1 Week 1

0:01
Hello and welcome to our expanded version of the course in Introduction in Dental Medicine.
0:07
I along with my esteemed colleagues who are all faculty members at Penn Dental Medicine at
the University of Pennsylvania have been very pleased to learn that this course has been
viewed by over 9,000 people in over 100 countries, spanning the entire globe.
0:24
In this current edition, we have other new modules dealing with water fluoridations, local
anesthesia, patient's first visit to their dentist, as well as all manifestations of oral health prior to
medical and surgical procedures. We hope you will find this course informative and
interesting. Last but not the least, we want to convey a passion and pride we all feel
as members of a respected exciting and ever expanding professional dental medicine. If you
happen to visit our nation's first capital, the city of brotherly love Philadelphia please come and
explore the beautiful campus of the America's first university, the University of
Pennsylvania. And take this opportunity to visit our school to learn about the education, clinical
care, as well as the groundbreaking research taking place in our school. Thank you.
1:16
>> Our mouth is an integral part of the human body. It often mirrors our systemic health,
and can be the initial site of an underlying disease. More than 90% of all systemic diseases
produce oral signs and symptoms. The public health impact of dental medicine should not be
underestimated. While the majority of Americans have adopted safe and effective means of
maintaining oral health. Many experience needless pain and suffering affecting there overall
health and well-being. An exacting financial and social costs that significantly diminishe the
quality of life. That's why we created this course. Introduction to Dental Medicine. To inform
and engage you in oral health care. Founded in 1878, Penn Dental Medicine is among the
oldest university affiliated dental institutions in the nation. With history be truth and in forging
precedence in dental education, research, and patient care. Our four year DMV program not
only reflects the strong commitment to developing knowledge and skills. But also offers the
flexibility for students to tailor their education to their interest. As members of one of the world's
leading biomedical research community, our faculty actively pursue it into disciplinary
collaborations. That runs the practice of dentistry.
2:37
>> I'm Uri Hangorsky. I'm Clinical Professor of Periodontics and the Associate Dean for
Academic Affairs at the School of Dental Medicine at the University of Pennsylvania. >> I'm
Eric Stoopler I'm an Associate Professor of Oral Medicine and Director of Post-doctoral Oral
Medicine. I'm Tom Sollecito, professor and chairman of the Department of Oral Medicine. And
our philosophy is that dentists are health care providers who specialize in oral health. With
responsibilities including diagnosing oral diseases, promoting oral health and disease
prevention, and creating treatment plans to maintain or restore the oral health of their
patient. As a participant you will learn to appreciate the modern aspects of dental
medicine. Understand basic oral and dental anatomy and techniques for clinical
examination. And understand common disease processes affecting the oral cavity and peri-oral
structures. With this course we will engage, educate and excite you about Dental Medicine we
hope you join us. [MUSIC]

2
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[MUSIC]
0:16
So for this module, we will talk a little bit about the goals of the course.
0:22
First, we'd like to point out that primarily this course is geared toward the non-dental healthcare
professional.
0:30
However, we also feel that this course is very important for those individuals contemplating a
career in oral healthcare with our dental students, our dental hygienists, and our dental
assistants, will gain from viewing our course.
0:45
It is also important for those oral healthcare providers that are today providing care who are
interested in understanding a broader scope and practice of oral healthcare.
0:59
And of course, we believe that this course is important for those who are receiving oral
healthcare, and that is our patients, all of whom will learn by participating in this course.
1:14
So the specific goals of the course are to better understand oral healthcare
1:20
and its relationship to general health.
1:24
We'd also like to provide you with some better understanding of the scope of dental medicine,
including the educational opportunities available in dentistry today, the public health impact of
dental medicine,
1:37
as well as understanding dental technology.
1:41
We will give a very brief basic dental anatomy followed by an understanding of the
comprehensive evaluation of the dental patient.
1:55
We will then talk about the most common dental diseases and periodontal disease.
2:02
Followed by those diseases that occur in the mouth, but may not be related to the teeth or the
gums in various types of oral mucosal disease. We will also talk about oral facial pain.
2:17
And, finally, present a number of cases in dentistry. We hope you'll enjoy the course and get a
better appreciation for dentistry in today's world.

3
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[MUSIC]
0:31
Welcome, in this segment, we'll discuss the important relationships between oral and systemic
health. When considering the relationship between oral and systemic health, the oral cavity
must be viewed as an integral component of the human body. This connection, which is
accepted as fact today by both patients and healthcare professionals, was not always
considered in this manner. This concept has laid the foundation for overall improvement of
healthcare as physicians, dentists, nurses and all other professionals dedicated to healthcare
now understand the oral cavity provides critical information regarding a patient's overall health
condition. This concept was strongly supported by Dr. Lester a former dean of Penn Dental
Medicine, considered by many to be a founding father of the discipline of oral medicine.
1:19
The oral cavity and perioral region consist of tissues not unlike other parts of the body. In
addition to a complex dentition and its supporting structures, bone, muscles, nerve, fat,
mucosa, connective tissue, vascular structures, tendons, and ligaments are found in these
regions as well. Due to the presence of all of these tissue types there are a multitude of
pathologic conditions that can affect this anatomical structures, which may represent a local
systemic problem. The bidirectional relationship between oral health and systemic health
cannot be over emphasized.
1:53
Health care providers realized the oral cavity maybe a potential source of implementation or
infection due to a variety of reasons. When local oral disease is present it may have a direct
impact on the systemic health of the individual. For example, if patient with diabetes has an
oral infection or an inflammatory condition, this can potentially affect their nutritional intake and
overall well being. Which may further complicate their diabetic status, and may necessitate
alteration of therapy for their systemic condition.
2:23
The oral cavity is considered a mirror of systemic health. This may be the initial sight of
presentation of an underlying medical disorder. Hematologic disorders, endocrinopathies, and
gastrointestinal diseases are but a few types of systemic disorders that may present with initial
signs and symptoms localized to the oral cavity.
2:44
In addition, the oral cavity may serve as a more accessible location for diagnostic testing to
detect systemic disease. For example, obtaining a minor salivary gland biopsy of the lower
labial mucosa may aid in the diagnosis of Sjogren's syndrome, an autoimmune disease that
may be difficult to detect via other diagnostic testing modalities. We will now review clinical
examples of patients with oral manifestations of systemic disease.
3:11
This is a clinical photograph of a patient who presented with excessive bleeding from the
gingival tissues. It is important to rule out local factors that cause gingival bleeding, such as
gingivitis and/or periodontitis. Clinical examination of this patient's gingiva revealed
normal, healthy tissue without evidence of dental plaque or calculus. Gentle provocation of the
interdental gingival tissue caused significant hemorrhage which was difficult to control.
3:39
After all potential local factors were ruled out, the patient underwent a medical workup to
investigate possible systemic causes for excessive bleeding, which included basic laboratory
evaluation.
3:52
It was determine that the patient had a platelet disorder, which accounted for the excessive
bleeding.
3:57
The patient was referred to the appropriate medical specialist for further evaluation and
management of the hematologic disorder.
4:07
This is a clinical photograph of a patient who presented with enlarged gingival tissues. This
patient had a history of leukemia, which was treated successfully and was considered to be in
remission.
4:18
Clinical examination revealed swollen, edematous maxillary gingival tissue that covered part of
the patient's teeth. The affected tissue had a spongy feel on palpation. The concern was that
the edematous gingival tissue represented a return of the patient's leukemia. A biopsy of the
affected tissue was performed and confirmed the presence of leukemic cells. The patient was
promptly referred to his oncologist for further evaluation and management of the systemic
condition.
4:48
This is a clinical photograph of a patient who presented with multiple oral complaints. This
patient complained of oral burning, dry mouth, altered texture of the oral tissues, and presence
of lesions. Clinical examination revealed generalized redness of the gingival tissues. Overall
dry mucosa and white plaques in the maxillary vestibule and buccal mucosa. After extensive
investigation, it was determined this patient had poorly controlled, type II diabetes, which
accounted for the majority of the patient's oral complaints.
5:20
After appropriate evaluation and management of the patient's type II diabetes by a
physician, the patient reported substantial improvement of the oral complaints.
5:30
This is a clinical photograph of a patient with yellow oral mucosa associated with liver
disease. The yellow discoloration of the gingiva and oral mucosa was indicative of
significantly elevated levels of bilirubin, which indicated progressive liver failure. At the
time, the oral tissues demonstrated the only evidence of progressive liver disease.
5:51
This is a clinical photograph of a patient with a non-specific ulcer of the gingival tissue that
cause significant discomfort. This patient had a previous diagnosis of a neuropsychiatric
disorder that led the patient to falsely believe that animate and inanimate objects were
emanating from the oral tissues. In response to this, the patient used sharp objects to pick at
the oral tissues to alleviate the discomfort and to allow for easier release of the perceived
object.
6:18
It was determined that the patient was not using psychiatric medications as prescribed to treat
this condition. And the patient was strongly encouraged to return to the treating psychiatrist
for management of the neuropsychiatric condition. The patient was prescribed topical
medication to resolve the ulcer and substantially limited the self harmful behavior while
using the appropriate medication regimen prescribed by the psychiatrist.
6:44
These cases are just a few examples of the oral cavity as a mirror to systemic health.
6:50
The concept of the bidirectional relationship between oral and systemic health has been
reinforced in a report by the US Surgeon General on oral health status in America.
7:02
In the report, it is stated that many systemic diseases and conditions have oral
manifestations. These manifestation maybe the initial sign of clinical disease, and as
such, serve to inform clinicians and individuals of the need for further assessment. This
demonstrates that the important link between oral and systemic health has been recognized at
the highest levels of healthcare administration and should be incorporated into clinical
practice.
7:31
In this slide, we will review key concepts as it relates to our current discussion. Appropriate
patient evaluation, formulating a differential diagnosis, obtaining adjunctive diagnostic testing,
and rendering a final diagnosis are all expected of today's modern dentist. Since the scope of
dental medicine has expanded beyond the oral cavity, this expectation is considered vital by
both patients and health care providers. It is of paramount importance for oral health care
professionals to diagnose an oral condition which may save a patient's life, or may significantly
decrease any disease-related morbidity.
8:09
This has been exemplified by the clinical cases reviewed in this segment. The important
relationship between oral and systemic health is now one of the cornerstones of the health
care profession. These concepts are foundational to dental education, and greatly emphasize
the role of dentists participating in overall health care of patients. This has positively affected
general health of the public and has significantly improved quality of life for many individuals. In
conclusion, it is important to understand and appreciate that the oral cavity is a functional unit
of the whole and is a window to overall health.

4
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[MUSIC]
0:15
I'd like to explain the Modern Scope of Dental Medicine. And understanding truly the dental-
medical collaboration that's necessary.
0:27
Oral health care is actually a component of overall general health. It is truly a part of the
whole. The oral cavity doesn't exist outside of the body. And therefore, there is this
bidirectional relationship that needs to be appreciated.
0:45
The oral cavity can affect general health. For example, diabetes might be much more difficult to
control in a patient who has oral disease. Chemotherapy, likewise, may have a significant
impact on the patient's oral cavity. In fact, in many cases chemotherapy might be limited by the
pain associated with Mucositis in the oral cavity. When you're managing a patient dentally, you
really need to understand their medical history. Those patients that are medically
compromised, often will have altered treatment plans based upon their medical condition.
1:31
So it's very important that the medical provider and the dental provider communicate.
1:37
In this graphic patient health is associated with primary medical care as well as primary dental
care, and of course preventive care, both in medicine and in dentistry. Specialty care will occur,
it's this circle of interaction and collaboration. Between physicians and among physicians, and
between dentists and among dentists, and between physicians and dentists, that have the
patient's health as the primary goal in mind.
2:15
This concept of oral health care being a part of general health will be further elaborated
throughout this course.

5
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[MUSIC]
0:31
Hello, in this section we're going to discuss the educational opportunities in dental
medicine. Dentistry's a wonderful yet demanding profession. Its study requires professionalism,
concern, and sensitivity to others' needs and feelings, emotional self control in difficult
situations, and the ability to accept criticism with grace and open mind. It also, demands the
ability to integrate basic and clinical sciences, attention to detail, mastery of good manual
dexterity, and, last but not least, willingness to take on responsibilities and challenges. Upon
graduation from the dental school, one can choose the most incredible dazzling array of career
options. Available to the roughly 160 plus thousand practicing dentists in the US. Many
graduates will choose practice as a solo practitioner or in partnership with other
colleagues. Within the scope of private practice, some opt to pursue advanced dental
education in one of the nine ADA recognized specialties. Thus joining the pool of
specialist, compromising roughly 20% of the private practitioners. There are nine recognized
dental specialties and we'll describe each one of them. The Dental Public Health is the science
and art of preventing and controlling dental diseases. And promoting dental health through
organized community efforts. Endodontics is the branch of dentistry which is concerned with
the morphology, physiology and pathology of the human dental pulp and periradicular tissues.
2:14
Oral and Maxillofacial Pathology is the specialty of dentistry and the discipline of pathology that
deals with the nature identification and management of diseases affecting the oral and
maxillofacial regions. Oral and Maxillofacial Radiology is the specialty of dentistry and
discipline of radiology concerns with the production and interpretation of images and data
produced by modalities of radiant energy. That they use for the diagnosis and management of
the diseases. Oral and Maxillofacial Surgery includes the diagnosis, surgical and attractive
treatment of disease injuries and defects involving both the function and the static aspects of
the hard and soft tissues of the oral and maxillofacial regions. In Orthodontics, the specialist
does the diagnosis, prevention, interception, and correction of malocclusion. As well as
neuromuscular and skeletal abnormalities of the developing or mature orofacial structures. The
Pediatric Dentistry provides both primary and comprehensive preventive treatment. And
therapeutic oral health for infants, children through adolescence including adults with special
health care needs.
3:36
Periodontics encompasses the prevention, diagnosis and treatment of diseases of the
supporting and surrounding tissues of teeth or their substitutes. Prosthodontics pertains to the
diagnosis, treatment planning, rehabilitation and maintenance of the oral function, comfort,
appearance and health of patience with clinical conditions associated with missing or deficient
teeth, and oral maxillofacial tissues, using bio-compatible substitutes. These dental specialties
require additional postgraduate training, ranging in length anywhere from two to six years. The
graduate students at times will choose to combine this training with an additional masters or
doctorate degree in a related scientific field.
4:25
Those with strong interests in medicine and collaborative care may opt to practice in a hospital
setting. There, they will be providing care to patients, with medical conditions and disabilities,
along physician colleagues often in operating rooms and emergency departments. Academic
dentistry is another exciting option available to you. It combines teaching, research, community
service and patient care. And enables you to work in an intellectually stimulating and exciting
academic environment. According to a recent American Dental Education Association report,
there were over 200 vacant positions in over 60 dental schools in the United States. Those
individuals whose research is their primary passion, will be able to conduct it not only in
academic institutions, but also in federal facilities such as the National Institute of Craniofacial
Research, National Institutes of Health or in private industry. Today's dental research includes
such exciting areas as postnatal stem research and tissue regeneration, salivary research to
produce diagnostic tests. Gene transfer therapy to produce hormones or other agents to
prevent or treat oral and systemic diseases. And studies of laps on trip for intraoral analysis of
different components in oral fluids as early indicators of oral and systemic diseases just to
name a few. In my own field of an Periodontology, an exciting new area of dealing with the
impact of periodontal infection on the systemic health of an individual is constantly
expanding. The role of the subgingival environment as the reservoir of bacteria in the
periodontal patient provokes host response, which has been implicated in such diverse
conditions as coronary heart disease, atherosclerosis, myocardial infarction, stroke, diabetes
mellitus, and low birth infants in pregnant women. Some of you may want to join the field of
public health dentistry. This career focuses on community settings rather than on private
practice. The public health dentist promotes dental health, develops health policy, and is
involved in disease prevention. Public health dentists are able to work in such diverse settings
as a research and teaching institutes, Indian Reservations, Coast Guard and others. Perhaps
the least publicized practice venue opportunities are in the area of international
healthcare. Today's dentists provide services to such agencies as the World Health
Organization, The United Nations Educational Scientific and Cultural organization and the
Food and Agricultural Organization of the United Nations. Many dentists also volunteer to
provide dentistry to people in third world countries.
7:31
No matter which pathway one chooses, the dental graduate will join a proud profession, highly
esteemed by the public at large. He or she will be able to help people maintain and improve
their oral health, quality of appearance and indeed their quality of life.

