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What are Veneers


Veneers

Veneers are thin laminates mostly made of porcelain or ceramic material which are fixed perfectly to the front of tooth/teeth. They can be used to improve the look and appearance of damaged teeth as they are made to match the colour of the teeth. Sometimes veneers are also used to close gap in between teeth.
Veneers
Benefits and Uses of Veneers
Most uses of veneers are cosmetic in nature, some of them are explained below.
1) The easiest way to describe veneers is to think of them like false fingernails, which are bonded to front surface of your teeth with dental cement. They are used if the teeth are dark, twisted or chipped.
2) In some cases, teeth edges are worn that makes your teeth appear aged and crooked, veneers are used to restore natural appearance in such cases.
3) They are also used to improve the appearance of dark, chipped and twisted teeth.
The latest and advanced version of veneers is known as lumineers. They are so thin that they rarely need any intervention on the teeth. You can think of them as contact lenses for your teeth as they are very thin.

COMEDK details..


COMEDK

Important Dates
Date for issue of online application is 3rd week of March, 2012
The test commences on 2nd week May, 2012
Publishing date of test Scores will be on 4th week of May, 2012.

Consortium of Medical Engineering and Dental Colleges of Karnataka (COMEDK) will conduct an examination for those candidates who are seeking admissions in Medical, Engineering and Dental courses in the State of Karnataka. After declaring the results, the successful candidates are invited for a one window counseling done at the state level.


Structure of CMEDK UGET
A combined paper including Physics and Chemistry is there for the candidates appearing in CMEDK UGET. Mathematics paper is compulsory for the candidates seeking Engineering courses. Biology is a mandatory subject for those in MBBS& BDS. Combined Physics and Chemistry exam will be held at 10.00 am to 12.00 pm. The duration for this paper is 120 minutes. Mathematics and Biology exams will be conducted on the same day in the afternoon. No negative marking is there for this examination.


Syllabus of CMEDK UGET
The syllabus includes Mathematics, Physics, Chemistry and Biology.
Chemistry
  • Chemistry of carbon compounds
  • Coordination chemistry and organo metallics
  • Electrochemistry
  • Chemical kinetics
  • Chemistry in action
  • Chemistry of biological processes
  • Biomolecules
  • Polymers
  • Transition metals including lanthanides
  • Chemistry of representative elements
  • Nuclear chemistry
Physics
  • Introduction
  • Heat and thermodynamics
  • Description of motion in two and three dimensions
  • Thermal and chemical effects of currents
  • Electromagnetic induction and alternating currents
  • Electrostatics
  • Oscillations
  • Physical world & measurement
  • Description of motion in one dimension
Biology
  • Diversity in Living World
  • Ecology and Environment
  • Structural Organisation in Plants and Animals
  • Biology and Human Welfare
  • Reproduction in Organism
  • Genetics & Evolution
Mathematics
  • Vectors and Three dimensional geometry
  • Matrices and determinants
  • Differential equations
  • Definite integral
  • Integral calculus
  • Differential calculus
  • Exponential and logarithmic series
  • Probability
  • Correlation and regression
  • Circles
  • Coordinate geometry
Eligibility Criteria for CMEDK UGET
Candidates who have passed Plus Two or equivalent are eligible for appearing  in the examination. Those candidates waiting for the results of Plus Two are also eligible to write examination.


How to apply for CMEDK UGET?
Candidates can fill the application forms from the official site of COMEDK. The website is www.comedk.org . This can be done only after drawing a DD of Rs. 800/- for 3 subjects and Rs. 1000/- for 4 subjects. The draft and related application documents should be sent on or before 3rd week of April.


How to fill the form of CMEDK UGET?
Application is to be filled according to the instructions given in the website www.comedk.org.


