ART OF DENTAL ANIMATIONS

Dental Splinting

Dental Splinting is defined as the joining of two or more than two teeth in a non-movable unit by mean of some fixed restorations most commonly used is Composite restoration or this can be attached by some removable devices. Dental Splinting has got its main use in the immobilization of injured teeth but some parts of the mouth can also be immobilized with the help of same.

Critical Aspects for Dental Splinting

• This creates an environment around the teeth where the food and bacteria assembles down very quickly and thus more is the plaque formation in that area.

• Since functional movement of the teeth that has undergone Dental Splinting is up to 0%, there are more chances of having ankylosis of the respective teeth in which the teeth get attached to the bony part or fibrous part underneath.

Beneficial Aspect of Dental Splinting

• Since the mobile teeth get splintered to the near by healthy teeth, mobility during the time of performing functions like mastication get prevented.

• Non mobile teeth have the capacity to heal faster than the mobile one and this is the basic principle of Dental Splinting.

Types of Dental Splinting

1. According to period of stabilization

• Temporary Stabilization
These are the one that are worn by the patient for less than 6 months and the examples are removable and fixed appliances.

• Provisional Stabilization
These are the one that has to be worn by the patient for months and this time period may increase up to several years. The examples are acrylic splints, metal bands.

• Permanent Splints
These are used by the patient for indefinite period of time and these can be removable or fixed depending upon the conditions.

2. According to type of material

• Bonded, composite resin button splint.
• Braided wire splint.
• A-splint.

Principles of Dental Splinting

There should be inclusion of sufficient number of healthy teeth in the procedure of Dental Splinting so as to provide the proper support. In the anterior teeth there is less surface area of the teeth as compared to the posterior ones so less number of healthy teeth in the posterior segment can be used for Dental Splinting.

Dental Splinting should be done on the way that the forces while performing normal functions don’t let it to be loose down.

Traumatic occlusion should be relieved down before going with the procedure of Dental Splinting.

Take care that the splints should be aesthetically acceptable and should not interfere with the other functions of oral cavity.

Dental Splinting is also used as a emergency treatment for the teeth that get loose by some trauma due to any sort of accident.

Hypoglycemia & Hyperglycemia

SIGNS AND SYMPTOMS OF ACUTE HYPOGLYCEMIA:

• Hunger
• Weakness
• Confusion (incoherence)
• Pallor
• Anxiety (agitation, belligerance)
• Sweating
• Dizziness
• Tachycardia

In severe cases the following can be present:

• Hypotension
• Hypothermia
• Seizures (tonic or clonic movements)
• Unconsciousness

========================================================


SIGNS AND SYMPTOMS OF DIABETIC KETOACIDOSIS:

• Deep, rapid breathing (Kussmaul's respiration)
• Nausea (with or without vomiting)
• Abdominal pain
• Disorientation (coma in severe cases)
• Dehydration (dry oral and nasal mucosas)

In severe cases the following can be present:

• Tachycardia
• Hypotension
• Generalized swelling of the skin.

Comparing the signs and symptoms of hypoglycemia with those of diabetic ketoacidosis it can be seen that disorientation (confusion), tachycardia and hypotension are common to both of them. Therefore, it is emphazised once more that it is of utmost importance for the dentist to know if the patient has a history of hypoglycemic attacks and either, have a glucometer in the office, or ask the patient to bring his/her own glucometer to monitor blood glocose levels