6
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[MUSIC]
0:14
In this vignette, we are going to discuss the global public health impact of dental diseases. This
problem should not be underestimated, as it has a profound impact on the overall oral and
systemic health of individuals, resorting in compromised oral function, pain and suffering as
well as potential for systemic complications. Let us specifically focus on two disease
entities which play a major role in this area, namely tooth decay and gum disease, collectively
referred to as periodontal disease.
0:50
Tooth decay, otherwise known as cavity or caries, refers to the destruction of the tooth caused
by certain oral bacteria. This destruction can be limited to the crown of the tooth, the root of the
tooth, or indeed involve the entire structure. When decay becomes extensive it can penetrate
the pulp of the tooth, causing its infection. When this happens root canal therapy, or indeed the
extraction of the tooth may become necessary.
1:20
If you look in the mirror would you be able to tell whether you yourself have caries? Most likely
not, at least not in the initial stages. Especially if the cavity has formed under an existing filling
bridge, or beneath the gum line. Carries which are not addressed in a timely manner can result
in severe pain, tooth loss, partial or complete compromised mastication, compromised food
digestion, infection of the dental pulp with potential bone involvement, abscess, cellulitis and
other potential systemic severe complications. To better understand the impact of tooth
decay, let us review some of the public health data on caries. Worldwide, close to 2.5 billion
people or at least 36% of the population have dental caries in their permanent teeth. According
to World Health Organization estimates nearly all adults have dental caries at some point in
time.
2:24
The second entity we will be addressing is periodontal disease, also commonly referred to as
gum disease. Periodontal disease is actually a collective name for different conditions affecting
the supporting structures of teeth, namely the gums, the periodontal ligament, and the
bone. Once again, if you look in the mirror would you be able to tell whether you have gum
disease? And once again, most likely not. Unless the disease has reached more advanced
stages. The pathogenesis of periodontitis will be discussed in subsequent lectures. But it is
caused by certain pathogenic oral bacteria which through direct effect or via provoking host
immune response leads to the inflammation and subsequent destruction of the periodontia.
3:14
Periodontal disease initially does not result in obvious symptoms, which often cause lack of
awareness until the disease has reached more advanced stages. The signs and symptoms of
gum disease include red and swollen and/or bleeding gums, bad taste, and bad breath. In
more advanced stages of gum disease, the gums become separate from the root of the tooth
forming what we refer to as gum pockets, and bone loss will take place resulting in loosening
and subsequent loss of the teeth.
3:48
Let us look at some of the generalized characteristics of periodontal disease. Periodontitis is
generally more common in men than in women, so about 56% versus 38% of women. It is
more common among those below the federal poverty level and those with less than a high
school education. And it is definitely more prevalent among smokers. Recent CDC illustrates
prevalence periodontitis in the U.S. across all ages. 47% of all adults age 30 years and older,
have some form of gum disease. Periodontal disease increases with age and among adults
over 65, 70% and older have some form of gum disease. Research indicates that periodontal
disease can exacerbate or be exacerbated by heart disease, stroke, osteoporosis, respiratory
disease such as pneumonia, diabetes and it can also result in low birth weight in infants.
4:59
As an oral health care professional, you have the ability to play an important role in prevention
and treatment of these conditions, thereby making a lasting impact on another person's life.

7
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[MUSIC]
0:27
Hello, I'm Dr. Joan Gluch, Division Chief and Professor of Clinical Community Oral Health At
Penn Dental Medicine. In this segment, I'll be presenting concepts of dental public
heath, which bring the population perspective to oral health and dental care. Materials
previously presented in this course have focused on a wide range of clinical activities that are
completed with individual patients in order to promote health, prevent disease and restore the
mouth to proper function.
1:01
In this section, we'll expand the focus to examine community based approaches to disease
prevention and health promotion in dental public health.
1:11
Defined as the science and art of preventing and controlling disease and promoting oral health
through organized community efforts, dental public health has been recognized as a core
competency for all dental care providers as well as a dental specialty by the American Dental
Association since 1950. Dental public health includes three core competencies, Assessment,
Policy Development, and Assurance.
1:42
This illustrates dentistry's dual perspective in providing health care for individuals as well as
community members.
1:51
Just as clinical dentists complete a comprehensive examination and determine patient's
diagnosis, public health can assess community needs Through epidemiologic studies and
surveys.
2:03
Just as dentists develop treatment plans and provide clinical care, public health dentists
develop and implement oral health policies, educational and clinical programs in order to best
meet community needs.
2:16
After providing care, dentists will evaluate the success of treatment and determine recall
intervals. Similarly, public health dental practitioners want to assure the effectiveness of
programs to monitor community interventions.
2:33
As an example, Fluoridation of Community Water Supplies To Reduce Dental
Decay represents one of the most enduring and successful dental health programs. Defined as
the adjustment of drinking water to the ideal of 0.7 parts per million, the implementation of
community water fluoridation has shown a steady increase throughout the United States since
1940, as identified in this CDC graph, with 74.6 of the Unites States population able to access
fluoridated water. Flouridation of community water systems is a good dental public health
example that includes each of the three core activities of public health dentistry. Assessment of
the fluoride content of drinking water as well as periodic assessment of decay rates among
both children and adults are essential components when analyzing community oral health
needs. Once the needs are determined, policies are developed and recommended
for implementation such as the policy recommendation in addition of fluoride to drinking water,
to reach optimum level 0.7 parts per million.
3:42
In order to assure that the policy recommendations are implemented, monitoring measures
which involve frequent analysis of fluoride content in drinking water, as well as ready
decimation of the information to all stake holders are completed by dental public health
practitioners. For example, the Centers for Disease Control and Prevention maintains
technical support for water engineers regarding best fluoridation practices, as well as maintains
an interactive map on the CDC website, My Water's Fluoride, to identify fluoride content in
community water systems in the United States.
4:18
Assurance activities also include attention to best practices, based on research evidence such
as defending water fluoridation based on credible science and reputable professional journals.
4:32
Examples of other key dental public health programs have included the administration and
provision of dental care at community based and safety net clinics, policies to include dental
care and healthcare reform, and assessing program effectiveness of community interventions
in reducing dental decay.
4:53
Although oral health is an essential component of general health, assessment of oral health
status in the United States reveals that dental decay, periodontal diseases, and oral cancer
remain significant United States health problems. Data from the 2012 National Health
and Nutrition Examination Survey that's reveals the 23% of children age 2 to 5 years had
dental decay in their primary teeth.
5:22
Furthermore, untreated tooth decay in primary teeth was twice as high for Hispanic and non-
Hispanic black children, compared to non-Hispanic white children. These trends continue for
older children in their permanent teeth, with 17.5% of children age 5 to 19 with untreated dental
decay, and 27.4% of adults age 20 to 44 with untreated dental decay. Moreover, 47.2% of
adults 30 and older experience periodontal disease which increases with age and 70.1% of
adults 65 and over have periodontal disease.
6:01
These high disease rates are complicated by lack of access to dental care due to financial and
non-financial barriers to care. Many adults lack insurance for dental care, which is not a
required service in the health insurance plans for adults, and states vary widely in Medicaid
coverage for dental services.
6:23
In 2011, the American Dental Association reported one third of all United States adults, that's
33.7%, have no dental insurance and only 14.2% of children have no dental insurance. For
many adults without dental insurance or with limited public dental insurance coverage, the cost
of dental care is not affordable, given their budgetary constraints, and a reason for the increase
in dental visits to hospital emergency departments. In addition, non-financial barriers, such as
dental fear, limited geographic access to a dentist, maldistribution of dentist dental in the dental
work force. Lack of transportation and language barriers are frequently cited as obstacles to
accessing dental care.
7:11
Statistics regarding the frequency of dental visits reflect these difficulties. Healthy People 2020,
leading health indicator OH7, addresses annual dental visits and documents decline, from
44.5% in 2002 to 42.1% in 2012, which is way below the target goal of 49%. These low
numbers of annual dental visits are in contrast to the higher number of visits to healthcare
professionals. Because 82.1% of US adults and 92.8% of children reported that they had
contact with a health professional in the past year.
7:55
Clearly, we need to look at population-based solutions to increase access to dental
care. Health systems that integrate medical and dental care have a greater potential of
increasing access to dental care since patients are already visiting the medical provider, which
can also reduce those non-financial barriers to care, as well. Although there have been studies
to increase funding for dental care services in both public and private insurance
sectors, perhaps the most intriguing solution to increase access to dental care, has been to
add new dental care providers in the workforce in underserved areas. Pioneered by the
Alaskan Tribal Consortium in the United States, dental health aide therapists have been
employed to provide dental care in rural Alaskan communities and other tribal organizations as
a more sustainable solution to address access problems. Much like nurse practitioners, dental
therapists work in collaboration with dentists to extend dental care provided and research has
documented positive clinical care outcomes. Recent legislative efforts in Minnesota and Maine
have established dental therapists in order to increase the number of dental care providers in
areas traditionally underserved by dentistry.
9:12
However, even though 54 countries worldwide authorize dental therapists and mid-level dental
care providers, the dissemination of dental therapists among United States communities has
not been widely embraced and still remains controversial.
9:30
In summary, dental public health promotes a population based approach to dental care, which
compliments clinical dental activities. Dental public health practitioners assess the health of
populations, develop policies and programs that promote oral health at the community level,
and assure that community programs are effective and meet the needs of the population in
order to improve oral health. Dental public health practitioners also analyze the social cultural
and economic forces that affect oral health care, specifically to address increasing access to
dental care, promoting equitable funding for care, as well as assuring that the dental workforce
is sufficient to meet the oral health needs of the United States' population with the goal to
provide optimum access to oral health for all. Thank you.

8
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[MUSIC]
0:16
Hello, in this section we're going to discuss advances in dentistry. The art and science of
dentistry are constantly evolving. New and exciting innovations are integrated into the
treatment on an ongoing basis, and the mode of dental therapy has come a long way from the
traditional model. Let's now review some of the more significant recent advances in
dentistry. We will focus on two areas, the area of diagnosis and the area of treatment.
0:45
In the diagnostics tool we will review the digital x-rays, the caries detection system, the 3-
dimensional imaging and also some of the diagnostic tools which can detect soft tissue
lesions.
1:00
As far as the digital x-rays are concerned, the digital format is a very useful one. It can provide
a greater comfort and certainly reduce the exposure to radiation. Four digital x-rays have the
same radiation as one traditional paper x-ray. Three dimensional imaging is accomplished by
CAT scans and other three dimensional scans, which help dentists view and operate on the
jawbone with more accuracy. As implants become the standard of care in many cases, three
dimensional imaging has become increasingly specialized in dentistry.
1:41
Caries detection system compensates and complements the dentist to detect caries in addition
to visual detection. They detect it with more accuracy and they scan the teeth with pulses of
laser light. Decay emits a fluorescent light that is translated into an audible signal.
2:05
Laser fluorescents, or laser lights, of a specific frequency is directed at the tooth and the
amount of reflected light is measured. Healthy teeth exhibit little to no fluorescence, but carries
teeth structures exhibit fluorescence proportional to the degree of carries.
2:27
We also have diagnostic tool to detect soft tissue lesions such as VELScope. VELScope uses
natural tissue fluorescence visualization to help discover all of your causal abnormalities that
might otherwise have been overlooked.
2:46
Vizilite is another diagnostic tool which identifies oral lesion and provides painless screening
for the detection of small changes in your mouth.
2:58
One of the least favorite procedures in the dental office is the injection of the local
anesthetics. Actually, the pain is caused not by the anesthetic itself, but rather by the pressure
from the injection of the liquid anesthetic. The anesthetic wand uses computer regulated slow
and gentle flow of anesthetic to reduce pain of injection.
3:24
Another interesting device that has been implemented recently in dental offices is the computer
assisted design or computer assisted manufacture, known otherwise as the CAD/CAM. This
technology allows for the fabrication of dental restoration through computerized technology. A
digital impression is taken using an optical, a laser scanner, and entered into a computerized
system. This system is used to create a virtual model of your teeth and design your crown,
veneer, inlay, or onlay. This process involves identifying the appropriate color, shape, and
biting chewing surface, for your restorations. The design then is sent via cable or wirelessly to
milling unit in the dentist's office that will fabricate the restoration in a approximately 20
minutes. This technique also enables a dentist to use a camera to create a digital impression
thereby circumventing the traditional impression which is generally not very much favored by
the patients. Perhaps the development of a modern implant has revolutionized the practice of
dentistry in recent years more than any other innovation. While the dental implants were being
places as early as in the 70s, the osseointegrated implant has become popular in the 80s. In
1952, an orthopedic surgeon noted that he could not remove a small titanium cylinder he had
placed in a bone to study how the bone healed. This special property that titanium has of
fusing to bone is called osseointegration, a fusion joining with the bone and it is the biological
basis for modern implant success.
5:19
Dental implants today are being used in the replacement of single or multiple teeth. They can
serve as abutments for bridges. Furthermore, they can also serve as a stabilizing anchorage
for complete dentures, thereby improving their retention as well as speech and mastication of
food. The biointegration of the titanium tooth root with human bone is highly predictable and
the results are very long lasting. The industry has also focused on reducing treatment time
and some implants can be placed immediately after the tooth extraction, as opposed to waiting
six months after extraction. In many instances, dental implants are now the standard of care if
a tooth needs to be extracted, or if there is a question as to whether a root canal procedure
needs to be done.
6:14
The use of microscope in dentistry has been one of the latest trends to perfect acute vision for
the dentist. Microscopes offer the dentists the ability to see microcracks, weakened underlying
tooth structure and proximity of dental nerves with precision. The microscope is an improved
diagnostic tool as well as a treatment assisted tool. Today, this technique is used to improve
the precision of surgery and root canal therapy.
6:46
One of the most dreaded aspects of dental office is the dental drill. Patients neither like the
vision of it nor the sound. Well, there is some research going on into bypassing this unit. It is
something air abrasion. It is used to treat small cavities. The system uses a blast of air and
aluminum oxide pellets to remove decay. Often works without the need for anesthesia, in other
words, there is also no needles. Bone replacement is particularly important to those patients
who have weakened tooth support due to periodontal disease, related bone loss, or they are
dentures patients whose alveolar process has shrunk over the years. Three types to assist
people suffering from bone loss or those requiring tooth extraction. The first one is the
autografts, which are bone taken from the same patient. This bone is taken from another part
of the body such as the iliac crest, for example.
7:50
The second part are the allografts and an allograft is a bone taken from another human
being. This bone is taken from a cadaver and processed in a lab so that it is ready for
grafting. The third part is the alloplast which is a synthetic bone replacement material. It is
made in a lab to mimic bone structure. Bone growth factors, such as platelet derivative growth
factor, known otherwise as PDGF, are used in conjunction with bone grafts to achieve
maximum results. The use of lasers has been increasing in the past decades. We have four
types of lasers. The diodide, which is absorbed by pigmented tissues, such as the
hemoglobin and melamine, and it is particularly good for treatment of soft tissue. There is the
Nd-YAG and CO2 laser which is excellent for homeostasis, for stopping bleeding. There is the
erbium laser, which is good for heart tissue, and hence can potentially replace the drill. And the
argon laser, which can cure resins and improve bonding.
9:02
Lasers surgery is an alternative to traditional scalpel surgery that can often reduce discomfort
and doesn't require sutures. Lasers can also be used for a variety of procedures, including
tumor surgery, cold sores, crown lengthening, aesthetic gum changes, tongue tie and speech
impediment and nerve regeneration. Laser may also be applied in the treatment of select
dental conditions Such as sleep apnea, certain cases of temporomandibular disorder and tooth
sensitivity. This is a very exciting area of development in dentistry. One of the most exciting
future trends, is the tissue engineering, the ability to regrow teeth. When this happens it'll be a
very exciting new phase of dental practice.