List of CMEDK UGET Centers
  • Bangalore
  • Bellary
  • Gulbarga
  • Udupi
  • Davangere
  • Mysore
  • Belgaum
  • Dharwad
  • Shimoga
  • Tumkur
  • Bijapur
  • Mangalore
Colleges Participating in CMEDK UGET
  • Adichunchangiri Institute of Medical Science B.G. Nagara
  • K V G Medical College  Sullia
  • Kempegowda Institute of Medical Sciences  Bangalore
  • M S Ramaiah Medical College Bangalore
  • S.S. Institute of Medical Sciences & Research Centre Davangere
  • Father  Muller  Medical College (Christian Minority) Mangalore
  • SDM College of Medical Sciences & Hospital
  • Sri Dharmasthala Manjunatheswara College of Medical Sciences & Hospital (Tulu Minority)
  • Basaveshwara Medical College & Hospital Chitradurga
  • BVV Sangha’s S. Nijalingappa Medical College and HSK Hospital and Research
  • Centre Bagalkot
  • H K E Society’s M R Medical College Gulbarga
  • J J M Medical College Davanagere
  • A M E ’s Dental College & Hospital  Raichur
  • Bapuji Dental College & Hospital  Davanagere
  • H K E ’s S. Nijalingappa Institute of Dental Sciences & Research Gulbarga
  • Krishnadevaraya College of Dental Sciences Bangalore
  • College of Dental Sciences Davanagere
  • D A Pandu Memorial R V Dental College Bangalore
  • Dayananda Sagar College of Dental Sciences Bangalore
  • Dr. Syamala Reddy Dental College Bangalore
  • HKDET’s Dental College Hospital & Research Institute Bidar
  • K G F College of Dental Sciences K G F
  • K.L.E. Society’s Institute of Dental Sciences Bangalore
  • K V G Dental College & Hospital Sullia
Contact Address for CMEDK UGET
  • COMEDK, #37, first floor, Ramanashree chambers, Lady curzon road, Bangalore-560001, Karnataka,
  • Fax 080-2598309,
  • Email uget@comedk.org
  • Help desk 080-41132810 (4 lines)
  • website www.comedk.org
Reference Books for CMEDK UGET
  • Chemistry for Karnataka CMEDK by Base
  • Biology: Karnataka CET and COMEDK by S.H.Maruthi
Coaching Centers for COMEDK UGET
  • Brilliant Tutorials
  • FIITJEE
  • Narayana Institute
Study Plan
Thorough preparation is required for this examination. Previous years question papers will help to score good marks in this exam. Coaching centers are available. A detailed study in each of the subjects is important for this exam. It is important to prepare notes on important topics as well as formulae, short cuts etc which can help you for a final brush up during the last few days. Practice is the best approach, you can manage to allot time for different sections by doing more and more sample papers.


How and Where To Get the Results?
The results can be downloaded from the website http://www.comedk.org/.


Cutoff Marks
Cutoff mark is different for different Universities and for in different stream of courses. For Engineering it can vary from 60-70% and in medical it is 65-90%. The cutoff can change according to the overall performance of the students and to the available number of seats.


Score Validity
The score validity is one year( for the academic Year).



PLEASE LEAVE A COMMENT FOR ANY OTHER INFO YOU KNOW OR YOU NEED....

AIIMS NOV 2011

AIIMS-PG (MD/MS/M.Ch.(6 yrs.)/MDS)-January, 2012
Entrance Examination 13th November, 2011 (Sunday)
Result (to be declared) 29th November, 2011
1st Counselling 12th December, 2011
2nd Counselling 19th December, 2011
Open Selection 27th January, 2012 (Friday)

link for the notifications: http://aiims.edu/aiims/events/exams-results.htm

composite



Dental composite is composed of a resin matrix and fillers.  Acrylic, which was introduced to dentistry in the 1940's, was used to construct dental prosthesis.  Monomer, which consists of single molecules, is joined together to form a polymer which is composed of a long chain of monomers.  In the 1950's, resins were found to have better physical properties.  Physical characteristics were improved by combining more than one type of monomer to form a mixed polymer and is referred to as a copolymer.  Cross linking monomers join long chain polymers together along the chain and improve strength.

Single molecules of a monomer are held together by Van Der Waal's forces at Van Der Waal's distances of 4 angstroms.  Application of heat, acid base reactions or free radical formation are catalysts that join monomers to form polymers where molecules are at atomic bond distances of 1.9 angstroms.  Volumetric shrinkage can be dramatic, for example, acrylic materials shrink as more than 20%.

Filler materials reduce shrinkage by creating less resin.  They further increase the physical properties of composite.  Filler affects on composite behavior depend on filler material, surface, size, load, shape, surface modifiers, optical index, filler load and size distribution.  It is critical for filler to be wet by resin.  This limits the amount of filler that can be incorporated into resin.  A filler to resin interface is a high stress area when resin cures and for this reason, surface treatment of fillers is common to overcome interface breakdown. 

Resin cure is inhibited by oxygen.  Oxygen inhibition is useful during the restorative process to allow layering techniques that minimize negative affects of shrinkage.  Layering techniques that maintain an oxygen inhibited layer result in a uniform structure as if the composite had been placed in bulk.  Layering techniques during restoration minimize negative affects of shrinkage by creating small incremental shrinkage.  The final outer layer must be covered to eliminate contact with air and complete composite polymerization.  Coating composite with glycerin and light curing is a popular technique.

