Author: Dr.Urusa Inamdar

LYMPH NODES EXAMINATION

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Examination of neck nodes is important, particularly in head and neck Malignancies and a systematic approach should be followed.Neck nodes are better palpated while standing at the back of the patient. Neck is slightly flexed to achieve relaxation of muscles.

Lymph nodes of head and neck region are classified according to their position level:

  • Level I includes :
  1. IA Submental nodes , which lie in the Submental triangle, i.e between right and left anterior bellies of diagastric muscles and the hyoid bone.
  2. IB Submandibular nodes , lying between anterior and posterior bellies of diagastric muscle and the body of mandible.
  • Level II Upper jugular nodes :

They are located along the upper third of jugular vein, i.e between the skull base above and the level of hyoid bone ( or bifurcation of carotid artery ) below.

  • Level III Middle jugular nodes :

They are located along the middle third of jugular vein , from the level of hyoid bone above, to the upper border of cricoid cartilage.

  • Level IV Lower jugular nodes :

They are located along the lower third of jugular vein , from upper border of cricoid cartilage to the clavicle.

  • Level V Posterior cervical group :

They are located in the posterior triangle ,i.e between posterior border of sternocleidomastoid ( anteriorly ) , anterior border of trapezius ( posteriorly ) , and the clavicle below. They include lymph nodes of spinal accessory chain , transverse cervical nodes and supraclavicular nodes.

  • Level VI Anterior compartment nodes :

They are located between the medial borders of sternocleidomastoid muscles ( or carotid sheath ) on each side, hyoid bone above and suprasternal notch below. They include prelaryngeal, pretracheal , paratracheal nodes .

  • Level VII :

They are located below the suprasternal notch and include nodes of the upper mediastinum.

Examination of various lymph nodes:

  1. Submental nodes : Roll the fingers below the chin with patients head tilted forward.
  2. Submandibular nodes : Roll your fingers against inner surface of mandible with patients head gently tilted on one side.
  3. Parotid ( preauricular ) nodes : Roll your fingers in front of the ear , against the maxilla .
  4. Postauricular ( mastoid ) nodes : Roll the fingers behind the ears.
  5. Internal jugular chain : Examine the upper , middle and lower groups. Many of them lie deep to sternomastoid muscle which may need to be displaced posteriorly.
  6. Transverse cervical nodes
  7. Supraclavicular ( scalene ) nodes : Roll your fingers gently behind the clavicles.

A normal lymph node cannot be felt. If a node is palpable, it must be abnormal.

Area of lymphatic drainage of face :

The face has 3 lymphatic territories :

  1. The upper territory : Including the greater part of the forehead, the lateral halves of the eyelids, the conjunctiva, the lateral part of the cheek and the parotid area, drains into the preauricular (parotid) nodes.
  2. The middle territory : Including a strip over the median part of the forehead, the external nose, the upper lip, the lateral part of the lower lip, the medial halves of the eyelids, the medial part of the cheek and the greater part of the lower jaw, drains into the Submandibular nodes.
  3. The lower territory : Including the central part of the lip and chin, drains into the Submental nodes.

References:

A practical manual of Public Health Dentistry by CM Marya.

http://www.dentalcare.com

Written by - Dr.Urusa I Inamdar

RUBBER DAM ISOLATION

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Written by – Dr.Urusa I Inamdar

In 1864, S.C. Barnum, introduced the rubber dam into dentistry. It is used to define the operating field by isolating one or more teeth from the oral environment. The dam eliminates saliva from the operating site and retracts the soft tissue.

Advantages

  • A dry and clean operating field
  • Improved access and visibility
  • Potentially improved properties of dental materials
  • protection of the patient and operator
  • Operating efficiency

Disadvantages

Time consumption and patient objection are the most frequently quoted disadvantages of the rubber dam.

Certain oral conditions may preclude the use of the rubber dam , these include :

  • Teeth that have not erupted sufficiently to support a retainer
  • Some third molars
  • Extremely malpositioned teeth

In addition, patients suffering from asthma may not tolerate the rubber dam if breathing through the nose is difficult. Latex allergy.

However, latex free rubber dam material is currently available.

Materials

  • Holder
  • Retainer
  • Punch
  • Retainer forceps
  • Napkin
  • Lubricant
  • Modeling compound
  • Anchors

Hole size and position

Placement

  • Testing and lubricating the proximal contacts.
  • Punching the holes.
  • Lubricating the dam.
  • Selecting the retainer.
  • Testing the retainers stability and retention.
  • Positioning the dam over the retainer.
  • Applying the Napkin.
  • Positioning the Napkin.
  • Attaching the frame.
  • Attaching the neck strap ( optional )
  • Passing the dam through posterior contact.
  • Applying low fusing modelling compound ( optional )
  • Applying the anterior anchor ( if needed)
  • Passing the septa through the contacts without tape.
  • Passing the septa through the contacts with tape.
  • Inverting the dam interproximally.
  • Inverting the dam faciolingually.
  • Using a Saliva ejector ( optional )
  • Confirming a properly applied rubber dam .
  • Checking for access and visibility.
  • Inserting the wedges.

Removal

  • Cutting the septa.
  • Removing the retainer.
  • Removing the dam.
  • Wiping the lips.
  • Rinsing the mouth and massaging the tissue.
  • Examining the dam.

Alternate / additional methods and factors

The procedure just detailed describes the method of sequentially placing the retainer and rubber dam on the anchor tooth.

  • Applying the dam and retainer simultaneously.
  • Applying the dam before the retainer.
  • Cervical retainer placement.
  • Fixed bridge isolation.
  • Substitution of a retainer with a matrix.

Errors in application and removal

  • Off center arch form
  • Inappropriate distance between the holes
  • Incorrect arch form of holes
  • Inappropriate retainer
  • Retainer pinched tissue
  • Shredded or torn dam
  • Incorrect location of hole for class v lesions
  • Sharp tips on no. 212 retainer
  • Incorrect technique for cutting septa

Reference:

Sturdevant’s – Art and science of Operative Dentistry (4th edition)

HOT TOOTH

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Written by – Dr. Urusa I Inamdar

Hot tooth:

A tooth that is difficult to anesthetize is known as a ‘hot tooth ‘. This is most commonly encountered in a mandibular first molar tooth wherein after the anesthetic block , the patient may describe profound numbness of the ipsilateral lip and tongue but still may experience acute pain during the access opening procedure.

Most common sites of occurrences:

  • primary and permanent teeth
  • sites of recent or defective restorations
  • Sites of recent trauma
  • mandibular molars
  • patients with anxiety about dental treatment or patient who have been in pain for several days usually require a more sophisticated approach.

Signs and symptoms

Hypothesis

Mechanism

There is a special class of sodium channels on C – fibers, known as tetrodotoxin-resistant (TTXr) sodium channels. The expression shifts from TTX- sensitive to TTXr during neuroinflammatory reactions and the TTXr sodium channels play a role in sensitizing C-fibers and creating inflammatory hyperalgesia. One of the clinically significant characteristics of these sodium channels is that they are relatively resistant to lidocaine. These channels are five times more resistant to anesthetic than TTX- sensitive channels. Hot tooth may be explained by the fact that the TTXr sodium channels have not been adequately blocked by the anesthetic.

Management

Bupivacaine has been found to be more potent than lidocaine in blocking TTXr channels and may be the anesthetic of choice when treating ‘hot tooth.’ Supplemental intraligamentary or intraosseous injections are most helpful to ensure profound local anaesthesia.

References:

  • Grossman’s Endodontic Practice (13th edition)
  • Article – International journal of Biomedical research ( Hot tooth – A challenge to endodontists)