications:

-Uncontrollable metabolic disease e.g Diabetes, End stage renal disease, Uremia.

-Uncontrollable leukemia and lymphomas.

-Uncontrollable cardiac diseases ; Severe M.I.,Angina Pectoris, Recent M.I., Dysarrythmias.

Uncontrolled hypertension ; Risk of myocardial insufficiency, C.V.A.

-Bleeding diathesis ; Hemophilia, Thrombocytopenia.

-Pregnancy ; 1st and 3rd Trimester ; Relative contra-indication.

Local Contraindications:

-Therapeutic irradation ; osteoradionecrosis.

-Teeth in area of malignant tumor.

-Severe pericoronitis.

-Acute dento-alveolar abscess.

TypesExtractions are often categorized as "simple" or "surgical".

Simple extractions are performed on teeth that are visible in the mouth, usually under local anaesthetic, and require only the use of instruments to elevate and/or grasp the visible portion of the tooth. Typically the tooth is lifted using an elevator, and using dental forceps, rocked back and forth until the Periodontal ligament has been sufficiently broken and the supporting alveolar bone has been adequately widened to make the tooth loose enough to remove. Typically, when teeth are removed with forceps, slow, steady pressure is applied with controlled force.

Surgical extractions involve the removal of teeth that cannot be easily accessed, either because they have broken under the gum line or because they have not erupted fully. Surgical extractions almost always require an incision. In a surgical extraction the doctor may elevate the soft tissues covering the tooth and bone and may also remove some of the overlying and/or surrounding jawbone tissue with a drill or osteotome. Frequently, the tooth may be split into multiple pieces to facilitate its removal. Surgical extractions are usually performed under a general anaesthetic.

Post-extraction healingFollowing extraction of a tooth, a blood clot forms in the socket, usually within an hour. Bleeding is common in this first hour, but its likelihood decreases quickly as time passes, and is unusual after 24 hours. The raw open wound overlying the dental socket takes about 1 week to heal. Thereafter, the socket will gradually fill in with soft gum tissue over a period of about one to two months. Final closure of the socket with bony remodeling can take six months or more.

TootExtraction Complications A tooth extraction is a routine dental procedure. In the majority of the procedures no complications are expected during or after the tooth extraction. But difficulties with extractions are unpredictable and sometimes complications do occur.

Tooth extraction difficulty increases when the following conditions exist: strong supporting tissues, difficult root morphology, teeth with weakened crown surfaces due to large restorations, teeth with deep caries, brittle teeth after endodontic treatment.

Tooth extraction complications during the procedurePotential tooth extraction complications during the procedure include :

Damage to nearby teeth. The adjacent teeth or dental restorations (e.g., crowns, bridges, implants) next to the extracted tooth may occasionally be damaged during the procedure. Nearby teeth may become fractured, chipped or loosened during the extraction of a tooth or teeth, sometimes requiring more dental work.

Fracture of the tooth. The tooth may fracture during the extraction process, complicating the procedure and requiring more time and effort to complete the extraction. Tooth sectioning may be needed.

Incomplete extraction. A small part of the tooth root may be left in the jawbone. Although it may increase the risk of infection, sometimes the dentist will prefer to not try to extract it because its removal may be too risky e.g. if it is very close to a nerve.

Damage to the sinus. The extraction of a molar from the upper jaw may damage the sinus cavities above it, by creating a hole that might become a source of sinus infections. Normally the hole will heal and close by itself, but if not it may require corrective surgery.

Nerve damage. A mistake during an extraction of a tooth from the lower jaw may damage the inferior alveolar nerve. Numbness in the lower lip and chin are common symptoms of a damaged nerve. The nerve will heal in a few weeks up to some months depending on the extend of the damage. In rare cases, the nerve is unable to heal completely, leaving the patient with a permanent numbness.

Jaw fracture. Patients with a weak jawbone structure (e.g. older women with osteoporosis) may have a risk of jaw fracture. Even if the actual tooth extraction procedure is performed smoothly without any problems, there are cases of complications during the healing process.

Tooth extraction complications after the operationPossible tooth extraction complications after the operation include :

Dry socket. A dry socket following a tooth extraction is a common complication in about 5% of people who have a tooth extracted. The condition occurs when a blood clot does not form normally in the tooth socket or the blood clot is washed out or dissolved prematurely. In a dry socket situation, the underlying bone and nerves are exposed to air and food, causing intense pain and sometimes bad odor or taste. A dry socket needs to be treated with a medicated dressing to stop the pain and help healing.

