Odontogenic Keratocyst 

 

Odontogenic keratocyst (OKC) is a parakeratin lined cyst like lesion within bone.

OKCs mostly occur in the 2nd and 3rd decades of life; although can occur over a wide age range with male predilection. Odontogenic keratocyst comprises of 4 to 12 percent of all odontogenic cysts. Ninety percent of odontogenic keratocysts are solitary. Multiple cysts are found in Nevoid Basal Cell Carcinoma Syndrome / Gorlin Syndrome[1]. 

The most commonly involved body part in mandible, 65-85%; mostly posterior mandible. Normally, they are associated with third molars but may be present without associating with third molars; rarely occur in soft tissues.

They are considered to arise from dental lamina. 

Clinical Features 

Odontogenic keratocysts are often asymptomatic. They are incidentally discovered on radiographs. They can cause symptomatic swelling. They can cause parasthesia of lip and teeth. Symptoms of pain and drainage are found if secondarily infected. They can cause local bone and soft tissue destruction, but usually spare teeth and roots.

Swelling observed at the right buccal mucosa (dotted area) posterior to the orifice of Stensen’s duct-arrow head [3].

Odontogenic keratocyst-exposed anterior to the masseter muscle.

Radiographic features 

Mostly, they are seen as small unilocular radiolucent lesions with variable sclerotic margins. Larger lesions are often seen multilocular with variable scalloped margins. Therefore, They may resemble radicular cyst, dentigerous cyst, lateral periodontal cyst, and ameloblastoma.

Keratocystic Odontogenic tumer in orthopantomograph being shown as  multiple radiolucencies associated with mandibular anterior region, maxillary right and left as well as mandibular left impacted third molar tooth [5].

Classic look to a keratocyctic odontogenic tumor in the right mandible in the place of a former wisdom tooth. Unicystic lesion growing along the bone. Lesion was seen by oral surgeon on routine panoramic radiography without any symptoms [2].

Histology

Histological findings in the above slides are
a: The cyst wall is lined with parakeratinized squamous cells with a corrugated surface.
b: Nuclei of the cells in the basal layer are palisaded. The rete ridge of the epithelium is not evident [3]. 

Differential Diagnosis

1. Ameloblastoma
2. Dentigerous cyst
3. Peri-apical cyst
4. Lateral periodontal cyst

Prognosis

Recurrence rates of OKC are from 20% to 56% with enucleation alone. Resection have been reported to have no recurrences, but it may be considered excessive for a benign cyst.

Multiple lesions can occur when OKCs are associated with Nevoid Basal Cell Carcinoma Syndrome (NBCCS)/Gorlin Syndrome Therefore, early diagnosis and follow-up of the patient with OKC is important as there is always a possibility of developing other features of NBCCS in the future.

Treatment

Treatment is given taking into consideration of recurrence and morbidity. Following are the treatments given alone or in combination to a patient of odontogenic Keratocyst. 

1. Decompression.
2. Enucleation with possible curettage.
3. Chemical curettage with Carnoy’s solution.
4. Marsupialization.
5. Resection.

Case Studies

For further studies on case reports, you can consult the reference number 4 and 5.

Ref:

1. Morrison A. Odontogenic keratocyst. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/mandiblemaxillakeratocyst.html. Accessed September 11th, 2022.
2. https://en.wikipedia.org/wiki/File:Classic_keratocystic_odontogenic_tumour.jpg
3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3837368/figure/F1/
4. https://www.pathologyoutlines.com/caseofweek/case503.htm
5. K. M. Veena, Rekha Rao, H. Jagadishchandra, Prasanna Kumar Rao, "Odontogenic Keratocyst Looks Can Be Deceptive, Causing Endodontic Misdiagnosis", Case Reports in Pathology, vol. 2011, Article ID 159501, 3 pages, 2011. https://doi.org/10.1155/2011/159501

   

Classification of Epithelia

The main criterion for the division of keratinized epithelia is the presence or absence of nuclei in the keratinized layer viewed under light microscope. In the orthokeratinized epithelium the cell nuclei disappear in the keratinized layer, whereas in the parakeratinized epithelium flattened, highly condensed nuclei remain in the cell cytoplasm of the keratinized layer until cells exfoliate. 

Ref: https://www.sciencedirect.com/science/article/abs/pii/S0968432814001486#:~:text=In%20the%20orthokeratinized%20epithelium%20the,the%20keratinized%20layer%20until%20exfoliation.

INBDE - Integrated National Board Dental Examination

 What is the INBDE?

The Integrated National Board Dental Examination (INBDE) is the 500-item licensing exam administered by the American Dental Association (ADA) which allows graduate dental students to practice in the United States of America. The content of the INBDE is formulated by the Joint Commission on National Dental Examinations (JCNDE).