IV Fluids

 INTRODUCTION
Intravenous fluids are chemically prepared solutions that are administered
to the patient. They are tailored to the body’s needs and used to replace lost
fluid and/or aid in the delivery of IV medications. For patients that do not
require immediate fluid or drug therapy, the continuous delivery of a small
amount of IV fluid can be used to keep a vein patent (open) for future use.
IV fluids come in different forms and have different impacts on the body.
Therefore, it is important to have an understanding of the different types of
IV fluids, along with their indications for use.
How Intravenous Fluids Are Created
There are several types of IV fluids that have different effects on the body.
Some IV fluids are designed to stay in the intravascular space (intra, within;
vascular, blood vessels) to increase the intravascular volume, or volume of
circulating blood. Other IV fluids are specifically designed so the fluid leaves
the intravascular space and enters the interstitial and intracellular spaces. Still
others are created to distribute evenly between the intravascular, interstitial,
and cellular spaces. The properties that an IV solution has within the body
depends on how it is created and the specific materials it contains. It also determines the best type of IV solution to use in relation to the patient’s needs.
The majority of an IV solution is sterile water. Chemically, water is
referred to as a “solvent.” A solvent is a substance that dissolves other
materials called “solutes.” Within IV solutions, the solutes can be molecules
called electrolytes (charged particles such as sodium, potassium, and
chloride) and/or other larger compounds such as proteins or molecules.


Together, the  solvent (water) and  solutes (electrolytes, proteins, or other
molecules dissolved in the water) create the IV solution. Consider a cup of
coffee to which sugar is added for sweetness. The coffee is the solvent,
which dissolves the solute sugar.
Intravenous Fluids
IV fluids come in four different forms:
• Colloids
• Crystalloids
• Blood and blood products
• Oxygen-carrying solutions
Understanding these IV fluids is important because each has a different
impact on the body and particular indications for use:
• Colloid Solutions. Colloid solutions are IV fluids that contain solutes in
the form of large proteins or other similarly sized molecules. The proteins and molecules are so large that they cannot pass through the walls
of the capillaries and onto the cells. Accordingly, colloids remain in
the blood vessels for long periods of time and can significantly increase
the intravascular volume (volume of blood). The proteins also have the
ability to attract water from the cells into the blood vessels. However,
although the movement of water from the cells into the bloodstream
may be beneficial in the short term, continual movement in this direction can cause the cells to lose too much water and become dehydrated.
Colloids are useful in maintaining blood volume, but their use in the
field is limited. Colloids are expensive, have specific storage requirements, and have a short shelf life. This makes their use more suitable in
the hospital setting. However, familiarity is important because in a
mass casualty incident the EMT may be required to assist with the administration of colloids either in a field hospital or during the transport
of critically injured patients. Commonly used colloid solutions include
plasma protein fraction, salt poor albumin, dextran, and hetastarch. To
learn more about colloidal solutions, the EMT should consult a critical
care or paramedic textbook.
• Crystalloid Solutions. Crystalloid solutions are the primary fluid used
for prehospital IV therapy. Crystalloids contain electrolytes (e.g.,
sodium, potassium, calcium, chloride) but lack the large proteins and
molecules found in colloids. Crystalloids come in many preparations
and are classified according to their “tonicity.”
A crystalloid’s tonicity describes the concentration of electrolytes
(solutes) dissolved in the water, as compared with that of body plasma
(fluid surrounding the cells). When the crystalloid contains the same
amount of electrolytes as the plasma, it has the same concentration and
is referred to as “isotonic” (iso, same; tonic, concentration). If a crystalloid contains more electrolytes than the body plasma, it is more concentrated and referred to as “hypertonic” (hyper, high; tonic, concentration).


