Anatomy

Trigeminal nerve (CN V):

- From the Gasserian ganglion; trigeminal ganglion.

- Branches:

1- Ophthalmic nerve; exits the skull from the superior orbital fissure.
Sensory nerve
Branches:
a. Frontal nerve, gives off into supraorbital and supratrochlear nerves.
b. Lacrimal nerve.
c. Nasocillary nerve, gives off into
1- Infra-trochlear nerve.
2- Anterior ethmoid nerve.
3- Posterior ethmoid nerve.
4- Long ciliary nerve.
5- Communicating branch to ciliary ganglion.

2- Maxillary nerve:
Sensory nerve

- Maxillary nerve course:

Lateral wall of cavernous sinus à foramen rotundumà pterygopalatine fossa à
infra orbital fissure.
- Gives off Middle meningeal nerve Before entering the foramen Rotundum.

• From the pterygopalatine fossa:

a. Zygomatic nerve and its branches: zygomaticotemporal and zygomaticofacial
nerves.
b. Nasopalatine nerve from the sphenopalatine foramen.
c. Posterior superior alveolar nerve.
d. Greater and lesser palatine nerves.
Greater palatine nerve supplies gingiva and hard palate
Lesser palatine nerve supplies soft palate, uvula and tonsils.
e. Pharyngeal nerve.

à The most common complication of the posterior superior alveolar nerve block is hematoma
due to trauma to the pterygoid plexus of veins.

• In the infra- orbital canal:

a. Anterior superior alveolar nerve.
b. Middle superior alveolar nerve.
c. Infraorbital nerve.
à Infra orbital fissure is between the greater wing of sphenoid and the maxillary process.

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 • On the face:
a. Inferior palpebral nerve.
b. Superior labial nerve.
c. Lateral nasal nerve.

3- Mandibular nerve:
Both; sensory and motor nerve.

• Exits the cranial cavity through the foramen Ovale.

• From the main trunk:

Motor branches:
a. Medial pterygoid.
b. Tensor veli palatini.
c. Tensor tympani.
Sensory branch: meningeal branch.

• From the anterior division:

Motor branches:
a. Deep temporal nerves.
b. Masseteric nerve.
c. Lateral pterygoid nerve.
Sensory branch: buccal nerve.

• From the posterior division:

a. Auriculo-temporal nerve (sensory nerve)
b. Lingual nerve (sensory nerve)
c. Inferior alveolar nerve:
Gives off
1- Mental nerve (sensory nerve)
2- The nerve to mylohyoid nerve (motor nerve); which innervate mylohyoid
muscle and anterior belly of digastric muscle.

** Auriculotemporal nerve surrounds (encircle) middle meningeal artery.

** lingual nerve is located between hyoglossus and deep part of the submandibular gland.
** Inferior alveolar nerve in relation to mental foramen is superior and lateral.
** Mandibular foramen is located below the lingula.
** Superior orbital fissure: between greater and lesser wings of sphenoid.
- Contents passed:
1- CN III, IV, V1, VI
2- Superior ophthalmic vein.

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Facial nerve (CN VII):
Sensory and motor nerve.
- Exits the skull from the stylomastoid foramen.
- Two roots (motor and sensory) fuse to form the facial nerve before entering the petrous
temporal bone via the internal auditory meatus.
- Geniculate ganglion is a sensory ganglion of the facial nerve.
- Facial nerve pierces the posteromedial surface of parotid gland.

• intra- cranial branches:

a. Greater petrosal nerve; parasympathetic fibers to lacrimal gland and the mucous
glands in the palate and nose.
** pterygopalatine ganglion; AKA sphenopalatine ganglion.

b. Nerve to stapedius (motor).

c. Chorda tympani which carries:
1- Taste fibers for the anterior two third of the tongue.
2- Parasympathetic innervation to the sublingual and submandibular glands.
** submandibular ganglion.

• Exits the skull through the stylomastoid foramen (in the temporal bone) to gives off:
Motor branches:
a. Posterior auricular nerve.
b. Nerve to the posterior belly of digastric.
c. Nerve to stylohyoid muscle.

• Enter the parotid gland and gives off:

a. Temporal branch supplies:
1- Frontalis.
2- Upper part of orbicularis oculi.
3- Corrugator supercilii.

b. Zygomatic branch supplies:

1- orbicularis oculi.
2- Zygomaticus major.

c. Buccal branch supplies:

1- Orbicularis oculi.
2- Buccinator.
3- Zygomaticus major.

d. Marginal mandibular nerve supplies:

1- Depressor anguli oris.
2- Depressor labii inferioris.
3- Mentalis.
4- Orbicularis oculi.

e. Cervical branch supplies the platysma.

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 Chorda tympani:

- Nucleus of solitary tract; accept the taste fibers. à Gustatory cortex.

- Superior solitary nucleus; parasympathetic to submandibular and sublingual glands.
- Arises from geniculate ganglion.
- Emerges from petro tympanic fissure.
- Joins the lingual nerve of V3 in the infratemporal fossa.

Glossopharyngeal nerve (CN IX):

Sensory and motor nerve
- Exit the skull from the jugular foramen.
Branches: “This Could Pull Me To Love.”

1- Tympanic branch; Jacobson’s nerve.

Sensory and parasympathetic for the Otic ganglion.
Supplies:
a. Middle ear.
b. Eustachian tube.
c. Parotid gland.
d. Mastoid air cells.

2- Carotid sinus nerve.

3- Pharyngeal nerve.
4- Muscular nerveà supplies stylopharyngeus muscle.
5- Tonsillar nerve.
6- Lingual nerve; which is the terminal nerve that supplies the posterior one third of the
tongue.

Spinal accessory CN XI
- Divisions:
1- Cranial pass from jugular foramen to supply cranial muscles; larynx, pharynx and esophagus.
2- Spinal pass from foramen magnum to supply sternocleidomastoid and trapezius muscles.

- Spinal accessory nerve pass under the surface of the sternocleidomastoid at the posterior
margin, at the midpoint.
- Torticollis: head tilt to the affected side, as a result of injury to the sternocleidomastoid.

CN XII lesions:
- Lower motor neuron: tongue toward side of lesion.
- Upper motor neuron: tongue away from side of the lesion

** Hypoglossal nerve is lateral to the common carotid artery (external and internal carotid arteries)
**The only cranial nerve to emerge from the dorsal side of the brain is the trochlear nerve.