9 week 2
0:00
[MUSIC]
0:31
Hi. In this lecture, we'll talk about the embryology of the oral cavity and of tooth
development. We'll learn about how the bones in the oral cavity develop and how the teeth
develop inside those bones.
0:44
We can see that already at 28 days or four weeks of development, the face is starting to
form. I'd like to draw your attention to the green, the yellow, and the blue in this image. The
green being the frontal nasal prominence where the top part of the face and nose will
develop. The yellow being the maxillary prominence, where the top jaw, the upper jaw or the
maxila will develop, and the blue being the mandibular prominence where the lower jaw will
develop.
1:11
We can see that at twenty eight days there is actually a space between the yellow, the green,
and the blue. This space will need to be filled in so there is not a space within the upper jaw. At
forty-eight days, approximately seven weeks, we can see that the green portion has started to
grow down the nose is developing a little bit more and growing downwards to meet the maxilla,
or the upper jaw.
1:34
The yellow portion, the upper jaw, is growing toward the center to fuse with itself on either
side.
1:41
We can also see that eyes have started to develop, and, the lower portion of the image we can
see that the yellow or upper jaw is fully fused with itself in the midline. The green forming the
nose has come down and fused with the yellow for the upper jaw. Now that we know
something about the development of the facial bones, we can understand how cleft lip and
palate occurs. Cleft lip and palate is a condition that happens approximately once in every 700
live births. It's the most common congenital abnormality in the orofacial complex.
2:16
We can see at the bottom of the image, a gap in the midline of the maxilla or the upper
jaw. This happens when the two yellow halves that we saw, the two halves of the maxilla do
not fully fuse.
2:29
On the upper portions of the image, we see what happens when the yellow and the green do
not fully fuse, when the maxilla does not fully fuse with the nasal bones. Now that we've seen
how the bones in the upper jaw and the upper face develop let's focus on the mandible or the
lower jaw in the neck region. These develope from a series of arches that we call pharyngeal
arches. There are five of them, number one through six, because there were actually originally
six, and the fifth disappears very early on in development.
2:59
These arches will form the bones of the mandible, or lower jaw, and the cartilage in the neck.
3:06
This image show us in a color coordinated fashion what these arches will form.
3:12
We can see in the orange red color that the first pharyngeal arch will form the bones of the
mandible or lower jaw, as well as some bones of the ear.
3:21
The other pharyngeal arches are responsible for bones in the neck and cartridge of the neck
forming other faringial structures.
3:30
We've now seen how the bony framework of the upper jaw and the lower jaw upper face, and
the neck form. Now let's talk about how the teeth form within those jaws.
3:41
In order to discuss tooth formation, we first have to start with a roadmap. So this is what a
mature tooth looks like in histological section.
3:50
The enamel is the topmost structure. It is the hardest structure in the human body, and it takes
the brunt of all the biting forces.
3:58
Underneath that is the dentin, which forms a cushioning for the enamel and extends all the way
down to the bottom of the tooth in the root.
4:06
Covering the rest of the root is a structure called cementum, and in the middle is a soft tissue
structure called pulp.
4:14
This houses the nerve and blood supply of the tooth. This is what a mature tooth looks like and
let's see how that develops.
4:25
Looking at an image that we're now familiar with I want to highlight the white portions of this
image. This is where tooth development occurs. It occurs in the maxillary prominences,
mandibular prominences, and the middle portions of the nasal prominences.
4:41
Tooth development happens in three stages that we call the bud stage, the cap stage, the bell
stage, and after these stages, hard structure forms, to form the crown of the tooth.
4:53
These stages form a spectrum, and are only distinguishable histologically, based on how they
look. This is a histological image, which shows us the initial forms of tooth formation, or also
called the bud stage. In the middle portions of the images is the tongue.
5:11
Surrounding that is oral mucosa.
5:14
We're now highlighting the tooth bud, which is actually epithelial cells or the top cells that have
been signaled to grow downwards into the underlying ectomesenchyme that we're highlighting
now.
5:30
This image shows us the early cap stage of tooth development. We can see that the tooth bud
has taken on more form. The epithelial cells are denser and thicker, and the underlying
ectomensenchymal cells are also starting to aggregate.
5:45
The epithelial cells and the underlying cells are constantly signaling to each other to create
tooth formation.
5:53
This histological slide shows us the late cap stage of tooth development and highlights an
important structure called the enamel knot. The enamel knot is a dense aggregate of epithelial
cells that will orchestrate and shape the form of the crown.
6:09
The next stage of development is the bell stage of tooth development.
6:14
We can see that the tooth bud has now taken on great shape.
6:19
We are highlighting an area that will be the eventual shape of the actual tooth.
6:26
Now that the cells have all lined up, the epithelial cells and the underlying ectomesenchymal
cells, they are ready to start making hard tooth structure. Another interesting aspect of this
image is that on the right hand side you can see a developing tooth bud.
6:43
This will be a permanent tooth that replaces the primary tooth which is currently in the bell
stage of tooth development. This image is also showing us the bell stage of tooth development
but for a molar.
6:56
Note the difference in the shape, that's because molars have a different cusp anatomy and
these cells are lining up to create that different shape.
7:06
This image, is showing us the late bell stage where we can now see the beginning of formation
of hard tooth structure.
7:14
All the way at the top, and we are now highlighting the outline of what was the bell stage, we
can see the beginning of formation of hard tooth structure, the enamel and the underlying
dentin.
7:27
These start to form at the cusp tip all the way at the top of the tooth and they form sideways
and downwards.
7:34
This image shows us a later stage of crown formation. We are now highlighting where the hard
matrix was first created, and you can see that from there, it has spread downwards and
sideways. And in this slide, actually, most of the hard structure of the crown, or the top half of
the tooth, is formed.
7:54
Now that the hard structure in the top half of the tooth, the crown is formed, we have to form
the structure in the root.
8:00
Once the enamel is formed, it does not continue downwards into the root. The dentin however
does continue downwards and forms the hard structure of the root. This is a great histological
section which shows us different stages of tooth development. We're now highlighting the
primary molars that are currently in the mouth, and the first permanent molar that has erupted
behind it.
8:25
Underneath the primary molars we can see the permanent premolars developing.
8:31
The first permanent premolar is in the crown stage of development, hard tooth structures
forming. Second permanent premolar is in the late bell stage of development, and only just
now we're beginning to see hard tooth structure. This last image is a panoramic radiograph of
a seven year old child and pulls together some of the concepts of tooth development
and eruption that we've been talking about.
8:55
Firstly, I'd like to highlight the second molars developing.
8:58
They have essentially finished the crown stage of tooth development and you can see that
most of the tooth structure of the crown is formed but the roots are not yet formed. The roots
will take several more years to form, and as they form it will push the crown into the mouth.
9:14
Another interesting aspect of this image is just how complicated it is. If you were to look into
the mouth of this child you would see approximately 24 teeth, but really you can see that many
more are developing in the bone and at different stages of development.
9:30
One last thing I want to highlight is that we can see that when a tooth erupts into the mouth, its
actually not fully formed yet. When a tooth erupts, the root is approximately two-thirds to three
quarters developed, which means that even after a child gets a tooth erupted, it is still
developing.

10
0:00
[MUSIC]
0:15
Hi, in this lecture we'll talk about oral structures and functions. We'll discuss the main oral facial
structures, and talk about how they contribute to all the functions of the oral facial
complex. First we'll talk about the major functions, and then we'll talk about structures and
relate them back to the functions that they provide.
0:34
The first and perhaps most obvious is food and drink intake, or ingestion. We all use our
mouths to eat.
0:42
Our upper and lower jaw, the musculature surrounding it, and our teeth are all essential for
ingestion. Another major aspect of the mouth is taste, which is mainly provided by the tongue.
0:54
Not only does taste make ingestion a whole lot more enjoyable, but it means that we can
actually discern between foods that are more nutritious, like sweeter or fattier foods, and foods
that may be harmful for us that would taste bitter.
1:08
Another essential function of the oral facial complex is speech and expression. We all use our
mouths to speak. We don't often think about how complicated facial expressions are. We have
approximately 20 paired muscles of facial expression.
1:24
They can create hundreds of unique facial expressions for us to augment our verbal
communication.
1:31
Another essential aspect of the oral facial complex is esthetics, or how we look.
1:37
It creates our identity, confidence in ourselves, allows us to interact with one another, allows us
to be attracted to one another. In the United States alone, the esthetic dentistry industry is over
a billion dollars, because a person's smile is such an important aspect of how they look. The
last function of the oral facial complex that I want to highlight is the immune function. We
actually have immune system tissues within our mouth.
2:02
In this image, we can see the yellow highlighted tissues known as tonsils. In the very, very
back of the throat, there's pharyngeal tonsils. On the side of the throat are the palatine
tonsils, which are the ones that get swollen when we get a cold or strep throat. And on the
back of the tongue are lingual tonsils.
2:20
These tonsils are immune tissues that form a protective ring known as Waldeyer's
ring. Essentially, it's the body's first barrier of defense against any bacteria or other pathogens
that want to enter our systems through our food.
2:34
Now that we've talked about the major functions of the oral-facial complex, let's talk about the
major structures, and then relate them back to the functions. Let's start with the bones. The
major bones of the jaws are the maxilla, or the upper jaw, and the mandible, the lower
jaw. These both have an alveoli process that we're now highlighting.
2:54
The sole purpose of the alveoli process is to house the teeth.
2:59
Like we touched upon previously, the jaws and the teeth are absolutely essential for eating.
3:04
The lower jaw moves up and down for chewing, and the teeth physically break down our food.
3:12
So let's relate the bones of the upper jaw and the lower jaw back to the functions.
3:17
They're responsible for mastication, or chewing, like we just mentioned. They're essential for
speech. When we make an s sound, for example, our upper and lower teeth come together
and just touch each other. In an individual whose upper and lower teeth do not touch each
other, that person will have a lisp, because two much air will escape when they try to speak.
3:41
Upper and lower jaws are also essential for facial expression indirectly through the muscles
that overlay them.
3:49
The maxilla, the upper jaw, where the bone highlighted in the peach color in this image,
extends posteriorly to form the hard palette, or the roof of your mouth.
4:01
The hard palate is essential because it forms a barrier between the oropharynx and the
nasopharynx, or the oral cavity and the nasal cavity. It extends posteriorly to the soft palate.
4:13
The soft palate is also essential to forming this barrier.
4:17
When we swallow, the soft palate presses up against the back of the nasal pharynx. Without
that, the pressure of swallowing would force food up into the nasal cavity.
4:27
This image is just to highlight that the bones of the maxilla extend to form other oral facial
structures as well. The top most portion of the maxilla actually forms a part of the orbital wall.
4:40
The upper jaw gets extensive nervous innervation. These nerves are mostly running to the
teeth to provide them with sensation. They also run to the overlying structures of the teeth,
such as the gums and the soft tissues.
4:54
Now lets talk about the lower jaw, or the mandible.
4:58
It also has an alveolar process, which houses the teeth. The mandible has many lines,
grooves, and spaces to accommodate attachments for muscles, and space for glands to
sit. Here, we're highlighting the external oblique ridge, which is important because it's the sight
of attachment of an important muscle.
5:19
This muscle is the Buccinator, or the cheek muscle.
5:22
Here we're looking at the posterior aspect of the mandible, as if we were behind it looking
towards it. We can see these bony protrusions called the mental spines. These are also sites
for muscle attachment. In this cross-section of the mandible, we can see where the muscles
attach to those mental spines. We're now highlighting the muscles that attach to the mental
spines that extend superiorly to hold the tongue in place, and inferiorly to extend towards the
pharyngeal architecture.
5:54
In this image, we're highlighting two spaces on the back portion of the mandible. These spaces
are called the sublingual fossa and the submandibular fossa.
6:06
These fossa are important because they house salivary glands, the sublingual salivary gland
and the submandibular salivary gland.
6:15
This is a great segue for us to talk about saliva, which is not an oral structure per say, but is
incredibly important for all oral functions. Firstly, it is a lubricator and it is very, very difficult to
chew without saliva to lubricate our food.
6:32
Its second function is that it has a lot of minerals to keep our teeth healthy. It is hyper
mineralized, which means that it bathes the teeth in a constant stream of minerals so that the
teeth do not lose minerals and become soft.
6:47
It's also essential for our immune system, as our saliva has antibacterial and antiviral
functions. Lastly, it is the starting point of digestion. We often think about digestion starting in
the stomach, but in fact it starts in the mouth with the mechanical digestion by teeth, and the
beginnings of chemical digestion by saliva.
7:08
Since we were talking about salivary glands, I just want to highlight the third major salivary
gland, which is the parotid gland.
7:15
It sits outside of and just behind the mandible.
7:19
The parotid gland, submandibular, and sublingual glands are our major salivary glands.
7:26
Coming back to the mandible, let's highlight this triangular protrusion called the coronoid
process. This is another very important site of attachment for a muscle. The muscle is called
temporalis, because superiorly it attaches to the temple bone of the skull. This is one of our
four muscles of mastication.
7:46
And its function is to raise the mandible for chewing. Other muscles of mastication include the
masseter and medial pterygoid muscles, which are also used to raise the mandible for
chewing.
7:58
Lastly we had the lateral pterygoid muscle, which is the only muscle mastication used to
depress the mandible or open the jaws.
8:07
As you can see, it extends posteriorly and attaches to the top most portion of the mandible
knows as the condyle. When it flexes, it pulls the condyle out of its socket to open the jaws.
8:20
Since we're talking about the condyle, that's a great segue to talk about the joint of the
mandible. This is known as the temporomandibular joint, because it's between the mandible on
the bottom, and the temporal bone of the skull on top.
8:33
Like any other joint in the body, it's got a disc made of cartilage to cushion between the two
bones. This disc is incredibly important, because it has a lot of sensory enervation, and if
there's any pathology associated with the disc, it can be very, very painful.
8:49
Just like the maxilla, the mandible also has extensive enervation.
8:53
We can see highlighted the inferior alveolar nerve running through the mandibular canal, and
supplying sensation to the teeth, the overlying gums, and some of the overlying soft tissues.
9:06
Now that we've discussed the bones of the orofacial complex, I'd like to draw us back the
musculature. We already saw buccinator, and now I'd like to highlight just how many muscles
of facial expression there are.
9:19
We mentioned that there are 20 paired muscles of facial expression.
9:24
The tongue is another incredibly important oral facial structure. In of it itself is also a muscle,
but it's an intraoral muscle. And it contributes to almost every aspect of the oral facial complex
that we've been talking about.
9:38
Firstly, it is almost solely responsible for taste, as most of our taste buds lie on the top surface
of our tongue.
9:46
Secondly, the tongue is very important for eating, because it helps direct food towards our
teeth for chewing. It's also very important for our immune system. We mentioned that at the
very, very back portion of the tongue we have lingual tonsils, which form part of Waldeyer's
Ring. And again, that's a protective shield in our body against any pathogens that are trying to
enter our body through our food.
10:10
Last but certainly not least, our tongue is absolutely essential for speech. And we know that
individuals who don't have a tongue cannot form words properly.
10:20
In this segment, we've talked about essential oral structures and their functions. We've talked
about the maxilla and the mandible, the upper and lower jaw, how they help with chewing and
how they house the teeth. We've talked about the muscles of facial expression, the
tongue, which is also a muscle, and the salivary glands. We talked about how all of these react
and interplay with each other to create the different functions, eating and ingestion and taste,
speech, the esthetics of our face and of our smile, and an immune barrier to any pathogen that
wants to enter through our mouths.

11
0:00
[MUSIC]
0:15
Hello. In this section we're going to discuss the form and function of the
periodontium. Periodontium is defined as a set of tooth-supporting tissues including the
cementum, periodontal ligament, alveolar bone and gingiva. In this image, we can visualize the
structures in place. It demonstrates the periodontal ligament. Which is the thin structure
attaching the tooth to the bone. You can see the cross section of the gingiva tissues, the root,
and the crown of the tooth. When describing gingiva, or gums, the dentist will use four terms to
communicate his or her findings. In terms of color, contour, texture, and consistency.
1:09
Let's describe texture and consistency. The texture is the surface characteristics. Healthy
gums generally have a stippled appearance, similar to a peel of an orange. And consistency
refers to the resiliency. Healthy gums are usually very resilient, as opposed to gums which are
inflamed which are rather edematous. In caucasian the color is generally coral pink, but
deposits of melanin, render it darker, depending on the racial background of the individual. This
image demonstrates the color of gums in an African-American male, demonstrating the
melanin pigments accounting for the dark colors. Variations in color and texture, are also
important in differentiating healthy from unhealthy gingiva. In this images, the very top slide
demonstrates healthy gingiva, where the tissues are stippled, coral pink, and firm. As opposed
to the slide demonstrating periodontitis, where gingiva are the bluish, dark, and there is
separation from the pockets. The gingival margin is the most coronal part of the gingiva, and it
parallels to the border between the crown and the root of the tooth.
2:34
At times, due to intrinsic factors, such as excessive abrasion or disease. The gingival margin
recedes apically. When this happens, gum recession becomes, takes place. This particular
image demonstrates gum recession, causing exposed root surfaces, which can lead to thermal
sensitivity.
2:59
The gum tissue between the two teeth, is referred to as the interdental papilla. It is usually
triangular and covers completely the interproximal space. In health, it is usually flat and covers
the interproximal space completely, however, in teeth where there are spaces large spaces
exist. That interdental papilla may be slightly blunted, such as this slide demonstrates.
3:27
There are two sets of papilla. There is the facial papilla, and the lingual papilla on the lingual
side, and the area connecting the two papilla, is known as the interdental col. The interdental
col has significance in health and disease, because this is the area most susceptible to
inflammation. Col is the most concave in posterior area of the mouth. And if the patient does
not floss their teeth, plaque accumulates leading to bleeding and inflammation in those col
areas.
4:03
The gingiva are composed of keratinized and non-keratinized gingiva. The keratinized gingiva
has a layer of keratin which results in a paler color.
4:16
The differentiating area between the keratinized and non-keratinized tissue, is the
mucogingival junction.
4:26
Periodontal ligament is that structure which attaches the root of the tooth into the bone. It
consists of layer of soft connective tissue, which covers the root of the tooth. It attaches the
root to the bone of the tooth socket. It is composed mainly of fiber bundles. The fibers attach
on the one side to the cementum, and on the other side to the alveolar bone. Then entire
periodontal ligament is only .2 millimeters thick, yet it is a very efficient structure, as it holds the
teeth firmly in the jaw socket. There are several functions of periodontal ligament. IT offers
support, because it suspends and maintains the tooth in its socket. It has a sensory function,
as it provides sensory feeling to the tooth, pressure and pain sensation. It has a nutritive
function, because it provides nutrients through cementum and bone. It has a formative
function, as it builds and maintains cementum, and the alveolar bone on the tooth socket, and
it also has a resorptive function. It can remodel the alveolar bone in response to pressure or
tension.
5:43
The alveolar bone forms the bony sockets that provide support and protection for the roots of
the teeth.
5:51
That bone develops when the teeth erupt. However, when the teeth are extracted, the alveolar
bone resorbs. This is something that's not understood by many patients, who opt to have full
dentures. The denture initially be well fitting, but over the years as the bond resorps due to lack
of the teeth, the denture has to be completely and constantly realigned.
6:18
Significant ridge resorption, can make it difficult to utilize traditional dentures, as they rely on
alveolar bone support.
6:26
This image demonstrates the alveolar process which holds the teeth in place. And you will
notice that there are two types of bone. The cortical plate which is the compact bone, which
forms the outer layer. And this cancellous bone, known as the spongiosa, which is forms the
back of the bone.