An Introduction to Dental Crowns

 

• Dental Crowns

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• Crowns are a far more complex procedure than most people realise. To make a good quality crown, a dentist has to work in within a fraction of a millimetre. There is almost no margin for error. Getting the appearance correctly and communicating accurately with the dental lab can be an issue. Added to these, discussions about the balance between appearance and maintaining tooth tissue can be tricky. It can take a lot of painstaking adjustment at every step. Add in time pressure and any other added difficulties and it's a recipe for a stressed dentist, particularly if the dentist has recently graduated with limited experience. 

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• A calm and supportive dental nurse can work slickly with the dentist and makes the entire procedure easier. The roles of a good dental nurse and efficient lab technician are vital to the success of crowns.

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  Diagram showing transvers view of a tooth showing shape and thickness of a dental crown in pink colour.

  
  

• Planning for Making a Crown

• The first stage is the treatment planning, and deciding whether or not to place a crown. A decision has to be made about whether a filling is sufficient, whether a crown is most appropriate, or whether the tooth has become unrestorable and an extraction is the only choice. Crowns can be quite destructive due to the amount of tooth material to be removed. On the contrary, the advantage of the crowns is that they can be protective to the tooth and can help to hold the tooth together just like a helmet on the head, preventing the tooth splitting outwards, specifically after a root canal treatment. No restorative material can replace original tooth tissue so unnecessary tooth destruction must be avoided. so although they certainly have their place, crowns should not be placed without good reason.

•  

• The next big question comes is whether the patient's priority is the appearance or saving tooth tissue. Sometimes choosing to aim for the optimum appearance can be done without endangering the pulp of the tooth but at other times a compromise has to be made in order to keep the tooth alive and healthy. Some patients will be willing to accept a metal-coloured tooth quite happily to keep as much of their own tooth as possible because the metal crowns can be made much thinner, but for others that will not be an acceptable option.

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• At most occasions, compromises are done and agreed upon, like a metal band around the gingival margin of the tooth, or just having the visible part of the crown tooth coloured and the rest metal coloured. Discussing the patients' priorities and making sure that they know what exactly they will get end of treatment is a very important part of the process, to ensure their happiness and satisfaction.

• Another important part of the planing is checking whether the tooth is vital. Often crowns are placed following root canal treatment. Therefore, it is important to check that any infection under the tooth has improved. If the tooth is not root canal treated, then vitality tests and radiographic examination is a must for long term prognosis.

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• Crown Preparation

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• The first stage of the crown preparation appointment is normally making an impression for making a temporary crown while the permanent crown is being fabricated. The impression can be made using alginate or putty. Alginate needs to be mixed smoothly and the impression needs to be accurate with no big air bubble in the relevant area specially the margins. Putty needs to be used if the impression may be needed at a later date, as alginate impressions soon lose their shape.

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• Then comes the actual ‘crown preparation’ stage. Local anaesthetic is normally given to anaesthetise the tissues around the tooth being prepared. Cutting the tooth for the crown is the time where the dentist's real skill is needed. The amount of tooth tissue removed and the space needed for the crown depends on the material to be used for each part of the crown. A thicker porcelain is needed for porcelain whereas metal need to be kept thinner. For a patient, the difference between little tooth tissue removal and too much removal is fairly small. The dentist will try to create a clear margin, ideally finishing on natural tooth rather than filling material, for the dental lab to work on. On one hand, a written laboratory authorisation form will communicate a lot of the information about the crown to be made, the work done on the actual tooth can give a lot of information about what the dentist is intending for the tooth and how they want the lab to make the crown. The margin needs to be clear in order for it to be picked up clearly in the impression so that the lab has something useful to work with and so that the end result is good.

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• Shade Selection

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• After the crown prep is completed, the shade(s) for the crown needs to be decided on, in the case of porcelain. A shade guide is used and the dentist will look at different shades compared with the surrounding teeth. If the crown is full porcelain, rather than part porcelain with metal underneath, the dentist may also record the colour of the tooth underneath that is being crowned. This can then be communicated to the lab, to give them a greater idea of what they are working with, as the underlying colour can shine through and affect the colour of the crown needed. Any little details wanted, for example, stains or slight cracks on the tooth, can also be recorded and communicated.

• 
  

• Before the patient leaves, the tooth needs to be temporised. This is where the tooth is covered in order to keep it safe and healthy while the crown is made by the lab. It also helps to prevent movement or further eruption of the tooth that could prevent the crown fitting. The impression taken earlier in the process is used; temporary crown material is put into the impression and the impression is put back over the tooth. A small blob of the material is often put somewhere to give an indication of when the material is set. Once the material has set, the impression and temporary crown is removed. The edges are smoothed off using polishing discs. Temporary cement is then used for cementing the temporary crown in place.

• 
  

• The dental laboratory will then make the crown. This is also a very complex process, but largely falls outside of the clinical practice. The dental technician will fill the impression with dental stone to create a model/die of the tooth to work on. The lab will work to the instruction of the dentist, creating what has been asked for. The process will vary depending on whether it is a full metal, a porcelain fused to metal or a full porcelain crown.