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Tendinous ring “Annulus of Zinn”:
- Four Rectus muscles: inferior, superior, medial and lateral Rectus.
- Nerves passing through:
1. Optic.
2. Oculomotor.
3. Nasocillary of trigeminal
4. Abducens.
- Nerve pass medial to it: Trochlear.

Cervical plexus of nerves

- Lesser occipital nerve C2 supplies the area posterior superior to auricle, Skin of the neck and
scalp.
- Transverse cervical nerve C2, C3 carries sensory innervation to anterior and lateral neck
(anterior triangle).
- Greater auricular nerve C2-C3 innervate:
1- Skin over parotid.
2- Posterior aspect of auricle.
3- Area from angle of mandible to mastoid.

- Phrenic nerve:
• mixed sensory and motor (bilateral).
• C3, C4, C5 spinal nerves in the neck.
• Motor control of the diaphragm for breathing.
• Sensory à central tendon of diaphragm and mediastinal pleura. (around lung

- Ansa cervicalis
• Motor division of cervical plexus.
• Comes from C1 (runs with CNXII), C2,C3.
• Innervate all infra hyoid muscle except thyrohyoid (innervated by C1 via CNXII).
• On the anterior wall of internal jugular vein.

- Skin of the neck is supplied by C2, C3, C4

- C1 is motor only.
- Sympathetic nerve to heart: lower cervical and upper thoracic.

Cervical vertebra

- Atlas 1st cervical vertebrae has an anterior and posterior arch (no body or spinous process).
- Axis 2nd cervical vertebrae has an odontoid process.
- The Longest spinous process in cervical vertebrae: C7.
- The transverse foramen in the cervical vertebrae allow the passage of the vertebral artery.

** The trachea extends from C6 to T4.

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Arteries

External carotid artery

- Branches from the common carotid artery at the level of the upper border of thyroid
cartilage.
- Gives off branches and continues to the substance of the parotid where it ends as:
1- Maxillary artery.
2- Superficial temporal artery.

- External carotid artery supplies:

A. Most of head and neck (except the brain).
B. Carotid sinus; baroreceptor for blood pressure.
At the common carotid bifurcation.

C. Carotid body; chemoreception including CO2, O2, PH and temperature.

Posterior to the bifurcation.

** REMEMBER: carotid sinus and body innervated by Glossopharyngeal nerve CNIX.

Branches:
1- Superior thyroid artery.
2- Lingual artery.
3- Facial artery.
4- Ascending pharyngeal artery.
5- Occipital artery.
6- Posterior auricular artery.
7- Maxillary artery.
8- Superficial temporal artery.

Lingual artery
- Originate from the External carotid artery at the greater horn of hyoid (in the carotid
triangle.)
- Supplies:
1- Tongue.
2- Sublingual gland.
3- Floor of the mouth.

Branches:
a. Dorsal lingual.
b. Suprahyoid.
c. Sublingual arteries. (to the sublingual gland)

- Ends as the deep Lingual courses around hypoglossal nerve between hyoglossus and
genioglossus muscles.

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Facial artery
- Facial artery runs at the anterior border of masseter, deep to the submandibular gland.
- facial artery is considered in two portions:
a. cervical:
1- tonsillar supplies the tonsils.
2- Ascending palatine supplies the pharyngeal wall.
3- Glandular supplies the submandibular gland.
4- Submental supplies the area beneath the chin.

b. Facial:
1- Inferior labial supplies the lower lip.
2- Superior labial supplies the upper lip.
3- Lateral nasal supplies the lateral wall of nose.
4- Angular supplies the medial eye; anastomose with ophthalmic artery. à the terminal
branch of facial artery.

Maxillary artery
- Maxillary artery divided into three parts by lateral pterygoid muscle:

a. Mandibular.
1- Deep auricular.
2- Anterior tympanic.
3- Middle meningeal.
4- Accessory meningeal.
5- Inferior alveolar.

b. Pterygoid.
1- Deep temporal.
2- Pterygoid.
3- Masseteric.
4- Buccal.

c. Pterygopalatine.
1- Posterior superior alveolar.
2- Infraorbital becomes à Anterior superior alveolar.
3- Descending palatine which supplies the greater and lesser palatine arteries to
posterior palate.

- The terminal branch of maxillary artery is sphenopalatine artery.

- Middle meningeal artery and vein pass through foramen spinosum in the sphenoid bone.

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• At risk of superficial parotidectomy:
FEARS
F à Facial nerve.
Eà ECA
Aà Auriculotemporal nerve
R à Retromandibular vain
S à Superficial temporal artery

Internal carotid artery

- Internal carotid artery enters the cranium through carotid canal in the temporal bone.
- Internal carotid artery grooves the body of sphenoid.
- Carotid canal transmits:
1- ICA
2- Internal carotid plexus
From the neck to the cranial cavity.
Branches:
1- Anterior cerebral artery.
2- Middle cerebral artery; continuation of internal carotid artery.

** Internal carotid artery and external carotid artery separated by styloglossus muscle.
**the sympathetic chain is located posterior to the internal carotid artery

Subclavian artery
- Subclavian artery is divided into three parts by Scalenus anterior.
- Subclavian artery pass behind the Scalenus anterior.
- Scalene muscles: three pairs of muscles in the lateral neck (anterior, middle, posterior).
- Branchial plexus arises in the neck between scalenus anterior and medius.

Circle of Willis
- Contents:
1- Posterior cerebral artery.
2- Posterior communicating artery.
3- Internal carotid artery.
4- Anterior cerebral artery.
5- Anterior communicating artery.

- Feeder arteries:
1- Right and left internal carotid artery.
2- Basilar artery; which arises from convergence of right and left
vertebral artery.

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Kiesselbach’s plexus
- This plexus is the anastomosis of five arteries:
à from the maxillary artery:
1- Greater palatine artery.
2- Sphenopalatine artery.

à from ophthalmic artery:

3- Anterior ethmoid.

à from the facial artery:

4- Superior labial artery.
5- Lateral nasal branches.