12
0:00
[MUSIC]
0:14
Today, we're going to discuss the structure of the human tooth. We humans have only two
dentitions. The primary dentition, also known as the baby teeth. The first tooth erupts around
the age of six months, followed by the permanent dentition, which starts around six years. The
period between 6 and 14 years old is referred to as the period of mixed dentitions, where both
primary and secondary dentitions are present. Among primary teeth, they're are 20 of them, 10
in the upper jaw, known as the maxilla, and 10 in the lower jaw, known as the mandible, a total
of 20 teeth.
0:57
The primary teeth, there are two types of incisors, these are the front teeth centrals and
laterals. And two types of molars, these are the back teeth, first and second.
1:08
All primary teeth are normally later replaced with their permanent counterparts.
1:14
The primary teeth are significantly smaller than their permanent counterparts, and they usually
characterize by large interproximal spaces visible in this image.
1:27
Among the permanent teeth, 16 are found in the maxilla, the upper jaw, and 16 in the
mandible, so there's a total of 32 teeth.
1:39
In each of these, there are typically four incisors, which are the front teeth that we show during
our smile, two canines, also referred to as the eye teeth, four premolars, sometimes referred to
as bicuspids, and six molar teeth.
1:57
Many people have heard the term wisdom teeth, and assumed that there is
something inherently wrong with them, as they often seem to be slated for extraction. Turns out
that these teeth are no different in structure than their counterparts. What is different is that
those teeth are the very last teeth to erupt into the jaw, somewhere between 17 and 21 years
of age. Often, there is not enough space for these teeth to erupt properly. So what happens is
that in these situations, partial eruption may occur, leading to gum infection, abscess and
cavity formation on the adjacent teeth. At times, there is so little room that these teeth never
erupt and remain completely embedded in bone. This condition is known as a full bone
impaction, and it can lead to cyst formation and other tumor formations. So there's often a
dilemma whether those impacted teeth should remain embedded, or should they be
extracted. And that decision has to be done in conjunction with a qualified oral surgeon.
3:09
The tooth itself consists of two major part, the root and the crown of the tooth. The crown is
that part that sticks above the gum line, and the root is that part of the tooth which is embedded
in bone. The root, generally, is twice as long as the crown, and that ratio is necessary to
maintain the stability of the root.
3:34
The front teeth are generally single-rooted teeth, meaning there is one root per tooth, however
the back teeth have two or three roots. The maxillary of the upper molars have three roots per
tooth. The mandibular molar have two roots per tooth, and of course, the extra roots provide
the tooth with additional support. In multi-rooted teeth, there is an area where the roots divide,
which is known as furcation.
4:09
In healthy dentition, this furcation is completely embedded in the bone. However during
periodontal disease, when there is bone loss, the furcation becomes exposed to saliva and
bacteria, and can often lead to formation of abscess and other infection. When this happens
this condition is now furcation involvement.
4:36
Shown in the pink, there is the pulp chamber which is underneath the hard structure of the
tooth.
4:43
And it contains the tooth nerves and the vascular supply. Pulp chamber is the dental pulp is the
central part of the tooth filled with self connective tissue. This tissue contains blood vessels
and nerves that enter the tooth from a hole at the apex of the root.
5:04
Let us look at the cross section of the tooth and we will see that there is enamel, dentin,
cementum, and the dental pulp. And we will discuss each section separately.
5:17
Let's start with the enamel. Enamel is the hardest and the most highly mineralized substance
of the body. 96% of the enamel consists of mineral, with water and organic material comprising
the rest. The normal color of enamel varies from light yellow to grayish white. Some enamel is
semi translucent. The color of dentin and any restorative dental material underneath the
enamel strongly effects the appearance of the tooth.
5:47
Enamel can vary in thickness over the surface of the tooth, and is often thickest at the cusp up
to two and a half millimeters, and thinnest at its border, which is seen clinically at the
cementum enamel junction.
6:03
Beneath the enamel is the dentin. Dentin is the substance between enamel or cementum, and
the pulp chamber. It is created by the odontoplast of the pulp. This porous yellow based
material is made up of 70% inorganic materials, 20% organic materials, and 10% water by
weight. It is less mineralized and less brittle than enamel, and it is necessary as an underlying
structure for the enamel. Because dentin is softer than enamel, it decays more rapidly and is
subject to severe cavities if not properly treated.
6:44
The dentin has microscopic channels called dentinal tubules, which radiate outward throughout
the dentin from the pulp cavity to the exterior cementum or enamel border. The diameter of
these tubules range from 2.5 millimicrons near the pulp to 1.2 millimicrons near the mid portion,
and 900 nanomicrons near the dentin enamel junctions.
7:12
These dentinal tubules contain cell projections known as the odontoblasts which connect with
nerves axons in the dental pulp. The exposed dentin is very sensitive to thermal changes, as it
causes movement of fluid in the odontoblast projections, which anastamose with nerve
endings.
7:34
Cementum is that structure which covers the root of the tooth. It is a specialized bone-like
substance. It is approximately 45% inorganic material, mainly hydroxyapatite, 33% organic
materials, and 22% water. Cementum is excreted by cells, known as cementoblasts, within the
root of the tooth, and it's thickest at the root apex. The principal role of cementum is to serve as
a medium through which periodontal ligaments can attach and render the tooth its stability.
8:12
The cellular cementum is very active at the root of the tooth. And it compensates in length for
the attrition of the tooth.
8:22
The area where the cementum and the enamel of the tooth meet is referred to as C.E.J. or the
Cementoenamel Junction.
8:33
The structure has very important clinical significance. So there are three possibilities of this
junction. In some instances, the cementum overlaps the enamel. In other instances, enamel
overlaps the cementum. But in some cases, the cementoenamel actually do not meet, leaving
the area of exposed dentin. In these situations, the patient tends to have increased sensitivity
to thermal stimuli, such as hot and cold.
9:11
The Dental Pulp is the central part of the tooth filled with soft connective tissue. This tissue
contains blood vessels and nerves that enter the tooth from t a hole at the apex of the root.
9:24
Along the border between the dentin and the pulp are odontoblasts which initiate the formation
of the dentin. Other cells in the pulp include fibroblasts, pre-odontoblasts, macrophages and T
lymphocytes. This area is commonly referred to as the nerve of the tooth.
9:46
Another important aspect to remember is the occlusion, or how the teeth come together. The
study of occlusion involves both the static and the dynamic relationship of maxillary to
mandibular teeth.
10:03
So, the most common classification of the static occlusion is the so-called angles
classification. In angle class one, the maxillary teeth just overlap the mandible.
10:19
In class two, the maxillary teeth, especially the front teeth, are positioned forward to the ideal
place.
10:28
And in class three malocclusion, the mandibular lower incisors overlapped the maxillary teeth,
resulting in protrusion of the jaw. In dynamic occlusion, we consider how the lower and upper
jaw meet each other during movements. It is important that the chewing forces, or the closing
forces of the upper and lower jaw should be equalized so that the pressure is even on both
sides. Imagine a dining room table with six legs, with one leg even a few millimeters longer
than the other five. If people were to lean on such a table, that particular longer leg would get
more pressure and would either buckle or would become loose. Pretty much the same situation
happens in human dentition. If one tooth hits their opposing tooth prematurely,
11:30
the tooth then sustains increasing occlusal forces which can result in increasing wear facets or
loosening of the tooth. Other signs and symptoms of occlusal trauma may include thermal
sensitivity, increased mobility, trismus, and clicking of the temporal mandibular joint. When
such conditions exist, the dentist needs to correct it either with occlusal adjustment, or with
appliances which minimize such destructive forces.

13
0:00
Hello, my name is Dr. Eva Anadioti. I'm a prosthodontist and an Assistant Professor at the
Department of Preventive and Restorative Sciences at Penn Dental Medicine. [MUSIC]
0:31
Today, I will give you an overview of the procedures that take place during the first
appointment at a dental office.
0:39
The purpose of this presentation is to familiarize you with the process, and to answer potential
questions on the rationale behind each step.
0:49
Let's begin by briefly reviewing the basic sequence in patient care.
0:54
The first step is the comprehensive examination that will take place at the first appointment.
1:01
The completion of the examination and the information collected will lead to a proper
diagnosis.
1:08
Based on that, the dentist will create a treatment plan.
1:12
After the treatment is completed, patients enter the recall system, in which periodic dental
appointments are established for prevention and maintenance.
1:23
As you realize, each step leads to another in order to ensure success and longevity of the
dental therapy. Each step along the way is necessary and equally important.
1:37
Now, we will focus on the first step.
1:40
The comprehensive examination includes a thorough examination of intra- and extraoral
structures, along with a detailed collection of relevant information.
1:52
A comprehensive examination will be done the first time you visit a dental office.
1:58
Even if you had had regular care under a different dentist, the new dentist will want to become
familiar with your oral and medical health.
2:09
At the first appointment, the dentist will interview the patient, in order to gather data on the
patient's medical history, dental history, and chief complaint.
2:22
Then the dentist will perform a thorough physical extraoral and intraoral examination,
radiographic examination, and in addition to those, other diagnostic tools, such as consults,
records, and dental impressions may be required.
2:40
During the review of the medical history, the dentist will ask if you have been diagnosed with
any diseases, if you have had any surgeries,
2:50
or if you're taking any medications, prescriptions and over-the-counter. It is important to tell the
dentist about all medicines you take. Even diseases that seem to be unrelated to the
mouth may require a different approach to dental treatments or prevention.
3:09
The dental history review will include questions on your oral hygiene habits, like how often you
brush your teeth or floss, mouth habits like grinding or clenching your teeth, frequency of dental
visits, past dental treatments and experience. The dental and medical histories should be
considered by the dentist to identify medications and predisposing conditions that may affect
prognosis, progression, and management of oral health condition.
3:44
Chief complaint is the main reason that you're visiting the dentist at that particular moment.
3:51
The dentist will document in the patient's own words the reason why you are seeking
treatment, because this information, along with the diagnosis, will be use to create an
appropriate treatment plan later. The chief complaint may be as specific as, my tooth on the
lower right side broke off, or, I don't like my smile.
4:14
But it can also be something broader and vague like, my teeth are in bad shape, or, I just need
a cleaning.
4:24
After the dentist has collected the data, the physical examination will begin.
4:30
First of all, the vital signs will be recorded and documented, such as blood pressure and pulse.
4:37
Extraoral examination includes head and neck palpation to identify lymph nodes, asymmetries,
temporomandibular joint disorders,
4:49
structural or functional anomalies, and signs of physical abuse.
4:56
Let's move on to the intraoral examination, which is the check and evaluation of anatomical
structures in the entire oral cavity or the inside of the mouth.
5:08
First of all, the dentist will perform an oral cancer screening. It is a thorough examination of the
tongue, the inside of the lips and cheeks, the floor and the roof of the mouth, to identify the
presence of abnormalities or disease.
5:25
Then we move on to the periodontal examination.
5:30
This includes a detailed check of the gingiva, or gums, and supporting structures of the teeth.
5:38
With this examination, we record the pocket depths around the teeth, mobility, and bleeding, to
identify the presence of disease in the tooth's supporting structures, which is called gingivitis
or periodontitis, based on the affected anatomical structures. The dental examination includes
the exam and evaluation of each individual tooth and tooth surface.
6:04
The dentist will document missing or fractured teeth, presence of disease, which is called
caries or tooth decay, any existing restorations such as fillings, crowns, bridges,
and removable dentures, and other dental conditions like wear and erosion.
6:26
Lastly, the dentist will check the occlusion, how well your teeth fit together when you bite down
and move your jaw side to side.
6:36
The number and type of radiographs or images required to provide information for diagnostic
purposes will vary according to the needs of the individual patient, and will be determined by
the dentist. Most commonly, the radiographs used for dental purposes may be divided into two
categories.
6:56
Intraoral radiographs are small and give great detail for each individual tooth and its bone
support.
7:04
Those are called periapical when the root of the tooth is included, and bite wings when only the
crowns of the teeth are shown, and are used to detect carries and lesions related to the
teeth. Extraoral radiographs provide information for all teeth together in relation to other
anatomic structures, like the panoramic radiograph.
7:29
All the above radiographs provide two-dimensional representation of the three-dimensional
structures, teeth and bone.
7:38
Nowadays, the cone beam computed tomography, CBCT, that provides a three-dimensional
image, is routinely used in dentistry. One of the most common indications for a CT scan is the
surgical planning of dental implants, in order to assess the bone volume at adjacent anatomical
structures such as nerves and roots, for a very predictable and successful treatment.
8:05
What is discussed until now are the most common diagnostic tools. Many times, though,
depending on the dental complexity of the particular patient, additional information may be
required. That includes photographs. Intraoral and extraoral photos with a digital
camera, provide a baseline record for the dentist, and are also a communication tool with the
patient, laboratory technicians, and other members of the health care team.
8:34
The dental impression is a negative imprint of hard and soft tissues in the mouth from which a
positive reproduction, that is called cast, can be produced.
8:45
Those are the same impressions that we take in order to make crowns, bridges, dentures, and
night guards or bleaching trays. At this stage of the treatment, though, we call them diagnostic
impressions, and are used to more easily detect problems with the bite that are difficult to
see inside the mouth, and also to use them while discussing and planning with other dental
specialties or technicians.
9:12
Today, with the advancements in digital technology, the digital intraoral scanners have been
introduced in the dental office. With those scanners, the dentist can very quickly scan all
surfaces of the teeth and the bite, and instantly the image will appear on the screen.
9:30
This digital impression, along with the digital radiographs and photographs that we described
above, can be used to diagnose and accurately plan very complex dental treatments.
9:43
Lastly, when the dentist considers it necessary, other dental or medical specialists should be
consulted to acquire additional information.
9:54
When all subjective and objective information is collected, the dentist will analyze the data in
order to form patient-specific diagnoses and risk assessment. Then we'll formulate the
treatment plan that best addresses the patient's dental needs.
10:12
The American Dental Association has established patient centered approach for the treatment
decisions which provides personalized dental care based on the most current scientific
knowledge.
10:25
Evidence-based dentistry integrates the dentist's clinical expertise, the patient's needs and
preferences, and the most current, clinically relevant evidence.
10:37
All three are part of the decision-making process for patient care.
10:42
We should keep in mind that, depending on the complexity of dental needs of each particular
patient, there may be more than one possible treatment options.
10:52
In such a case, after the dentist presents the options, a discussion follows on the advantages
and disadvantages of each option, the priorities and expectations of the patient, and the
required timeframe and cost of each option.
11:08
The patient then makes an informed decision as to which plan best meets their needs and
desires.
11:16
The dentist may also refer the patient to other dental specialists to complete parts of the
treatment, if it's determined that it's in the best interest of the patient.
11:26
Finally, let's look at the phases of a dental treatment. Phase one, disease control. Appropriate
treatment is rendered in order to establish oral health, that usually includes prophylaxis,
meaning tooth cleaning, and caries removal.
11:42
Phase two, restorative treatment. When the oral cavity is free from disease, the restorative
phase begins, which involves the replacement of missing tooth structure with biocompatible
materials in order to restore optimum aesthetics and function.
11:59
Phase three, maintenance. It is of great importance to understand that when the dental
treatment is completed, the patient should establish a recall system with the dentist
for maintenance of provided treatment, prevention, and early detection of oral diseases.
12:17
The frequency and type of evaluation should be determined by the dentist, depending on the
patient's risk factors and treatment complexity.
12:27
To quickly summarize, in this presentation, we showed the procedures that take place during
the first appointment at a dental office, which is the comprehensive examination that includes
discussion with the patient, physical and radiographic examination.
12:44
By thoroughly collecting all the necessary information, the dentist will properly diagnose
and plan the evidence-based treatment that best meets each patient's dental needs.
12:56
I hope you enjoyed your first visit to the dental office, and thank you for watching.