Infection. The wound of the tooth extraction can be a doorway for bacteria causing an infection, particularly in patients with a weakened immune system. If a patient has a high risk of infection the dentist will generally prescribe antibiotics before and

after the extraction.

Excessive bleeding and/or swelling, redness or fever. If you have any of these symptoms, especially if they continue after the first 24 hours, contact your dentist or oral surgeon for advice.

Why you must replace an extracted tooth

After a tooth extraction, dentists will always recommend that the extracted tooth has to be replaced by a bridge or an implant (unless the extraction was made as part of preparation for full dentures). If the tooth is not replaced, its absence may cause a series of problems in the long term.

These complications because of tooth extractions include :

Teeth misalignment. The teeth next to an extracted tooth tend to shift in the empty space left by the extracted tooth causing problems with the alignment of teeth. Potential long term risks of teeth misalignment include tooth wearing, teeth grinding (bruxism) and temporomandibular joint disorders.

Chewing problems. The loss of a tooth, especially if it was a molar, may affect the chewing ability. Besides that, the opposing tooth will press hard foods against the soft tooth socket of the extracted tooth, causing irritation and pain.

Loose teeth. The neighboring teeth on the sides of a tooth extraction site loose their lateral support and have increased risk of becoming loose over time.

Cosmetic problems. The patient’s appearance is severely affected by the loss of one or more front teeth.

The best treatment after tooth extractions is to replace missing teeth with dental implants.

The cost involved with dental

treatments needed to replace an extracted tooth is significant and many patients can not afford it if they are not covered by their dental insurance. Learn how to choose a dental insurance that will help you provide the best dental treatment to yourself and your family.

Anesthesia and Pain Control in Dentistry

IntroductionThe practice of various psychological, physical, and chemical approaches to the prevention and treatment of preoperative, operative, and postoperative anxiety and pain.

Methods of pain controlAnesthetic agents Inhalation sedationAntianxiety agents Intravenous sedation General anesthesia

Anesthetic AgentsThe numbing of a specific site or area.Topical Anesthesia provides a temporary numbing effect on nerve endings that are located on the surface of the oral mucosa. Supplied as:OintmentsLiquidsSprays

Local Anesthesia

Agents most frequently used for pain control in dentistry. Criteria for use:Be nonirritating to the tissues in the area of the injection. Produce minimal toxicity. Be of rapid onset. Provide profound anesthesia. Be of sufficient duration. Be completely reversible. Be sterile.

What are local anesthetics?Local anesthetic: produce loss of sensation to pain in a specific area of the body without the loss of consciousness

Method of ActionLocal anesthesia temporarily blocks the normal generation and conduction action of the nerve impulses. Local anesthesia is obtained by injecting the anesthetic agent near the nerve in the area intended for dental treatment. Induction time is the length of time from the injection of the anesthetic solution to complete and effective conduction blockage.

DurationLength of time from induction until the reversal process is complete.Short-acting:Local anesthetic agent lasts less than 30 minutes.Intermediate-acting: Local anesthetic agent lasts about 60 minutes. Long-acting:Local anesthetic agent lasts longer than 90 minutes.

VasoconstrictorCriteria for use:Prolongs the duration of an anesthetic agent by decreasing the blood flow in the immediate area of the injection. Decreases bleeding in the area during surgical procedures. Types:Epinephrine Levonordefrin Norepinephrine

Ratio of vasoconstrictor to anesthetic solution: 1:20,000 1:50,000 1:100,000 1:200,000

Contraindications for the use of vasoconstrictors

Unstable angina. RecentContraindications for the use of vasoconstrictors Unstable angina. Recent myocardial infarction. Recent coronary artery bypass surgery. Untreated or uncontrolled severe hypertension. Untreated or uncontrolled congestive heart failure. myocardial infarction. Recent coronary artery bypass surgery. Untreated or uncontrolled severe hypertension.

Untreated Contraindications for the use of vasoconstrictors

Unstable angina. Recent myocardial infarction. Recent coronary artery bypass surgery. Untreated or uncontrolled severe hypertension. Untreated or uncontrolled congestive heart failure. or uncontrolled congestive heart failure.

