Different Types of Proteoglycan Sulfates

• Chondroitin sulfates are the most prominent proteoglycans in cartilage and bone.
• Keratin sulfates are most prominent in the cornea (type I) and loose connective tissue (type II).
• Heparin sulfate is present mostly in basement membranes, cell surfaces, and ECM.
• Dermatan sulfate is widely distributed in skin and vascular tissue.
• Hyaluronic acid is the most unique GAG in that it consists of an unbranched chain of repeating disaccharide units. It does not form a proteoglycan and does not contain sulfur. It is widely distributed in ECM, vitreous humor, synovial fluid, and loose connective tissue.

Q) Which of the following is the most abundant glycosaminoglycan?

A. Keratansulfate

B. Heparansulfate

C. Chondroitin sulfate 

D. Dermatan sulfate 

E. Hyaluronic acid

Fulcrum Lines in RPD

A fulcrum line is an imaginary line around which an RPD will tend to rotate. 
Fulcrum lines may be in the horizontal, frontal or vertical plane. 
An important point to remember: Indirect retainers provide resistance to rotational movement of RPD away from the denture bearing tissues around the retentive fulcrum line. 

LOCATION OF STABILIZING FULCRUM LINES
KENNEDY CLASS I - the fulcrum line passes through the rest areas on the most posterior abutment on either side of the arch.

KENNEDY CLASS II - the fulcrum line passes diagonally through the most posterior occlusal rests. In the image, the line is passing through abutment on distal extension side and the most posterior abutment on opposite side.

KENNEDY CLASS III - the fulcrum line is non-existent.A tooth supported RPD is totally supported by occlusal rests and has no rotation because of no soft tissue movement.

In above image,
posterior tooth on right side which has a poor prognosis and will eventually be lost,
fulcrum line is considered the same as though posterior tooth were not present.

In above image, with nonsupporting anterior teeth, adjacent edentulous area is considered to be tissue- supported end, with diagonal fulcrum line passing through two principal abutments as in class II arch

KENNEDY CLASS IV - the fulcrum line passes through the two most anterior rests adjacent to the edentulous space.

Abdominal Regions: Mnemonic

HELLO EIGHT is used:

H: Hypogastric region
E: Epigastric region
L: Lumbar region
L
U: Umbilical region

E
I: Iliac region
G
H: Hypogastric
T:

Chronic Periodontitis

What is periodontium? 

It involves all supporting structures which is composed of:

• gingiva
• alveolar mucosa
• cementum
• periodontal ligament
• alveolar bone

• Slowly progressive disease 
• It occurs in response to plaque and calculus. 
• It progresses aggressively in patients with
  • diabetes: type I 
  • Smoking habits: more attachment loss and bone loss, more furcation involved, and deeper pockets.
  • Thyroid condition 
  • It can occur in childhood and adolescence also

What is pocket? 

It is pathological deepened cervical gingiva. We can observe that junctional epithelium (attachment of gingival structure) is broken down or detached from coral end. This causes deepened sulcus. Hence, Plaque and calculus are deposited. 

Clinical Features

• Gingival Inflammation is present 
• We can see pocket formation
  • Slight: 1-2mm 
  • Moderate: 3-4 mm 
  • Severe: 5 mm or more 
• Loss of attachment (recession) 
• Presence of inflammatory swelling
• Colour ranges from pale red to magenta 
• Loss of stippling 
• Blunted or rolled gingival margin
• Blunt or flattened interdental papilla 
• All the signs of inflammatory may not always be present 
• May bleed on probing the pocket 
• Increased gingival fluid exudation
• Purulent exudate may be present 
• Signs of inflammatory may be masked because of fibrotic changes
• Horizontal and Vertical bone loss 
• Progressive increase in the mobility of teeth involved due to bone loss

How do you differentiate periodontitis and gingivitis? 

It’s simple, in giginvitis, you can observe no bone loss and mobility whereas, in periodontitis, you can observe mobility, deep pockets and recession.

Differential Diagnosis

• Age of patient 
• Rate of disease progression 
• Familial nature of the aggressive disease
• Can be correlated with the amount of plaque and calculus present 

How to calculate whether chronic periodontitis is generalised or localised based on number of teeth? 

Rules: 

Generalised – when >30% of teeth show attachment loss 

Localised- when <30% of teeth show attachment loss

Let’s consider two type of patents. 

In patient A, the number of teeth is 32. 

We calculate 30% of total teeth, which means 10 teeth are affected by periodontitis. This denotes patient has the generalized condition.

If 7 teeth have recession and pockets, that’s is less than 10. The patient had localized condition. 

In patient B, the total number of teeth is 28

We calculate 30% of 28 teeth, which means 8 teeth are affected. This denotes patient has a generalized condition.

If 6 teeth have recession and pockets, that’s is less than 8. The patient had localized condition. 