Catalysts initiate a reaction that propagates to termination.  However, there is only partial conversion of monomer to polymer.  Conversion is more complete and therefore, a composite with better physical properties is produced, when the reaction takes place in the absence of oxygen combined with heat and pressure application.  These are referred to as indirect or laboratory processed composites.
  
RESIN MATERIALS

 BIS-GMA resin is the base for composite.  In the late    1950's, Bowen mixed bisphenol A and glycidylmethacrylate thinned with TEGDMA (triethylene glycol dimethacrylate) to form the first BIS-GMA resin.  Diluents are added to increase flow and handling characteristics or provide cross linking for improved strength.  Common examples are:

RESIN

 BIS-GMA      bisphenol glycidylmethacrylate

DILUENTS
MMA          methylmethacrylate     
BIS-DMA   bisphenol dimethacrylate
UDMA        urethane dimethacrylate

CROSS LINK DILUENTS

EGDMA      ethylene glycol dimethacrylate
TEGDMA    triethylene glycol dimethacrylate 

COUPLING AGENTS

Dental composite is composed of a resin matrix and filler materials.  The resin filler interface is important for most physical properties.  There are three causes of stress on this interface including:  resin shrinkage pulls on fillers, filler modulus of elasticity is higher than resin, and filler thermo coefficient of expansion allows resin to expand more with heat.
Coupling agents are used to improve adherence of resin to filler surfaces. Modification of filler physical structure on the surface or aggregating filler particles create mechanical locking to improve interface strength.  Coupling agents chemically coat filler surfaces and increase strength.  Silanes have been used to coat fillers for over fifty years in industrial plastics and later in dental fillers.  Today, they are still state of the art.
Silanes have disadvantages.  They age quickly in a bottle and become ineffective.  Silanes are sensitive to water so the silane filler bond breaks down with moisture.  Water absorbed into composites results in hydrolysis of the silane bond and eventual filler loss.  Common silane agents are:

vinyl triethoxysilane
methacryloxypropyltrimethoxysilane

HEAT CATALYST
Polymerization of resin requires initiation by a free radical.  Initiation starts propagation or continued joining of molecules at double bonds until termination is reached.  Heat applied to initiators breaks down chemical structure to produce free radicals, however, monomers may polymerize when heat is applied even without initiators.
Resins require stabilizers to avoid spontaneous polymerization.  Stabilizers are also used to control the reaction of activators and resin mixtures.  Hydroquinone is most commonly used as a stabilizer.  
Common heat based initiators are peroxides such as 
benzoylperoxide
t-butylperoxide
t-butylperoxide     
     
CHEMICAL CATALYST

Polymerization of resin requires initiation by a free radical.  Initiation starts propagation or continued joining of molecules at double bonds until termination is reached.  Chemical activation of peroxides produces free radicals.  Chemical accelerators are often not color stable and have been improved for this reason.
The term self cure or dual cure (when combined with photo chemical initiation) describes chemical cure materials.  Chemical composites mix a base paste and a catalyst paste for self cure.  Bonding agents mix two liquids.  Mixing two pastes incorporates air into the composite.  Oxygen inhibits curing resulting in a weaker restoration.
Chemical accelerators include:

Dimethyl p-toludine

N,N-bis(hydroxy-lower-alkyl)-3,5-xylidine

PHOTOCHEMICAL CATALYST 
Polymerization of resin requires initiation by a free radical.  Initiation starts propagation or continued joining of molecules at double bonds until termination is reached.  Early photochemical systems used were benzoin methyl ether which is sensitive to UV wavelengths at 365 nm.  UV systems had limited use as depth of cure was limited.  Visible light activation of  diketones is the preferred photochemical systems.  Diketones activate by visible, blue light  to produce slow reactions.  Amines are added to accelerate curing time.  
Presently, different composites use different photochemical systems.  These systems are activated by different wavelengths of light.  In addition, different curing lights produce various ranges of wavelengths that might not match composite activation wavelengths.  This can result in no cure or partial cure.  Composite materials must be matched to curing lights.  

Common photochemical initiators are:  
Acenaphthene quinone
Camphoroquinone
Benzyl 
  
PLASTICIZERS 
Dental composite is composed of a resin matrix and filler materials.  Coupling agents are used to improve adherence of resin to filler surfaces.  Plasticizers are solvents that contain catalysts for mixture into resin.   They need to be non reactive to the catalyst and resin.

Indications:

anterior composite restoration of surface defects, class 3, class 4, class 5, veneering, diastema closure, peg laterals, rotated teeth, periodontal papillae loss, porcelain repair, use as temporary crowns, general principles, color management, surface shaping, contouring and texturing, hypocalcification and craze line placement, direct and indirect posterior composites and esthetic recontouring.  
Dental composites are versatile and have many indications.



