External jugular vein

- posterior division of retro mandibular + posterior auricular vein
- Drains:
1- Skin
2- Parotid gland
3- Muscles of face and neck

Internal jugular vein

- anterior division of retro mandibular + anterior facial= (common facial vein)
- Common facial vein= anterior facial + anterior of retro mandibular vein.
- Internal jugular vein is forms from the inferior petrosal and sigmoid sinuses.
- Cavernous sinus drains into inferior petrosal vein into Internal Jugular Vein.

- The IJV is separated from the sympathetic chain by the prevertebral fascia, anterior-
lateral to the sympathetic chain, it is a continuation of sigmoid sinus.

Eye drainage
- Venous:
Medially à angular and ophthalmic veins.
Laterally à superficial temporal vein.

- Lymph:
Medially à submandibular nodes.
Laterally à superficial parotid and per-auricular nodes.

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SCALP
- The components of scalp:
1- Skin
2- Connective tissue
3- Aponeurosis
4- Loose connective tissue
5- Periosteum

- Scalp innervation: from trigeminal nerve and C2, C3.

• Trigeminal:
• Supra trochlear nerve; frontal branch of V1.
à anterio-medial forehead.
• Supra orbital nerve; frontal branch of V1.
à anterio- lateral.
• Zygomaticotemporal nerve; V2.
à temple.
• Auriculotemporal nerve; V3.
à anterior superior to auricle.

• Cervical:
1- Lesser occipital nerve; anterior division of C2.
à skin posterior to the ear.
2- Greater occipital nerve; posterior division of C2.
à skin of occipital region.
3- Greater auricular nerve C2-C3.
4- 3rd occipital nerve; posterior division of C3.
à skin inferior occipital region.

- Arterial supply of the scalp:

• From the external carotid artery:
1- Superficial temporal.
2- Posterior auricular.
3- Occipital artery.

• From the ophthalmic artery:

1- Supraorbital artery.
2- Supratrochlear artery.

- Lymphatic drainage of the scalp:

a. Anterior: parotid.
b. Posterior: occipital and posterior auricular (mastoid).

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 - Meninges: Epidural hematoma; involves the middle
à Epidural space meningeal artery. AKA; extradural hematoma.
1- Dura mater Subdural hematoma involves a bridging vein.
à subdural space Subarachnoid haemorrhage often
2- Arachnoid involved a ruptured aneurysm (eg, anterior
3- à subarachnoid space communicating artery.)
4- Pia mater

- Cerebrospinal fluid found in:

1- Subarachnoid.
2- Ventricles of the brain.

- Pterion = H shaped bony neurological land mark at junction of frontal, sphenoid,

parietal and squamous part of temporal.
• Between the anterior-inferior margin of the parietal bone and greater wing of sphenoid.
• Weakest part of the skull.
• Anterior branch of Middle meningeal artery runs beneath it.

- The cerebral venous system:

1- Superficial: superior sagittal sinus (superior longitudinal sinus)
• Unpaired area along the attached margin of flax cerebri.
• Allow the blood to drain from the lateral aspects of anterior cerebral hemispheres.
2- Deep.

- Torcula: connecting points of the:

1- Superior sagittal sinus.
2- Straight sinus.
3- Occipital sinus.

- Flax cerebri: fold of dura matter, arises from the crista galli of the ethmoid bone, around
corpous collosum between right and left central hemispheres, contains superior sagittal
sinus.
- Vein that connect venous sinuses with scalp = emissary vein.

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Tongue
- All muscles of the tongue are supplied by CN XII except the palatoglossus muscle which is
supplied by CN X (pharyngeal plexus).
- General sensation of the tongue: V3, IX and X.
- Taste sensation: VII, IX and X.

- Blood supply of tongue:

1- Lingual artery.
2- Tonsillar branch of facial artery
3- Ascending pharyngeal artery.

- Lymphatic drainage for posterior tongue:

a. Deep cervical lymph nodes
b. Initially = jugulo-digastric
c. Jugulo-omohyoid

- Lymphatic drainage for tip of the tongue: submental lymph nodes.

- Lymphatic drainage for lateral sides of the tongue (anterior two thirds): Ipsilateral
submandibular lymph nodes.

- Lymphatic drainage at the center of anterior two thirds of the tongue: Submandibular nodes
on both sides/ deep cervical lymph nodes.

- The medulla oblongata is responsible for swallowing.

- The brain stem controls mastication.

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Temporomandibular joint
- Bilateral synovial joint (diarthrodial).
- Upper compartment: translation.
- Lower compartment: rotation; hinge.

- Proprioception of TMJ:
1- Nerve to masseter.
2- Auriculotemporal nerve.
3- Posterior deep temporal nerve.

- Nerve receptors:
a. Capsule.
b. Ligament.
c. Lateral pterygoid muscle.

- Normal range of motion is 50mm opening, 10mm protrusive laterally.

- TMJ can be dislocated anteriorly only, known as lock jaw.
• Luxation: requires assistance for reduction.
• Subluxation: auto- reduces.

- TMJ displacement usually occurs anteromedial, collateral ligaments loosen or tear allowing
the lateral pterygoid to pull the disc anteromedially.

- Mandibular ligaments:
1- Temporomandibular ligament (lateral): limits the posterior movement.
2- Sphenomandibular ligament: remnant of Meckel’s cartilage.
3- Stylomandibular ligament: limits the anterior movement.
4- Otomandibular ligament:
a. Disco malleolar ligament: malleusà retro-discal tissue of TMJ.
b. Anterior malleolar ligament: malleusà lingula of the mandible via sphenomandibular
ligament.

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Muscles

- Infrahyoid muscles:
1- Omohyoid.
2- Sternohyoid.
3- Sternothyroid.
4- Thyrohyoid innervated by C1 via CN XII.

- Intrinsic muscles of the larynx:

5- Cricothyroid.
6- Posterior cricoarytenoid.
7- Lateral cricoarytenoid.
8- Thyroarytenoid.
9- Transverse and oblique arytenoids.
10- Vocals.

- Extrinsic muscles of larynx:

• Raise the larynx:
1- Suprahyoid muscles.
2- Stylopharyngeus.

• Depress the larynx:

3- Infrahyoid muscles.

- Muscles that open Eustachian tube:

1- Tensor veli palatini
2- Salpingopharyngeus.

- Tensor and levator veli palatini muscles prevent food from entering the nasopharynx.

