October 14, 2025 • 20 mins
Designed to help students prepare for a specialty review exam, likely in dentistry or oral health. The content is presented in a multiple-choice question format with detailed explanations covering a wide array of clinical topics, including pharmacology, endodontics, oral surgery, periodontology, and oral pathology. Notably, the resource provides general advice on verifying drug information and emphasizes a commitment to Continuous Quality Improvement (CQI) through user feedback. The text also lists several contributing authors and their affiliations, highlighting the collaborative nature of the educational material.
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Episode Transcript
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Speaker 1 (00:00):
Welcome back to the deep dive. You know how we
do it. We take dense, really specific source material. Today
it's excerpts from the STAT Pearls NBD review, and we
pull out the essentials exactly.
Speaker 2 (00:13):
We're looking for those clinical pearls, the things that are
easy to forget but make a.
Speaker 1 (00:16):
Real difference, right, not just reading facts, but finding the
stuff that changes how you might handle a case this afternoon.
Speaker 2 (00:23):
And our mission really for you listening is to help
you quickly synthesize these critical points. We're covering a lot pharma,
systemic links, trauma, operative stuff.
Speaker 1 (00:34):
All backed by that huge STAT Pearls database reviewed by
thousands of professionals. So these aren't just random.
Speaker 2 (00:40):
Facts, definitely not. These details connect textbook knowledge to actual
clinical decisions.
Speaker 1 (00:45):
Okay, let's jump right in first sections systemic health, Pharmacology,
and oral manifestations. This feels like groundwork preventative thinking.
Speaker 2 (00:53):
It really is, and we have to start with a
major one. Statins and pregnancy.
Speaker 1 (00:57):
Ah, yes, a serious contraindication.
Speaker 2 (01:00):
Absolutely non negotiable. You know, for any woman who could
become pregnant. Statins are contraindicated period during pregnancy, breastfeeding even
to its first something serious like familial hypercholesterolemia.
Speaker 1 (01:11):
But what's the key timing detail from the source. That's
often the tricky part.
Speaker 2 (01:16):
The critical number is three months. Statins must be stopped
a full three months before planned conception. That's because of
the tatogenic risk.
Speaker 1 (01:25):
Three months. Okay, that's the actionable takeaway right there. Sticking
with drug risks, let's talk doxycyclin high clate. We all
know tetracycling stains teeth, but what's the specific rule.
Speaker 2 (01:35):
So it's contraindicated in pregnancy, breastfeeding, and specifically in kids
under twelve years old.
Speaker 1 (01:41):
Under twelve Why that age.
Speaker 2 (01:42):
Because that's when permanent teeth are still mineralizing. Exposure can
cause that permanent gray banded discoloration. You can't fix it later.
Speaker 1 (01:49):
Right, that's locked in. Okay. Shifting from contraindications to speed
of action. Nitroglycerin for angina, Why sublingual? Why not just
swallow it?
Speaker 2 (02:00):
It's all about avoiding the liver Initially. Sublingual absorption goes
straight into the venous system super rapid.
Speaker 1 (02:06):
Onset bypassing first pass metabolism exactly.
Speaker 2 (02:09):
Compare that to say oral isor bide dinitrate. You need
much higher doses because so much gets breaken down by
the liver first time through low bioavailability. In an emergency,
that delay is critical.
Speaker 1 (02:22):
Makes sense, and speaking of emergencies lytokine reactions, this is
important to get right. Anaphylaxis versus systemic toxicity, different responses needed.
Speaker 2 (02:32):
Totally different. Anaphylaxis is an allergic immine response. You treat
that with epinephrine, okay, But systemic toxicity it's more like
an overdose, often showing CNS signs first. The antidote there
is lipid emulsion.
Speaker 1 (02:43):
Lipid emulsion, got it? Using epi for toxicity would be
the wrong roof, entirely.
Speaker 2 (02:48):
Completely wrong. Knowing the difference is vital.
Speaker 1 (02:50):
Okay, Moving to chronic stuff. Opioids lots of side effects,
but which one is the most common long term one?
The one. People don't develop tolerance to constipation.
Speaker 2 (03:00):
It's driven by those MEW receptors and the gut slowing
things down.
Speaker 1 (03:03):
And unlike the pain relief, tolerance doesn't kick in for
the constipation.
Speaker 2 (03:06):
Correct the analgesic effect might diminish over time, but the
constipation risk stays constant for long term users. That's a
key counseling point.
Speaker 1 (03:14):
Definitely. Okay. Now for a complex one drug induced gingibal
overgrowth diego, we know the usual suspects phoenetoyin, cyclosporin, calcium
channel blockers like amlodipine. But pathophysiologically, where does it start?
Speaker 2 (03:29):
It starts deeper than you might think. In the connective
tissue with the gingible fiber blasts. The trigger seems to
be increased expression of platelet derived growth factor PDGF.
Speaker 1 (03:39):
PDGF increases. Okay, what cascade does that set off inside
the fiberblast cell? What?
Speaker 2 (03:44):
It seems to block cash and influx. Specifically, sodium and calcium.
Ions can't get into the cell as.
Speaker 1 (03:49):
Easily blocked ion channels, and that effect it.
Speaker 2 (03:52):
Reduces the cell's ability to take up fullic acid.
Speaker 1 (03:54):
Okay, So PDGF up castions blocked fullic acid uptake down?
What's the final step that makes the tissue actually overgrow?
Speaker 2 (04:01):
Because the fibroblasts can't process fullic acid properly, it can't
activate collagenes effectively. Collagenes is what breaks down collagen.
Speaker 1 (04:09):
Ah, So if you can't break down collagen, you.
Speaker 2 (04:11):
Get accumulation collagen and extracellular matrix just build up. That's
why the tissue feels firm.
Speaker 1 (04:17):
Fibrotic, fascinating cascade and a quick clinical check. Does it
happen everywhere?
Speaker 2 (04:22):
Almost never? In ADDENTIALUS areas, you need teeth and the
surrounding gingiva for the process to really take hold.