Contraindications for the use of vasoconstrictors Unstable angina. Recent myocardial infarction. Recent coronary artery bypass surgery. Untreated or uncontrolled severe hypertension. Untreated or uncontrolled congestive heart failure.

Types of Local Anesthesia InjectionsInfiltration is achieved by injecting the solution directly into the tissue at the site of the dental procedure.Most frequently used to anesthetize the maxillary teeth. Used as a secondary injection to block gingival tissues surrounding the mandibular teeth.

Block anesthesiaThe solution is injected near a major nerve, and the entire area served by that nerve is numbed. Type of injection required for most mandibular teeth.

Inferior alveolar nerve block Obtained by injecting the anesthetic solution near the branch of the inferior alveolar nerve close to the mandibular foramen.Type of injection for half of the lower jaw, including the teeth, tongue, and lip.

Incisive nerve blockInjection given at the site of the mental foramen. Used when the mandibular anterior teeth or premolars require anesthesia.Periodontal ligament Alternative infiltration anesthesia method by which the anesthetic solution is injected directly into the periodontal ligament and surrounding tissues.

Local Anesthesia SetupAnesthetic carpule: Care and caution of useCartridges should be stored at room temperature and protected from direct sunlight.Never use a cartridge that has been frozen. Do not use a cartridge if it is cracked, chipped, or damaged in any way

Never use a solution that is discolored or cloudy or has passed the expiration date. Do not leave the syringe preloaded with the needle attached for an extended period of time. Never save a cartridge for reuse.

Local Anesthetic CautionsInjection into a blood vesselInfected areaLocalized toxic reactionSystemic toxic reactionTemporary numbnessParesthesia

Electronic AnesthesiaA noninvasive method to block pain electronically by using a low current of electricity through contact pads that target a specific electronic waveform directly to the nerve bundle at the root of the tooth.

Benefits to the patient:No needles. No post-operative numbness or swelling. Chemical-free method of anesthesia. No risk of cross-contamination. Reduces fear and anxiety. Patients have control over their own comfort level.

Dental Injuries An average of 22,000 occur annually among children less than 18 years of age.Over 80% of all dental injuries involve the upper teeth.30% of preschoolers have had a dental injury of some kind.Of all sports, baseball and basketball were associated with the largest number of dental injuries.Children with primary teeth, less than 7 years old, sustained over half of the dental injuries in activities associated with home furniture.Outdoor recreational products and activities were associated with the largest number of dental injuries among children ages 7-12 years of age.

Management and dental trauma evaluationCheck airway, breathing, and, circulationDetermine if there are any other life-threatening injuries present.Perform a neurological exam.Assess the cervical spine.Evaluate extra oral soft tissue injuries. Conduct intraoral examinationDetermine if the injury is to primary or permanent teethAssess availability of dental care

Three broad categories of injuries result from impacts during play to the soft tissues, the jaws and teeth:Soft Tissues – bruises, lacerations and cuts to the lips, cheeks and tongue.

Jaws – Dislocations of the lower jaw (mandible) or fractures of the upper arch (maxillary).

Dental – Tooth related; this can be as simple as a chipped tooth or as serious as an avulsion (tooth removed from the socket)

The goal is to try to save the teeth that have been affected.Avoid tooth lossAssessment, diagnosis and treatment will differ in damaged baby teeth compared to adult teeth.Keep the child comfortable.

Immediate treatment – within 5 minutesFor a tooth that has been completely knocked out

(avulsed tooth)

Physically try to place the tooth back into the socketRinse the tooth with clean water: do not scrub or

scrape the root surfaces.Hold the tooth’s crown and push it back into the

socket. You will need to hold the tooth in the socket for several minutes to keep it from extruding back out of the socket.

It is okay if the tooth is not completely aligned. The dentist can adjust it later.

What if no one can replant the tooth?

Control the bleeding with pressure.Place the tooth in either cold milk or the patient’s saliva to keep it from drying out. The person needs to transported to their dental provider/ emergency room immediately.

Why replant the tooth within 5 minutes?

Evidence suggests that placing the tooth back into the socket is an important factor for long term survival of knocked out teeth.

More than 5 minutesTransporting the tooth in milk or the person’s own saliva will keep the tooth from drying out. If the tooth dries out, it will be unable to regenerate the periodontal ligament cells.

What if a baby tooth is completely knocked out?