- Muscle that abduct the vocal cords: posterior cricoarytenoid only.

- Muscles that adduct the vocal cords:

1- Lateral cricoarytenoid.
2- Thyroarytenoid.
3- Interarytenoid.
4- Cricothyroid.

- Vallecula: located between the root of the tongue and epiglottitis. (between
glossoepiglottic folds.)
à food dislodge in vallecular or pyriform recess.

- Rima glottidis: is the opening between the true vocal cords and the arytenoid cartilage of
the larynx. (opening between vocal folds)

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 - Glottis: composed of vocal folds (cords) and Rima glottis.

- All intrinsic laryngeal muscles supplied by the recurrent laryngeal nerve except cricothyroid
muscle supplied by external laryngeal (branch of superior laryngeal nerve

- Modiolus:
1- Orbicularis oris
2- Levator angulioris
3- Depressor anguli oris
4- Zygomatic major
5- Risorious
6- Buccinators
7- Quadratus labil superioris
8- Quadratus labil inferioris

- The Posterior portion of temporalis retracts the mandible.

- The Inferior belly (head) of lateral pterygoid open the mouth.

- Accessory muscles of inspiration:

1- Scalene
2- SCM
3- Trapezium
4- External intercostal

- Accessory muscles of expiration:

1- Internal intercostal
2- Abdominal

Skeleton

- Laryngeal skeleton:
1- Thyroid (Adam’s apple).
2- Cricoid: a complete ring around the airway.
3- Epiglottic (fibrocartilage).
4- Arytenoid (pair).
5- Corniculate (pair).
6- Cuneiform (pair).

** Cricoid and thyroid cartilage are hyaline cartilages.

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 - Lateral wall of orbital cavity is formed by:
1- Zygomatic bone.
2- Greater wing of sphenoid.

- Orbital margin is formed by maxilla and frontal bone.

- Body of sphenoid articulate with:

1- nasal septum in the midline.
2- Ethmoid anteriorly.
3- Vomer inferiorly.

- Pterygoid Hamulus: is the lower part of medial pterygoid plate.

Sutures

o Bregma is the junction between sagittal and coronal sutures.

o Coronal suture: junction between frontal and parietal.
o Lambdoid suture: junction between parietal and occipital.
o Squamous suture: junction between temporal and parietal.
o Calvarium suture: the junction between coronal, lambdoid and squamous. Have a parallel
pattern of growth.

Spaces

• Danger triangle of the face:

c. Superficial veins communicate with deep system (Dural sinuses)
1- Apex: infraorbital region.
2- Base: anterior maxilla and upper lip.

• Canine space = infraorbital space:

1- infraorbital nerve
2- angular artery + vein

b. Retropharyngeal space borders:

a. laterally by carotid sheath.
b. posteriorly by prevertebral fascia.

• Digastric triangle floor composed of mylohyoid and hyoglossus muscles.

• The floor of posterior triangle formed by prevertebral fascia.
• Inferior of posterior triangle is the clavicle.

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 General Pathology

• Autosomal abnormalities:
1- Down syndrome (trisomy 21)
Special findings:
a. Simian crease.
b. Epicanthal fold.
c. Decreased caries susceptibility as a result of Increased salivary flow.

2- Edward syndrome (trisomy 18)

Special findings:
- Rocker bottom feet.
- Malformed ear.
- Pinched facial appearance.
- Heart defects.
- Prognosis: months.

3- Patau syndrome (trisomy 13)

Special findings:
a. Cleft lip and palate.
b. Polydactyly.
c. Microphthalmia.
d. Microcephaly.
e. Brain abnormalities.
f. Heart defect.
g. Prognosis less than one year.

• Sex abnormalities:
1- Klinefelter syndrome (XXY)
2- Turner syndrome (XO)
Special finding: coarctation of aorta.

• Cystic fibrosis:
- Autosomal recessive genetic disorder, generalized exocrine dysfunction.
- Problem with Cl- transporter.
- Deletion in chromosome 7q 508 in the CFTR (cystic fibrosis transmembrane regulator) gene.
- Multiple organ systems; characterized by respiratory and digestive problems.

- Affect the movement of salt and water in and out of the cell with infection leads to build-up of
thick sticky mucous in body tubes (in the lung and digestive tract).
- Findings:
1- Chronic pulmonary disease.
2- Pancreatic exocrine insufficiency.
3- Meconium ileus.

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• White sponge nevus “cannon’s disease”, “familial epithelial hyperplasia”:
- Autosomal dominant.
- Mutation of keratin 4 and 13 genes.
- Bilateral white, rough, surface lesion caused by epithelial thickening of buccal mucosa.
- The lesion mimic check biting or Squamous cell carcinoma.
- No treatment required.

• Lesch- Nyhan syndrome:

- Genetic disorder; X linked recessive.
- More in Male.
- Increased level of uric acid production; mutation cause deficiency in enzyme leads to
hyperuricemia.

- Increase uric acid in blood and urine.

1- Characterized by self–mutilating behaviour; lip and finger biting.
2- Associated with severe gout (inflammatory arthritis) and kidney problems (stones).
3- Neurological signs:
a. poor muscle control.
b. intellectual disability (mental retardation).
4- Megaloblastic anaemia B12 deficiency.

• Gout: form of inflammatory arthritis, recurrent attacks of red tender hot and swollen joints
caused by deposition of monosodium urate.

• Tetralogy of Fallot:
Four congenital heart defects:
1- Ventricular septal defect. (most common type of heart defect.)
2- pulmonary stenosis.
3- misplaced aorta.
4- Thickened right ventricular wall; hypertrophy.

• Shock: decrease tissue perfusion; decreased blood flow; decreased O2 and metabolic supply to
tissue.
- Weak rapid pulse (tachycardia); decreased Cardiac output.
- Types:
1- Hypovolemic shock: decreased blood volume.
Examples:
o Haemorrhage.
o Dehydration.
o Diarrhea.
o Vomiting.
o Fluid loss from burn.

2- Cardiogenic: pump failure; left ventricle.

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 - Sudden decrease of cardiac output.
Examples:
o MI
o Arrhythmia

3- Distributive:
a. Septic: infection (gram positive bacteria) leads to vasodilation.
b. Neurogenic: CNS injury leads to vasodilation.
c. Anaphylactic: Type I hypersensitivity; histamine release leads to vasodilation.

