Branchial Arches Simplified

                                                                   
                                                      BRANCHIAL ARCHES

            

  There are six pharyngeal arches but in humans the fifth arch only exists transiently during embryonic  growth and development.Since no human structures result from the fifth arch ,the arches in human are I,II,III,IV and VI.The first three contribute to structures above the larynx,while the last two contribute to the larynx and trachea.

Pharyngeal Arch	Muscular Contributions	Skeletal Contributions	Nerve	Artery	Corresponding Pouch Structures
1st (Mandibular Arch)	1)Muscles of mastication 2)Anterior belly of the  digastric 3)Mylohyoid 4)Tensor Tympani 5)Tensor veli Palatini	1)Maxilla 2)Mandible(only as a model for mandible not actual formation of mandible) 3)Incus and Malleus 4)Meckels Cartilage 5)Anterior ligament of malleus 6)Sphenomandibular ligament	Trigeminal nerve (V2 and V3)	1)Maxillary artery 2)External carotid artery	1)Eustachian tube 2)Middle ear 3)Mastoid antrum 4)Inner layer of tympanic membrane
2nd (Hyoid Arch)	1)Muscles of facial expression 2) Buccinator 3)Platysma 4)Stapedius 5)Stylohyoid 6)Posterior belly of digastric	1)Stapes 2)Styloid process 3)Hyoid bone(lesser horn and upper part of body) 4)Reicherts Cartilage 5)Stylohyoid ligament	Facial Nerve	Stapedial artery	1)Middle ear 2)Palatine tonsils
3rd	Stylopharyngeus	Hyoid(Greater horn and lower part of body)	Glossopharyngeal nerve	Common Carotid/ Internal Carotid	1)Inferior parathyroid 2)Thymus
4th	1) Cricothyroid muscle 2)All intrinsic muscles of soft palate including levator veli palatini	1)Thyroid cartilage 2)Epiglottic cartilage	1)Vagus nerve 2)Superior laryngeal nerve	1)Right Fourth Aortic arch: Subclavian Artery 3)Left 4th Aortic arch:Aortic arch	1)Superior Parathyroid 2)Ultimobranchial body Which forms the Para follicular C cells of thyroid gland)
6TH	All intrinsic muscles of larynx Except the cricothyroid muscle	1)Cricoid cartilage 2)Arytenoid cartilage 3)Corniculate cartilage	1)Vagus nerve 2)Recurrent Laryngeal nerve	1)Right 6th Aortic arch:Pulmonary artery 2)Left 6th aortic arch: Pulmonary artery and ducts arteriosus	1)Rudimentary structure becomes the part of the fourth pouch contributing to thyroid C-cells.

So Friends,all that you need to know regarding the branchial arches is presented above in a nutshell.
Refer this when you are preparing your embryo section.


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50 IDENTIFICATION OF COMPLETE DENTURE PROBLEMS AND THEIR MANAGEMENT

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In this section, guidelines to the diagnosis of complete denture problems are presented in tabular form. Suggestions to the management of these problems are listed.

There is, inevitably, the potential for problems to arise subsequent to the insertion of complete dentures. These problems may be transient and may be essentially disregarded by the patient or they may be serious enough to result in the patient being unable to tolerate the dentures. Factors causing problems may be grouped, essentially into four causes.

• Adverse intra-oral anatomical factors eg

atrophic mucosa.

• Clinical factors eg poor denture stability.

• Technical factors eg failure to preserve the

peripheral roll on a master cast.

• Patient adaptional factors.

By far the most critical factors are the patient adaptional factors. Many patients with positive stereotypes may overcome errors of prescription.Some patients, however, are unable to adapt physically and/or psychologically to dentures that satisfy clinical and technical prosthodontic norms. Clearly it would be in the best interests of the clinician and the patient to determine this at the assessment stage, and was referred to in Part 2.The prescribing clinician is responsible for planning complete dentures after diagnosing potential problems; be they anatomical,

physiological, pathological or emotional. Once a denture-wearing problem becomes apparent, it is important that it is addressed in a logical and systematic way.

That is to say, an adequate history of the problem must be obtained and a careful examination of the mouth carried out so that an accurate diagnosis can be made, and an appropriate treatmentplan devised.