Primary teeth (baby) are different than adult teeth and the treatment is different.Primary teeth are generally not replanted into the socket.The reason is for not replanting is that the primary tooth may cause an infection to spread to the permanent tooth. It may also affect the eruption pattern of the permanent tooth.

Urgent Treatment – Within 6 hours

A painful injury from a permanent tooth moved from its original position

This will cause the tooth/teeth to be driven in or out of the jaw.This may cause a fracture to the roots of the teeth.The person should seek treatment as soon as possible.If the person has a dental provider it’s best to contact them immediately.The dentist may be able to splint the teeth back together.

Primary (baby) Tooth InjuriesIf the child is unable to bite and close his teeth together normally, you should contact the child’s dental provider as soon as possible, or go to the emergency department of the nearest hospital.Primary teeth can be treated in up to 6 hours. This will usually not have an impact on long-term outcomes.Contact the child’s medical and or dental provider.Following treatment with pain control and some rest may result in the child being more comfortable with treatment.

Less Urgent Treatment – Within 12 Hours

Fractured or Chipped Permanent ToothCrown fractures are the most common traumatic injury.These teeth will be sensitive to temperature. These will need medical/dental follow up, but treatment of the pulp nerve exposure will not affect long term outcomes.Contact the child’s dental/medical provider.

MouthguardsMouthguards are designed to absorb and distribute the forces of impact received while participating in athletic activities.Properly fitted mouthguards help protect the soft tissues of the lip, cheeks, gums, and tongue by covering the sharp surfaces of the teeth.They can also reduce the potential for jaw joint fractures and displacement by cushioning against the impact.They can reduce the force upon impact helping to protect the jaws from fracture.

Your Role in Injury Prevention

It is far better to prevent injuries than to have to deal with them after they occur. Anterior trauma can have life-long consequences

affecting aesthetics, self-image, and pocketbook. Raising awareness and stressing prevention to parents of young children are important public health messages. A trusted clinician is in a powerful position to provide

preventive recommendations to parents.

Cleft Lip & Palate

Malformations alterations in normal development

Deformations abnormal mechanical force on an otherwise normal fetus

Disruptions disruption of an otherwise normal developmental process

Birth defects

IntroductionMost common craniofacial malformation Cleft lip with or without cleft palate (CL/P) or isolated cleft palate (CP). CL/P and CP differ with respect to

Embryology, etiology, candidate genes, associated abnormalities, and recurrence risk.

PrevalenceCL/P is more common than CP and varies by ethnicity. CL/P

High in American Indians and Asians (1/500 newborns)Low in American blacks (1/2000 newborns)Intermediate level in Caucasians (1/1000 newborns)

Isolated CP occurs in only 1/2500 newborns and does not display variation by ethnicity

Cleft LipComplete closure at 35 days postconception:

7 weeks from the LMP. Lateral nasal, median nasal, and maxillary mesodermal processes merge.

Failure of closure can produce unilateral, bilateral, or median lip clefting.Left side unilateral cleft is the most common

Cleft lip SeverityMild, involving only the lip

Extend into the palate and midface thereby affecting the nose, forehead, eyes, and brain.

Cleft PalateLack of fusion of the palatal shelves. Abnormalities in programmed cell death may contribute to lack of palatal fusion(?). Isolated disruption of palate shelves can occur after closure of the lipPalatal closure is not completed until 9 weeks post-conception.

EtiologyGenes

Control cell patterning, cell proliferation, extracellular communication, and differentiationClefting usually represents a genetically complex eventSingle Mendelian disorders associated with clefting are rare2 to 20 genes are thought to interact to result in facial clefting

Dlx gene Direct the destination of the distal skeletogenic mesenchyme elements to the palate. Mutations of these genes result in isolated palatal defects.

Sonic hedgehog gene Protein that mediates ectodermal functions, might regulate the outgrowth and fusion of the facial domains.

TGF-alpha variant Receptor ligand, usually a rare variant of TGF-alpha Family histories of cleft defectsAdditive teratogenic effect with agents such as cigarette smoking and alcohol

TGF-beta-3 gene Expressed just prior to palatal fusion. Results in isolated cleft palate.

IRF 6 Identified in autosomal dominant van der Woude syndrome.

Environmental agentsSeveral agents that are associated with an increased frequency of midfacial malformation.Medications —phenytoin, sodium valproate, methotrexate. With corticosteroids there is no evidence of an increase in malformations.