Speaker 1 (04:28):
Good diagnostic clue, all right, last one in this section
systemic links Jugrin's syndrome. We know dry eyes dry mouth
may be linked with lupus anti roy anti li antibodies.
But what if a Shogrin's patient mentions numbness or burning
in the face.
Speaker 2 (04:44):
You have to consider trigeminal neuropathy as a potential complication.
Speaker 1 (04:48):
Okay, And for treating the dry.
Speaker 2 (04:49):
Mouth itself, savinemeline is often the go too. It's a
muscarinic agonist that specifically targets the M three receptors and
salivary glands to stimulate saliva.
Speaker 1 (04:58):
Flow M three specific good detail and quickly infections and immunity,
ano acute necrotizing, all sort of gingabtis. What's the big
association there?
Speaker 2 (05:08):
High association with being immunocompromised. The source notes that seeing
a ando can actually be an indicator, sometimes prompting an
Elisa essay for a potential new HIV diagnosis.
Speaker 1 (05:17):
Wow, that's a strong link.
Speaker 2 (05:18):
It is and related to pathology. Think about ORALTB. You'd
see granulumitous inflammation. Langan's giant cells contrasts that with Harry
lukoplakia often seen in immunosuppression, where Langerhand cells are actually
decreased or absent. Different cellular pictures telling a story about immunity.
Speaker 1 (05:36):
Great connections. Okay, let's shift gears completely. Segment two, Acute
trauma and emergency management. Time is everything here, especially with avulsion.
Speaker 2 (05:46):
Absolutely. The big one is the sixty minute rule for
extroral dry time. If a permanent cook is out and
dry for more than an hour, replantation success plummets.
Speaker 1 (05:55):
So getting it into a good storage medium quickly is key. Milk, saline,
even the patient's.
Speaker 2 (06:00):
Own mouth, right, that buys you time. Now there's a
nuance for immature teeth, teeth with open apises.
Speaker 1 (06:05):
Okay, what's different there?
Speaker 2 (06:06):
The goal shifts slightly towards trying to get revascularization. Soaking
the tooth in doxycycline is recommended to help that process along.
Speaker 1 (06:14):
Doxycycline soak for immature teeth. Interesting, no splinting. This isn't
one size fits all. As it depends on other injuries.
Speaker 2 (06:20):
Totally depends standard of vulsion. No bone fracture. Use a
summer rigid splint like a titanium trauma.
Speaker 1 (06:26):
Splint, and for how long?
Speaker 2 (06:27):
Only about ten days? The idea is stabilization for PDL
healing but allowing some physiological movement.
Speaker 1 (06:34):
Okay, ten days summer rigid. But what if there is
an alveolar fracture along with the evulsion.
Speaker 2 (06:39):
Then the whole game changes. You need rigid splinting and
for much longer six to eight weeks. Wow, big difference,
because now you're not just stabilizing the tooth, you're immobilizing
bone fragments to allow the fracture to heal. Rigidity is
key for bone healing.
Speaker 1 (06:53):
Makes sense? What about primary teeth? Baby teeth? If one
gets knocked out, do we rush to put it back in?
Speaker 2 (06:58):
Generally no replantation for primary teeth is usually contraindicated. Was
that high risk of damaging the developing permanent tooth underneath?
You can cause deviation, enamyl hypoplasia, even ankylosis of the
primary tooth, which then interferes with exfoliation, especially if the
child is near the natural exfoliation age, like seven for
a central incisor observation.
Speaker 1 (07:20):
Is usually preferred good to know, avoid causing more problems, okay.
Shifting to jaw fractures, mandibular fractures specifically, what's a classic
sign almost pathognomonic for a sympathial or body.
Speaker 2 (07:32):
Fracture sublingle hematoma that bluish swelling under the tongue. It's
a dead giveaway, okay.
Speaker 1 (07:37):
And if the fractures further back, like the angle of
the mandible, what nerve sign might you see?
Speaker 2 (07:42):
Numbness or altered sensation in the lower lip That points
to injury to the inferior alveolar nerve which runs right
through there.
Speaker 1 (07:49):
Important diagnostic clue. Now, airway risk which mandibular fracture pattern
is particularly dangerous for airway obstruction.
Speaker 2 (07:57):
Bilateral fractures either body or parasimp seal, especially if they're
combined with condolar fractures.
Speaker 1 (08:02):
Why is that combination so risky.
Speaker 2 (08:04):
Because the muscle attachments, particularly the super hides, pull that
now mobile front segment of the mandible backwards and downwards.
The tongue goes with it, potentially blocking in the ore pharynx.
It's an immediate airway concern.
Speaker 1 (08:16):
Needs careful quick management. Okay, a practical tip reducing a
simple jaw dislocation the bimanual technique thumbs on the molars.
What's the risk to the clinician.
Speaker 2 (08:26):
Getting your thumbs bitten when the jaw snaps back into place,
can even really fast ouch? So protection absolutely. Always wrap
your thumbs in gauze or place tongue depressors over the
occlusal surfaces before applying that downward and backward pressure. Protect
yourself smart.
Speaker 1 (08:42):
Let's wrap trauma with pulp issues. How do we know
if pulpitis is irreversible versus reversible?
Speaker 2 (08:47):
The key test is prolonged pain to cold. If the
pain lingers for more than say, thirty seconds after you
remove the cold stimulus, that pulp is likely beyond saving itself.
It's irreversible over thirty seconds.
Speaker 1 (09:00):
Got it and complicated crown fractures where the pulp is exposed.
When is pulp capping most likely to succeed?
Speaker 2 (09:06):
The Size of the exposure matters a lot. If it's small,
not exceeding one point five millimeters in diameter, pulp capping
has a decent chance. Much bigger than that and success
rates drop significantly.
Speaker 1 (09:17):
One point five millimeter threshold. Okay. Lastly, root resorption. Chronic
external root resorption often needs a pexification before you can
fill the canal. What material is preferred for that.
Speaker 2 (09:26):
Mineral triaxide aggregate or MTA yt. It's highly biocompatible, which
is crucial, But the really neat thing is that it
actually induces the formation of a hard tissue barrier, kind
of like hydroxy appetite. When it contacts vital tissue, it
creates a good apical seal, allowing you to then fill
the rest of the.