  

ORAL CANCER

oral cancer definition:
 
a malignant neoplasm on the lip or in the mouth that occurs at an average age of 60, with a frequency eight times higher in men than in women. Predisposing factors are alcoholism, heavy use of tobacco, poor oral hygiene, ill-fitting dentures, syphilis, Plummer-Vinson syndrome, betel nut chewing, and, in lip cancer, pipe smoking and overexposure to sun and wind. Premalignant leukoplakia or erythroplasia or a painless nonhealing ulcer may be the first sign of oral cancer; localized pain usually occurs later, but lymph nodes may be involved early in the course. Diagnostic measures include digital examination, biopsy, exfoliative cytology, x-ray film of the mandible, and chest films to detect metastatic lung lesions. Almost all oral tumors are epidermoid carcinomas. Adenocarcinomas occur occasionally, whereas sarcomas and metastatic lesions from other sites are rare. Small primary lesions may be treated by excision or irradiation, and more extensive oral tumors may be treated by surgery, with removal of involved lymph nodes and preoperative or postoperative radiotherapy. Among chemotherapeutic agents administered are cisplatin, methotrexate, 5-fluorouracil, bleomycin, and adriamycin. Postoperative nursing care involves maintenance of airway patency, relieving pain, promoting adequate nutrition, and health teaching regarding follow-up care and psychosocial adjustment if body image has been affected.
Mosby's Medical Dictionary, 8th edition.

cancer (kan´sur),
n a malignant neoplasm. The term is sometimes incorrectly used to include any neoplasm, whether benign or malignant.
Carcinoma and
sarcoma are more specific terms.
cancer, oral,
n malignancies indicative of unchecked cell growth that are mainly found in and around the oropharynx, gingiva, floor of the oral cavity, lower lip, and base of the tongue.
Mosby's Dental Dictionary, 2nd edition. 

 

Types

Oral cancer is classified according to two criteria:
1. The cancer location. According to this criterion, there are two types of oral cancer:
1) Oral cavity cancer - the cancer that starts in the mouth, which includes the tongue, lining of the cheeks, gums and teeth, upper or lower jaw, the hard palate (the mouth’s roof), the mouth’s floor (the area beneath the tongue), and salivary glands.
2) Oropharyngeal cancer - the cancer that starts in the oropharynx, which includes the soft palates (the back of the mouth), the base of the tongue, uvula, and tonsils (one of two small masses of lymphoid tissue located on either side of the throat). Around two-thirds of the oral cancers are found in the mouth, while one-third are found in the pharynx.
2. The cells where the cancer starts. There are two types of oral cancer:
1. Squamous cell carcinoma: This is a type of cancer that starts in the flat cells (called squamous cells) that cover the surface of the oral cavity and orophadynx. Squamous cells carcinoma represents more then 90 percent of all oral cancers. In its early stages, this cancer is confined to the lining layer of the cells and is called carcinoma in situ, but when it extends beyond the lining, it is called invasive squamous cell carcinoma.
A variant of squamous cell carcinoma is verrucous carcinoma. This is a low-grade cancer that rarely metastasis, and has a good prognosis. This type of oral cancer is common among patients that chew tobacco or use snuff (a fine -ground tobacco which is sniffed or snorted). It represents less than 5 percent of all diagnosed oral cancers.
2. Minor salivary gland cancer: This is a type of cancer which starts within the salivary glands located in the oral cavity and orophadynx lining tissue. This is a rare type of oral cancer.

Causes and Risk Factors

The exact causes of oral cancer are not known, but there are a few factors which increase the risk for oral cancer. These risk factors are:
Smoking cigarettes, pipes, or cigars: This is one of the main risk factors that causes oral cancer. Smoking cessation represents one of the most effective prevention approaches.
Use of smokeless tobacco: The risk for oral cancer is also increased when people use smokeless tobacco such as plug, leaf, and snuff.
Excessive consumption of alcohol: This is another risk factor that directly causes oral cancer. Studies conducted in developed countries suggest that tobacco and alcohol, together, increases the risk for oral cancer by almost 80 percent because they act synergistically.
A deficient diet: The lack of vitamin A, C, and E, iron, selenium, and folate in the diet can increase the risk for oral cancer. Doctors recommend a low-fat, high-fiber diet rich in vegetables and fruits.
Exposure to ultraviolet radiation without proper sunscreen protection: The risk for lip cancer is high when exposed to the sun without a proper protection.
 