Consider the example of coffee and sugar. The more sugar that is added
to the coffee, the more concentrated the sugar becomes relative to the
amount of coffee, and the sweeter tasting the coffee becomes.
Conversely, when a crystalloid contains fewer electrolytes than the
plasma, it is less concentrated and referred to as “hypotonic” (hypo, low;
tonic, concentration). The less sugar a cup of coffee contains, the lower
its concentration or tonicity, and the less sweet the coffee may taste.
Depending on their concentration, crystalloids can affect the distribution of water within the body. To better understand this, the EMT must
first know what  total body water (TBW) is. TBW describes the entire
amount of water contained within the body and accounts for approximately 60% of body weight. It is distributed among the intracellular and
extracellular compartments. The intracellular space is the space within all
the body cells (intra, within; cellular, cell). The extracellular space is the
space outside the cells (extra, outside;  cellular, cells). The extracellular
compartment can be further divided into the intravascular space (space
within the blood vessels) and the interstitial space (space between the cells
but not within the blood vessels) 
The different compartments are separated by membranes through
which the body water can easily pass. As a general rule, body water is
pulled toward the solution with a higher concentration of dissolved
molecules. The movement of water across a semipermeable membrane
that selectively allows certain structures to pass while inhibiting others
(i.e., a capillary wall or cellular wall) is known as osmosis. The osmotic
movement of water occurs as the body attempts to create a balance between the different solute concentrations that exist on either side of a
semipermeable membrane. What this means is that the water will easily
cross the semipermeable membrane from the side that has a lower concentration of particles to the side that has a higher concentration of
particles. The net movement of water stops when each side of the membrane becomes equal in its concentration of water and particles. With
this in mind, isotonic, hypertonic, and hypotonic IV fluids cause the
following shifts of body water:
• Isotonic. Isotonic crystalloids have a tonicity  equal to the body
plasma. When administered to a normally hydrated patient, isotonic
crystalloids do not cause a significant shift of water between theblood vessels and the cells. Thus, there is no (or minimal) osmosis
occurring
• Hypertonic. Hypertonic crystalloids have a tonicity higher than the
body plasma. The administration of a hypertonic crystalloid causes
water to shift from the extravascular spaces into the bloodstream,
increasing the intravascular volume. This osmotic shift occurs as the
body attempts to dilute the higher concentration of electrolytes contained within the IV fluid by moving water into the intravascular
space .
• Hypotonic. Hypotonic crystalloids have a tonicity lower than the
body plasma. The administration of a hypotonic crystalloid causes
water to shift from the intravascular space to the extravascular
space, and eventually into the tissue cells. Because the IV solution
being administered is hypotonic, it creates an environment where
the extravascular spaces have higher concentrations of electrolytes.
The osmotic change results in the body moving water from the intravascular space to the cells in an attempt to dilute the electrolytes.


Of the different types of IV solutions, crystalloids are the mainstay of
IV therapy in the prehospital setting. The particular type of IV solution
selected beyond this depends on the patient’s needs. For instance, based
on the osmotic movement of water as described previously, a person
with a low volume of blood may benefit from a hypertonic or isotonic
crystalloid solution that will increase blood volume, whereas a hypotonic crystalloid would be more appropriate for a person suffering from cellular dehydration. The EMS system’s medical director will determine
which crystalloids will be used for prehospital IV therapy.
The most common isotonic solutions used in prehospital care are
• Lactated Ringer’s. Lactated Ringer’s (LR) is an isotonic crystalloid
that contains sodium chloride, potassium chloride, calcium chloride, and sodium lactate in sterile water.
• Normal saline solution. Normal saline solution (NSS) is an isotonic
crystalloid that contains 0.9% sodium chloride (salt) in sterile water.
• 5% Dextrose in water. 5% Dextrose in water (D5W) is packaged
as an isotonic carbohydrate (sugar solution) that contains glucose
(sugar) as the solute. D5W is useful in keeping a vein open by delivering a small amount of the fluid over a long period of time
and/or supplying sugar, which is used by the cells to create energy.
However, once D5W enters the body, the cells rapidly consume
the glucose. This leaves primarily water and causes IV fluid to
become hypotonic in relation to the plasma surrounding the cells.
Accordingly, the now hypotonic solution causes an osmotic shift of
water to and from the bloodstream and into the cells.
In the prehospital setting, LR and NSS are commonly used for fluid
replacement because of their immediate ability to expand the volume of
circulating blood. However, over the course of about 1 hour, approximately two-thirds of these IV fluids eventually leave the blood vessels
and move into the cells. Some authorities recommend that for every
1 liter of blood lost, 3 liters of an isotonic crystalloid be administered
for replacement. This is only a guide, and the volume of IV fluid administered should be based on medical direction or local protocol, as
well as the patient’s clinical response to fluid administration.
• Blood and Blood Products. Blood and blood products (e.g.,
platelets, packed red blood cells, plasma) are the most desirable
fluids for replacement. Unlike colloids and crystalloids, the hemoglobin (in the red blood cells) carries oxygen to the cells. Not only
is the intravascular volume increased, but the fluid administered can
also transport oxygen to the cells. Blood, however, is a precious
commodity and must be conserved to benefit the people most in
need. Its use in the field is generally limited to aeromedical services
or mass casualty incidents. The universal compatibility of O-negative
blood makes it the ideal choice for administration in emergent situations. To learn more about blood and blood products, consult a
critical care or paramedic textbook.
• Oxygen-Carrying Solutions. Oxygen-carrying solutions are synthetic
fluids that carry and deliver oxygen to the cells. These fluids, which remain experimental, show promise for the prehospital care of patients
who have experienced severe blood loss or are otherwise suffering
from hypovolemia. It is hoped that oxygen-carrying solutions will
be similar to crystalloid solutions in cost, storage capability, and ease
of administration, and be capable of carrying oxygen, which
presently can only be accomplished by blood or blood products.