Without doubt listening to the patient (as their difficulties are described) is the most important first step in the process, and its importance cannot be overemphasised.Because of the plethora of potential complete denture problems, this section is largely confined to those that are most commonly encountered at the time of insertion of replacement dentures or during review appointments in the days and weeks after insertion. For a comprehensive overview of the diagnosis and management of complete denture problems, readers are referred to standard prosthodontic texts

Here below is the link to download the pdf of the important tables that will help you to sort out the various problems that are encountered in your daily clinical practice.

https://drive.google.com/file/d/0B2WjEzI2Ozv5NjRDX2VhMVdHVVk/view?usp=sharing

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PERKS OF HAVING A STRONG ACADEMIC FOUNDATION

                   

A GREAT DOCTOR IS AN AMALGAMATION OF STRONG ACADEMIC FOUNDATION AND PRACTICAL SKILLS.

1)  ‘Stronger the foundation laid, stronger stands the fort’. The same principle applies to our field also. Having your academic foundation strong will enable you to surpass any test.

2)   Having your concepts cleared, will enable you to stand apart. You will be acknowledged as a knowledgeable person and that in turn will fetch you many patients at your door step.

 3)  Your dreams might be directed towards making money, popularity or self-esteem. What it all boils down to simply is this you have to be great on the dental chair, and that comes with the acquired knowledge and clinical skills.

4)   excel first in the applied part of dentistry, requires lot of learning. If your concepts are clear, you are within the elite club of doctors.

     5)   Think about being a successful, knowledgeable practitioner first. No matter what specialty you choose for yourself. Success is when you reach the level of naming your fees and not caring if your patients think it’s a lot. That is a certain AURA, which you can carry.

So, my friends if you are a student pursuing dentistry, preparing for competitive exams, a dental practitioner, you can follow these simple tips to set yourself as a UNIQUE DENTIST

1)      Read and re-read from standard textbooks and prepare notes in the form of pointers. This will serve as a ready to go material when you are caught up in a doubt.

2)      Read various articles that are available. But one word of caution, see the proper source from where it is picked up and do not rely on net articles blindly.

3)      Attend CDE lectures and conferences that you can afford. That will broaden your horizon.

So folks, we all have to pass through the learning curve to achieve excellence. Following these points will help you for sure. J

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DENTAL MANAGEMENT OF DIABETES PATIENT.

The article consists of the following topics:

1)What is Diabetes?

2)Types of Diabetes

3)Complications

4)Laboratory tests

5)Patient Management

A.What is Diabetes?

Diabetes is a chronic disorder of carbohydrates,fat,and protein metabolism wherby a defective or deficient insulin secretory response leads to impaired glucose use.Diabetes creates a physiologic predisposition for developing  generalized microvascular,macrovascular,and neuropathic complications.

B.TYPES OF DIABETES:

1) Type 1 diabetes: This form is usually associated with young people.These patients require insulin to maintain glucose homeostasis secondary to beta cell destruction in the process.

2) Type 2 diabetes: These patients cells have lost their sensitivity to insulin secondary to environmental fand genetic factors.Therefore their muscle and adipose cells cannot transport glucose.

3) Gestational diabetes: This usually develops secondary to pregnancy.Upto 40 % of women with gestational diabetes will develop type 2 diabetes within 10 years of developing geatational diabetes.

4) Secondary diabetes: This is related to a specific cause,such as removal of pancreas.

C.COMPLICATIONS OF DIABETES:

1) Complications associated with Type 1 Diabetes:

a) Diabetic ketoacidosis almost exclusively occurs in patients with type 1 diabetics.DKA is the result of severe insulin deficiency coupled with an absolute or relative increase of glucagon.

b) Patients with DKA usually have blood glucose levels >250mg/dl,ketones in the urine and serum,ph<7.2,and plasma bicarbonate <15 mEq/L.

c) Clinical manifestations include nausea and vomiting to compensate for the metabolic acidosis and kussmaul respiration to reduce carbon dioxide levels in blood.

d) The goals of treatment are to correct dehydration by starting 0.9% normal saline intravenously,using regular insulin,reversing the acidosis and treating the potassium deficiency.

2) COMPLICATIONS ASSOCIATED WITH TYPE 2:

a) Hyperosmolar nonketotic coma usually occurs in patients who are age 65 or older.The symptoms may go unrecognized for weeks.These patients have enough insulin to prevent a ketotic state,but they are severly hyperglycemic(usually>600mg/dl).

b) Left untreated,they become severely dehydrated and progress into a comatose state.

c) The treatment includes increased insulin and slow fluid replacement to prevent cerebral edema because of the sorbitol accumulation in the brain.