Management of anaphylactic shock:

1. Call 911.
2. Adrenaline auto injector.
3. Establish airways; give high flow of O2.
4. Antihistamine / cortisol: beta agonist (bronchodilator).
Note: antihistamine might be used for a mild allergic reaction, but adrenaline is
currently the only medication that will reverse anaphylaxis.

• Rigor mortis: stiffening of the joints and muscles of a body a few hours after death.
- Post mortem rigidity after death in four hours.
- Due to ATP deficiency.
- After death: aerobic respiration ceases, depleting source of O2 used in ATP production.
- ATP required to separate actin- myosin during relaxation; no more O2 stimulates ATP
production via anaerobic glycolysis.
- When glycogen depleted; no ATP leads to rigor mortis.

• Troponins: most widely recognized cardiac enzyme in diagnosis of Myocardial infarction (heart
failure).
- Protein found normally in heart muscle, but not in blood stream.
- When the heart muscle damaged it will release into the blood stream after 12- 24 hours.

• Myxoma: benign (non- cancerous) growth in the heart.

- Recurrence= 2-3 %
- Myxoid tumor: tumor of connective tissue; mostly heart.

• Glanzmann’s disease:
- Autoimmune or genetic disease.
- Defect or low level of glycoprotein II b/III a; receptor for fibrinogen responsible for platelet
bridging.
- Abnormality of platelets; bleeding disorder.
- prolonged or spontaneous bleeding starting from birth or acquired.
- Bruise easily, epistaxis, bleeding from the gingiva.

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• Takayasu’s arteritis “aortic arch syndrome” “pulseless disease”:
- Type of vasculitis, mainly affect aorta as well as pulmonary arteries, female.

• Broken heart syndrome = Takostubo cardiomyopathy; when the heart muscle becomes
suddenly stunned or weakened.

• Wegener granulomatosis ‫اﻟﺘﮭﺎب اﻷوﻋﯿﺔ اﻟﺪﻣﻮﯾﺔ‬

- Anti-neutrophilic cytoplasmic antibody (ANCA)
- granuloma and vasculitis; AKA granulomatosis with polyangitis.
- Inflammation of blood vessels in nose, sinuses, throat, lung and kidney.
B. Glomerulonephritis.
C. Necrotizing granuloma of respiratory tract.
D. Necrotizing cutaneous vasculitis.
E. DECREASED BLOOD FLOW.
F. Raynaud’s phenomena, gangrene and CNS abnormalities.
G. Strawberry gingivitis.

• Hereditary haemorrhagic telangiectasia “Osler- Rendu- Weber syndrome”:

- Autosomal dominant.
- Abnormal blood vessel formation in the skin, mucous membrane, liver, lung and brain.
- Associated with IgA deficiency or rarely von-willebrand disease.
- Nose and digestive tract bleeding.
- Bleeding leads to iron deficiency which leads to cardiac failure(rarely).

• Most common complication of haemophilia A (if left untreated): arthritis; Bleeding in joints.

• Sickle cell crisis:

- When a sickle shaped RBCs clump blocking small blood vessels.
à acute ischemic pain on long bone, lung and abdomen lasts for several days.
- Precipitated by:
1- Hypoxia; decreased O2 supply à increase blood acidity.
2- Infection; increase susceptibility of streptococcus pneumonia.
3- Hypothermia
4- Dehydration
- Impaired kidney function.
- Characteristics of sickle cell anaemia:
a. Healing leg ulcers,
b. Recurrent bouts of abdominal and chest pain.
c. Hair on end appearance on skull.

• Most common leukaemia in children: Acute lymphocytic leukaemia ALL.

• Most common leukaemia in adult: Acute myelogenous leukaemia (AML) and chronic
lymphocytic leukaemia (CLL).

20
• Schilling test:
- the ability of gastric intrinsic factor of Vitamin B12 absorption.
- Used for patient with Vitamin B12 deficiency.
• Hyper-segmented neutrophils associated with Megaloblastic anaemia (B12+ folic acid).

• Plummer – Vinson syndrome:

- increase risk of squamous cell carcinoma of esophagus and pharynx.
1. Dysphagia; difficulty in swallowing.
2. Iron deficiency anaemia.
3. Oesophageal webs.

• Wolf Parkinson’s white syndrome

- Common heart condition causes the heart to beat abnormally fast for periods of time.

** Parkinson’s disease: degeneration of dopamine releasing neurons.

à dopamine control voluntary movement, motivation, learning and memory.
• Cirrhosis of the liver:
- Scarring, loss of hepatic architecture and formation of regenerative nodules.
- Fibrinogen and prothrombin are deficient.
- Causes:
d. 75% alcoholism.
e. Viral hepatitis (HBV, HCV).
f. Hemochromatosis; iron build up.
g. Wilson disease.
h. Drug toxicity.

- Symptoms:
a. Jaundice.
b. Ascites.
c. Spider like blood vessels.
d. Confusion.
e. Slurred speech.
f. Clubbing fingers.

• Bronze diabetes: triad of cirrhosis, hemochromatosis and diabetes.

• Kernicterus: toxic accumulation of unconjugated bilirubin in the brain and spinal cord.

• Wilson’s disease:
- Rare inherited disease that causes copper to accumulate in liver, brain, kidney and cornea.
1- Cirrhosis of liver.
2- Degeneration of basal ganglia in the brain.
3- Deposition of green pigment in the periphery of cornea. (Build-up of copper in eye;
Kayser- Fleischer rings.)

21
• Hodgkin’s lymphoma:
- More common in male.
- Painless progressive enlargement of lymphoid tissue.
- Unknown cause.
- Theories: immune disease (primarily) or inflammatory reaction of infectious process that
become a neoplasm.
- Reed- Sternberg cells; pathognomonic histological, either bi- nucleated or multinucleated
(actual malignant cell).
- Treatment: chemotherapy.

• Castle man disease:

- Rare lymphoproliferative disorders.
- Outgrowth of body’s lymph nodes; hyperplasia.
- Uni-centric or multi-centric.
- Associated with HHV8 and HIV.

• Kaposi’s sarcoma:
- More common in male.
- Associated with HIV (AIDs).
- Causative factor: Human herpes virus 8 (HHV 8).
- Vascular in origin, plaque, patches or nodules.

