2021 FALL

3- Give an account on submandibular salivary gland duct calculi (sialoith), its

clinical Feature and management. ?

Answer :

- Sialolithiasis: is the formation of sialolith (salivary calculi, salivary stone) in the

salivary duct or the gland resulting in the obstruction of the salivary flow.
- Sialolith: is a calcareous substance, which may form in the parenchyma or the duct
of the major or minor salivary glands. It results from the crystallization of salivary
solutes.
- The sialolith is yellowish white in color, single or multiple, may be round, ovoid or
elongated having the size of 2 cm or more in diameter. It is said that the sialoliths
grow at the rate of 1 mm/year.
Causes:
- Inflammation
- Local irritation
- Leads to stagnation of saliva buildup of organic nidus ……calcify

Clinical Features

- May occur at any age ,common in middle aged persons

- There is Pain with psychic stimulation of salivary flow.
- There is Pain and swelling during and after eating the food.
- Partial obstruction acute pain and swelling especially during and following meals
and it diminish between meals.
- Partial obstruction may lead to glandular infection.
- It may cause dull pain following meal, it may be described as originating in the
throat, molar tooth, or ear.
Etiology:
- Mucous plug.
- Calculi within the duct (sialalithasis).
- Ductal stricture or ulceration or neoplasm.
Investigations
- Radiographs: AP view, lateral, lateral oblique or occlusal view.
- Sialography: The radiographs demonstrate the presence of salivary calculi; which can be
appropriately located by the sialography.

Management :

There are several techniques available for the removal of the sialolith. a suitable procedure is
selected depending upon the number, size, and site of the stone in the duct or the gland and
age of the patient,

 The smaller sialoliths, which are located peripherally near the ductal opening
may be removed by manipulation (Called milking the gland).
 Larger sialoliths are surgically removed.
 Sometimes, the stones, which are not impacted, may be extracted through the
intubation of the duct with fine soft plastic catheter and application of the suction to the
tube.
 Multiple stones or stones in the gland require the removal of the gland.
 Some investigators have successfully used modern techniques like Piezoelectric
shockwave lithotripsy to fragment the salivary stones. The fragments pass through
 4- How to differentiate clinically between benign and malignant tumors? Describe
sign & Symptoms, radiographic features and management of central
ameloblastoma .

Answer : Difference between c benign and malignant tumors

 - Central ameloblastoma ( sign & Symptoms, radiographic features and
management of central ameloblastoma)

Ameloblastomas :

- The most common epithelial odontogenic tumor.

- It accounts about 1% of all oral tumors.
- Ameloblastoma is locally invasive tumor.
- Ameloblastic changes may take place in the wall of cystic lesions in association with
dentigerous cysts.
Site

- 80 % in mandible. & 20 % in maxilla.

- Ramus-molar area in about 70 % of the cases and is associated with impacted tooth with
root resorption
Clinical features (signs and symptoms):

- Sex: Males > females.

- Age: Third to fifth decade of life.
- May be asymptomatic and discovered in routine radiographic examination.
(The ameloblastoma is asymptomatic and remains undiscovered until lesional growth
produces intraoral and/or external jaw swelling, tooth eruption and dental occlusion
disturbances, or incidental radiographic examination reveals a lesion.)
- Slow growing , hard, non-tender Painless unless secondarily infected.
- Facial disfigurement occur when the tumor attains a large size.
- mobile teeth, exfoliation of teeth, ill-fitting dentures, malocclusion, ulcerations and
nasal obstructions, inability to occlude properly.

Radiographic picture:

- Multilocular R.L. (Honey comb or soap bubbles appearance).

- Unltilocular R.L. (less commonly).
- Roots of adjacent teeth may show resorption.
- Common with impacted lower wisdom.
Local spread:

1. Ameloblastoma invades intertrabecular spaces of cancellous bone without resorption of

the trabeculae.
2. It does not invade the cortical bone, although it may erode it.
3. Good safety margin in cancellous bone is a must during excision of ameloblastoma that
should pass the clinically and radio graphically involved regions to ↓ the chances of
recurrence of this tumor.
Management of central ameloblastoma:

4. Block excision (marginal resection).

5. Partial resection (discontinuity resection).
6. Total resection (discontinuity resection).
7. Reconstruction of the resected mandible.
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5- What is conscious sedation ? what are the indication and methods of conscious

sedation ?