D.CRITERIA FOR THE DIAGNOSIS OF DIABETES MELLITUS.

a) The signs and symptoms plus a random plasma glucose concentration >=200mg/dL.

b) The fasting plasma glucose >=126 mg/dL at least two times.

c) Oral glucose tolerance test with a 2 hour postload glucose concentration >=200mg/dL and a time 0 serum glucose level >126 mg/dL.

d) The American Diabetes Association has accepted the fasting plasma glucose test as a diagnostic marker for diabetes.

e) Oral glucose tolerance test:This test measures a person’s ability to handle a glucose load over a period of time.The patient fasts overnight.In the morning,the fasting blood glucose is determined.The patient then ingests a 75-g glucose load.In children and nonpregnant adults,the blood glucose is tested every 30 mins for 2 hour.The test is considered normal if the fasting blood glucose is <110 mg/dL and the 2 hour postload blood glucose is <140mg/dL.

f) Lab findings of Type 2 Diabetes:1) High Plasma glucose 2) Glucose in the urine 3) High urine volume.

E.PATIENT MANAGEMENT OF DIABETES:

1) If plasma levels exceed and remain above 250 mg/dL as a consequence of surgical stress or infection,sliding-scale insulin therapy should be instituted.

2) Use of oral agents other than chlorpropamide should be stopped on the day of the procedure chlorpropamide,which has a longer half-life than other oral hypoglycemic,should be discontinued the day before surgery.These patients often require insulin perioperatively during major surgical procedures.Post operatively,follow the same regime adhered to for diabetes controlled by diet.

3) Most of the diabetic patients who receive insulin use a combination of intermediate-acting and regular insulin.In these patients ,total insulin dosage is usually given in the morning or divided between morning and afternoon.Usually,two thirds of the total dose is NPH and one third is regular insulin.

4) Their management includes half of the normal daily insulin is given as NPH in the morning.An intravenous line is placed and lactated Ringer’s solution started.A preoperative blood sugar is obtained.

5) During surgery,plasma glucose,serum electrolytes and arterial blood gas should be monitored.Additional regular insulin is provided as needed by titrating an insulin infusion of 5-10U/hr either subcutaneously or in the IV fluids.

6) Postoperatively,blood glucose is checked every 6-4 hr.Regular insulin should be administered to maintain plasma glucose between 150 and 200mg/dL.

7) Once the patient has resumed oral intake,NPH insulin is started.The patients plasma glucose is monitored,and the insulin dosage is adjusted with regular insulin as needed

Reference for the above article:Dental Secrets

Hope the above article was of great help.

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DENTAL MANAGEMENT OF BLEEDING DISORDER PATIENTS

BLEEDING DISORDERS AND THEIR MANAGEMENT IN DENTAL CLINICS

IN THIS ARTICLE WE WILL DISCUSS THE FOLLOWING POINTERS:

1) IMPORTANT TERMINOLOGIES TO BE REMEMBERED

2) POINTERS RELATED TO THE BLEEDING DISORDERS.

3) PATIENT MANAGEMENT

 A)IMPORTANT TERMINOLOGIES:

1)    INR:International Normalized Ratio=(Patient protime/mean of the normal range) raised to ISI.

The ISI is the International Sensitivity Index value assigned by the manufacturer to each lot of thromboplastin calibrated to the world health organization. Reference material.

The INR standardizes reporting of anticoagulation activity and monitors patients on stabilized oral anticoagulant therapy only.

The therapeutic range is 2.0-3.0 for most of clinical situations.

Patients with mechanical heart valves are maintained at 2.5-3.5.

2)     IVY BLEEDING TIME: The Ivy Bleeding Time laboratory test has been routinely used as a screening test for assessing adequacy of platelet function. When performed, the bleeding time test calculates the time required for a standard skin incision to stop bleeding by the formation of a hemostatic plug.9 The normal range of the Ivy Bleeding Time test is usually between 2 and 10 minutes

3)   PLATELET FUNCTION ANALYZER(PFA-100): is a sophisticated   laboratory screening testing devise that is  currently being used in place of the Ivy Bleeding Time test. Platelet    function tests or platelet function assay (PFA) evaluate the qualitative function of platelets.

These tests provide an assessment of platelet adhesion.                      platelet activation and platelet aggregation during the development of a platelet plug, or primary hemostasis.2,12

4) Prothrombin Time (PT), measures the patient’s ability to form a definitive clot by monitoring the proper functioning of the extrinsic coagulation pathway (Factor VII) and the common pathway (Factors V, X, prothrombin and fibrinogen). Generally, the laboratory testing range is between 11–15 seconds.8 Testing results beyond 15 seconds indicate an abnormal or prolonged PT.