Speaker 1 (09:43):
Canal forms its own seal. Very cool. Okay. Moving on
segment three Operative dentistry, endodontics, and diagnostics. Let's start with prevention.
Selence indications are clear deep pits high risk, but the
chemistry of placing them. What does the chant the orthophosphoric
acid actually.
Speaker 2 (10:02):
Do right, usually thirty seven percent orthophosphoric acid. Its job
is simply to demineralize the very surface layer of the enamel.
It creates microscopic roughness, like little nooks and.
Speaker 1 (10:12):
Crannies for micromechanical bonding.
Speaker 2 (10:14):
Exactly. The sealant flows into those irregularities and locks in mechanically.
That's why the surface must be completely dry. That classic
chalky white appearance tells you it's properly etched and ready.
Speaker 1 (10:24):
And a quick tip to avoid bubbles in the sealant,
gently vibrate.
Speaker 2 (10:27):
The liquid adhesive with a probe as you apply. It
helps it flow better and reduces voids.
Speaker 1 (10:32):
Good tip and sticking with prevention. Fluoride for early childhood
carries ECC varnish gel rinse, which.
Speaker 2 (10:40):
Is preferred for ECC Specifically, fluoride varnish is generally preferred.
Why varnish longer contact time. It sticks to the enamel
surface better than gels or rinses, giving the fluoride more
time to work, promoting remineralization, especially important in young kids
or high risk situations.
Speaker 1 (10:57):
Makes sense. Okay, shifting to ENDO prepare sharing canals. We
want to remove debris shape the canal, But what about
that smear layer left by instruments. How do we get
rid of it completely?
Speaker 2 (11:07):
It's a two part problem, so you need a two
part solution. Sodium epochloride is great for dissolving the organic
stuff pulp remnants, bacteria, but leaves it leaves the inorganic
component of the smear layer behind. That's where edta comes in.
Etta is a chelating agent. It binds to and dissolves
the inorganic mineralized debris. You really need both for a
truly clean canal surface.
Speaker 1 (11:28):
Okay, NaOCl for organic, DTA for inorganic. Got it now,
working length? Where do we ideally stop instrumentation?
Speaker 2 (11:35):
The anatomical ideal is the apical constriction that's usually about
zero point five to one millimeters short of the actual
radiographic apex the very tip of the root.
Speaker 1 (11:44):
So not right to the end seen on the X ray.
Speaker 2 (11:47):
Correct. However, there's a specific situation if you're dealing with
the vital inflamed pulp. Some protocols suggest stopping instrumentation even shorter,
maybe two to three milimeters from the radio graphic apex.
The idea is to preserve a small plug of healthy
abicle pulp tissue as possible.
Speaker 1 (12:05):
Interesting nuance okay, fun fact check, good a purchase? What's
the main ingredient by weight? It's not good at purchase?
Speaker 2 (12:12):
Is it deprisingly?
Speaker 1 (12:13):
No?
Speaker 2 (12:13):
The largest component is actually zinc oxide. It makes up
somewhere between like fifty nine percent and seventy five percent
of the cone.
Speaker 1 (12:19):
Wow, So the good approcha itself is much less.
Speaker 2 (12:22):
Yeah, only about nineteen percent to twenty two percent. The
rest includes heavy metal salts like barium sulfate, which are
added purely for radiopacity, so we can see the fill
on an.
Speaker 1 (12:29):
X ray zinc oxide. Who knew all right? Instruments barbed brooches,
those are for grabbing and removing bulk pulp tissue right
with a little rotation exactly.
Speaker 2 (12:37):
Like ninety to one hundred and eighty degrees rotation to
engage and pull out the tissue. What about gates gliden burrs?
Where do they fit in?
Speaker 1 (12:44):
Gates? Glutons are primarily used in retreatment cases. They're good
for removing good a purchase, especially from the more coronal,
straighter parts of the canal.
Speaker 2 (12:51):
Yeah for taking old fillings out right.
Speaker 1 (12:53):
But a word of caution. They work by friction and
can generate a lot of heat pretty quickly, so use
them carefully with irrigation. Short bursts.
Speaker 2 (13:01):
Good point heat is bad for the tooth. Okay, let's
talk impression materials. Algenate and polyether very common, but they
have a shared limitation when it comes to disinfection, don't
they They do.
Speaker 1 (13:14):
You cannot immerse them in disinfectant for very long. The
recommendation is generally no more than ten minutes.
Speaker 2 (13:19):
Why the time limit?
Speaker 1 (13:20):
They both absorb water and swell. Alginate is water based
to begin with, and polyether, while different chemically, is hydrophilic.
It likes water too much contact time. They distort dimensionally, so.
Speaker 2 (13:32):
Accuracy goes out the window. How should you disinfect them?
Then rapidly either spray disinfectant on them or use a
very short immersion following the manufacturer's instructions for the specific
disinfectant like an ittophor perhaps quick in, quick out, got it?
Speaker 1 (13:47):
And one more. Alginate detail what chemical acts as the
retarder slowing down the setting reaction.
Speaker 2 (13:53):
That would be tri sodium phosphate. It's added to control
the working time, give you enough time to mix and
seat the tray, and.
Speaker 1 (13:59):
Some way to extend that working time even more.
Speaker 2 (14:02):
Use cooler water. Wind mixing slows the reaction down a bit.
Speaker 1 (14:05):
Cool water, longer time, easy tip okay.
Speaker 2 (14:09):
Final point in this segment periodontal screening. The Basic periodontal
examination BPE six sextants. When does a BPE score automatically
trigger the need for radiographs?
Speaker 1 (14:20):
Radiographs become mandatory if any sextant scores a code three
or a.
Speaker 2 (14:23):
Code four, remind us what those codes mean.
Speaker 1 (14:26):
Code three means you've got pocket depths between four and
five millimeters. Code four means the color band on the
BPE probe completely disappears, indicating pockets or six milimeters or deeper.