14
0:00
[MUSIC]
0:28
Hello, I'm Doctor Helen Giannakopoulos. I'm an Associate Professor of Oral Maxillofacial
Surgery and Pharmacology. And the director of Post Doctoral Oral Maxillofacial Facial Surgery
Residency program. I will be presenting on dental local anaesthesia. Dental local anaesthesia
usually involves the trigeminal nerve or cranial nerve V. The trigeminal nerve is what's
responsible for providing the majority of the sensory innervation from the teeth, bone and soft
tissues of the oral cavity.
0:59
First, it is necessary to understand how local anesthetics work. They decrease the permeability
of the ion channel to sodium ions, thereby, nerve impulses cannot be conducted in a region
that has been injected with a local anesthetic.
1:14
Local anesthetics can be classified accordingly by their chemical structure into two major
categories, esters and amides. Due to their significant pharmacologic advantages over their
earlier ester counterparts, amides soon became and have remained the standard
local anesthetic type and are the most widely used anesthetics in dentistry.
1:34
Local anesthesia can be administered via local infiltration or via a nerve block.
1:40
In local infiltration, small nerve endings are flooded with local anesthetic.
1:45
With a nerve block, local anesthetic solution is deposited close to a main nerve trunk. Maxillary
anesthesia techniques, depending on the area, these include local infiltration, anterior superior
alveolar, middle superior alveolar, posterior superior alveolar, greater palatine, and
nasopalatine nerve blocks. With mandibular anesthesia, also depending on the area, these
include local infiltration, inferior alveolar, mental and long buccal nerve blocks.
2:26
The armamentarium needed to administer local anesthesia includes a dental syringe, needle
and cartridge. This is a syringe that is used specifically in dentistry and its subspecialties. The
basic injection technique is as follows. Step one, communicate with the patient. Step two, load
the syringe and check the flow of the local anesthetic.
3:18
Step three, position the patient.
3:23
Step four, dry the tissue.
3:40
Step five, apply topical local anesthetic. Okay. >> Mm-hm. >> It will help with the injection.
3:48
Bite down on that for me. Step six, retract the tissue. Okay.
3:58
Okay, you'll feel a small pinch. Stay open just like you are. Step seven, insert the needle.
4:06
Step eight, aspirate.
4:12
Step nine, slowly deposit the anesthetic solution.
4:29
And step ten, withdraw the syringe.
15
0:00
[MUSIC]
0:30
Hi, my name is Tom Sollecito. I'm a Professor of Oral Medicine at the University of
Pennsylvania School of Dental Medicine, and for this module, were going to talk a little bit
about comprehensive patient evaluation.
0:43
You may ask, why do we really need a topic about comprehensive patient evaluation? Well, it
turns out that dentistry is far different than it had been many years ago. There is, in fact, a
changing patient population, and that patient population tends to be an older population and a
patient population that has more medical problems. So before we engage in dental treatment,
often a risk assessment is done.
1:17
So what do I mean when I say risk assessment? Well, a risk assessment is understanding the
dental procedure that you need to perform on the patient and assessing whether or not they
can withstand the dental procedure, mindful of their medical condition. We couple this with the
emotional state of the patient. Is the patient afraid or frightened by having a dental
procedure? The cornerstone of patient evaluation and risk assessment is the medical history
supplemented by the physical examination, and then any diagnostic tests that you would either
evaluate or order yourself.
1:59
In understanding the comprehensive patient evaluation,
2:03
first you'd like to understand a little bit about the demographics of the patient. Where did the
patient come from?
2:10
Who referred the patient to you and for what purpose? And that referral, of course, could be a
self-referral.
2:19
Also included in the comprehensive patient evaluation is both the medical and the dental
history. The last component of the comprehensive patient evaluation is the
physical examination, that which is performed after you've taken a medical and a dental
history.
2:38
From your medical history and your physical examination, one would then undergo some
process of clinical reasoning,
2:46
thinking about what you've heard in the medical history and what you've seen on the physical
exam, to help you diagnose what is wrong with the patient.
2:57
Sometimes this clinical reasoning is helped by ordering or reviewing diagnostic laboratory
procedures, or even taking radiographs or other imaging studies. Once the data is all compiled,
you would review that data and you would list what are the problems that the patient has. From
there, you'll come up with a diagnostic summary of your thoughts and then perform what we
would call a treatment plan.
3:27
So, it is with this process of comprehensive patient evaluation that you'll go through all of these
these steps.
3:36
I'd like now to talk a little bit of each of these steps individually. The first part is the components
of the medical history. The components of the medical history include understanding the
source and the reliability of the patient. When I say the source of the medical history, did it
come from other medical charts? Did it come from another physician, or another dentist, or
another clinician?
4:03
And when I refer to reliability of the medical history, is the patient a reliable historian? Some
patients have trouble remembering. You do need to make an assessment of the reliability of
the patient, as well as list all the sources of that medical history.
4:23
The first thing you'll ask a patient is, what is your chief complaint, what brings you in to see us
today? And this is a statement usually presented in quotations by the patient as to what their
problem may be. Well I have this sore in my mouth and it hasn't gone away, and I'd like to have
it checked, or, I have pain in one of my teeth.
4:46
You develop that chief complaint in a process known as the history of the present
illness. Within the history of the present illness, you're really trying to understand the context of
why the patient is presenting with that chief complaint.
5:02
We'll go into this in greater detail in just one minute.
5:06
Suffice it to say, now the present illness is a time when you're trying to understand, let's say the
severity of the pain, where the pain is coming from, does it radiate anywhere, is it associated
with anything? And you'll ask very specific questions to the patient to try and get answers to
these questions.
5:29
The next component of the medical history is understanding the past medical history of the
patient. It's quite important to understand all of the medical problems that the patient
does have, and these are often elaborated in the patient's past medical history. For instance, if
a dental procedure needs to be done, and yet the patient tells you they had a heart attack or a
myocardial infarction two weeks ago, that's an important piece of information that you need to
understand before you would proceed with any dental treatment.
6:04
Another component of the medical history is understanding the medications that the patient
has. It's interesting, occasionally a patient will remember a medication but not remember the
reason that they're taking the medication.
6:18
It's with the medication list sometimes that we're even able to determine the severity of a
patient's underlying medical disease.
6:28
Also equally important is understanding if the patient has any allergies.
6:33
Understanding if a patient has an allergic reaction is a very important part of the patient's
medical history.
6:43
Moving on in the medical history, the next thing we ask is the social history.
6:48
The social history for a dental patient is not very different than what you would ask if a patient
is coming in to see their primary care physician. You'd like to know details of the patient's
social history, including use of alcohol, use of tobacco, use of drugs, as these may all have
impact. Let me give you an example of this. If someone comes in and says, yes I drink alcohol,
and they tell you that they drink a significant amount of alcohol, this could have a direct effect
on their liver's ability to produce clotting factors. And if the patient is coming in for a toothache
which you determine that the tooth needs to come out, you'll want to know if they have a
bleeding problem prior to taking out that tooth.
7:42
It's with this medical history information, once again, that you're able to make a very good risk
assessment before you start the procedure and perhaps get into some trouble.
7:54
A family history is also equally important. It's an equally important component of the medical
history. The family history is really trying to give us an idea of some of the genetic diseases
that we do see that affect not only the teeth and the gums, but really the intraoral cavity.
8:16
The next component of the medical history is the review of systems. Sometimes it's referred to
as a review of symptoms.
8:26
When we're reviewing a patient's symptoms or systems, we're not only reviewing it for their
present chief complaint, but actually we're reviewing all of the body's systems. So, we will start
often asking questions about how they feel generally, and then we'll focus on different body
systems. For instance, we'll talk a little bit about the patient's eyes. We'll ask if they have blurry
vision or double vision or dry eyes.
8:57
By asking about symptoms going on in other systems within the body,
9:03
we often can determine perhaps underlying medical conditions that heretofore have not been
diagnosed. Now let's go back, if we will, to the history of the present illness.
9:18
As I mentioned earlier, the history of the present illness is really developing that chief
complaint. And that chief complaint often focuses around a symptom itself.
9:30
The chief complaint can be developed by asking questions about location of, well in this case,
let's say pain.
9:40
Where is the pain?
9:42
Tell me a little bit about the quality of the pain.
9:46
Tell me a little about the severity of the pain.
9:50
Tell me about the onset of the pain. What happened when you first noticed the pain?
9:55
How long does the pain last? Certainly a toothache pain usually lasts and lasts until
treated, whereas other neurologic pain sometimes can come on very quickly and then go away
very quickly and then come back very quickly. So it's important to understand the onset, the
duration, and frequency of a symptom such as pain.
10:18
You also want to know the setting in which it occurs. Can this pain occur spontaneously, or
does it always occur when you're eating?
10:27
You want to also understand what relieves the pain or what aggravates the pain. Does
ibuprofen help the pain?
10:39
Does drinking cold water make the pain worse?
10:43
And of course you want to note any associated manifestations associated with the pain. For
instance, you might want to ask a patient, do you have headache pain?
10:55
Have you noticed this pain being associated with a sore throat or sinus congestion?
11:02
The next part of the comprehensive patient evaluation is the physical evaluation. In dental
medicine, we perform the first part of the physical evaluation by just monitoring the patient as
we're talking with them.
11:16
From the moment that we meet them, that we talk to them, our eyes meet, you want to get a
sense of the patient themselves. Do they look fearful? Are there lesions on the patient's
face? Does the patient look as if they were tearing? Does the patient's face look symmetric? All
of these impressions upon first meeting we categorize as a general survey.
11:44
Matter of fact, some would say that the general survey should continue throughout the physical
evaluation.
11:51
More specifically however to dentistry, we also perform both an extraoral as well as an intraoral
physical evaluation.
12:01
The intraoral examination includes a dental examination which will be covered in another
module, so I will not go into any detail at this time.
12:13
Also is an oral mucosal examination, an understanding of the oral cavity as not only teeth and
gums, but rather a very complex cavity with oral mucosal tissue, salivary gland tissue,
muscular tissue, bony tissue. That all needs to be assessed in addition to the dental
examination of the patient's teeth and their supporting structure, the gums.
12:45
In addition to the intraoral examination is an extraoral examination, which does need to be also
pursued. This extraoral examination occurs in many different steps. First, during the general
survey when you first meet a patient, you will do some inspection of the patient's face for
symmetry, again, or for lesions.
13:09
In addition, an extraoral examination would include the head and neck evaluation in which you
will examine the patient's lymph nodes, their salivary gland tissues, as well as their thyroid
gland.
13:25
Part of a extraoral exam might also include a temporomandibular examination, particularly if a
patient comes in complaining of some dysfunction with their jaw. Perhaps not being able to
open wide, or perhaps their jaw clicking, or perhaps their jaw causing pain that may not be
related to a tooth or to gums.
13:53
In patients that do complain of pain, often a cranial nerve examination is included in the
extraoral examination.
14:02
We'll have the ability to talk a little bit more about this examination when I meet with you again
chairside and perform these examinations on a patient.

16
0:00
[MUSIC]
0:14
As you recall, as a main part of patient evaluation we perform a history as well as a physical
examination of the patient. So for today's purposes, during our physical examination, I would
ask to remind you of the cardinal techniques of any evaluation including inspection,
auscultation, percussion, and palpation. You'll see these various techniques being performed
as we examine our patient today. The main components of the dental examination can be
divided into three parts. The general survey, the intraoral examination, and the extraoral
examination.
0:56
The general survey should occur during the time that you're taking the medical history of the
patient. Where you notice various lesions or various sores or perhaps gross asymmetry of the
patient's face and exposed skin, notice if there's any distress on the patient, if they look like
they're under significant amount of stress.
1:21
Notice, as they walk into the dental operatory, whether they have any impediment in their
movements.
1:29
Notice as you begin to discuss the history with the patient, to see if in fact they have any
difficulty in communication. During the general survey, you might notice also some facial
lesions, things such as moles, discolorations, rashes, once again, on the exposed skin,
including the ears. Notice if there is a significant amount of hair loss, all of which could relate to
various underlying medical conditions which may be important to review with the patient before
you begin.
2:04
Included in the general survey is also some notice of the patient respiratory pattern. Whether
they are breathing without any significant distress, whether there's any different coloration of
their face, and whether they seem appropriate to the weather outside, the temperature outside,
and if they're grooming properly.
2:28
So the oral dental examination usually is divided into two components, the intraoral
examination as well as the extraoral examination. We'll perform both of those components on
our patient today.
2:44
For the extraoral component, this includes a head and neck examination, an examination of the
thyroid glands, an examination of the salivary glands, a temporal mandibular examination, as
well as a cranial nerve examination. We will review all of these in the next modules ahead.

17
0:00
[MUSIC]
0:14
As part of our extra-oral examination, the first part of our extra examination is to do a facial
inspection. So what I like to do when I see a patient is to observe if there are any lesions on
their face. Any abnormal different colors of their skin. If in fact there's any rash, in and around
their face. If their eyes appear to be even, and if they're grossly symmetrical. I'll also briefly
look at their ears, as well as their hair. To see if there's any significant loss of hair or any
changes in their ear. It's very important in patients that have been sun exposed, to understand
that basal cell carcinoma is sometimes often seen on the face as well as in the lower lip area,
as well as in the helix of the ear.
1:04
The next part of our extra-oral examination will be to examine the patient's lymph nodes. As a
reminder of anatomy, we will take a look at the anterior cervical lymph nodes, which are
anterior to the sternocleidomastioid as I'm pointing. As well as the posterior cervical lymph
nodes, which are posterior to the Sternocleidomastoid. We'll also palpate underneath into the
submandibular glands, into the submandibular area, excuse me, into the submandibular
area. And we'll palpate for enlarged lymph nodes around there. We'll also palpate in the
supraclavicular area to make sure there are no enlarged lymph nodes in that area either.
1:54
Finally, we'll palpate the occipital area and the occipital region, that is the back of the head, the
back of the skull. To palpate for any occipital lymph node swelling or lymph node enlargement.
2:08
A lymph node examination would take place as we palpate from the beginning of the
sternoclytomastoid up the cervical region.
2:21
Holding the patients head steady up to the angle of the jaw and move forward to palpate and
see if in fact there are any swollen lymph nodes. And in this case there are none.
2:34
Supraclavicularly, we like to identify the clavicle and press in and around the area once again
to feel for any enlargements. Finally, in the occipital area, we'll ask the patient to just nod
their head just a tiny bit and palpate in the posterior neck region. Once again for lymph node
enlargement. During the head neck examination, we also like to perform a thyroid
examination. At which time we'll have the patient naturally extent their neck just slightly. We'll
identify the cartilaginous tissue in the neck area and we'll palpate on either side of the
laryngeal cartilage. We'll palpate for, first, enlargement of the thyroid gland and also palpate to
see if there are any nodules that are present.
3:29
In order for us to be able to palpate a thyroid nodule, it often needs to be very large and
somewhat
3:40
close to the surface, in order for us to be able to identify it as a nodule.
3:45
Often, we'll have our patients swallow. [SOUND] And we will feel the thyroid gland move, which
assists us in our palpation of the thyroid gland. For the third part of our extra oral
examination, part of this actually takes place intraorally. And that is when we palpate the
salivary gland tissue. However, the first portion of that examination is, actually, to inspect the
patient for swelling in the sub-mandibular areas, as well as in the parotid areas.
4:20
Sometimes, it's much easier to see the parotid gland when you are looking from behind the
patient to see for swelling. This is the gland that used to be swollen when patients had
mumps.
4:36
I will show you the process of palpitating the glands during the intraoral examination.