Infection with viruses: There are several viruses that seem to increase the risk for oral cancer:
  • Human papillomaviruses (HPV) - are a diverse group of DNA-based viruses that infect the skin and mucous membranes within the human body. Studies suggest that infection with HPV 16 and 18 (sexually transmitted viruses) increase the risk for oral cavity cancer and oropharynx cancer.
  • Epstein-Barr virus - is a virus from the herpes family that causes an asymptomatic infection called infectious mononucleosis (a medical condition common among young adults and adolescents, characterized by fever, sore throat, muscle soreness, and fatigue, and sometimes, with a development of white patches on the tonsils or in the back of the throat). The connection between the Epstein-Barr virus and oral cancer is still being investigated.
  • Herpes simplex viruses causes a viral infection. The connection between this virus and oral cancer is still being investigated.
Medical treatments: Patients that undergo a renal transplant are at a higher risk to develop lip cancer. This risk might be linked to the immunosuppressant effect that can follow the transplant.
Poor oral cavity hygiene and ill-fitting denture: These two factors can increase the risk for developing oral cancer when associated with tobacco use and alcohol consumption, offering a perfect location for tumors to develop.
Age: Men over the age of 40 are at higher risk for developing oral cancer.
Race: African Americans are at higher risk than Caucasians to develop oral cancer.
Gender: Men are at higher risk than women to develop oral cancer.

Signs and Symptoms

Unfortunately, most oral cancers are asymptomatic in the early stages and the symptoms occur when the tumor has reached an advanced stage of development.
Some of the symptoms include:
  • A mouth sore or ulcer that does not heal or bleeds easily.
  • A white or red patch in the mouth.
  • An irritation, lump, or thick patch in the mouth, lip, or throat.
  • A discomforting sensation such as something is caught in the throat.
  • Chewing or swallowing difficulties.
  • Difficulties moving the jaw or tongue.
  • Speaking difficulties.
  • Hoarseness, chronic sore throat, or changes in the voice.
  • Unexplained bleeding in the mouth.
  • Unexplained numbness, loss of feeling, pain or tenderness in the face area, mouth, or throat.
  • Jaw swelling which causes the denture to not fit anymore.
  • Ear pain.
  • Unexplained weight loss.
These symptoms vary from patient to patient, depending on the tumor type and location. Only a doctor can establish if the symptoms you display are signs of oral cancer or other medical conditions.

Stages

An important prognostic predictor for oral cancer is the clinicopathologic stage. A clinicopathologic stage describes the cancer developmental phase, and is established according to several criteria: (1) the tumor size, (2) the cancer location, and (3) the cancer extent (how far it has spread).
The most common staging system used for oral cancer is the American Joint Committee on Cancer (AJCC) TNM system. The TNM system refers to: (T) the tumor features -size and invasion level; (N) the lymph nodes involved - lymph nodes are part of the body immune system; (M) the cancer metastasis - metastasis stage is the last developmental cancer stage when the cancer has spread to distal organs (organs situated far from the origin point).

T stage for oral cancer

T0: No primary tumor is present.
Tis: Carcinoma in situ (the cancer is confined to the tissue where it developed)
T1: The tumor is 2 cm or less.
T2: The tumor is 4 cm or less.
T3: The tumor is larger than 4 cm.
T4: The tumor is larger than 4 cm, and it has deeply invaded the muscle, bone, or other adjacent structures.
N stage for oral cancer
N0: No lymphatic nodes are affected.
N1: The cancer has affected one homolateral lymphatic node, but its size is smaller than 3 cm.
N2: The cancer is present in one or more homolateral lymphatic nodes, but their size is smaller than 6 cm.
N3: The cancer is present in a few homolateral or bilateral lymphatic nodes, having a size larger than 6 cm.

M stage for oral cancer

M0: No metastasis are present.
M1: The cancer has spread to distal organs (organs located far from the origin point where the cancer had developed initially).
Based on the TNM system, the oral cancer is classified in four stages:
Stage I: (T1, N0, M0)
In this stage, the cancer is confined to tissue where it initially occurred, and the tumor is not larger than 2 cm.
Stage II: (T2, N0, M0)
In this stage, the tumor is no larger than 4 cm.
Stage III: This stage includes two substages:
Stage IIIA: (T3, N0, M0)
In this stage, the tumor is larger than 4 cm, but no lymphatic nodes or metastasis are present.
Stage IIIB: (T1, T2, T3, N1, M0)
In this stage, the tumor size is either less than 2 cm, under 4 cm, and 4 cm or over, but the cancer has affected one homolateral lymphatic node.
Stage IV: This stage includes three substages:
Stage IVA: (T4, N0, M0)
In this stage, the tumor is larger than 4 cm, and it has deeply invaded the muscle, bone, or other adjacent structures.
Stage IVB: (Any T, N2 or N3, M0)
In this stage, the tumor can have several sizes (1) less then 2 cm, (2) less or more than 4 cm, (3) more than 4 cm but it has deeply invaded the muscle, bone, or other adjacent structures, or the cancer has spread to several homolateral or bilateral lymphatic nodes.