Intravenous Fluid Packaging
Most IV fluids are packaged in soft plastic or vinyl bags of various sizes
(10, 50, 100, 250, 500, 1,000, 2,000, and 3,000 milliliters) (Figure 3.5).
The EMT will most likely be using 250-, 500-, and 1,000-milliliter bags.
Some IV solutions are premixed with medications that are not compatible
with plastic or vinyl and must be packaged in glass bottles. Glass bottles
are not common to prehospital IV therapy but may be encountered during
interfacility or critical care transports.
Every IV fluid container must contain a label. The label provides important information that you must examine before administering the fluid
to a patient. This information includes
• Type of IV fluid (by name and by type of solutes contained within).
• Amount of IV fluid (expressed in milliliters or “mL”).
• Expiration date.
Always carefully read the label to ensure you are administering the
correct IV solution. Many different IV fluids are packaged in similar containers, including those containing premixed medications. Administering an inappropriate IV fluid may be detrimental or even fatal to the patient, resulting
in disciplinary and/or legal action. Like any other medication, IV solutions
have a shelf life and must not be used after their expiration date.
The IV fluid container contains a medication injection site and administration set port. Both ports are located on the bottom of the IV bag when holding it upright. The medication injection port permits the injection of
medication into the fluid for use by advanced life support (ALS) or hospital
personnel after the EMT has initiated the IV. The administration set port
receives the spike from the IV administration set (IV tubing)

Management of Diabetic patient in a dental clinic

• What is Normal Blood glucose level- Fasting:60-110mg/dl of blood     Postprandial (after 2 hr. of taking main course meal) : 90-140mg/dl of blood
• What happens in diabetes- Fasting: >126mg/dl   postprandial : >200mg/dl
• Complications-

1. Hypoglycemic shock (when blood glucose level goes below 60mg/dl)
2. Hyperglycemic coma(Ketotic/nonketotic)( Ketotic coma: >600mg/dl  Nonketotic coma:<600mg/dl)
3. Delayed wound healing
4. Increased chances of infection

• Management of a diabetic patient whose blood sugar is under control-

1. Patient whose diabetes is under control doesn't need any specific preoperative precaution.
2. Patient should be given an early morning appointment.
3. Ask patient to come to the dental clinic after having breakfast,at least 2 hr before the visit.Also make sure that patient doesn't miss his oral anti diabetic drug regime.
4. Before starting any treatment postprandial glucose level should be measured.It should be under normal range.
5. If possible during and after the end of treatment,also measure the blood glucose level.
6. If your patient is too much anxious regarding dental surgery,than you can prescribe a dose of diazepam for at least 3 to 4 days before surgery.If patient is becoming anxious during the process of dental surgery,just stop the process there and ask patient to relax.
7. At the time of stress catecholamines (norepinephrine is augmented mostly during surgery and epinephrine postoperatively) stimulate gluconeogenesis and glycogenolysis, inhibit glucose utilization by peripheral tissues, and inhibit insulin secretion. Therefore its must too control stress in a diabetic patient.Stress is common due to fear of surgery.
8. Try not to keep appointment for a long time.
9. Give proper antibiotic coverage along with ethamsylate,to allow proper healing in future.