Symptoms

• Usually painless due to absence of receptors
• Sometimes, localised dull pain radiating deep into the jaw during brushing 
• Sensitivity to hot and cold or both due to exposure of root dentin. The sensation will be tingling 
• Food lodgement in the areas of bone loss cause discomfort 
• Due to food accumulation, patients feel itchness in the gingiva. They try to remove it using a toothpick. 

Disease Progression

• Slow rate- depends on the post immunity but ageing or disease factors or diabetes play a role in the rate.
• Onset can occur at any time in the presence of calculus and plaque at site-specific surfaces. 
• It is more evident in the mid-30s due to accumulative effect. 
• Some areas progress at a faster rate or slower rate. 
• Faster Rate- due to more accumulation of plaque and short conical roots such as anteriors

Infective Endocarditis: Types

Defination

In simple words, It’s a microbial infection of heart valves or lining of endocardium.

The microbial organism can be bacteria or parasite or fungus or rickettsia or chlamydia.

Let’s check out different types!

1. Subacute Bacterial Endocarditis 
2. Acute Infective Endocarditis 
3. Post Operative Endocarditis 
4. Right Sided Endocarditis 

What’s Subacute Endocarditis? 

• It is caused by relevantly low virulence organisms like streptococcus viridan
• It mainly effects 
  • damaged heart valves
  • MacCallum plaque which is irregular thickness usually found in the left atrium in patients with rheumatic fever
  • Also, Low pressure areas of heart 
• What are the Characteristics Features? It’s simple 4 points 🙂 
  • Formation of vegetation 
  • Emboli formation 
  • Mycotic aneurism 
  • Valvular Regurgitation

What is Acute Infective Endocarditis?

• It is caused by high virulence organism like staph. aureus 
• It effects both normal and damaged valves
• Doc, you need to be careful cause clinical course can be fatal if untreated within 6 weeks!!
• What are the Clinical features? How is it different from subacute?
  • Valve destruction is greater 
  • Abscess formation is common
  • Valve cusp perforation can also occur

What is Post-operative Endocarditis? 

• As the name indicates, during cardiac surgery, the patient develops infective endocarditis 
• What is a prosthetic valve? It’s an artificial valve replacing the mitral or aortic valve 
• It mainly affects the prosthetic valves, especially aortic valve 
• Source of infection- staph epidermis 
• Generally, within 3-60 days of a health care facility admission, the nosocomial infections will cause endocarditis
• It accounts for 20% of Infectious Endocarditis. So, provide clean facilities in hospital, doc.
• Typically, it is associated with invasive procedures like dental procedures and intravenous access.

What is Right-sided Endocarditis?

• Who is mainly affected? Intravenous drug addicts 
• It is caused when they share a syringe with other people during drug abuse
• Source of infection: staph aureus and candida present on the surface of the skin
• So, the microorganisms enters into the body through veins during drug abuse.
• The right side of the heart is affected, especially tricuspid valve.
• Larger bloodborne particulate matter in IV drug abusers typically deposits on the tricuspid valve.
• Remember, tricuspid valve is rarely involved in other causes of Bacterial Endocarditis
• Generally, the clinical course will be subacute or chronic or insidius.

Infective Endocarditis- Pathophysiology

What are the sites where the infection can occur? Cause these are areas of the nidus where the infection can occur! 

• Normal cardiac endothelium 
• Damaged valves
• Mitral valve and aortic valve are most likely to be involved
• Surgically constructed AV shunts 
• Prosthetic valves

Imagine, a breach in the endothelium caused by

• Turbulent flow (e.g. valvular stenosis or valvular regurgitation) or 
• Intravascular device-related injury (e.g. catheters)

After the breach, the platelets and WBC’s aggregate near injured endothelium like soldiers and give rise to the thrombus.

If dental procedures or any surgery takes place after thrombi formation, chances of transitent bacterium to colonize the thrombi is more.

Hence, immune system will be form fibrin meshwork on bacteria to seal it.

So, thrombus + bacteria + fibrin = is called vegetation 

When vegetation is dislodged, it may go anywhere in the body. 

• It can form embolus
• Since, it contains bacteria, it’s septicaemia in nature 
• It contains foreign particles too, hence immunogenic in nature

Abrasion

In simple words, Abrasion is loss of tooth structure due to foreign substances , like heavy brushing, hard bristels. Abrasion occours in the cervical region of tooth

Etiology

• Faulty oral hygiene practice 
  • Horizontal brushing 
  • Excessive forces
• Quality of toothbrush 
• pH and amount of dentifrice used 
• Ill-fitting clasps of partial dentures cause localised abrasion lesions
• Fiction from toothpicks and interproximal brushes
• Tobacco Chewing

Treatment

We need to take careful consideration of aetiology and progression of the condition. That means, correct diagnosis is the prerequisite for the management of the lesion.

• If the lesion is localized and not interfering with the physiological function of the stomatognathic system = It may be restored 
• If the abrasion is generalized and substantial = the habit should be discontinued and controlled
• If teeth are sensitive = use Flouride application 
• If it’s class V lesion = Restoration with GIC
• If lesion involves a none conscious area in the posterior teeth = use metallic restorationon