Stage IVC
: (Any T, any N, any M)
In this stage, there are several situations which include the tumors having different sizes (between 2 and more than 4 cm), the cancer is present in the homolateral or bilateral lymphatic nodes and in other organs within the body.

Medical Tests & Diagnosis

Oral cancer symptoms can be similar with other medical conditions and only a doctor can establish a correct diagnosis. The diagnosis procedure involves a certain number of steps which include:
Anamnesis (detailed medical review of past health state):
One of the first steps in establishing an oral cancer diagnosis is a detailed and complex medical review of a patient's past health problems and general health state, family medical history, oral cancer risk factors (especially smoking habits, tobacco and alcohol use), and symptoms.
Physical examination
During a physical examination, the doctor examines the oral cavity and pharynx, the face, neck, and lips looking for signs of oral cancer. The doctors looks for any possible lump, abnormal or discolored tissue, or sores.
Imaging techniques
  • Computed Tomography: This imaging test is similar with an x-ray test, and creates a detailed, cross-sectional image of the body. This test can identify abnormal mass tissues.
    A CT scan is usually performed in two steps for a better diagnosis outcome:
    1). First, the targeted area is scanned without a contrast agent.
    2). Second, the targeted area is scanned after a contrast agent was administrated.
    In patients that suffer from oral cancer, this technique is used to localize metastases.
  • Magnetic resonance imaging (MRI): An MRI is an advanced technique that uses radio waves and strong magnets to reveal a complete image of a targeted area of the body. The energy from the radio waves is absorbed by the tissues and then released into a pattern that allows the cancer to be detected and diagnosed. This technique is also used to establish whether or not the cancer has spread, and to visualize its location within the body.
 
  • Ultrasonography: Ultrasound imaging is a medical technique that uses high-frequency sound waves to create an interior image of the body on a special computer screen. This image is formed from the echoes of the sound waves on the surface of the organs. Abnormal tissue masses and organs reflect sound waves differently. This test involves a device called transducer, that is placed on the upper part of the abdomen, and a computer that translates this sound into an image. Ultrasound imaging is a safe, noninvasive and fast test that can detect tumors.


  • Endoscopy: This is a minimally invasive, painless diagnostic procedure used to visualize interior surfaces of certain organs and cavities. During this procedure, a flexible tube, called an endoscope, is inserted into the body in order to provide a clear image of the targeted area. This procedure is used to investigate tissues within the pharynx area which cannot be visualize during a normal examination.

  • Biopsy:
    This is a painless medical procedure that removes a certain amount of tissue for a microscopic examination. This procedure allows the pathologist to establish the nature of the cells and determine whether they are cancerous or not, and the stage of the cancer. In some cases, the doctor might perform a scalpel biopsy. A scalpel is a thin, straight surgical knife used in dissection and surgery. This type of procedure is performed under anesthesia to reduce patient discomfort. 