5) Activated Partial Thromboplastin Time (aPTT) also measures the patient’s ability to effectively form a definitive clot by evaluating the effectiveness of the intrinsic and common pathways of the coagulation cascade.2,5,9 It tests for deficiencies in the intrinsic pathway, specifically factors VIII, IX, XI, XIII; and deficiencies in the common pathway, specifically factors V and X, prothrombin and fibrinogen. A normal aPTT is usually 25 to 40 seconds.

6) Thrombin Time laboratory test assesses the conversion of fibrinogen to insoluble fibrin by adding thrombin to the patient’s blood sample.2,8 Specifically, this test bypasses the extrinsic, intrinsic and common pathways to determine the stability of the clot. Normally, the range of this test is between 9 and 13 seconds.2 A prolonged time, in excess of 16 to 18 seconds, is considered abnormal

B.POINTERS TO BE REMEMBERED:

1)    Vitamin K and its significance:

a)    Clotting factors II,vII,IX and X require vitamin k for synthesis.

b)    Long term antibiotic therapy can suppress the normal flora in the gastrointestinal tract that are necessary for the synthesis for vitamin k.Therefore they should be used cautiously.

c)     Vitamin K and Warfarin:Vitamin K reverses the effect of warfarin.Once vitamin K is administered ,the patient may be resistant to further anticoagulation with warfarin for a few days .In certain patients they may have an underlying tendency that puts them at risk for thrombosis and embolic complications should the effects of anticoagulant be stopped abruptly..

2)   Differentiate Hemophilia A and Hemophilia B:

:Hemophilia A is an X linked disease in which factor VIII is deficient,whereas the affected serine protease in type B is factor IX.Initially the two disorders will appear similar with elevated PTT and Normal PT and bleeding time,but they are managed differently.

3)    Transxemic Acid:It is an antifibrinolytic agent that is used to promote stability of a formed clot.The final phase in the common pathway  to blood clot formation is the activation of fibrinogen to fibrin in the presence of thrombin.

     

     Fibrin forms the basis for the blood clot,fibrinolysis or clot breakdown begins in the presence of plasmin that is formed from activated plasminogen.Transxemic acid inhibits the activation of plasminogen,therby  promoting stability of the blood clot.

It can be used effectively as a topical agent and mouthrinse to promote clot stability in patients receiving warfarin anticoagulation therapy.

4)   The effect of Aspirin on Platelets:

PATIENT MANAGEMENT GUIDELINES:

Step 1: Take accurate, comprehensive histories: personal, medical, dental and pharmacological. Perform a thorough extra and intraoral examination to identify lesions indicative of a bleeding disorder. When a known bleeding disorder is evident, understand the pathophysiology and its related impact on dental treatment. When an unknown bleeding disorder is suspected,

Step 2: Consult with the supervising physician to obtain additional information about the patient’s disorder or bleeding history. Continue to investigate and/or to obtain medical clearance to treat. Secondly, retrieve and evaluate the blood laboratory test results while scheduling the appointment within 24 hours of the results.

Step 3: Develop an appropriate treatment plan: establish whether or not the invasive dental procedure will be carried out in the dental office or in a hospital-based dental facility. Possibly, prior to invasive treatment, consider blood and/or clotting factor replacement therapy for patients with hemophilia; and, patients with platelet disorders may require platelet transfusion therapy. 

In addition, other medical interventions may be required beyond infusion therapies for the respective disorders; for example, fibrinolytic defects, vascular defects or modification of anticoagulant therapy may require specialized medical care. 

When performing the invasive dental procedure recommendations include: minimize tissue trauma; consider hemostatic systems for predictable extensive bleeding during and after complex surgical procedures; consider alternative pain control techniques other than nerve-block anesthesia

More importantly, when selecting a hemostatic therapy that achieves adequate hemostasis when performing invasive dental procedures on patients with bleeding disorders one must consider the following elements:

• The specific bleeding disorder.

• The need for a hemostatic agent and/or intervention.

The type of local and/or systemic hemostatic agent.

• The need for a consultation with the patient’s supervising physician to determine the need for coagulation factor replacement as indicated.

• The severity of the bleeding disorder.

• The specific invasive dental procedure that will induce a bleed intraoperatively and postoperatively.

click on the below link to get a pdf of important charts and tables that will help you to solve any case related to bleeding disorder.

https://drive.google.com/file/d/0B2WjEzI2Ozv5RjlnQXA0aWxZRDg/view?usp=sharing

The above article is prepared with references from

1) Crest® Oral-B®

at dentalcare.com Continuing Education Course

2) Dental Secrets

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