• Management of a diabetic patient whose blood sugar is not under control-(>200mg/dl)

1. Only emergencies should be treated.
2. Ask patient to stop his oral anti diabetic drug one day before the day of surgery.Keep patient on fast before the day of surgery and ask him to come empty stomach for surgery.
3. Measure the blood glucose level before the commencements of surgery.Also monitor sugar during the procedure.
4. For minor surgery, perioperative hyperglycemia (>200 mg/dl) can be managed with small subcutaneous doses (4–10 units) of short-acting insulin.
5.  For major surgery,intravenous insulin,with glucose & potassium chloride,should be administered.(Table1)
6. After the end of surgery,normal drug regime can be started.
7. Diazepam,antibiotics and ethmsylate to be used same as above.
8. In case of minor surgery its must to avoid hypoglycemia.

*  1 IU is the biological equivalent of about 45.5  pure crystalline insulin (1/22 mg exactly).

TRIGEMINAL NEURALGIA (tic douloureux)

• Trigeminal neuralgia (TN) presents as a stabbing unilateral facial pain that is triggered by chewing or similar activities or by touching affected areas on the face. The disorder affects the right side of the face 5 times more frequently than the left.
• Pain localization

Patients can localize their pain precisely. The pain is not confined exclusively to 1 of the 3 divisions of the trigeminal nerve but more commonly runs along the line dividing either the mandibular and maxillary nerves or the mandibular and ophthalmic portions of the nerve. Of affected patients, 60% complain of lancinating pain shooting from the corner of the mouth to the angle of the jaw; 30% experience jolts of pain from the upper lip or canine teeth to the eye and eyebrow, sparing the orbit itself—this distribution falls between the division of the first and second portions of the nerve. According to Patten, less than 5% of patients experience ophthalmic branch involvement.

• Pain quality

The pain quality is characteristically severe, paroxysmal, and lancinating. It commences with a sensation of electrical shocks in an affected area, then quickly crescendos in less than 20 seconds to an excruciating discomfort felt deep in the face, often contorting the patient's expression. The pain then begins to fade within seconds, only to give way to a burning ache lasting seconds to minutes. During attacks, patients may grimace, wince, or make an aversive head movement, as if trying to escape the pain, thus producing an obvious movement, or tic; hence the term "tic douloureux."

• Pain chronicity and frequency

This condition is an exception to the rule that nerve injuries typically produce symptoms of constant pain and allodynia. If the pain is particularly frequent, patients may be difficult to examine during the height of an attack. The number of attacks may vary from less than 1 per day, to a 12 or more per hour, up to hundreds per day.

• Pain triggers and zones

A valuable clue to the diagnosis is the triggering of the pain with certain activities. Patients carefully avoid rubbing the face or shaving a trigger area, in contrast to other facial pain syndromes, in which they massage the face or apply heat or ice. Also, many patients try to hold their face still while talking to avoid precipitating an attack. According to Sands, trigger zones, or areas of increased sensitivity, are present in one half of patients and often lie near the nose or mouth.^[15] Chewing, talking, smiling, or drinking cold or hot fluids may initiate the pain of trigeminal neuralgia. Touching, shaving, brushing teeth, blowing the nose, or encountering cold air from an open automobile window may also elicit pain.

In contrast to migrainous pain, persons with this condition rarely suffer attacks during sleep, which is another key point in the history.