Treatment Options

The treatment plan for oral cancer varies from patient to patient and is established according to five main factors: (1) the patient's age, general health and past medical history, (2) the cancer type, size, and location, (3) the treatment tolerance, (4) the risk for hidden disease, and (5) the need to save certain functions.
A better treatment outcome is achieved in patients diagnosed with oral cancer in early stages.
The main treatment approach in patients with oral cancer are: surgery and radiotherapy. Chemotherapy is also used to treat oral cancer, but it is usually used in patients with metastasis and it does not represent a primary treatment approach for oral cancer.
Surgery
Surgery is a medical procedure aimed to completely remove the tumor tissue together with adjacent healthy tissue in order to prevent a future cancer relapse.
There are six surgery techniques performed in patients with oral cancer. These are:
  1. Primary tumor resection: This is a type of surgery where the entire tumor together with surrounding tissue is removed.
  2. Mandible resection: This is a type of surgery where the tumor is removed together with part or the entire jaw bone.
  3. Maxillectomy: This is a type of surgery where the tumor is removed together with part or the entire hard palate (the roof of the mouth). This surgery is usually performed when the cancer has spread to the mouth roof bone.
  4. Mohs' micrographic surgery: This is an advanced surgically procedure that relies on the microscope accuracy to trace and assure a complete removal of the cancer down to its roots, leaving healthy tissue unharmed. Moh‘s micrographic surgery removes the tumor in thin layers. Each layer of tumor removed is checked under a microscope for cancer cells and the procedure will continue until there are no more cancer cells in the removed layer. This type of surgery can be performed when the tumor is on the lip.
  5. Laryngectomy: This type of surgery is performed in patients with large tumors on the tongue or oropharynx. In some cases, the surgeon has to remove the larynx (the voice box).
  6. Neck dissection: This type of procedure is performed when the cancer has spread to the lymph nodes within the neck. During this procedure, the tumor is removed together with the lymph nodes affected by cancer.
When performed in early stages, the surgery is small with less post-surgery scars or disfiguration. When performed in advanced stages, the surgery is complex, it removes a substantial amount of tissue, and in most cases requires future reconstruction work.
The side effects are also influenced by the complexity of the surgery and the tumor size. The most common post-surgery side effects include:
  • Swelling (the tissue around the operated area can swell for couple of weeks).
  • Pain
  • Feeling tired
  • Weakness
When the removed tumor is too big and the procedure involves removing surrounding tissues or organs (such as palate, tongue, or jaw), the patient can experience the following side effects:
  • Disfiguration
  • Chewing, swallowing, or talking difficulties
Radiation therapy or radiotherapy
This is a local type of therapy that uses high-energy rays or particles to destroy cancerous cells. The purpose of this treatment is to destroy cancerous tissues preserving the healthy tissue. Radiation therapy is used (1) as a curative treatment in patients that cannot be operated on with small tumors, (2) as an adjuvant treatment - in addition to surgery (to enhance the results of the surgery by destroying possible cancerous cells that could have been left behind, and reducing the risk of cancer relapse), 3) as a neoadjuvant treatment - before surgery (to reduce the size of the tumor).
There are two types of radiation therapy performed in patients with oral cancer:
1. External beam radiation: This form of radiation therapy uses a device called a linear accelerator that generates an external beam that is concentrated on the tumor area and breaks it up into smaller pieces. Sessions last a few minutes and are administered every day for several weeks.
 
2. Internal radiation: The radiation is administrated from radioactive materials (such as seeds, needles, thin tubes) inserted into the tumor. When this time of treatment is administrated, the patient has to stay in the hospital.
In some cases, a patient can receive both types of radiation therapy for a better treatment outcome.
Radiation therapy side effects depend mainly on the radiation dosage and the targeted area. The most common side effects displayed by oral cancer patients that undergo radiation therapy are:
  • Dry mouth.
  • Eating, swallowing, and talking difficulties.
  • Mild to major tooth decay (this side effect can be diminished with a correct and good mouth care, keeping the teeth and gums healthy).
  • Sore throat or mouth (painful sores and inflammations).
  • Sore or bleeding gums.
  • Mouth infections (radiation therapy can damage the mouth lining causing infection).
  • Delayed healing (radiation therapy can slow down the healing process for the mouth tissue).
  • Jaw stiffness (radiation therapy can affect the chewing muscle which leads to difficulties in opening the mouth).
  • Denture problems (radiation therapy might cause the denture to not fit anymore).
  • Taste and smell changes (during radiation therapy the food might taste and smell different).
  • Voice quality changes (the voice might become weak especially at the end of the day).
  • Larynx swelling (this also cause the voice to change and the patient can feel a lump in their neck).
  • Thyroid changes (radiation therapy might affect the normal function of the thyroid, decreasing the amount of hormones normally produce by this gland. These can cause the patient to gain weight, to feel tired, to have cold sensations, and dry skin and hair.
  • Dry, red and extremely sensitive skin in the area exposed to radiation.
  • Fatigue.
Most of these side effects can be controlled and diminished with medication.

Chemotherapy

This is a systemic type of treatment (affects cells throughout the entire body) that uses drugs either to stop the abnormal growth and dividing process of the cancerous cells, or to kill them. This treatment also has the ability to interfere with the cancerous cells’ replication.
Chemotherapy can be administrated in combination with surgery and radiation therapy for a better treatment outcome. The chemotherapy drugs can be given intravenous or as pills.
Chemotherapy side effects include:
  • Mouth bleeding and deep pain (that is felt like a toothache).
  • Dry mouth
  • Gums pain
  • Taste changes
  • Mouth infections
  • Temporary hair loss
  • Nausea with or without vomiting
  • Diarrhea
  • Loss of appetite
  • Fatigue
  • Weakness
  • General vulnerability to infection
  • Easy bleeding and bruising
These side effects vary from patient to patient according to the drugs and the body reaction to these drugs. Some side effects can be controlled with medication to increase the patient’s comfort during the treatment.

Ludwigs Angina


LUDWIG’S ANGINA

DEFINITION

It is defined as the acute toxic swelling with bilateral involvement of the sublingual,submandibular,and submental spaces.