• HIV test: blood, oral fluid and urine might be done.

- ELISA test: enzyme linked immunosorbent assay (antibodies).
Most common HIV test; blood or oral fluid.

- Western blot test: separate the blood protein and detects specific proteins (HIV antibodies);
to confirm a positive ELISA.

- IFA test: indirect fluorescent antibody. Used to confirm the result of ELISA. (less commonly
used.)

22
• Bechet’s disease “silk road disease”: blood vessels inflammation throughout the body.
- Signs and symptoms:
1- Mouth sores (aphthous ulcer)
2- Eye inflammation (uveitis)
3- Genital ulcer.
4- Arthritis
5- Skin rash and lesions.

- Pathergy test: “non-specific test for Bechet’s”

Inserting sterile needle into the skin and examines it 1-2 days after.
à red pump à immunity over reaction.

• Sjögren's syndrome:
- 10 Female: 1 male.
- Clinical triad:
1- Xerostomia.
2- Keratoconjunctivitis sicca (dry eyes).
3- Presence of other immune disease; secondary Sjögren's.
- CD4 infiltrate.

- Proliferation of ducts to form epimyoepithelial islands.

- Snow storm appearance in sialogram.
- Cobblestone appearance of the tongue.
- Parotid swelling in 30% of the patients.

• Schirmer’s test: eye production of tears; tears secretion.

- Evidence of systemic autoimmune disease:
1- Elevated titer of rheumatic factor.
2- Elevated titer of ANA; anti-nuclear antibodies.
3- Presence of anti-SS A (RO) or anti-SS B (LA) antibodies

• Reiter’s syndrome: can’t see, can’t pee, can’t climb a tree.

- Reactive arthritis; triggered by infection in another part of the body.
- HLA-B27
1- Eye inflammation.
2- Urethritis.
3- Arthritis.

23
• Multiple sclerosis:
- Female 20-40 years old.
- Autoimmune disease against myelin; Most common demyelinating disease, myelin sheath of
neuron is damaged.
- Insulting cover of nerve cells in brain and spinal cord.

- IgG increased level in CSF.

- Symptoms:
Triad
1- Scanning speech.
2- Nystagmus: eyes make a repetitive uncontrolled involuntary movement.
3- intention tremor; task specific tremor.

- Treatment: Interferon intravenous injection, to decrease the frequencies of relapses.

- In Dental treatment: as a result of decreased or blocked nerve transmission decrease the
dose of local anaesthesia.

• Myasthenia gravis:
- Antibodies that block or destroy nicotinic acetylcholine receptor at the junction between
nerves and muscles.
- Thymoma (tumor of the thymus) is associated with myasthenia gravis.
- Treatment: cholinesterase inhibitor.

• Coeliac disease: dermatitis Herpetiform.

- Immune system attacks own tissues when eating gluten.
- Associated with:
1- DM type 1
2- Autoimmune thyroid disease.
3- Hashimoto thyroiditis
4- Addison
5- Crhon’s disease
6- SLE. Rarely reported.

• Ewing’s sarcoma:
- malignant tumor.
- More common in male.
- In bones or soft tissue around the bone.
- Most often begins in the leg bones.
- Onion- peel appearance.

24
• Porphyria “vampire disease”:
- Metabolic disorder of heme. (Porphyrin precursor of heme)
à heme produced in liver and bone marrow.
- Build-up of porphyrin in the body. à decreased heme formation.

- Affect skin and nervous system.

Skin: chronic porphyria; blisters or itching occur with sunlight exposure; extreme sensitivity
to sunlight: photosensitivity.
Nervous system: acute porphyria; Seizures
- Symptoms: abdominal pain, chest pain, vomiting, fever and increase blood pressure and
heart rate.

• Multiple myeloma “Kahler disease”:

- Malignant condition; proliferation of neoplastic plasma cell in bone marrow with phagocytic
activity. (in this disease only.)
- More in Male.
- Frequent infection of streptococcus pneumonia and haemophilus influenza. (increase ESR)
- Symptoms of anaemia.
- Bone pain, pathological fractures.
- Renal insufficiency (late stage) à renal failure.

- Amyloidosis: abnormal build-up of amyloid in organ and tissue make it difficult to work.
- Soap bubble appearance.
- Monoclonal gammopathy IgG, Free Kappa and Lambda light chain and IgA.
à increases blood viscosity.
à Bence Jones proteinuria.
- Plasma cell 10-20%
- Treatment: thalidomide.
** normal plasma cell is less than 5%.

• Neurofibromatosis type I: Von Recklinghausen’s disease. (autosomal dominant)

- Mutation in NF1 gene (tumor suppressor gene).
- Increase the incidence of tumors; fibrosarcoma.
a. Multiple neurofibromas in skin (café au lait spots).
b. Pigmented iris hamartomas (Lisch nodules).
c. Skeletal disorders; scoliosis and bone cyst.

à Von Recklinghausen’s disease associated with multiple endocrine neoplasm MEN.

• Neurofibromatosis type II:

- Mutation in NF2 (merlin gene) in chromosome 22q.
a. Bilateral vestibular nerve CN VIII schwannoma.
b. Meningioma.
c. Ependymoma.

25
• Wermer’s syndrome: Multiple endocrine neoplasia MEN type I:
- Malignant or benign tumors.
- Mutation in MEN I gene
- Tumors in pituitary gland, parathyroid gland and pancreas.

• Multiple endocrine neoplasia MEN type II (II a):

- Tumors in thyroid gland, parathyroid gland and adrenal gland (pheochromocytoma).

• Multiple endocrine neoplasia MEN type III (II b):

- Doesn’t include hyperparathyroidism.
- Tumors in thyroid and adrenal glands.

• Cachexia “wasting syndrome”:

- Loss of skeletal muscle and fat.
- Associated with
1- Cancer
2- TB
3- Heart disease
4- HIV
5- Kidney disease
- Infection with E. coli doesn’t cause cachexia.

• Granular cell tumor: Abrikossof tumor

- Soft tissue tumor, usually begin in Schwan cells.
- Most of them benign.
- Develop in any skin or mucosal surface. (especially in the mouth or tongue.)
- Occur in tongue 40%
- More in female.

• Leiomyoma: non-cancerous growth of uterine.