Answer : conscious sedation

Definition: combining local anesthesia . With sedation to render dental procedures easier
and comfortable

Indications

- Difficulty to control patients under L.A e.g. nervous patients; mentally retarded or
children
- the dental procedure is very prolonged

Limitations and complications.

- L.A.still used; G.A. still needed in some cases;

- Difficulty in adjusting the dose;
- some complications may occur in sensitive individuals which may need
resuscitation
 Advantages;

- reduce reliance on g.a. and retains communication and cooperation of the patient
during the procedure

Techniques; ( methods )

Ideal drug should be safe, potent, fast acting, easy to administer, with predictable effect
and rapid recovery.

A. Oral Sedation; safe and simple but unpredictable.

B. Parental Sedation; more effective and rapidly acting; drugs include; Hypnotics like
phenoparbitone or hyocine; narcotics like morphine or pithedine; narcotic agonist
antagonist like stadol; or tranuilisers like valium or ativan or dormicum
C. Inhalational Sedation ; 50% NO2 with 50% Oxygen via a nasal mas
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6- Write brief account on maxillary nerve block techniques .

Maxillary anesthesia:

Nerve blocks: Local anesthetic deposited near main nerve trunk and is usually distant
from operative site

Maxillary nerve block (V2 block):

- Can be used to anesthetize maxillary teeth, alveolus, hard and soft tissue on the
palate, gingiva, and skin of the lower eyelid, lateral aspect of nose, cheek, and
upper lip skin and mucosa on side blocked

Maxillary nerve block Techniques

Two techniques exist for blockade of V2

1- High tuberosity approach

2- Greater palatine canal approach
 1- High tuberosity approach Technique

- Area of injection is height of mucobuccal fold of maxillary 2nd molar

- Advance at 45° superior and medial same as in the PSA block
- Insert needle ~30mm
- Inject ~1.8cc of local anesthetic

2- Greater palatine canal technique:

- Area of insertion is greater palatine canal

- Target area is the maxillary nerve in the pterygopalatine fossa
- Perform a greater palatine block and wait 3-5 mins
- Then insert needle in previous area and walk into greater palatine foramen
- Insert to depth of ~30mm
- Inject 1.8cc of local anesthetic
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7- Enumerate the most common medical emergencies that could occur on the dental chair,

discuss the management of 3 medical emergencies

Answer : common medical emergencies

1. Vasovagal syncope (faint)

2. Hyperventilation/'panic attack'
3. Acute asthma attack.
4. Angina/myocardial infarction.
5. Epileptic seizures.
6. Diabetic emergencies.
7. Allergies/hypersensitivity reactions.
8. Choking and aspiration.
 Medical emergencies Management
VASOVAGAL SYNCOPE - PABC
- Usually no treatment is required
- Use ammonia spray
- Monitor vital signs
- If severe bradycardia occur,: give atropine and call help
BRONCHIAL ASTHMA - Provide the bronchodilator inhaler through the aero chamber
- Oxygen
- If signs got worse:
- Call help
- Give sub.cu epinephrine
- Give IM 100mg corticosteroids
ANGINA ATTACK - P, A, B, C
- Give sublingual nitrates & oxygen and wait for 5 min
- If attack remains, give another tablet and wait
- If attack remains, call help
- For severe pain, give morphine IM

GRAND MAL SEIZURE - Put the patient on the floor

- Secure his arms and legs
- Put tongue depressor between his teeth
- IM/ IV diazepam
- Monitor vital signs
- If hypotension occurs, provide subcutaneous epinephrine

HYPOGLYCEMIC COMA - If patient is conscious, provide any sugary fluids

- If patient is unconscious, IM glucagon
- Monitor glucose level
ANAPHYLAXIS - Call help
- PABC
- IM 1mg epinephrine
- 100mg corticosteroids•150mg anti-histaminic
- Dextrose IV
- Continuous supply of oxygen
- Monitor vital signs

P A B C = Position •Airway •Breathing •Circulation