Possible association could not be excluded

EtiologyCigarette smoking

Noted with mothers of children with facial clefting, both CL/P and CP.Teratogenesis has been attributed to hypoxia as well as a component of tobacco (cadmium).

Alcohol Associated with an increased risk of fetal facial clefting. Alterations in cell membrane fluidity or reduced activity of specific enzymes such as superoxide dismutase.

Folate deficiency Contributes to a range of birth defects. Evidence is emerging for a similar association with the development of CL/P.

Prenatal Diagnosis

Diagnosed until the soft tissues of the fetal face can be clearly visualized sonographically (13 to 14 weeks).The majority of infants with cleft lip also have palatal involvement:

85% of bilateral cleft lips 70% associated with cleft palate. Cleft palate with an intact lip comprises 27% of isolated CL/P

The sensitivity is highest when is associated with other structural anomalies. Isolated CL/P in a low risk population, the sensitivity may only reach 50 percent. Cleft palate with an intact lip is the most difficult orofacial malformation to diagnose prenatally.Detected in only 13 of 198 cases in one large series.Three-dimensional ultrasound, can provide a clear image of the malformation

Syndrome ?A thorough examination of the newborn or stillbirth is always warranted. Orofacial clefting is noted in over 300 syndromes. 3 deserve additional comment.

frequency, variable presentations, and modes of inheritance

Deletion of chromosome 22q11 DeGeorge syndrome.Spectrum in addition to cleft palate:

Conotruncal cardiac defects, thymic hypoplasia, and velopharyngeal webs.

Majority of cases represent a new microdeletion In families with conotruncal malformations and/or CP, further evaluation is appropriate.

Oral-facial-digital syndrome, type IX-linked dominant syndromes.

Manifestations in affected females are variable and subtle:

hyperplastic frenulacleft tonguecleft lip/palatedigital anomalies

Treacher-Collins syndromeAutosomal dominant disorder Downward slanting palpebral fissures, micrognathia, dysplastic ears, and deafness.

Mental development is normal. The mutations appear to increase cell death in the prefusion neural folds. A family history with deafness, ear abnormalities, or CP.

Obstetrical ManagementAmniocentesis for karyotype should be offered.

high rate of chromosomal defects Difficulty in prenatal sonographic diagnosis supports chromosomal evaluationAs of January 2002, "in utero" correction had been attempted only once in Mexico

The child delivered prematurely and died at two months of life

Recurrent RiskRecurrent RiskRecurrent Risk

Affected relative Risk in child, percent

Cleft lip with or without cleft palate

Parent 2%

Sibling 4 – 7%

Parent and Sibling 11 – 14%

Two Siblings 10%

Cleft palate only

Parent 7%

Sibling 2 – 5%

Parent and sibling 14 – 17%

Recurrent RiskRecurrent Risk

Recurrent Risk

Postnatal Managementrepair, but also more immediate needs such as feeding. Primary lip repairs can often be undertaken at three months of age with palatal repairs around six months. Additional surgeries as well as speech and orthodontic therapies are often needed.

Cleft lip repair. The edges of the cleft between the lip and nose are cut (A and B). The

bottom of the nostril is formed with suture (C). The upper part of the lip tissue is closed (D), and the stitches are extended

down to close the opening entirely (E).

FeedingsInfants with CL/P have few feeding problems. If the cleft involves the hard palate, the infant is usually not able to suck efficiently.

Experiment (special nipples or alternate feeding positions)

The infant should be held in a nearly sitting position during feeding

Prevents flowing to the back into the nose.Should be burped frequently, (q 3-4min).

It is important to keep the cleft clean

Breastfeeding is extremely challenging.

Haberman Feeder Activated by tongue and gum pressure.Milk cannot flow back.Replenished continuously as the baby feeds.Prevents the baby from being overwhelmed with milk.A gentle pumping action to the body of the nipple will increase flow.

http://en.wikipedia.org/wiki/Image:HabermanFeederCrosssection.svg

Family Care

Have a family meeting with both parents present.Infant should be brought to the parents as soon the mother and the infant are in satisfactory condition.Allow the parents to observe, react and ask questions about the infant.Explained the defect and the how the surgeon will most likely correct the clefts.Before and after pictures are helpful.

Emphasize as possible to the parents the normal healthy features of the baby. The baby should be present when the defect is explained, as ugly as the cleft might be.Training the mother about feeding techniques and avoiding complications.