Speaker 2 (14:36):
So four milimeter or deeper pockets basically means you need
X rays pretty much. Horizontal bite wings might be enough
for code three sometimes, but code four often requires more
comprehensive imaging like vertical byte wings or periapicals to assess
the boon loss properly.
Speaker 1 (14:51):
Clear guidance, okay, Final stretch. Segment four Oral pathology and
developmental conditions. Let's set some key diagnoses. Key lightest cranulm
tosa that recurrent lip swelling that becomes persistent. How do
you confirm the diagnosis?
Speaker 2 (15:04):
You need a biopsy? The key finding. The definitive thing
you're looking for on histopathology is non case eating epithelioid
cell granulomas.
Speaker 1 (15:12):
Non case eating granulomas got it now or like in
planets OLP common condition. The reticular form, the lacy white
lines might be recognizable clinically that the erosive form, the
red painful areas. Why is careful follow up and often
biopsy needed there.
Speaker 2 (15:27):
Because there's a small but real risk of malignant transformation.
A ros of olp can sometimes develop a Disquiemeus cell
carcinoma SEC.
Speaker 1 (15:35):
So the biopsy isn't just for diagnosis, it's to rule
out something worse.
Speaker 2 (15:39):
Exactly. You need to rule out dysplasia or outright carcinoma
before you start treating it, usually with topical cordocosteroids as
first line therapy, and even then long term follow up
is crucial because of that.
Speaker 1 (15:51):
Transformation risk makes sense, Okay, congenital stuff ankyloglossia, tongue tie,
thick frenulum causing issues. What specific speech sounds are often affected?
Speaker 2 (16:02):
The source mentions difficulty with sounds like DTSZRNL. Those require
more precise tongue tip.
Speaker 1 (16:08):
Movement and assessing it isn't just about looking at the frenulum, right.
There's a functional assessment.
Speaker 2 (16:13):
Yes, things like the Hazelbaker assessment look beyond just anatomy.
It evaluates function elasticity. How the tongue moves during swallowing
peristalsis how well it can spread out its function.
Speaker 1 (16:23):
Not just foreign good distinction Now microglossi a large tongue,
specifically in down syndrome. How does the source describe this?
Speaker 2 (16:30):
It calls it relative and congenital macroglossia, relative, meaning the
tongue itself might not be abnormally huge in absolute terms,
but because other structures in the mouth like the jaw
micronatheia might be smaller, and because there's often generalized low
muscle tone hypotonia, the tongue appears large relative to the
(16:50):
space available.
Speaker 1 (16:51):
It's about proportion, okay. Quick tooth anomalies dens and vaginata
is sometimes called dens in dente. What's the radiographic appearance?
Speaker 2 (16:59):
It looks like a tooth with a tooth rhadiographically often
described as a pear shaped in vagination extending from the
crown surface down towards the pulp. This makes it super
prone to decay, getting trapped and causing early pulp problems.
Speaker 1 (17:11):
Hair shaped vagination and dilaceration. What's the main challenge there?
Speaker 2 (17:15):
Dilaceration is just a sharp bend or curve in the
root or sometimes between the crown and root. That bend
makes everything harder. Endodontics is tough. Orthodonics can be complicated
even extractions can be tricky because the root might fracture unpredictably.
Speaker 1 (17:29):
That bend complicates things. Okay, last couple of points. Neonatal lesions.
We mentioned epstein pearls, those little white bumps on the
palette midline that go away on their own. What about
regafade disease riga.
Speaker 2 (17:40):
Feet isn't a bump, It's an ulceration. It typically happens
on the underside of the tongue in infants who have
natal or neonatal teeth teeth present at birth or erupting
very early. The friction of the tongue moving over those
sharp little teeth causes the ulcer oach.
Speaker 1 (17:58):
How do you treat that?
Speaker 2 (17:59):
Usually pretty simple. Either smooth the sharp incisile edges of
the offending teeth, or if it's severe or persistent, sometimes
the teeth need to be removed to allow healing.
Speaker 1 (18:08):
Okay, smoothing or removal. Got it. Wow, we covered a
huge amount of detail there.
Speaker 2 (18:13):
We really did, from the specifics of drug timing and
mechanisms like DEGO to the exact splinting protocols in trauma
differentiating pathology.
Speaker 1 (18:22):
It's a lot, but hopefully broken down in a way
that connects the dots, you know, not just lists, but
the why behind the rules, like why ten days for
one splint and six weeks for another?
Speaker 2 (18:31):
Absolutely, that context is everything for making it stick and
making it usable. These aren't just exam questions, they're clinical
scenario right.
Speaker 1 (18:38):
So to cement that learning, let's do our final review question.
This is based purely on what we just discussed from
the source material.
Speaker 2 (18:44):
You're ready, let's hear it.
Speaker 1 (18:46):
Okay. A twenty one year old patient suffers an evulsion
of tooth hashtag twenty nine permanent lower second premoler and
keeps it dry for forty five minutes. There's no accompanying
alveolar fracture. Based on the provided guidelines, what is the
treatment goal for the replanted tooth and what is the
maximum duration and required mobility type for the splint?
Speaker 2 (19:06):
All right, so key facts. Permanent tooth dry time forty
five minutes. That's less than the sixty minute critical limits
or replantations. Definitely indicated no alveolar fracture. Okay, So the
treatment goal in this scenario, according to the guidelines, is
primarily focused on minimizing growth retardation of the alveolar bone.
This preserves the bone volume, keeping options open for a
(19:27):
potential future implant if the replanted tooth eventually fails.
Speaker 1 (19:31):
Good point about the future implant focus and the splinting details.
Speaker 2 (19:34):
Since there's no alveolar fracture, we go with the standard
evulsion protocol that means a semirigid splint and the maximum
duration is ten days.
Speaker 1 (19:41):
Perfect semirigid ten days goal focused on preserving bone for
future options. That pulls several threads together.
Speaker 2 (19:48):
It really does, and it highlights how these seemingly small
details splint type, duration, even the long term goal all
stem from understanding the specifics of the injury and the
bio biological principles.