18
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0:14
The next part of the extraoral examination includes a cranial nerve examination. We perform
this examination if there is a patient that has a significant facial pain component.
0:26
The gross cranial nerve exam is done with actual ease. The most important part is to
remember that there are 12 cranial nerves. So, for olfaction, which is cranial nerve number
one, we'll just often ask the patient if they can smell a certain substance, perhaps the hand
sanitizer, or if there is some type of solvent that has a very distinct odor.
0:55
Cranial nerve number two is the optic nerve, and again, we often will perform this by asking the
patient to read something on the history that they have brought into the patient.
1:11
Part of the optic nerve is to also identify the fields of vision, of which case you would ask the
patient to look straight, and for demonstration purposes, ask for them to evaluate when they're
able to see my fingers in their peripheral vision.
1:30
Tell me when you can see the fingers. >> Now. >> Beautiful. And. >> Now. >> The cranial
nerve number three is your ocular motor nerve, and that nerve often is tested by asking a
patient to follow your finger as they hold their head steady.
1:57
As you're asking them to look at your finger in all of its movements, you're also asking
them. You're also checking not only the third cranial nerve, but also the fourth cranial nerve,
and the sixth cranial nerve. The fourth cranial nerve being the trochlear nerve, and the sixth
cranial nerve being the abducens nerve, which controls the lateral rectus muscle. The lateral
rectus allows for lateral visualization, and the trochlear nerve allows for downward and inward
movement of the eye. As part of the gross cranial examination, often we will have either a pen
light, or if one is not handy, we'll ask the patient to look at the light, and be able to determine
whether or not the pupils are reacting to that light. We'll often cover one, followed by covering
the other, and making sure that the light is in fact causing the pupil to constrict. For cranial
nerve number five, which is most important to the dentist,
3:06
we will perform this cranial nerve examination in a little bit more detail than some of the
others. If we remember, cranial nerve number five is divided grossly into three segments. V1
which is the upper portion of the head, V2 which is the mid portion of the face, and V3 which is
the lower portion of the face. All of which go to midline.
3:32
Sorry about that. So we would like to test cranial nerve number five to light touch
3:39
to be able to discriminate between a sharp point and a dull point, as well as to be able to
discriminate if something is cool, has a cool sensation. So for these purposes, I'm going to use
just a standard gauze.
3:58
And I'll ask the patient, as I
4:01
place a little bit of the wisp of the gauze in different segments of their face.
4:08
So I'll first ask them if they can feel this as light touch in all three segments. And can you feel
that? >> Yes. >> And then I'll ask them, does it feel equal on both sides?
4:22
>> Yep. >> In all three segments. >> Yes.
4:26
>> Good.
4:28
As part of this examination, I'll also perform a corneal reflex. I'll ask the patient to open up their
eyes wide, and I'll just sort of brush, very gently, the cotton in the corneal region, and you'll see
a normal twitch. In order to test sharp dull in a patient when we're in the dental office, we've
devised a cotton applicator, where we break the cotton applicator and it is a sharp point on one
end, and a dull point on the other. Now we will ask the patient if they're able to discriminate
sharp from dull. Once again, we'll do that in all three segments of the face, and we'll ask them if
the sharpness on the one side feels equal or roughly equal to the sharpness on the other side.
5:17
The last portion of the patient's examination, we'll be able to discriminate if the patient can tell a
cold sensation. And for this, our dental mirrors are very good tools where we can ask the
patient, the metal, does that feel cool? And does it feel equally cool on the other side? Once
again, we'll use that in three distinct areas. This is a very gross cranial nerve
examination. However, if there are deficiencies in that nerve, further testing can be done.
5:53
So thus far, we've accomplished cranial nerves one through six.
6:00
For cranial nerve number seven, this is our facial nerve, and this is the nerve that is associated
when a patient has a Bell's palsy. This is a relatively easy nerve to test because we ask
patients about facial expression. Would you please smile? And would you frown?
6:17
Wiggle your eyebrows up and down. Can you blow up your cheeks? And also, we'll ask them
to close their eyes, to see if we can part their eyes, just slightly.
6:29
Any facial weakness would be determined by this examination, and would warrant additional
evaluation.
6:36
Cranial nerve number eight is the vestibulocochlear nerve. This actually is a nerve that has two
purposes. One is for hearing, the other is for balance. I will not perform a standard balance
examination, but it will be obvious, in discussing with a patient if they're off balanced, or
upon the general survey of them walking in, if in fact the patient has balance issues.
7:05
A gross cranial nerve exam for hearing is to ask the patient if you can hear equally in both
ears.
7:14
Now mindful, this is not a very detailed examination. For those purposes a Rene or Webber
examination is often performed to determine whether or not there is a sense in neural hearing
loss or conductive hearing loss. For today's purposes however, we asked the patient if they
could just hear us whisping our fingers together equally on both sides.
7:39
Cranial nerve number number and cranial nerve number ten are associated with.
7:46
Well, cranial nerve number nine is associated with both motor and sensory perceptions. In fact,
if the patient has some pain or even has a lesion in the back of their tongue, they'll often feel
pain into their ear. And this is through cranial nerve number nine.
8:03
Cranial nerve number nine is also associated with the patients gag reflex. As is cranial never
number ten which is referred to as the vagus nerve. So often when we inspect a patient, and I'll
show you this when we look intraorally in just a minute. At the patient's back of their throat, we
like to see the tonsils and the back of the throat move up together evenly to make sure
there are no deficiencies in cranial nerves number nine or cranial nerve number ten.
8:34
Cranial nerve number 11 is the spinal accessory, and we'll ask the patient to shrug their
shoulders. And we'll feel if there's good muscular tone in the patient's shrugging of the
shoulders, which is again, associated with the spinal accessory nerve.
8:54
Lastly is cranial nerve number 12 which is referred to as the hypoglossal nerve. This is the
nerve that produces motor to the tongue, so often we'll ask the patient to stick out their
tongue. We'll ask to move their tongue right and left, and be able to follow commands in doing
so. In patients that have a deficiency in the hypoglossal nerve, when they protrude their
tongue, their tongue may move to one side only. Can you pretend to do that for us? >> Sure.
9:25
>> Right. Which would suggest that one of the nerves on the right side or the left side is
working properly, whereas the other side is not.

19
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0:15
The next part of our examination is a temporomandibular joint examination. Occasionally
patients will come to dentist complaining of pain in and around and their jaw. After a tooth has
been ruled out as a source of pain, often the next spot to look for that source of pain might be
the temporomandibular joint complex and this could be associated with the jaw joint or the jaw
muscles. For this examination we often will ask the patient go through a series of range of
motion exercises with their jaw. We will measure their range of motion by placing a little ruler
specially performed to see how wide the patient can open and in this patient's case, the patient
is able to open a normal range of jaw motion, over fifty millimeters. We'll also ask the patient to
be able to move their jaw left and right, where we'll line it up with the mid line of their front
teeth to make sure that they're able to go in a right and a left pattern.
1:18
During the range of motion examination, we'll ask the patient, if they have any discomfort in
doing so, as that may signify that there is some pain in the temporomandibular joint complex,
specifically in the joint itself.
1:32
After we've performed the range of motion exercise, we'll actually listen or gently hold our
fingers over the patient's jaw and we'll ask the patient to open and close.
1:46
At this point, we will notice if there's any click in the patient's jaw, or any popping or, in fact, if
there's any crepitus in the jaw. This will suggest that the patient has either a discal problem, a
temporomandibular disc problem, or in fact, they have an arthritide in their temporomandibular
joint. Traditionally, we were using a stethoscope to listen to the jaw
2:11
and in many cases, we would hear that the patient's skin moving across the stethoscope and it
would be actually too sensitive to be able to report if there were sounds in the jaw
joint. However light touch we'll be able to discriminate if in fact there's a click and or pop in the
jaw joint itself.
2:33
Next is we want to actually palpate the patient's temporomandibular joint. Now what I'd like to
do is show you exactly where we place our finger. It is immediately in front of the tragus of the
ear, and we'll ask the patient to open and close, at which time we're pressing over the lateral
pole of the temporomandibular joint, and we'll ask the patient, is that associated with any
discomfort or any pain? >> No.
3:00
>> Next we'll place our pinky, our little finger, our fifth digit, in the patient's ear pressing
interiorly as we place a finger in the ear, and once again ask the patient to open and close.
3:14
Once again we'll be able to palpitate if there is any click, but we will also be able to ask the
patient was that associated with any discomfort?
3:23
>> No. >> If those areas are associated with discomfort it often suggests that there is a
problem within the jaw joint itself.
3:33
Once again, when we're palpitating the jaw joint, either in the pretragal area or inside the ear
area, we'll ask the patient to not only to open and close wide, we'll ask the patient to maneuver
their jaw In a protrusive position, a forward position, as well as to move left and right and we'll
notice if they have any discomfort. Finally in a temporomandibular examination, we also want
to get a sense of the patient's musculature and we want to know If in fact the patients muscles
are contributing to the pain. In many temporomandibular disorders a patient will have muscular
pain. Firstly they may complain of a headache a temporal headache. So we will palpitate both
the interior and posterior temporalis muscles as I am doing right now. We'll also palpate the
masseter origin, which is just inferior to the patient's cheekbone, or zygomatic arch. As well as
the body of the masseter muscle, which continues down from the cheekbone to the lower jaw.
4:36
We will also palpate the patient's neck muscles, both the trapezius muscle and the sternal
colloidal mastoid muscle. And we'll ask the patient if these are associated with any pain.
4:50
Finally, we'll press on the patient's occipital area and once again in the trapezius muscle, as
these muscles tend to be associated with patients that have a muscular temporal mandibular
problem.
5:05
For the remainder of this examination, we're able to palpate muscles from the oral cavity itself.

20
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0:14
The interoral part of the salivary gland examination requires that we palpate the salivary glands
both from the outside as well as from the inside. Open, please.
0:27
And what we will do is we'll palpate the parotid gland, and look for clear flow through the
parotid duct upon palpation.
0:38
For the submandibular gland, we'll ask the patient to relax, as we bi-digitally palpate the
gland. I will place my fifth digit in the recesses of the patient's mouth as I am placing
counterpressure on the patient's gland from the outside.
0:57
Once again, I will gently squeeze on the gland and note consistency, as well as note, as the
quantity and quality of the saliva as it expresses from the submandibular duct.
1:12
If you'd hold your head down just a tiny bit I think we might be able to see that. And we'll look
expression of flow through the submandibular ducts for both quantity as well as quantity.
1:26
The intraoral examination of the muscles of mastication include the medial pterygoid muscle,
the lateral pterygoid muscle. As well as the masseter origin and the temporalis insertion areas.
1:41
For the medial pterygoid, we will palpate the patient's muscle on the anterior and
1:50
medial portion of their ramus right back where my finger is right now. And we'll ask the patient
if that hurts them.
2:00
For the lateral pterygoid muscle, this is a very, very difficult muscle to palpate, in fact, would
you hand me that Q-tip please?
2:10
I will often ask the patient to move their jaw to me and then be able to palpate the lateral
pterygoid muscle with the Q-tip. It may be a little difficult for the audience to see, but we will
ask the patient if that is tender. The masseter origin is another important muscle intraorally to
palpate. I'll remind you that it's just inferior to the zygomatic arch, or the cheekbone.
2:37
So I'll ask the patient to close, then I'll palpate just under the cheekbone area where the
masseter muscle originates.
2:46
Lastly, I will palpate the temporalis's insertion on the coronoid process. I'll ask the patient to
open and then I will follow the anterior portion of the ramus, all the way up to the coronoid
process and I will press on this muscle. Typically this muscle will be tender if in fact the patient
is clenching and or grinding their teeth at night.
3:09
And that completes the muscle mastication intra oral examination. The interoral examination
includes a dental and periodontal examination, which will be covered in a different module.
3:23
For this module, we will look at the oral mucosa of the patients' oral cavity. First thing once
again, is we'd like to inspect the lips for any changes in color or consistency.
3:35
Once again, sometimes we'll note if a patient is being exposed to the sun, we'll notice changes
on the lip, particularly at the vermillion border to the skin.
3:46
We'll also want to note the angles of the patient's lips for any significant changes.
3:53
Open, please. Intraorally, we begin a process of inspecting the entire tissue that the patient has
in their oral cavity. We'd like to look at the labial mucosas, both on the upper as well as the
lower. As we're doing that, we're also inspecting the patient's gingival tissue for any signs of
lesion, inflammation and/or infection.
4:18
Next portion of the examination is the patient's buccal mucosa. Open and please turn toward
me. Let me just adjust that light.
4:30
And we'll inspect the patient's buccal mucosa. We'll look for any changes once again in color,
consistency or texture of the tissue It is not uncommon to see a linea alba as was described in
the previous module.
4:44
Turn a little away from me, please. And we will also want to inspect the patient's opposite
buccal mucosa. And as we stretch out the tissue, we can get a very good appreciation for any
changes that we may see.
4:58
In this case, we are starting to see a slight linea alba or a white line. Suggesting perhaps a little
bit of check biting in our patient.
5:10
Close. Turn a little bit back toward me.
5:17
Close again. One other area intraorally that we like to inspect is the vestibule.
5:24
Now, although we do this in all four quadrants, I will just point it out in the lower right quadrant
of the patients mouth. We want to make sure that there are no changes in color, texture, or any
lesions that may appear in this area here.
5:42
Okay. You can close.
5:45
Next, we'll move to the patient's tongue. And I'll ask the patient to please stick out their tongue.
5:52
And I'll inspect the dorsum of the patient's tongue. That's the top portion of the tongue. I'll note
any changes and I'll gently palpate the tongue to see if there are any lesions or masses within
the tongue.
6:04
Next, I will ask the patient to stick out their tongue again and this time I will wrap it a little bit in
gauze so then we're able to extend the tongue even further. This is a very important
examination as an oral cancer screening as many of the oral cancers occur in the lateral
border of the tongue.
6:23
Which, once again, is this section of the tongue.
6:28
It is very very important, turn to me, to inspect deep into the floor of the mouth. So we'll actually
displace the tongue to the opposite side as we look deep into the vestibule of the mouth. Once
again it is in this posterior floor of the mouth region where oral cancer may begin.
6:54
We will do this for both sides of the tongue. Once again noting any change in color, texture or
any lesions thereof.
7:03
Open please, another common area for oral cancer is known as the retromolar trigone area,
which is the area just beyond the last molar on the lower as it moves to the upper tissue into
the soft palate.
7:20
We'll want to note any change in color in this retromolar trigone area.
7:27
Finally I'll ask the patient to extend their neck slightly so that we're able to view the patient's
hard palate and inspect once again for changes in color, texture, any lesion, or any mass that
is noted. There are minor salivary glands in this area which could be a source of a benign or
malignant salivary gland tumor.
7:57
And, so, we'd like to inspect is the soft palette for any legions, changes in color or texture, as
well as for asymmetry of the tonsils.
8:08
Also mindful of cranial nerves number nine and ten for symmetric movement of the palate. That
is, that it's moving up on both sides equally. Would you say please.

21
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0:30
Hello, in this section we are going to discuss several dental diseases that affect the teeth. Let's
start with dental caries, which is a term foreknown as cavities. Dental caries is the most
common of the dental diseases. Worldwide, approximately 2.4 billion people, or 36% of the
population, have dental caries in their permanent teeth.
0:58
In the US, dental caries is the most common disease of childhood. It is five times more
common than asthma. In addition to caries, we're also going to discuss erosion, abrasion, and
pulpal conditions.
1:14
Caries is basically the localized destruction of tissues of the teeth by bacterial fermentation of
dietary carbohydrates. It is a chronic androgynous infection that is caused by members of the
neural oral flora. The result of the caries process, the caries lesion is a manifestation of the
mineralization of enamel, dentin, and cementum. The development of caries is a multifactorial
diseases that is dependent on four aspects. The most important one is the development of the
bacterial plaque which sets the caries in motion. The second one is the quality and quantity of
the salivary flow.
2:00
The third aspect is the presence of minerals such as fluoride and the fourth aspect that you
need to consider is the quality of nutritions. Caries is definitely associated with diet which is rich
in refined carbohydrates and is associated with foods which are sticky to the tooth structure.
2:24
Caries can affect both the baby teeth or the deciduous teeth as well as permanent teeth. And
caries can also develop in different locations on the tooth. There are caries that develop in the
pit and fissure caries, sometimes referred to as occlusal caries. They can also develop on the
smooth surfaces on the teeth, either in between the teeth, known as interproximal, and also on
the root surfaces of the teeth. Those caries on the root surfaces generally develop more in
older age.
2:58
Pit and fissure caries can start developing actually within days of tooth eruption providing that
the diet is rich in suitable carbohydrates and begin shortly thereafter. Compare to coronal
smooth surface caries, proximal caries progresses much quicker because it can pass through
enamel much more rapidly. As mentioned, root surface caries develop in a later age.
3:27
Caries can effect both the enamel, the dentin, and the cementum. And caries with effect the
cementum of the root are particularly difficult to manage because cementum has the least
calcium, it's the softest of the mineral structures in the tooth.
3:48
There are caries which are associated with radiation. Radiation in certain cancers, head and
neck cancers, destroys salivary glands. Those patients suffer from lack of saliva, which has a
protective function, and they tend to develop caries at a high rate. And there also something
which we refer to as rampant caries. Which occur in people with bad diets and with very poor
oral hygiene.
4:17
There are also the secondary, recurrent caries which can develop under poor fitting
restorations. In those restorations which are not well adapted or do not form a perfect
seal, they form an area where a patient has a difficulty in plaque control. The baby bottle caries
are the caries which occur in very young children. They usually occur there's a really poor oral
hygiene and where the diet is very rich in fermentable carbohydrates. Such caries usually
develop within months of tooth eruption and they do so when the diet is rich in sucrose,
glucose, and sticky foods. Bacteria metabolizes sugar which produces acid. This acid then
stands to soften and break down the tooth structure. Therefore, a high sugar diet is a risk factor
for dental caries. Dental caries is more common in the developed world due to the high
sugar content of the diet. The frequency that bacteria are exposed to sugars definitely affect
the likelihood of caries development. This is why snacking between meals promotes caries.
5:32
The saliva plays a very important role in control of caries. It is a fluid secreted by the salivary
glands mainly the parotid, the submaxillary, sublingual, and outer minor glands. It contains a
pH buffering capacity, cleansing effect, antibacterial action, and remineralization by salivary
calcium. Individuals with dry mouth, known as xerostomia, due to radiation therapy, certain
drugs, or other diseases, exhibit increased rate of caries.
6:09
In humans, some of the more important bacteria that have been associated with different
caries are the actinomyces viscosus, actinomyces naeslundii, the lactobacilli, enterococci, and
the mutans streptococcus bacteria.
6:29
Mutans streptococci bacteria actually are important for the caries to develop. Its virulence of
the strep mutans is actually due to the adhesion, acidogenesis, and adhesion colonization, i.e.,
formation of biofilms.
6:45
The host factors which can influence the development of caries are the tooth location, the
presence of sugars and sticky foods, frequent snacking, inadequate oral hygiene, such as
brushing and flossing, lack of fluoride, either in the diet or in the water, or in the toothpaste,
lack of saliva, and various type of eating disorders. The best way to treat caries is actually
prevention. Oral hygiene is extremely important. This includes daily brushing and flossing to
inhibit the development of the bacterial biofilm. Regular visits with a dental hygienist are
needed to clear away any remaining plaque and calculus. Fluoride plays incredibly important
role in caries prevention. It both strengthens the teeth and inhibits bacterial ability to ferment
sugars. Fluoride tooth pastes, fluoride rinses, and water fluoridation are all measures to ensure
that teeth have enough exposure to fluoride. According to Center for Disease Control, water
fluoridation is one of the top ten greater public health achievements of the twentieth century.
8:01
Once caries develop, the way to treat them is to remove the decayed material and placing
filling materials or crowns. This includes excavation of all caries tooth structure and placement
of filling material to restore the tooth to proper form and function.
8:20
Other types of conditions affecting the teeth are erosion, abrasion, occlusal trauma, and palpal
conditions. Erosion is the loss of tooth structure due to chemical acidic breakdown from a non-
bacteria source. That happens frequently in people who have acid reflux and have very acidic
saliva.
8:43
Erosion is many times associated with bulimia.
8:49
Dental abrasion is the loss of the tooth structure due to mechanical work and incorrect
brushing techniques. This picture which shows you the example of toothbrush abrasion due to
incorrect brushing.
9:04
Attrition is a loss of tooth structure from opposing teeth. This condition is found in patients who
have excessive tooth grinding. This condition occurs frequently in patients who are emotionally
stressed and they tend to grind the teeth either during the day or at night.
9:25
Abfraction are lesions at the gumline thought to be caused by flexile forces that degrade the
tooth structure.
9:34
Occlusal trauma is a damage incurred by teeth or surrounding structures due to traumatic
occlusion. Traumatic occlusion happens when the forces acting on the teeth exceed the
capacity of the periodontal ligament to withstand such forces. There are two types of occlusal
trauma. The first type, the more common type, happens when there are excessive forces
acting on healthy periodontium. Example of such forces would be excessive
grinding, clenching, chewing on nails, pencils, etc.
10:14
These conditions, occlusal trauma, can be treated by occlusal adjustment, realignment of the
teeth, and also, by appliances, such as night guard. Secondary occlusal trauma happens when
there are normal occlusal forces, but the periodontal support is compromised and weakened by
periodontal disease. The treatment for this condition, of course, requires, if possible,
regeneration of the supporting structures and also splinting of the teeth to distribute the forces
more equally.
10:51
Caries, when it becomes severe, can actually penetrate the nerve of the tooth. When that
happens, a palpable condition happens. The nerve becomes infected and becomes slowly, but
surely, destroyed.
11:09
The toxins and the byproducts from this infection can then spill into the surrounding bone.
11:16
Even if a filling is placed, the immune system cannot clear the infection in the pulp chamber,
and therefore the pulp tissue needs to be removed. This treatment is known as the endodontic
therapy.