HISTORIC BACKGROUND:

It is a distinct clinical entity known since the time of Hippocrates.
It was first described by ‘Wilhelm Friedrich Von Ludwig’
But the name was coined by ‘Cramer’ in 1837 who presented cases which include classical description of entity by W.F.Ludwig.

AETIOLOGY:
1.Odontogenic infections:
a.Acute dentoalveolar abscess
b.Acute periodontal abscesss
c.Acute pericoronal abscess
most commonly teeth involved are mandibular second & third molars
2.usage of contaminated needles
3.traumatic injuries of orofacial regions
4.submandibular & sublingual sialadenitis
5.secondary infections of oral malignancies
CLINCAL FEATURES:

GENERAL FEATURES:
Constitutional features like pyrexia ,anorexia,chills and malaise.
Patient looks toxic very ill and dehydrated.

SPECIFIC FEATURES:
1. Swelling develops and spreads rapidly involving submental & submandibular lymph nodes bilaterally which soon extends into the anterior part of the neck into the clavicles.
2. It is described as the brawny, non-pitting, non-fluctuant swellingassociated with severe tenderness.
Classically it shows ill defined borders with induration.
3.Because of its location ,the floor of the mouth and tounge becomes elevated causing difficulty in breathing.
4. in extreme cases tounge may actually protrude from the mouth and its movements are reduced.
5. deglution and speech may also become difficult.
6. saliva may drool from the mouth.
7. this situation may be compounded by the edema of glottis causing  STRIDOR which is the alarming sign of this fatal extension needing emergency intervention.
8. signs and symptoms of respiratory obstruction:
a.increased respiratory rate
b.breathing being shallow with use of accessory muscles of respiration.
c.dilation of external nares
d.raising of thoracic inlets
e.indrawing of tissues above clavicles
f.cyanosis may be seen because of the progressive hypoxia.

Pathology:
It is a diffuse inflammation of soft tissues which is not circumscribed to one area in contrast to an abscess.
Usually caused by microbes which produce hyaluronidases and fibrinolysins which break tissue continuity.

Microbiology:
A plethora of microbes were identified as the causative organisms.
Streptococci the potent producers of hyaluronidase are always associated with classical ludwigs angina.
While the others are
-Staphylococci
-Gram negative entric organisms like..e.coli, pseudomonas.
Anerobes like..bacteriods(B.melanogenicus, B.oralis, B.corrodense).

Investigations:


 1.   General medical examination
 2.   Evaluate laboratory data for blood count, haemoglobin and proteins.
 3.   Pus samples sent for culture.
 4.   Chest radiograph to rule out pneumonia

Management:
 a.   Early diagnosis
 b.   Maintanence of patent airway
 c.    Intense and prolonged antibiotic therapy
 d.   Extraction of offending tooth/teeth
 e.   Surgical drainage or decompression of fascial spaces
 Commonly used antibiotics:

Bactericidal:
1.Aminoglycosides
amikacin                                                              
gentamycin                                                     
streptomycin                                                       
tobramycin                                                           
2.cephalosporins
3.penicillins

Bacteriostatic:

Chloramphenicol
clindamycin
erythromycin
lincomycin
tetracylines

SURGICAL MANAGEMENT:
It is by surgical decompression. The advantages of early surgical intervention are:
a. reduces pressure of the edematous tissue on the respiratory tract.
b. allows samples and specimens for culture and lab diagnosis.
c. allows for the placement of the drains
d. allows prompt drainage.
Following  adequate  anesthesia bilateral sub-mandibular  incisions and if required a midline submental incision  1cm below the inferior border of mandible are sufficient to drain the spaces.
                                  To be effective it is essential to divide deep fascia and mylohoid muscle, then only it will drain sublingual space.
In most of the cases of the ludwig’s angina little or no pus can be drained by surgical intervention.But,in later stages or during post-operative period profuse pus may be seen draining.
Care should be taken to prevent injury to following:
1.   Facial vessels near angle
2.   Lingual nerve
3.   Jugular vein laterally below angle region.

Apart from this patient should be hydrated because he might be dehydrated because of the following reasons:
1.   Diminished liquid intake due to dysphagia
2.   Due to toxic nature of the condition there might be excessive urination and perspiration with elimination of body fluids.

COMPLICATIONS:
a.   Osteomyelitis
b.   Maxillary sinusitis
c.    Localized respiratory tract disturbances
d.   Digestive tract disturbances
More serious complications include:
e.   Septicaemia
f.      Mediastinitis
g.   Neurological complications
h.   Cavernous sinus thrombosis
i.      Brain abscess
j.      Death…if untreated with in 12-24 hours after acute attack  due to asphyxia.