• Treatment

Trigeminal neuralgia is treated on an outpatient basis, unless neurosurgical intervention is required. Management of this condition must be tailored individually, based on the patient's age and general condition. In the case of symptomatic trigeminal neuralgia, adequate treatment is that of its cause, the details of which are out of the scope of this article.

Because most patients incur trigeminal neuralgia when older than 60 years, medical management is the logical initial therapy. Medical therapy is often sufficient and effective, allowing surgical consideration only if pharmacologic treatment fails. Medical therapy alone is adequate treatment for 75% of patients.

Patients may find immediate and satisfying relief with one medication, typically carbamazepine. However, because this disorder may remit spontaneously after 6-12 months, patients may elect to discontinue their medication in the first year following the diagnosis. Most must restart medication in the future. Furthermore, over the years, they may require a second or third drug to control breakthrough episodes and finally may need surgical intervention.

Thus, treatment can be subdivided into pharmacologic therapy, percutaneous procedures, surgery, and radiation therapy. Adequate pharmacologic trials should always precede the contemplation of a more invasive approach.
So effective drugs are-

1. Carbamazepine-A 100-mg tablet may produce significant and complete relief within 2 hours, and, for this reason, a 100 mg twice a day (bid) prescription is suitable to start. If this initial dose fails, one may push the dose to 1200 mg daily (qd), as the patient will tolerate, for initial relief; maintenance doses generally are lower, 100-800 mg daily bid. 
2. Baclofen(musscle relaxant) 10mg B.D
3. Amitryptiline(Tricyclic anti depressant) 50-200mg/day
4. Gabapentin -Small, uncontrolled studies have indicated possible effectiveness of gabapentin in patients whose pain has become refractory to carbamazepine. This agent is often better tolerated than carbamazepine by elderly patients. 

PULP PROTECTION

                        

    This is a step in adapting the preparation for receiving the final restoration material.

     Sound dentin is the best barrier between a restorative material and pulp. So conservation of all sound dentin possible during cavity preparation should be beneficial.

     When the thickness of remaining dentin is minimal, heat generated by injudicious cutting can result in pulpal burn lesion, abscess formation or pulpal necrosis. So water or air spray coolant should be used with high speed rotary instrument. The remaining dentin thickness is measured by using dentinometer.

     Cutting of previously unexposed dentinal tubules will result in degeneration and death of affected primary odontoblast and their processes resulting in formation of dead tracts.

Other pulpal irritants are:

1.      Some ingredients of various materials

2.      Thermal changes conducted through restorative materials

3.      Forces transmitted through materials to dentin

4.      Galvanic shock

5.      Injuries of noxious products and bacteria through microleakage.

To protect the pulp from these kinds of irritation cavity liners, varnishes, cavity liner suspension, intermediary bases, cement bases, etc. are used.

                                               CAVITY LINER:

              Liners are volatile or aqueous suspension or dispersion of Zinc oxide or calcium hydroxide that can be applied to a tooth surface in a relatively thin film. A few microns to about a millimeter in thickness.

Liners Provide:

1. A barrier that protect the dentin from noxious agents.
2. Initial electrical insulator.
3. Some thermal protection.

           A traditional liner is used to medicate the pulp when suspected trauma has occurred. The desired pulpal effects include sedation stimulation, later resulting in reparative dentin formation. If the removal of infected dentin does not extend deeper than 1-2mm from initially prepared axial or pulpal wall usually no liner is indicated. If the excavation extends into or closes pulpal tissue, Calcium hydroxide, Zinc oxide Eugenol liner is used. There liners in thickness of 0.5mm or greater have adequate strength to resist condensation forces of amalgam and provide protection against short term thermal changes. Then should be approximately 2mm of bulk between pulp and metallic restorative materials.

          The ability of calcium hydroxide to stimulate formation of reparative dentin when it is in contact with pulpal tissue makes it is the material of choice in very deep excavations and known pulpal exposures.