22
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0:14
Hello, in this section we're going to review Periodontal Diseases. Periodontal diseases,
otherwise known as gum diseases by the lay population. It is a group of diseases that affects
one or more of the tissues in the attachment apparatus of the tooth meaning Cementum,
Periodontal ligament, Bone.
0:36
Periodontal disease is actually a collective name of many different conditions affecting the
supporting apparatus of the teeth. What are the changes then during periodontitus? First of all
in gingiva, there is a change in color, contour, texture, and consistency. The gingiva becomes
more reddened. They are swollen. The texture varies from stippled to more shiny and
edematous. And consistency is bergis and edematous. There's also bleeding and some
separation. There is also bone loss, which can be more severe around some teeth than
others. There is destruction of periodontal ligament and the cementum itself also undergoes
changes. There's infiltration by plaque. By calculus and by endotoxins.
1:32
Periodontitis is more prevalent in some geographic areas of the world such as the far east and
India. It is associated with low socio-economic standing. It is definitely associated with
smoking, with diabetes, and people who exercise poor oral hygiene.
1:52
When it comes to tooth loss of periodontal disease, there is a certain mirror image that
emerges. In other words, the left and right side of the dentition mirror each other. The posterior
teeth are generally lost at a higher right than the infront teeth. And the maxillary teeth more
than the mandibular teeth. That's why in people who have lost partial dentition due to
periodontal disease it is more common to see a complete full upper denture, and partial lower
denture. As far as gender is concerned, there is a slightly higher prevalence of periodontitis
among men than women. What are then the signs and symptoms? As mentioned before,
there's bleeding, swollen and reddened gums due to vasodilation. There's formation of spaces
between the gum and the tooth, referred to as a pocket. Bad taste. Halitosis. Loosening and
drifting of the teeth. Changes in bite. And formation of abscess.
2:58
It is important to realize that in classic periodontitis. There's no linear progression. But rather a
series of periods of remission and exacerbations. Similar to many other chronic diseases.
3:13
Periodontal disease is an inflammatory process, caused by the presence of plaque by a film on
the teeth. It is both a direct effect from the bacteria of biofilm. Otherwise referred to as a dental
plug, as well as individual bacteria residing within the pockets and a collateral effect from the
body's immune system that contributes to periodontal disease.
3:38
It is important to remember that human fetuses are actually sterile, but bacteria are acquired
after birth. And there are more than 500 species of bacteria which establish residence in the
mouth. It is also important to remember that most bacteria are beneficial, but several have
been identified as pathogens.
4:03
To identify pathogens in the oral cavity is a rather challenging task. It is much easier to detect a
bacterial infection in a sterile environment. Such as a urine infection or blood infection. But
since the oral cavity is not sterile, identifying bacterial pathogen is quite challenging.
4:28
Emerging evidence from the last two decades shows that there is a strong link between
periodontal disease and other systemic conditions. Such as cardiovascular disease, the
common link here is inflammation. Periodontal disease therefore has been associated with
other inflammatory states such as heart disease, strokes, kidney disease, pre-term birth, and
other conditions.
4:55
How did then bacteria cause periodontitis? There are direct bacterial effects. Bacteria release
enzymes such as proteases, collagenases, fibrionlysin, and phospholipase. Parts of cells walls
of gram negative bacteria are the endotoxins which are also the Lipopolysaccharides
and those stimulate osteoclastic activity, which is bone resorption. There's also the indirect
effect on the bacteria. Through immune system and inflammation. The polymorphic nuclear
side via phagocytosis and opsonization, spill lysozymes, degranulation, causing tissue
destruction. Activation of monocytes, lymphocytes, fibroblasts by lipopolysaccharides to
produce cytokines and inflammatory mediators such as prostaglandins, which in turn
stimulate collagenases destructive to extracellular matrix and bone. Cytokines and interleukin
stimulate plasma cells to produce antibodies, resulting in osteoclastic activity. Tumor necrosis
factor stimulates the production of matrix proteinases.
6:13
So in other words, to summarize there are two mechanisms. There is a direct bacterial effect
and there is also the mediated effect through inflammation and immunological reaction. So
what does the tissue in periodontal disease look like? The fact is that they can vary from one
individual to another. If you look at this image, you will see that some gums are very reddened
due to vasodilation, and bleed easily on probing while other gums look darker in color and have
bluish appearance.

23
[MUSIC]
0:14
Let's review the classification of periodontal diseases. Generally speaking, periodontal
diseases encompass two groups of diseases, the gingival and the periodontal. When the
disease is confined to the gums only, it is then known as gingivitis. When the destruction
and the inflammation spreads to lower structures, such as the bone, and the periodontal
ligament the condition is known then as periodontitis. Let's start discussing gingival diseases
first. We have the plaque-induced gingival diseases which are the diseases induced by
bacteria and we have non-plaque-induced gingival diseases which are produced by
contributing factors. The plaque-induced gingival diseases are gingivitis associated with dental
plaque only. Gingival diseases modified by system factors. Gingival diseases modified by
medications. And, gingival diseases modified by malnutritions. The local contributing factors
are plaque,
1:27
poorly performed dental work like crowding and otherwise any condition that prevents the
patient from exercising good oral hygiene.
1:38
There's a group of gingival diseases which is influenced by systemic factors. One such
example is gingival diseases associated with endocrine system. An example would be puberty
gingivitis, hormonally mediated gingivitis, or gingivitis during pregnancy, stimulated by the
hormone progesterone. There's also gingivitis associate with blood dyscrasias, such as the
various types of leukemias.
2:11
Gingival diseases can also be modified by medications. We have drug induced gingival
enlargements and drug induced gingivitis. There are three classes of drugs that cause such
gingival enlargement. The first one is the Dilantin, which is used to control seizures. The
second one is the Cyclosporine which is the anti-rejection drugs administered to patients who
have organ transplants. The last group of medications are the calcium channel blocking
drugs used to control hypertension. They all result in gingival enlargements.
2:52
We also have the non-plaque induced gingival legions of specific bacterial origin.
2:58
Gingival diseases specific of viral origin, such as herpetic gingivostomatitis. We could also
have gingival diseases of fungal origin. Fungus may grow and cause gingivitis in situations
where the patient has been taking antibiotics for a long time, or under appliances such as full
or partial dentures.
3:22
There are also gingival lesions of genetic origin, and an example of such a condition is
hereditary idiopathic fibromatosis.
3:33
Gingival condition could also be a manifestations of systemic conditions such as
mucocutaneous disorders, allergic reactions, and other. Gingivitis can also be caused by
traumatic lesions such as chemical injury, physical injury, and internal injury as well as by
embedding of foreign body reactions. We will now go and start reviewing the various types of
periodontal diseases.
4:03
There are two types of periodontitis. The chronic periodontitis which can be localized to one
area of the mouth, or generalized. And we also have a group of very aggressive periodontal
disease which also can be localized and generalized. The difference between the chronic and
the aggressive condition is that the progression is much more rapid in the aggressive type. And
the onset is at much earlier age. This picture demonstrates a typical appearance of generalized
chronic periodontitis. The gums are swollen, edematous. The color is bluish-red, and you can
see that the teeth start spreading a little bit due to lack of bony support.
4:53
In the aggressive periodontitis often start in late teenage years and they can affect either
selected teeth, such as first molars and anteriors, or they could spread like wildfire and indeed
effect the entire dentition. It is not uncommon in patients with aggressive form of
periodontitis to have a very significant bone loss in their early adulthood. Periodontitis can also
be a manifestation of systemic diseases. They can be associated with hematological disorders,
such as leukemia. They can be associated with genetic disorders, such as idiopathic
fibromitosis and other non-specified conditions. There is a whole host of diseases known as
Necrotizing Periodontal Diseases. Those diseases are caused by actual infiltration of the
gums Into the gingival tissues. The first areas affected, are actually the inter-dental pappili.
5:58
The interesting thing about these conditions, is that they have been strongly correlated with
stress and poor oral hygiene. In fact, the earlier term for this conditions were trench
disease, trench mouth, because it was associated with soldiers in first World War I, who were
fighting in the trenches and of course were subjected to a tremendous amount of stress.
6:25
The necrotizing ulcerative gingivitis causes cratering in the gingival papilla and permanent
scarring which then has to be corrected surgically.
6:37
In this photograph, you can see the cratering of the gingiva which has destroyed the normal
gingiva architecture, causing exposure of the root and increased interproximal spaces.
6:54
During periodontal inflammation, there is increased secretion of gingival fluid, which becomes
very similar to pus and is sometimes referred to as purulent exudate. Because this purulent
exudate can be secreted freely from the gingival pockets, the patient usually does not feel any
pain and therefore does not seek treatment for periodontitis in a timely manner. Once in a
while, due to misplaced calculus or food, the orifice of a pocket becomes clogged and the
purulent exudate has no place to escape. When this happens an abscess may form. Abscess,
therefore, is a localized area of intense inflammation which results in swelling and possible
fever and intense pain. Those abscesses can be confined to the gingiva only or they can
spread to deeper structures and are then known as periodontal abscesses. Abscess which is
not treated can destroy the entire bony support within a very short time resulting in the loss of
the tooth. It can also lead to potentially dangerous and fatal conditions such as cellulitis, which
can then result in patients' deaths.
8:14
In this picture you can see an example of both a gingival and a periodontal abscess. The first
way to treat this abscess is, of course, to establish a drainage and then perhaps use antibiotic
treatment, and once the acute phase subsides then a treatment to eliminate the causes needs
to be taken.
8:39
Periodontitis can also be associated with palpal lesions. So if there is infection of a palp that
destroys and infects the nerves, that infection can then spread to the adjacent areas. And
escape through the periodontal ligament. When this happens, we have a combined
endodontal-periodontal lesion, or periodontal and odontic lesion. In this slide, we demonstrate
the escape route of the toxins and inflammatory fluid from the apex of the root through the
periodontal ligament, resulting inflammation of a gingival pocket. There are some localized
tooth related factors which modified or predisposed the patient to plaque induced
diseases. This could be poor quality dental work, such as overhang fillings which prevent the
patient from exercising good plaque control. It could also be a restoration which is overly bulky
and does not permit the patient to either brush or floss effectively for plaque removal.
9:48
Periodontal diseases also encompass bunch of conditions known as mucogingival
conditions. These are deformities or diseases that affect soft tissue only, namely the
keratinized gingiva and the uvular mucosa. The most common condition is the gingival
recession, which could be due to inappropriate toothbrushing or due to other traumatic
factors. It could also be through a frenal pull which attaches the muscles and is overly
strong. Both of these conditions can be corrected surgically.

24
0:00
[MUSIC]
0:14
Hello. In this session we're going to discuss the contributing factors to
periodontal disease. These are factors, which in themselves, do not initiate, but rather
predispose or modify the progression of periodontal disease. There are two such factors, we
can lump them into two groups. The first group are the Local Factors, those exist within the oral
cavity. And the second groups are the Systemic Factors. The local factors include such factors
as incorrect tooth brushing, occlusal trauma, food impaction, mouth breathings and iatrogenic
dentistry. In this image, you can see the result of incorrect tooth brushing, resulting in tooth
abrasion. Patients often brush teeth incorrectly with very hard toothbrush and this leads to
gingival recession and worfacets exposing the roots of the teeth.
1:10
In a normal alignment, teeth touch each other very tightly. When the contact is slightly open
between the two teeth, that results in food impaction which can damage the gingival
tissues. This picture illustrates which result in open contact. Another contributing local factor is
the Iatrogenic Factor, these are incorrectly constructed restorations with overhanging
ledges, over bulking contours, incomplete seal, improper occlusion. Those may actually
contribute to gum inflammation by trapping bacterial plaque and rendering its removal very
challenging to the patient.
1:55
Occlusal Trauma is another factor and it is defined as injury to attachment apparatus as a
result of excessive occlusal force. There are two types of Occlusal Trauma. In Primary
Occlusal Trauma, the forces acting on teeth exceed their capacity. And secondary occlusal
trauma, these are normal occlusal forces acting on a weakened periodontium. The best way to
explain would be a very heavy person sitting on a regular, well-constructed chair and breaking
the chair.
2:33
Secondary occlusal trauma would be akin to a normal person with normal weight sitting on a
damaged chair and breaking. In both cases, the result is the same, but the cause is quite
different. So while occlusal trauma does not initiate or accelerate inflammatory effect of
periodontal disease. It may have an adverse effect on the supporting bone of the tooth
and increase it's mobility.
3:01
These pictures on occlusal trauma demonstrate what happens when posterior teeth are
extracted without subsequently being replaced. The occlusal forces are shifted to the anterior
teeth, which are unable to withstand the pressure. As a result, these teeth drift, spread, and
become loose. The lower jaw over-closes and the ability to chew food is severely
compromised. This condition is known as Posterior Bite Collapse. And it often happens in
those patients who extract their back teeth or are not willing to have them replaced.
3:39
The systemic factors include age, smoking, diabetes mellitus, pregnancy, puberty, stress,
genetics and heredity.
3:50
Older people have higher rate of periodontal disease.
3:55
Center of disease control estimates that over 70% of Americans 65 years and older have
Periodontitis. Keeping in mind, however, that association is just that, it is not an indication of
cause and effect.
4:09
Diabetes is another significant factors in periodontitis.
4:15
Diabetics have more severe and prevalent form of periodontitis. Patients with diabetes have a
faster rate of bone loss. Diabetic patients with periodontitis also have a high rate of acute
infections, such as abscesses, and experienced delayed healing following treatment. While
periodontal destruction in diabetes relates to metabolic control, periodontal infection adversely
affects glycemic control. Hence improvement in one factor leads to improvement in the other.
4:50
Patients who have interlocking one genotype positive have an increased inflammatory
response in the presence of bacteria, increased amount of pathogens and are at an increased
risk for severe periodontal disease. Above patients are less likely to respond favorably to
periodontal therapy. It is important to remember that the role of genetics in periodontitis is a
disease modifier, that means bacteria must be present for the disease initiation. But modifiers,
such as genetics, alter the body's response to the bacterial challenge. Smoking is another
important factor in pathogenesis periodontitis. There's a strong correlation between smoking
and periodontal disease. In smokers have smaller reduction in pocket depth following
surgery. And there's also poorer reduction in bleeding and probing death following scaling and
root planing.
5:48
What are the mechanisms of tobacco smoking? Well, periodontal pockets of smokers have
more anaerobic bacterias, which are the more pathogenic bacteria. They have decreased
amount of salivary antibodies, such as IGA and IGG. They have have fewer Helper T
Lymphocytes. Depressed chemotaxis and phagocytosis of polymorpho-nucleocites exert a
direct effect on periodontal tissues' attachments to fibroblast. Therefore, impaired ability to
synthesize collagen enhance impaired ability to heal.
6:25
Emotional stress is a significant factors in many disease and periodontitis is no exception.
6:32
Emotional stress has been linked to hypertension, cancer, and compromised immune
system. In the oral cavity, a strong correlation between necrotizing infection and stress has
been established.
6:46
Hermetologic factors have also an important influence in leukemia and various form of
dysfunction. There's increased rate of periodontitis, bond resorption, and bleeding. There's a
whole host of medications which can contribute to gingival pathology. Let's review them
briefly. The calcium channel blocker medications which are used for hypertension results in
swollen and bleeding gums. Anti-seizure medications such as dilantin have effect of gingival
hypoplasia and hypertrophy. Anti-organ rejection drugs used in organ transplantation such
as cyclosporin have similar effects. And last but not least, oral contraceptives
and antidepressants used by many patients result in dry mouth, which result in increased
gingival inflammation.
7:43
Poor nutrition also can compromise the body's immune system. Obesity may increase the risk
of periodontal disease and vitamin C deficiency, such as scurvy, can lead to gingival
inflammation, collagen deprivation and tooth loss. There are other conditions which have been
also associated with periodontitis, and those are being currently investigated. One is
osteoporosis and periodontal bone loss, association between oral bacteria and respiratory
disease, gum disease and cancer of the kidney, pancreas and blood. The common
denominator that links periodontal disease and other diseases is the site of inflammation and
this area is under current research.