• 
  

• Once the crown returns back from the lab, the dentist will check that it is as they expected. They will check if the crown goes on and off on the model perfectly.

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• Crown Cementation

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• The temporary crown will be removed, the temporary cement will be cleaned off the underlying tooth and a cement will be decided upon. The crown will be tried in and out so that the dentist is certain about the placement of the crown. Cement will then be mixed and put into the crown, the tooth will be dried, and the crown will be placed. Excess cement will be cleared away using floss and dental instruments. Pressure will be maintained on the crown so that the cement sets with the crown fully seated/in the correct position.

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• The patient will then be asked how it feels to bite on. Often it will be slightly ‘high’, so the dentist will mark the teeth using articulating paper, so that the heavy contacts show up. Adjustments will then be made so that the crown is comfortable and doesn't interfere with the patient's bite.

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• Crowns can be a fabulous restoration, helping to save teeth that would otherwise have to be extracted. They can also be a very aesthetic option, particularly those made of/with porcelain. Crowns can be a very complex and involved procedure, but really demonstrate the important roles that different members of the dental team play in producing an end result that really meets the needs of/pleases the patient.

•  

• Summary of stages:

1. Deciding whether a crown is the most appropriate restoration
2. Planning the material(s) of the crown
3. Taking an impression to allow a temporary crown to be made
4. Shaping the tooth ready for the crown
5. Temporising the tooth
6. The crown is made by the lab
7. The temporary crown is replaced with the permanent crown
8. Any necessary adjustments are made.

Ref: British Dental Journal

Bacterial Infection of the Oral Cavity

 

Bacterial lesions causing ulcerative conditions in the oral cavity

1. Syphilis
2. Gonorrhoea
3. Tuberculosis
4. Leprosy
5. Actinomycosis
6. Noma

For paid courses, a detailed description of the bacterial infection of the oral cavity is given HERE.

Properties of Dental Materials- Terminology

You must know the properties of the materials used in dentistry to understand its function and how and why it works in oral cavity. It also helps in manipulating it. The main properties you should know about are following:

• Stress
• Strain
• Elasticity Modulus
• Elastic Limit
• Thermal Expansion
• Hygroscopic Expansion
• Setting Expansion

To read the entire lecture (in premium Iridium course), click at the link HERE.

Annealing: Annealing is a process of heating and cooling of metal in a controlled manner. It is done/designed to produce desired properties in a metal. it is typically done to make the metal softer, increase ductility, stabilise the shape and improve/increase the machinability. When we talk about annealing of gold foil, it typically is done to remove surface contaminants just before the condensation.

Dental Anatomy and Terminology

Anatomy of the tooth and surrounding tissues

Enamel: This is the hard, calcified substance that makes the surface of a crown of a tooth.

Dentin: This is the calcified tissue that forms the major part of a tooth. In the crown of the tooth, the dentine is covered by enamel. The pulp
chamber of the tooth is surrounded by dentine.

Pulp: This is the organ at the centre of a tooth that contains blood vessels, connective and neural tissue, and cells that produce dentine-odontoblast. Blood vessels and neural tissue enter the tooth from the apex of the root.

Gingiva: This is the marginal part of the gum that surrounds the tooth where it emerges from the deeper, supporting tissues.

Periodontal ligament: This is the ligament that connects a tooth, by its root, to the supporting bone.

Cementum: This is the calcified tissue on the surface of the root of a tooth, which provides attachment for the periodontal ligament.

Fissure: It is a naturally occurring crevice in the enamel.

Crown: This is the part of the tooth that is visible and is above the gingival margin.

Root: This is the part of the tooth below the gingival margin; it is connected through cementum on its surface and the fibres of the periodontal ligament to the supporting bone.

Dental numbering system

There are numerous dental numbering systems to identify teeth and their maturity. The most commonly used system in Australia is the Federation Dentaire Internationale (FDI) system (see Figures). When communicating with a dentist, identify which numbering system is being used.

The FDI numbering system divides the mouth into quadrants. The first number indicates the quadrant and whether it is a primary or secondary tooth. The second number indicates the tooth; tooth numbering begins at the central incisor and counts backward to the molars.

Using the FDI numbering system, for adults, the quadrants are numbered as:

1. patient’s upper right is quadrant 1 
2. patient’s upper left is quadrant 2 
3. patient’s lower left is quadrant 3 
4. patient’s lower right is quadrant 4

For primary teeth in children, the quadrants are numbered as:

1. patient’s upper right is quadrant 5 
2. patient’s upper left is quadrant 6 
3. patient’s lower left is quadrant 7 
4. patient’s lower right is quadrant 8

Quick MCQ Test: 

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Ref: Therapeutic Guidelines 2019