                           CAVITY VARNISHES  

           There is no solution liner derived from natural gums, copal synthetic resins or rosin. When varnishes are applied to prepared tooth surface the solvent quickly evaporates leaving thin film of resinous materials (micro thickness). Two goals of varnish application are mandatory for complete seal. These are insoluble in oral fluids. These are applied to cavity wall using a small cotton pledge. Tooth varnishes usually applied just before the insertion of amalgam or cementation of cast gold restoration. These are the only material required in shallow preparations. These helps to prevent microleakage and reduce post operative sensitivity. These help to reduce pulpal irritation from leaking cement. They can be applied to enamel portion of the preparation. Tooth varnishes are not used under composite because solvent in the varnish reacts with resin component of composite and adversely affect the polymerization reaction. The free monomer of the resin can dissolve the varnish film. Varnishes will hamper the fluoride releasing property of glass ionomer cement. So they are not used under GIC also.

                                      CAVITY LINER SUSPENSIONS   

       These are suspensions of calcium hydroxide, zinc oxide which are particularly used under tooth colored restorative material. The film deposited by these materials is thicker. They will dissolve & disintegrate in oral fluids, thus allowing severe marginal leakage if they are brought in to cavosurface. The whitish color also affects the aesthetic value of restoration. So they are confined to dentinal wall only.

                                        

                                       INTERMEDIARY BASES.

          There is no clear distinction between intermediary bases & cavity liners. Two forms of intermediary bases used are calcium hydroxide &modified zinc oxide eugenol.

   Zinc oxide eugenol has topical anesthetic properties termed as obtudant effect. When a history of discomfort is found, zinc oxide intermediary base can be used.

    They are contraindicated under composite because they will affect the polymerization reaction. Calcium intermediary bases are used as indirect pulp capping agents, protective chemical barrier under filled &unfilled resins. Calcium hydroxide has no otundant properties.

                                         CEMENT    BASES

Cement bases are relatively thick materials placed under the restorative material which will provide chemical &thermal insulation. They should be capable of providing support to the restoration that is subjected to occlusal function. Four types of base material used are Zinc phosphate, Reinforced Zinc oxide eugenol, Glass ionomer cement and Zinc polycarboxylate.

The level to which the base is built should never compromise the desired tooth preparation resulting in inadequate restorative material thickness. Since cement base materials are subjected to stress during insertion of restorative material and also they are indirectly supportive of masticatory functions, they also require their own specific retention in the prepared cavity. Retentive grooves are made using round burs directly laterally in the dentin.

   In case of pin retained restorations, cemented pins are used for pulpal protection.

  These are different methods of pulpal protection.

Regardless of the material used protecting the pulp appropriately is mandatory for the successful restoration of the teeth

      

 REFERENCES-

                                  •Sturdevant’s Art&Science of Operative Dentistry

                                  •Principles&Practice of Operative Dentistry-Gerald T Charbeneau

                                  •Textbook of Operative Dentistry-Vimal Sikri

                                  •Textbook of Operative Dentistry-Satish Chandra

                                                               

Patient Complains of sensitive teeth on biting after Restoration. What to do?

A Pressure sensitive teeth after filling is an annoying condition. Many of us have such cases.Now lets see why this occurs and how to solve it.There are many causes for it lets see it one by one and consider the treatments
NOTE- In this article we will consider the causes of sensitive teeth on biting only (Pressure Sensitive teeth )  and not for Hot and cold sensitive or continuous pain after filling.

Cause 1. Composite restoration cases- if there is a bubble entrapment at the bonding interface of composite and dentin it will cause sensitivity. This occurs because the bubble shrinks during biting and applies pressure.
Solution-Remove the restoration and replace it with corrected one,use Single bond agents which does not require separate etching and boning.

Cause2. Deep caries.Dentin is too thin to protect the underlying pulp.
Solution - After removal of caries apply a nice layer of Calcium Hydrroxide/Dycal and cover it with temporary restoration. Ask the patient not to bite heavy on the particular tooth and recall after 4 weeks. Ask about the symptoms.If not resolved then let it be there for 4 more weeks.If resolved then replace the temporary restoration with permanent one.