25
0:00
[MUSIC]
0:30
In this module, we'll discuss various oral mucosal diseases that could affect the oral cavity.
0:37
First I'll talk a little bit about common oral anomalies, things that aren't truly diseases or
disorders, but rather common oral findings that may be different than what you would normally
see.
0:51
We'll follow this up with common oral mucosal diseases, diseases that do affect the oral
cavity.
1:00
The final segment of this module, we will discuss oral leukoplakia, oral erythroplakia and oral
cancer.
1:10
Leukoplakia and erythroplakia have been described as pre or rather potentially malignant oral
diseases.
1:20
In this slide we see a very common condition of the tongue. We call this benign migratory
glossitis. It's more conventionally referred to as geographic tongue.
1:32
Although the first picture, or the prior picture, looked rather significant, often we'll see just
subtle variations of normal.
1:44
Occasionally we can see this condition of geographic tongue in areas that are not the tongue at
all. In this picture, we're viewing the junction of the hard and soft palate. You'll notice the red
area of tissue with the white around it. Almost similar to what we would see on the tongue,
but an area distinct from the tongue.
2:06
Another very common oral anomaly is something we call linea alba, or white line.
2:15
This is a white line that is formed where the teeth abrade the inside of the cheek.
2:22
This is often at the area where the upper teeth and the lower teeth meet.
2:28
It is very, very common condition and seen in most of our patients.
2:35
Occasionally, a patient will be referred in to me for bluish pigmentation underneath the tongue.
2:45
This also is a very common condition, and this is a condition that's caused by varicosities
underneath the tongue. That's right, varicose veins. Occasionally we can also see varicosities
in other areas, but it is more common to see them underneath the tongue.
3:07
Another common condition that we see is what dentists will refer to as bony exostoses, or
sometimes referred to as tori, which are benign growths of bone in various areas of the
mouth. We can see them in the roof of the mouth or we can see them in the lower jaw. Most
commonly seen in the lower inside of the jaw, where the tongue rests. The next variation of
normal is what we see here, and that is some lingual tonsillar tissue. This is the posterior area
and the posterior lateral border of the tongue. This is quite commonly seen bilaterally,
and once again, is a normal representation of normal tissue.
3:59
Let's now move into some of the common oral mucosal disorders. The ones that I'd like to
cover in this segment are the ones that we most commonly see. That is, herpetic
infections, sometimes commonly referred to as the cold sore or the fever blister. We will then
talk a little bit about aphthous ulceration,
4:23
more commonly referred to as the canker sore.
4:28
And finally we will talk a little bit about Candidasis, which is a yeast infection, sometimes
referred to as thrush.
4:41
Lastly, we will talk about a very common chronic oral mucosal disorder known as lichen
planus.
4:50
So let's go ahead and take a look at some of these oral mucosal disorders.
4:55
First, let's talk a little bit about Herpes simplex.
5:00
Herpes is a viral infection that can occur in the mouth.
5:04
It has two representations, both in a primary fashion as well as a recurrent fashion.
5:11
The primary fashion often is associated with significant and severely painful oral ulcerations.
5:22
Most commonly, it will result in peeling of the gums, a term we refer to as herpetic
gingivostomatitis.
5:35
The recurrent form of herpes is often ones that we will see, and that is the cold sore or the
fever blister. Herpes, being a virus, has an incubation period of days to up to about two
weeks. So if someone is exposed to the Herpes virus, it's usually within days to up to about
two weeks that they'll first present with lesions or sores in their mouth.
6:04
Once again, it's often an ulcerative eruption, but sometimes we might even see little tiny
vesicles. These are clear, fluid-filled blisters in the mouth that quickly ulcerate, causing
significant amounts of discomfort. In this slide we see a young fella who has lesions on his lip,
6:30
both upper and lower lip, which are ulcerated, inflamed and extremely painful.
6:37
If we look inside the mouth, we can see some vesicles, which are these tiny little blisters, and
also some areas of erosion.
6:49
In this slide, we illustrate what is often seen in patients with primary herpetic infection, that
being a peeling of the gum tissues. We call this herpetic gingivostomatitis.
7:04
Now let's take a look, a little bit, at the recurrent lesions.
7:09
What we see here on this slide is the most common recurrent presentation of herpes, that
being recurrent herpes labialis. As I mentioned earlier, Herpes can also recur intra-orally, as
we see on this slide. When it does, we often associate shallow ulcers with a serpiginous
border, which gives you a sense that these tiny vesicles have coalesced and caused a rather
large ulcer.

26
0:00
[MUSIC]
0:15
Aphthous alteration is something that's experienced by the patient as being a rather acute oral
disease. It is often a disease that will recur at some point as a single ulcer or multiple
ulcerations. Some of these ulcers can be small, less than a half of a centimeter, or some can
be very larger, greater than a centimeter. Recurrent Aphthous stomatitis Is a very common
condition seen in children and adolescents.
0:49
Turns out that a child has approximately 90% chance of developing this condition, if he or she
has parents who have also had the condition.
1:00
It's also associated with a higher socioeconomic status. Those that have gone to professional
school also have noted to have a higher prevalence. If we see patients that present to us that
are 25 years old and are complaining of more ulcers rather than less ulcers that they can
remember,
1:21
we will evaluate the patient for various nutritional deficiency. As nutritional deficiencies have
been associated with Aphthous ulceration. Conditions like low iron, low folic acid, or low B12
have been associated with an increase in Aphthous ulceration. Aphthous ulcers have been
also associated with various disorders including very common disorders like anemia or Celiac
disease but they've also been associated with inflammatory disorders like Behcet's disease
and bowel disorders like Crohn's disease or Ulcerative colitis.
2:01
Apthous stomatitis or Apthous ulcers have also been associated with those patients with
immunologic problems such as those with HIV infection or those with low white blood cells.
2:17
Here we see a picture of the most common type of Apthous ulceration which we will usually
see in the lower gingival tissue.
2:28
Here's another very common sight, the lower lip, we refer to it as lower labial mucosa, in which
we see a very shallow necrotic ulcer.
2:39
The next condition I'd like to talk about is Candida albicans. Candida albicans often presents
as acute lesions in the mouth. It turns out Candida is a yeast that's found in the human
digestive and genitourinary tracts. It is also very common in the oropharyngeal region. There
are some studies that show approximately 60% of the non-immunocompromised patients will
harbor Candidal species in their mouth. Candida's an opportunistic unicellular yeast-like
fungus. It's often related to xerostromia or dry mouth. Patients that have diabetes, patients that
have been on broad spectrum antibiotic therapy and those patients that are
immunosuppressed. Candida has four clinical presentations. The pseudomembranous
presentation, which is the most common, and once again referred to as thrush.
3:42
The atrophic presentation, a presentation that involves the corners of the mouth and referred to
as angular chielitis. As well as hyperplastic candidiasis, a rather thickened candidal infection.
3:58
When we treat patients with Candidal infection we use often topical agents.
4:05
Topical antifungals that are either rinsed in the mouth or dissolved in the mouth in the
performable losinger.
4:15
In patients, however, that have a significant dry mouth, we will consider using a systemic anti-
fungal medication; a pill that's taken.
4:25
Some of these anti-fungal medications when used systemically, have significant drug
interactions and therefore we need to check what medications the patient is presently taking.
4:39
Here's an example of a pseudomembranous candidiasis that we see in the upper palate. This
is often described as a white, cheese-like material that's easily rubbed off, which leaves a raw
or bleeding surface. In this case we see sometimes what's referred to as a beefy, red
tongue. This is a red, erythematous tongue that is associated with a Candidal infection, a yeast
infection.
5:07
More commonly we'll see it underneath the denture, and in this case it's very easy to see that
this hard palate, which is the support structure for this denture, is arathematives or beefy red.
5:23
Here's an example of where a yeast infection affected the hard and soft palate.
5:29
As I mentioned earlier sometimes immunosuppression can cause a yeast infection. In this
case, the patient was using an oral inhaler that was a corticosteroid. The corticosteroid has
changed the local immunologic reactions that occur in the mouth, leading to a presentation as
you see on the slide. Here's an example of a yeast infection that is affecting the angles of this
gentlemen's mouth.
6:01
These are a yeast infection that causes erythema and thickening in the corners of his mouth.
6:08
Sometimes this is associated with over closure of the mouth. In this case, this gentleman was
going without dentures and, therefore, his facial structure collapsed over itself leaving a fold of
tissue
6:26
which made him susceptible to getting a yeast infection in that fold.
6:31
And, finally, here's an example of Hyperplastic Candidasis. Unlike the pseudomembranous
candidiasis, you're unable to wipe this tissue clear. You're unable to wipe this yeast away from
this tissue.
6:46
This is often much more difficult to treat and is often treated both with systemic and sometimes
topical preparations.
6:58
Another condition that is often associated with Candile infection, although perhaps not directly
caused by a yeast infection, is what we see here. And this is referred to as median rhomboid
glossitis, in which a rhomboid erythematous area in the dorsum of the tongue is associated
with some soreness. Occasionally, it can even be slightly nodular.
7:30
The reason I include this is often the first method of treating this is with an antifungal
preparation.
7:37
The last condition I'd like to talk about is Lichen Planus. Lichen Planus is the most common
oral mucosal condition that we see.
7:48
It effects approximately 2% of the population.
7:52
And when it does, it's often associated with multiple lesions, often occurring not only in the
mouth but also on the skin. These lesions often will occur in patients that are between the ages
of 30 and 60 years old.
8:11
There is a female predilection for this disorder. And this disorder of Lichen Planus can also
have various clinical presentations. Importantly, Lichen Planus appears to have a malignant
transformation potential.
8:31
It is the reason that our patients that have Lichen Planus, we will often request that they
monitor for this condition lifelong. Here are some various presentations of Lichen Planus. This
is the most common presentation in which we see white, lacy lines, sometimes referred to as
Wickham's striae, in the patient's right buccal mucosa.
8:54
Here is the same type of presentation in the roof of the mouth, or the hard pallet. Occasionally,
the Lichen Planus can also have a significant arathemitus component, with a very mild white
component. So, a significant red component, in absence of those white lacy lines.
9:13
In this case it's associated with desquamative, or peeling gingivitis. Here we're looking at the
roof of the mouth with a very, very similar presentation. And in this case, ulceration
formation. You'll notice at the border of the ulcer, we do see some white lacy lines extending
from the ulceral vereal. Here's a rather severe form of Lichen Planus that's referred to as
erosive Lichen Planus. This Lichen Planus is on the lateral border of the tongue, but with more
careful inspection, you can see white, lacy lines also on the dorsum or the top of the tongue.

27
0:00
[MUSIC]
0:15
In this module, I'd like to talk a little bit about malignant and pre-malignant oral disease. More
specifically, I'd like to talk about leukoplakia, which is a white lesion in the
mouth. Erythroplakia, which is a red velvety lesion in the mouth. And oral squamous-cell
carcinoma, which is an oral cancer.
0:37
Oral leukoplakia is defined as a predominantly white lesion of the oral mucosa that can not be
characterized by any other definable lesion.
0:48
The risk of malignant transformation of a leukoplakia is approximately 5 to 17%. Interestingly,
there's a higher risk for those non-smokers, which seems somewhat counterintuitive. Well, as it
turns out, patients who smoke, a normal response of the tissue is to become white and
perhaps even thickened.
1:16
So those that do not smoke do not have any good reason to have this white or thickened
tissue.
1:24
So therefore, there is a higher risk for malignant transformation in those patients that do not
smoke.
1:31
Additionally, if the tissue itself has a verrucal appearance, which I will describe and show a
slide of in a moment, they have a higher risk of malignant transformation. Those patients that
have a mixed color, both red and white, are at higher risk of malignant transformation.
1:53
It turns out that there really does not appear to be a time-related progression. Erythroplakia has
actually a greater risk of being dysplastic. Erythroplakia is the red velvety patch.
2:08
A study of asymptomatic oral cancers revealed that 60% were mixed red and white lesions,
where 35% were purely erythroplakic and 5% were leukoplakic.
2:23
The risk of malignant transformation of an erythroplakic lesion upon identification is upwards of
28%. Here's a slide of an erythroplakic lesion on the alveolar mucosa in the lower jaw.
2:43
As you can tell by the patient's dentition, this patient did not follow with the dentist regularly and
also used significant tobacco products. Upon biopsy of this lesion, this was, in fact, an oral
cancer, which leads us to a discussion of oral cancer and oropharyngeal cancer. Turns out
40,000 new cases of oral and oropharyngeal cancer are diagnosed yearly. Approximately
8,000 deaths are attributed to oral cancer on a yearly basis as well.
3:17
Presently the most important factor in survival is the stage of disease at diagnosis. It turns out
that localized tumors of the oral cavity and the oral pharynx have an overall survival rate
somewhere of 70 to 90%. However, patients with distant metastases, stage four
cancers, demonstrate an overall survival rate somewhere around 30%. Oral cancer occurring
in the posterior aspect of the oral cavity and the oropharyngeal area is often associated with a
worse prognosis, because these tumors are diagnosed in later stages. The only caveat to
these statistics are that when cancers are caused by HPV, they tend to have a better
prognosis. The risk factors for oral cancer include some very strong risk factors, and that being
the use of alcohol and tobacco, particularly when they are combined.
4:15
Other very strong risk factors include the use of betel nut or quid or paan that's used in certain
parts of the world.
4:26
Being immunocompromised also puts you at a very strong risk for oral cancer,
4:32
as does having a history of a prior oral cancer.
4:38
Additional strong risk factors that have been more recently identified is having a human
papilloma virus infection, especially subtype 16. Let's take a look at some presentations of oral
cancer.
4:53
Here's a gentleman who presented to me with a lip cancer.
4:59
This area was biopsied and determined to be an oral cancer.
5:05
Here's a patient with an oral cancer on the dorsum of the tongue, not a usual site for an oral
cancer, as it's more frequently found in the lateral border of the tongue.
5:16
Here's a rather large, extensive oral cancer involving a significant portion of the lower jaw. And
here's a tonsillar cancer, a cancer in this case that was HPV positive, we believe caused by the
human papilloma virus subtype 16. Presently the gold standard for predicting the malignant
potential of premalignant or potentially malignant lesions is the presence or degree of
dysplasia.
5:51
That is a histological diagnosis in showing cellular changes throughout the layers of the
epithelium. However, there are some who are questioning the validity of this being as the gold
standard.
6:06
In fact, many scientists who study oral cancer,
6:11
are now describing and defining newer molecular techniques which may predict the
molecularly high risk factor or individual in an otherwise clinically normal or histologically
benign tissue. As we move forward in medicine and understand these newer molecular
techniques, these series of discoveries may lead to earlier identification and therefore
improved patient survival statistics.

Which of the following is considered benign?

Bony exostoses

Leukoplakia

Erythroplakia

All of the above

1
point

2.
Which of the following is NOT true regarding pseudomembranous candidiasis?

It is a common infection among asthmatic patients using inhaled corticosteroids

The presentation is red and erythematous

It can be easily wiped off

It is associated with immunosuppression

1
point

3.
Erythroplakia
Has a 5% risk of malignant transformation

Has a higher risk of malignant transformation than leukoplakia

Is a term for a cancerous lesion

Is a white lesion in the mouth

1
point

4.
Primary herpes simplex virus

Has up to a 2 week incubation period

Is associated with peeling of the lips and oral mucosa

Causes significant and severely painful ulcerations

All of the above

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