- Uterine fibroid.
- Derived from smooth muscle; can happen anywhere in the body.
- Extremely common in women.

• Tuberous sclerosis:
- Autosomal dominant.
- Non- cancerous tumors in brain and on other vital organs; kidney, heart, liver, eye, lung
and skin.
1. seizures.
2. intellectual disability.
3. developmental delay.
4. behavioural problems.
5. skin abnormalities.
6. retinal hamartomas.

26
• Stroma in benign tumor
- composed of: blood vessels, fibroblast and collagen fibers.
- Tumor cell are nourished by it.
- Part of the tumor.
- Support the base of the tumor.
- Have no involvement in neoplastic changes.

• Tumor staging the higher the grade the worse the prognosis.
• Totipotent cell: able to produce all cell type.

• HeerFordt – waldenstrom syndrome:

- rare manifestation of sarcoidosis.
- Sarcoidosis of facial nerve, eye and salivary glands.
1- Facial nerve paralysis.
2- Enlargement of parotid or another salivary gland. (xerostomia)
3- Anterior uveitis.

• Glandular fever “infectious mononucleosis”

- Infection caused By Epstein- Barr virus.
- Symptoms: Fever, sore throat, enlarged LNs in the neck and tiredness.
- Clinical course for 2-4 weeks.
- Taking amoxicillin results in severe rash with those patients.

• Impetigo: common, highly contagious skin infection (streptococcus pyogenes and

staphylococcus).
- Affect infant and young adult.
- Reddish sores on the face, especially around the nose, mouth, on hand and feet.
- Over a week à sore burst and develop Honey- colored crust.

• Lyme disease:
- Endemic disease.
- Borrelia burgdorferi; spirochete bacteria transmitted by ticks, mice.
- Stages:
1- Erythema margins, bull’s eye rash.
2- Neuropathies: bilateral Bell’s palsy.
3- Arthritis
- Treatment: doxycycline.

27
• Leprosy “Hansen’s disease”:
- Granulomatous infection by mycobacterium leprae.
- Types:
1- Tuberculoid type: cell- mediated immune response leads to granuloma in nerves.
2- Lepromatous type: foam cells containing bacteria in skin.
- Infection can lead to damage to nerves, respiratory tract, skin, and eyes.

• Macrocheilia: is a condition of permanent swelling of the lip that result from greatly distended
lymphatic spaces.
- Abnormally largeness of lip.
- Seen sometimes in leprosy patients.
- Treatment corticosteroid or surgery.

• Tuberculosis:
- Granulomatous infection by mycobacterium tuberculosis.
- Symptoms: fever, night sweat, weight loss and haemoptysis.
- Increased susceptibility to infection by:
1- Poor sanitation.
2- Poverty.
3- Overcrowding.

- Types:
1- Primary 1o (Ghon complex): granulomatous lesion with hilar lymphadenopathy.
Usually asymptomatic, affect the lower and middle lobes.

2- Secondary 2o: Caseous granulomas may lead to military (rash) or disseminated infection.
Affect the upper lobe.

- Treatment:
1- Rifampin.
2- Isoniazid.
3- Pyrazinamide.
4- Streptomycin.

28
• Syphilis: a sexually transmitted infectious disease by Treponema pallidum (gram –ve
spirochete).
- Primary stage: at 3 weeks
à Chancre; painless contagious ulcer, red papule or crusted superficial erosion,
spontaneously heals.

- Secondary stage: 4-10 weeks after infection

a. Snail track
b. Split papule in oral commissure; false angular cheilitis. (perleche)
c. Condyloma lata; white papillary lesion.
d. Lues maligna; malignant syphilis in immunocompromised patients.
à Contiguous, spontaneously heal in 3-12 weeks.

- Tertiary stage: latent period (1-20 years)

a. Gumma; non-cancerous growth (form of granuloma).
b. Leutic glossitis; atrophy of the tongue and loss of dorsal tongue papillae.
c. Central nervous system manifestation (neuro syphilis); psychosis, dementia. (non-
contagious)
- Congenital syphilis:
Hutchinson’s triad:
1- Hutchinson’s teeth; screwdriver- like incisors and mulberry molars.
2- Interstitial keratitis; inflammation of cornea.
3- CN VIII Deafness.

• Snail track (oral feature of secondary syphilis)

- Painless or painful erythematous lesions.
1- Grayish- white mucous patches.
2- Irregular linear lesion; snail track ulcer.

• Koplik spots: small, white spots inside the cheek in measles (Rubeola) patients.

• Microcephaly:
1- Infections: Rubella, toxoplasmosis and CMV.
2- Severe malnutrition.
3- Exposure to harmful substances; alcohol, drug…

29
• Rheumatic fever:
- Inflammatory reaction to an infection; due to cross reactivity, not a direct effect of the
bacteria.
- Hypersensitivity type III
- infection with group A β -hemolytic streptococcus.
- Symptoms (FEVERSS)
1- Fever.
2- Erythema multiform.
3- Valve damage.
4- Increased ESR level (erythrocyte sedimentation rate)
5- Red – hot polyarthritis.
6- Subcutaneous nodules.
7- St. Vitus dance (chorea)

- Findings:
a. Aschoff bodies: focal interstitial myocardial inflammation, fragmented collagen and
fibrinoid material.
b. Antischkow myocytes: multinucleated giant cells.
c. Increased level of anti- streptolysin O (ASO).
d. Increased ESR.

• Sydenham chorea “St Vitus dance”:

- Autoimmune disease result from childhood infection with group A β- haemolytic
streptococcus pyogenes.
- Few weeks – 6 months after acute infection which may have a simple sore throat;
pharyngitis.
- Rapid, uncoordinated jerking movement primarily affecting the face, hands and feet.

- Neuropsychiatric disorder: emotional liability, mood swing and anxiety.

- 20-30% of people with acute Rheumatic fever.
- 70% have carditis.
- more in female.

• Conn’s syndrome “primary aldosteronism”:

- Increased aldosterone; reabsorption of Na+ and excretion of K+ (water retention).
- Increases the BP.
- Decrease K+ in blood leads to abnormal heart rhythm (often too slow) à cardiac arrest.
- Symptoms:
1- Muscular ache and weakness
2- Muscle spams
3- Tingling sensation
4- Dizziness
5- Low back pain à kidney problems
6- Excessive urination (only in this syndrome (not related to aldosterone action))
7- Kidney failure

30
• DiGeorge’s syndrome: “Velocardiofacial syndrome”
- Thymic aplasia; underdeveloped thymus and parathyroid.
à defective development of 3rd and 4th pharyngeal pouchs.