Cause 3. Pulp hyperemia or thermal trauma during cavity preparation.
Solution- Remove the restoration and replace it with ZOE filling ,Relieve the tooth from occlusion, Start any NSAID for three days Recall after 3 weeks ask about symptoms, if relieved then replace the ZOE with permanent restoration.
[Additional]-Check your bur and replace it if its worn out, check for water spray of your handpiece it should be directed on the bur, Don't apply pressure will tooth preparation.

Cause 4. High point on the restoration.
Solution- Take an Articulating paper,Check for the high point and clear them. Recall after 5 days. If patient still have pain relieve the tooth from occlusion and start any NSAID.  

Gingival Depigmentation Technique using Bur Abrasion {Step Wise}

When we talk about gingival depigmentation it all comes to "Smile". Most of your patients will come to you with a complain of blackish gums.They will say "My gums are black and they don't look good please do some treatment"  people are concerned about their smile. So what to do ? how to reduce the black discoloration of the gums?  
There are many techniques - Laser, scalpel surgery,Bur abrasion, epithelial excision, electrocautery, cryotherapy.

• Here we will discuss a technique which can be performed in a regular dental set up and does not require higher equipment,You don't have to be a Periodontist to do this surgery you can do this if you are a dental graduate,Bur abrasion is relatively easy and safe and it can be easily repeated if there is any residual pigmented area. 

Before Treatment

After Bur Abrasion

Initial Healing

The Process-


Step 1- 

• When patient arrives and show concern about the blackish gums tell them this condition can be treated and you can reduce the blackish color of their gums, Show your confidence in treatment (remember patient buys confidence in you) tell them about benefits of improved looks and improved confidence.  
• If patient shows interest, inform them about the treatment procedure and possible results.Show them before and after photographs of your successful cases ( If you don't have photos then "right click & save" the pics given in this article and use them)
• Once patient gets ready for the treatment take proper medical and family history,Do all the necessary blood investigations and rule out any contraindications for surgery,
• Take written consent this is very important I ask all the young dentist to take written consent before any kind of surgery, this will be very helpful if you are subjected to malpractice claims. 

Step 2

• Materials used- Lignocaine with adrenaline in the ratio 1:100000 by weight. Gauze pieces, A high speed hand piece with round diamond bur, hand piece should be sterilized before the treatment and you should use a new bur not the bur you are using for endo or operative purpose.

Step 3

• [Prepare the patient] Surgery is usually required from premolar to premolar region of maxillary anterior. If patient wants the treatment for both arch then involve mandibular arch too.Now anesthetize the area with local infiltration.

Step 4

• Start Deepithelization by removing the epithelium of the gingiva with help of round diamond bur, just touch the revolving bur on the surface of pigmented gingiva and move the bur with feather light strokes, don't keep the bur at one place for long time it may result in thermal trauma and permanent harm to underlying tissue.
• There is no need of pressure in this procedure just touch the bur to superficial part of epithelium and remove it upto connective tissue care must be taken not to harm underlying periostium.   
• Use round bur of biggest size because small bur will produce small pits rather then surface abrasion. 
• Controle the bleeding and check for any pigmented area and remove it to prevent relaps. Epithelium should be removed upto connective tissue/"Lamina proprria".
• Bleeding Control- It can be done by applying pressure by a gauze piece on the denuded epithelium Soak the  gauze piece in Adrenaline containing Local anesthetic.
• Caution- Removal of gingival melanin pigmentation should be performed cautiously and the adjacent teeth should be protected, since inappropriate application may cause gingival recession, damage to underlying periosteum and bone, delayed wound healing, as well as loss of enamel.    

Step 5- 

• Apply a surgical dressing like 'Co -pack' for few days and prescribe Chlorhexidine mouthwash for 1 week.

Step 6 -

•  Recall after 1 weeks and check for the status and any healing problems.