Speaker 1 (20:01):
Absolutely, that's the whole point, isn't it. Connecting these dense
facts to the bigger picture of diagnosis, treatment planning, and
long term patient outcomes.
Speaker 2 (20:09):
Couldn't have said it. Better keep making those connections.
Speaker 1 (20:12):
We'll be back next time for another deep dive.
Welcome back to the deep dive. You know how we
do it. We take dense, really specific source material. Today
it's excerpts from the STAT Pearls NBD review, and we
pull out the essentials exactly.
Speaker 2 (00:13):
We're looking for those clinical pearls, the things that are
easy to forget but make a.
Speaker 1 (00:16):
Real difference, right, not just reading facts, but finding the
stuff that changes how you might handle a case this afternoon.
Speaker 2 (00:23):
And our mission really for you listening is to help
you quickly synthesize these critical points. We're covering a lot pharma,
systemic links, trauma, operative stuff.
Speaker 1 (00:34):
All backed by that huge STAT Pearls database reviewed by
thousands of professionals. So these aren't just random.
Speaker 2 (00:40):
Facts, definitely not. These details connect textbook knowledge to actual
clinical decisions.
Speaker 1 (00:45):
Okay, let's jump right in first sections systemic health, Pharmacology,
and oral manifestations. This feels like groundwork preventative thinking.
Speaker 2 (00:53):
It really is, and we have to start with a
major one. Statins and pregnancy.
Speaker 1 (00:57):
Ah, yes, a serious contraindication.
Speaker 2 (01:00):
Absolutely non negotiable. You know, for any woman who could
become pregnant. Statins are contraindicated period during pregnancy, breastfeeding even
to its first something serious like familial hypercholesterolemia.
Speaker 1 (01:11):
But what's the key timing detail from the source. That's
often the tricky part.
Speaker 2 (01:16):
The critical number is three months. Statins must be stopped
a full three months before planned conception. That's because of
the tatogenic risk.
Speaker 1 (01:25):
Three months. Okay, that's the actionable takeaway right there. Sticking
with drug risks, let's talk doxycyclin high clate. We all
know tetracycling stains teeth, but what's the specific rule.
Speaker 2 (01:35):
So it's contraindicated in pregnancy, breastfeeding, and specifically in kids
under twelve years old.
Speaker 1 (01:41):
Under twelve Why that age.
Speaker 2 (01:42):
Because that's when permanent teeth are still mineralizing. Exposure can
cause that permanent gray banded discoloration. You can't fix it later.
Speaker 1 (01:49):
Right, that's locked in. Okay. Shifting from contraindications to speed
of action. Nitroglycerin for angina, Why sublingual? Why not just
swallow it?
Speaker 2 (02:00):
It's all about avoiding the liver Initially. Sublingual absorption goes
straight into the venous system super rapid.
Speaker 1 (02:06):
Onset bypassing first pass metabolism exactly.
Speaker 2 (02:09):
Compare that to say oral isor bide dinitrate. You need
much higher doses because so much gets breaken down by
the liver first time through low bioavailability. In an emergency,
that delay is critical.
Speaker 1 (02:22):
Makes sense, and speaking of emergencies lytokine reactions, this is
important to get right. Anaphylaxis versus systemic toxicity, different responses needed.
Speaker 2 (02:32):
Totally different. Anaphylaxis is an allergic immine response. You treat
that with epinephrine, okay, But systemic toxicity it's more like
an overdose, often showing CNS signs first. The antidote there
is lipid emulsion.
Speaker 1 (02:43):
Lipid emulsion, got it? Using epi for toxicity would be
the wrong roof, entirely.
Speaker 2 (02:48):
Completely wrong. Knowing the difference is vital.
Speaker 1 (02:50):
Okay, Moving to chronic stuff. Opioids lots of side effects,
but which one is the most common long term one?
The one. People don't develop tolerance to constipation.
Speaker 2 (03:00):
It's driven by those MEW receptors and the gut slowing
things down.
Speaker 1 (03:03):
And unlike the pain relief, tolerance doesn't kick in for
the constipation.
Speaker 2 (03:06):
Correct the analgesic effect might diminish over time, but the
constipation risk stays constant for long term users. That's a
key counseling point.
Speaker 1 (03:14):
Definitely. Okay. Now for a complex one drug induced gingibal
overgrowth diego, we know the usual suspects phoenetoyin, cyclosporin, calcium
channel blockers like amlodipine. But pathophysiologically, where does it start?
Speaker 2 (03:29):
It starts deeper than you might think. In the connective
tissue with the gingible fiber blasts. The trigger seems to
be increased expression of platelet derived growth factor PDGF.
Speaker 1 (03:39):
PDGF increases. Okay, what cascade does that set off inside
the fiberblast cell? What?
Speaker 2 (03:44):
It seems to block cash and influx. Specifically, sodium and calcium.
Ions can't get into the cell as.
Speaker 1 (03:49):
Easily blocked ion channels, and that effect it.
Speaker 2 (03:52):
Reduces the cell's ability to take up fullic acid.
Speaker 1 (03:54):
Okay, So PDGF up castions blocked fullic acid uptake down?
What's the final step that makes the tissue actually overgrow?
Speaker 2 (04:01):
Because the fibroblasts can't process fullic acid properly, it can't
activate collagenes effectively. Collagenes is what breaks down collagen.
Speaker 1 (04:09):
Ah, So if you can't break down collagen, you.
Speaker 2 (04:11):
Get accumulation collagen and extracellular matrix just build up. That's
why the tissue feels firm.
Speaker 1 (04:17):
Fibrotic, fascinating cascade and a quick clinical check. Does it
happen everywhere?
Speaker 2 (04:22):
Almost never? In ADDENTIALUS areas, you need teeth and the
surrounding gingiva for the process to really take hold.
Speaker 1 (04:28):
Good diagnostic clue, all right, last one in this section
systemic links Jugrin's syndrome. We know dry eyes dry mouth
may be linked with lupus anti roy anti li antibodies.
But what if a Shogrin's patient mentions numbness or burning
in the face.
Speaker 2 (04:44):
You have to consider trigeminal neuropathy as a potential complication.
Speaker 1 (04:48):
Okay, And for treating the dry.
Speaker 2 (04:49):
Mouth itself, savinemeline is often the go too. It's a
muscarinic agonist that specifically targets the M three receptors and
salivary glands to stimulate saliva.
Speaker 1 (04:58):
Flow M three specific good detail and quickly infections and immunity,
ano acute necrotizing, all sort of gingabtis. What's the big
association there?
Speaker 2 (05:08):
High association with being immunocompromised. The source notes that seeing
a ando can actually be an indicator, sometimes prompting an
Elisa essay for a potential new HIV diagnosis.
Speaker 1 (05:17):
Wow, that's a strong link.
Speaker 2 (05:18):
It is and related to pathology. Think about ORALTB. You'd
see granulumitous inflammation. Langan's giant cells contrasts that with Harry
lukoplakia often seen in immunosuppression, where Langerhand cells are actually
decreased or absent. Different cellular pictures telling a story about immunity.
Speaker 1 (05:36):
Great connections. Okay, let's shift gears completely. Segment two, Acute
trauma and emergency management. Time is everything here, especially with avulsion.
Speaker 2 (05:46):
Absolutely. The big one is the sixty minute rule for
extroral dry time. If a permanent cook is out and
dry for more than an hour, replantation success plummets.
Speaker 1 (05:55):
So getting it into a good storage medium quickly is key. Milk, saline,
even the patient's.
Speaker 2 (06:00):
Own mouth, right, that buys you time. Now there's a
nuance for immature teeth, teeth with open apises.
Speaker 1 (06:05):
Okay, what's different there?
Speaker 2 (06:06):
The goal shifts slightly towards trying to get revascularization. Soaking
the tooth in doxycycline is recommended to help that process along.
Speaker 1 (06:14):
Doxycycline soak for immature teeth. Interesting, no splinting. This isn't
one size fits all. As it depends on other injuries.
Speaker 2 (06:20):
Totally depends standard of vulsion. No bone fracture. Use a
summer rigid splint like a titanium trauma.
Speaker 1 (06:26):
Splint, and for how long?
Speaker 2 (06:27):
Only about ten days? The idea is stabilization for PDL
healing but allowing some physiological movement.
Speaker 1 (06:34):
Okay, ten days summer rigid. But what if there is
an alveolar fracture along with the evulsion.
Speaker 2 (06:39):
Then the whole game changes. You need rigid splinting and
for much longer six to eight weeks. Wow, big difference,
because now you're not just stabilizing the tooth, you're immobilizing
bone fragments to allow the fracture to heal. Rigidity is
key for bone healing.
Speaker 1 (06:53):
Makes sense? What about primary teeth? Baby teeth? If one
gets knocked out, do we rush to put it back in?
Speaker 2 (06:58):
Generally no replantation for primary teeth is usually contraindicated. Was
that high risk of damaging the developing permanent tooth underneath?
You can cause deviation, enamyl hypoplasia, even ankylosis of the
primary tooth, which then interferes with exfoliation, especially if the
child is near the natural exfoliation age, like seven for
a central incisor observation.
Speaker 1 (07:20):
Is usually preferred good to know, avoid causing more problems, okay.
Shifting to jaw fractures, mandibular fractures specifically, what's a classic
sign almost pathognomonic for a sympathial or body.
Speaker 2 (07:32):
Fracture sublingle hematoma that bluish swelling under the tongue. It's
a dead giveaway, okay.
Speaker 1 (07:37):
And if the fractures further back, like the angle of
the mandible, what nerve sign might you see?
Speaker 2 (07:42):
Numbness or altered sensation in the lower lip That points
to injury to the inferior alveolar nerve which runs right
through there.
Speaker 1 (07:49):
Important diagnostic clue. Now, airway risk which mandibular fracture pattern
is particularly dangerous for airway obstruction.
Speaker 2 (07:57):
Bilateral fractures either body or parasimp seal, especially if they're
combined with condolar fractures.
Speaker 1 (08:02):
Why is that combination so risky.
Speaker 2 (08:04):
Because the muscle attachments, particularly the super hides, pull that
now mobile front segment of the mandible backwards and downwards.
The tongue goes with it, potentially blocking in the ore pharynx.
It's an immediate airway concern.
Speaker 1 (08:16):
Needs careful quick management. Okay, a practical tip reducing a
simple jaw dislocation the bimanual technique thumbs on the molars.
What's the risk to the clinician.
Speaker 2 (08:26):
Getting your thumbs bitten when the jaw snaps back into place,
can even really fast ouch? So protection absolutely. Always wrap
your thumbs in gauze or place tongue depressors over the
occlusal surfaces before applying that downward and backward pressure. Protect
yourself smart.
Speaker 1 (08:42):
Let's wrap trauma with pulp issues. How do we know
if pulpitis is irreversible versus reversible?
Speaker 2 (08:47):
The key test is prolonged pain to cold. If the
pain lingers for more than say, thirty seconds after you
remove the cold stimulus, that pulp is likely beyond saving itself.
It's irreversible over thirty seconds.
Speaker 1 (09:00):
Got it and complicated crown fractures where the pulp is exposed.
When is pulp capping most likely to succeed?
Speaker 2 (09:06):
The Size of the exposure matters a lot. If it's small,
not exceeding one point five millimeters in diameter, pulp capping
has a decent chance. Much bigger than that and success
rates drop significantly.
Speaker 1 (09:17):
One point five millimeter threshold. Okay. Lastly, root resorption. Chronic
external root resorption often needs a pexification before you can
fill the canal. What material is preferred for that.
Speaker 2 (09:26):
Mineral triaxide aggregate or MTA yt. It's highly biocompatible, which
is crucial, But the really neat thing is that it
actually induces the formation of a hard tissue barrier, kind
of like hydroxy appetite. When it contacts vital tissue, it
creates a good apical seal, allowing you to then fill
the rest of the.
Speaker 1 (09:43):
Canal forms its own seal. Very cool. Okay. Moving on
segment three Operative dentistry, endodontics, and diagnostics. Let's start with prevention.
Selence indications are clear deep pits high risk, but the
chemistry of placing them. What does the chant the orthophosphoric
acid actually.
Speaker 2 (10:02):
Do right, usually thirty seven percent orthophosphoric acid. Its job
is simply to demineralize the very surface layer of the enamel.
It creates microscopic roughness, like little nooks and.
Speaker 1 (10:12):
Crannies for micromechanical bonding.
Speaker 2 (10:14):
Exactly. The sealant flows into those irregularities and locks in mechanically.
That's why the surface must be completely dry. That classic
chalky white appearance tells you it's properly etched and ready.
Speaker 1 (10:24):
And a quick tip to avoid bubbles in the sealant,
gently vibrate.
Speaker 2 (10:27):
The liquid adhesive with a probe as you apply. It
helps it flow better and reduces voids.
Speaker 1 (10:32):
Good tip and sticking with prevention. Fluoride for early childhood
carries ECC varnish gel rinse, which.
Speaker 2 (10:40):
Is preferred for ECC Specifically, fluoride varnish is generally preferred.
Why varnish longer contact time. It sticks to the enamel
surface better than gels or rinses, giving the fluoride more
time to work, promoting remineralization, especially important in young kids
or high risk situations.
Speaker 1 (10:57):
Makes sense. Okay, shifting to ENDO prepare sharing canals. We
want to remove debris shape the canal, But what about
that smear layer left by instruments. How do we get
rid of it completely?
Speaker 2 (11:07):
It's a two part problem, so you need a two
part solution. Sodium epochloride is great for dissolving the organic
stuff pulp remnants, bacteria, but leaves it leaves the inorganic
component of the smear layer behind. That's where edta comes in.
Etta is a chelating agent. It binds to and dissolves
the inorganic mineralized debris. You really need both for a
truly clean canal surface.
Speaker 1 (11:28):
Okay, NaOCl for organic, DTA for inorganic. Got it now,
working length? Where do we ideally stop instrumentation?
Speaker 2 (11:35):
The anatomical ideal is the apical constriction that's usually about
zero point five to one millimeters short of the actual
radiographic apex the very tip of the root.
Speaker 1 (11:44):
So not right to the end seen on the X ray.
Speaker 2 (11:47):
Correct. However, there's a specific situation if you're dealing with
the vital inflamed pulp. Some protocols suggest stopping instrumentation even shorter,
maybe two to three milimeters from the radio graphic apex.
The idea is to preserve a small plug of healthy
abicle pulp tissue as possible.
Speaker 1 (12:05):
Interesting nuance okay, fun fact check, good a purchase? What's
the main ingredient by weight? It's not good at purchase?
Speaker 2 (12:12):
Is it deprisingly?
Speaker 1 (12:13):
No?
Speaker 2 (12:13):
The largest component is actually zinc oxide. It makes up
somewhere between like fifty nine percent and seventy five percent
of the cone.
Speaker 1 (12:19):
Wow, So the good approcha itself is much less.
Speaker 2 (12:22):
Yeah, only about nineteen percent to twenty two percent. The
rest includes heavy metal salts like barium sulfate, which are
added purely for radiopacity, so we can see the fill
on an.
Speaker 1 (12:29):
X ray zinc oxide. Who knew all right? Instruments barbed brooches,
those are for grabbing and removing bulk pulp tissue right
with a little rotation exactly.
Speaker 2 (12:37):
Like ninety to one hundred and eighty degrees rotation to
engage and pull out the tissue. What about gates gliden burrs?
Where do they fit in?
Speaker 1 (12:44):
Gates? Glutons are primarily used in retreatment cases. They're good
for removing good a purchase, especially from the more coronal,
straighter parts of the canal.
Speaker 2 (12:51):
Yeah for taking old fillings out right.
Speaker 1 (12:53):
But a word of caution. They work by friction and
can generate a lot of heat pretty quickly, so use
them carefully with irrigation. Short bursts.
Speaker 2 (13:01):
Good point heat is bad for the tooth. Okay, let's
talk impression materials. Algenate and polyether very common, but they
have a shared limitation when it comes to disinfection, don't
they They do.
Speaker 1 (13:14):
You cannot immerse them in disinfectant for very long. The
recommendation is generally no more than ten minutes.
Speaker 2 (13:19):
Why the time limit?
Speaker 1 (13:20):
They both absorb water and swell. Alginate is water based
to begin with, and polyether, while different chemically, is hydrophilic.
It likes water too much contact time. They distort dimensionally, so.
Speaker 2 (13:32):
Accuracy goes out the window. How should you disinfect them?
Then rapidly either spray disinfectant on them or use a
very short immersion following the manufacturer's instructions for the specific
disinfectant like an ittophor perhaps quick in, quick out, got it?
Speaker 1 (13:47):
And one more. Alginate detail what chemical acts as the
retarder slowing down the setting reaction.
Speaker 2 (13:53):
That would be tri sodium phosphate. It's added to control
the working time, give you enough time to mix and
seat the tray, and.
Speaker 1 (13:59):
Some way to extend that working time even more.
Speaker 2 (14:02):
Use cooler water. Wind mixing slows the reaction down a bit.
Speaker 1 (14:05):
Cool water, longer time, easy tip okay.
Speaker 2 (14:09):
Final point in this segment periodontal screening. The Basic periodontal
examination BPE six sextants. When does a BPE score automatically
trigger the need for radiographs?
Speaker 1 (14:20):
Radiographs become mandatory if any sextant scores a code three
or a.
Speaker 2 (14:23):
Code four, remind us what those codes mean.
Speaker 1 (14:26):
Code three means you've got pocket depths between four and
five millimeters. Code four means the color band on the
BPE probe completely disappears, indicating pockets or six milimeters or deeper.
Speaker 2 (14:36):
So four milimeter or deeper pockets basically means you need
X rays pretty much. Horizontal bite wings might be enough
for code three sometimes, but code four often requires more
comprehensive imaging like vertical byte wings or periapicals to assess
the boon loss properly.
Speaker 1 (14:51):
Clear guidance, okay, Final stretch. Segment four Oral pathology and
developmental conditions. Let's set some key diagnoses. Key lightest cranulm
tosa that recurrent lip swelling that becomes persistent. How do
you confirm the diagnosis?
Speaker 2 (15:04):
You need a biopsy? The key finding. The definitive thing
you're looking for on histopathology is non case eating epithelioid
cell granulomas.
Speaker 1 (15:12):
Non case eating granulomas got it now or like in
planets OLP common condition. The reticular form, the lacy white
lines might be recognizable clinically that the erosive form, the
red painful areas. Why is careful follow up and often
biopsy needed there.
Speaker 2 (15:27):
Because there's a small but real risk of malignant transformation.
A ros of olp can sometimes develop a Disquiemeus cell
carcinoma SEC.
Speaker 1 (15:35):
So the biopsy isn't just for diagnosis, it's to rule
out something worse.
Speaker 2 (15:39):
Exactly. You need to rule out dysplasia or outright carcinoma
before you start treating it, usually with topical cordocosteroids as
first line therapy, and even then long term follow up
is crucial because of that.
Speaker 1 (15:51):
Transformation risk makes sense, Okay, congenital stuff ankyloglossia, tongue tie,
thick frenulum causing issues. What specific speech sounds are often affected?
Speaker 2 (16:02):
The source mentions difficulty with sounds like DTSZRNL. Those require
more precise tongue tip.
Speaker 1 (16:08):
Movement and assessing it isn't just about looking at the frenulum, right.
There's a functional assessment.
Speaker 2 (16:13):
Yes, things like the Hazelbaker assessment look beyond just anatomy.
It evaluates function elasticity. How the tongue moves during swallowing
peristalsis how well it can spread out its function.
Speaker 1 (16:23):
Not just foreign good distinction Now microglossi a large tongue,
specifically in down syndrome. How does the source describe this?
Speaker 2 (16:30):
It calls it relative and congenital macroglossia, relative, meaning the
tongue itself might not be abnormally huge in absolute terms,
but because other structures in the mouth like the jaw
micronatheia might be smaller, and because there's often generalized low
muscle tone hypotonia, the tongue appears large relative to the
(16:50):
space available.
Speaker 1 (16:51):
It's about proportion, okay. Quick tooth anomalies dens and vaginata
is sometimes called dens in dente. What's the radiographic appearance?
Speaker 2 (16:59):
It looks like a tooth with a tooth rhadiographically often
described as a pear shaped in vagination extending from the
crown surface down towards the pulp. This makes it super
prone to decay, getting trapped and causing early pulp problems.
Speaker 1 (17:11):
Hair shaped vagination and dilaceration. What's the main challenge there?
Speaker 2 (17:15):
Dilaceration is just a sharp bend or curve in the
root or sometimes between the crown and root. That bend
makes everything harder. Endodontics is tough. Orthodonics can be complicated
even extractions can be tricky because the root might fracture unpredictably.
Speaker 1 (17:29):
That bend complicates things. Okay, last couple of points. Neonatal lesions.
We mentioned epstein pearls, those little white bumps on the
palette midline that go away on their own. What about
regafade disease riga.
Speaker 2 (17:40):
Feet isn't a bump, It's an ulceration. It typically happens
on the underside of the tongue in infants who have
natal or neonatal teeth teeth present at birth or erupting
very early. The friction of the tongue moving over those
sharp little teeth causes the ulcer oach.
Speaker 1 (17:58):
How do you treat that?
Speaker 2 (17:59):
Usually pretty simple. Either smooth the sharp incisile edges of
the offending teeth, or if it's severe or persistent, sometimes
the teeth need to be removed to allow healing.
Speaker 1 (18:08):
Okay, smoothing or removal. Got it. Wow, we covered a
huge amount of detail there.
Speaker 2 (18:13):
We really did, from the specifics of drug timing and
mechanisms like DEGO to the exact splinting protocols in trauma
differentiating pathology.
Speaker 1 (18:22):
It's a lot, but hopefully broken down in a way
that connects the dots, you know, not just lists, but
the why behind the rules, like why ten days for
one splint and six weeks for another?
Speaker 2 (18:31):
Absolutely, that context is everything for making it stick and
making it usable. These aren't just exam questions, they're clinical
scenario right.
Speaker 1 (18:38):
So to cement that learning, let's do our final review question.
This is based purely on what we just discussed from
the source material.
Speaker 2 (18:44):
You're ready, let's hear it.
Speaker 1 (18:46):
Okay. A twenty one year old patient suffers an evulsion
of tooth hashtag twenty nine permanent lower second premoler and
keeps it dry for forty five minutes. There's no accompanying
alveolar fracture. Based on the provided guidelines, what is the
treatment goal for the replanted tooth and what is the
maximum duration and required mobility type for the splint?
Speaker 2 (19:06):
All right, so key facts. Permanent tooth dry time forty
five minutes. That's less than the sixty minute critical limits
or replantations. Definitely indicated no alveolar fracture. Okay, So the
treatment goal in this scenario, according to the guidelines, is
primarily focused on minimizing growth retardation of the alveolar bone.
This preserves the bone volume, keeping options open for a
(19:27):
potential future implant if the replanted tooth eventually fails.
Speaker 1 (19:31):
Good point about the future implant focus and the splinting details.
Speaker 2 (19:34):
Since there's no alveolar fracture, we go with the standard
evulsion protocol that means a semirigid splint and the maximum
duration is ten days.
Speaker 1 (19:41):
Perfect semirigid ten days goal focused on preserving bone for
future options. That pulls several threads together.
Speaker 2 (19:48):
It really does, and it highlights how these seemingly small
details splint type, duration, even the long term goal all
stem from understanding the specifics of the injury and the
bio biological principles.
Speaker 1 (20:01):
Absolutely, that's the whole point, isn't it. Connecting these dense
facts to the bigger picture of diagnosis, treatment planning, and
long term patient outcomes.
Speaker 2 (20:09):
Couldn't have said it. Better keep making those connections.
Speaker 1 (20:12):
We'll be back next time for another deep dive.
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