- Absence of T- cells / B- cells are normal.

à increase viral and fungal infection.

- CATCH 22
C: cardiac defect. (aortic arch and pulmonary artery)
A: abnormal faces.
T: thymic aplasia.
C: cleft palate (nasal and palatal cleft; fish mouth appearance.)
H: hypocalcemia.
22: microdeletion of chromosome 22.

• Diabetes insipidus:
- Rare condition affects the balance of fluid in the body.
- More common in male.
- It happens due to
A. Central: insufficient production of ADH (vasopressin).
B. Nephrogenic: lack of response to it in the kidney.

• Diabetic peripheral neuropathy:

1- Burning mouth syndrome; pain, dysesthesia and loss of sensation.
2- Feet or leg followed by arm/ hands; numbness: decrease ability to feel pain or
temperature changes.

• Syndrome of inappropriate ADH secretion (SIADH):

- Most commonly caused by ectopic production of ADH by various tumors especially small cell
carcinoma.
1- hyponatremia.
2- reduced serum osmolality.
3- inability to dilute urine.

• Hypothyroidism:
1- Cretinism (child): growth and mental retardation, abnormal development of bone.
Underdeveloped mandible, delayed tooth eruption and retained deciduous teeth.
2- Myxoedema (adult)
3- Hashimoto thyroiditis (Late).

** Hashimoto thyroiditis: early manifestation à hyperthyroidism.

• Hyperthyroidism: thyrotoxicosis
1- Grave’s disease: AB + TSH receptorà increase thyroxine release.
A. Goiter; enlarged thyroid.
B. Exophthalmos + IgG

31
 2- Plammer’s disease; toxic multinodular goiter.
3- Solitary toxic adenoma.
4- TSH- pituitary tuomar.

** thyrotoxicosis: tachycardia and exophthalmos.

In this case, the local anaesthesia to be used is prilocaine.

• Garre’s osteomyelitis:
- Chronic non-suppurative sclerotic bone inflammation; rigid bony swelling at periphery of
jaw.
- Most commonly in men below 30 years.

• Solitary bone cyst:

- Pseudocyst.
- benign cavity in bone, either empty or filled with fluids.
- Epithelial is not found = traumatic bone cyst= idiopathic bone cyst= simple bone cyst=
haemorrhagic bone cyst.
- Located posteriorly; premolar- molar area.

• Catarrhal inflammatory reaction: overproduction of mucous.

• Arthus phenomena: Hypersensitivity type III; localized sensitivity to foreign proteins after
vaccination.

• Inflammatory bowel disease:

- Crohn’s and ulcerative colitis UC.
- Both can present with: abdominal pain, obstruction and bloody Diarrhea.

Crohn’s disease Ulcerative colitis

Can affect entire GI from mouth to anus Only the colon
Cobble stone appearance Inflammation limited to mucosa and
Transmural inflammation (giant cell) à all submucosa.
layers. Increase risk of secondary malignancy.
- Oral features of Crohn’s disease:
1. Facial and lip swelling with angular stomatitis.
2. Mouth ulcers.
3. Gingival hyperplasia and redness.

• Craniosynostosis Syndromes:
1- Crouzon syndrome.
2- Pfeiffer syndrome.
3- Apert syndrome (acrocephalosyndactyly)

32
• Binder syndrome: maxillofacial dysplasia or hypoplasia.

• Goldenhar syndrome:
- Oculo-auriculo-vertebral spectrum; abnormal development of the eye, ear and spine.
à pre-auricular skin tags: accessory auricle.

- Hemi facial microsomia “craniofacial microsomia”: half of one side of the face is
underdeveloped and doesn’t grow normally.
à microstomia; small sized mouth.

• Apert syndrome: acrocephalosyndactyly.

- Genetic disorder that causes fusion of the skull, hands and feet bone.
- Deformities of the skull, face, teeth and limb.
- Ocular manifestation:
1- Exophthalmos.
2- Hypertelorisum.
3- Down slanting palpebral fissure.

• Trencher Collin syndrome: mandibulofacial dysostosis.

- First pharyngeal arch syndrome.
- Autosomal dominant; 50 % from mother to fetus.
a. Malor bone hypoplasia.
b. Down slanting palpebral fissure.
c. Lower eyelid defect.
d. External ear are absent (atresia), malformed or microtia.

• Rubinstein taybi syndrome:

- Mutation or deletion in gene located on chromosome 16.
1- Short stature.
2- Moderate to severe learning difficulties.
3- Distinctive facial features.
4- Broad thumbs and first toes.
5- Associated with dens Evaginatus.

• Ectodermal dysplasia:
- Group of disorders in which two or more of ectodermal derived structures developed
abnormally:
a. Skin/ hair/ nails / teeth; congenital absent, peg shaped or pointed.
b. Sweat gland/ salivary gland.
c. Mucous membrane.

33
• Wernicke- Korsakoff syndrome:
- Deficiency of B1 (thiamine).
- Associated with alcoholism.
- Damage to CNS.
- Wernicke encephalopathy: vision changes, ataxia and impaired memory.
- Korsakoff syndrome: amnesia; memory loss.

• Papillon- Lefever syndrome:

- Autosomal recessive.
- palmoplantar keratoderma with periodontitis.
- Cause by deficiency in Cathepsin C
- Dry scaly patches of the skin; hyperkeratosis of palm and soles.
- Loss of teeth.

• Sweet syndrome:
- Acute febrile neutrophilic dermatosis.
- Skin condition charachteraized by:
1- Fever, painful skin rash (arm, face, neck).
2- increase WBC’s count, increase ESR.

- The cause is unknown but it is sometimes triggered by

1- Drugs such as clindamycin.
2- Malignancy.
3- Illness.

• HELLP syndrome:
- H; haemolysis
- EL; elevated liver enzymes
- LP; low platelet count
- Type of preeclampsia: a condition in pregnancy characterized by high blood pressure,
sometimes with fluid retention and proteinuria.
- A pregnant who needs blood transfusion.

• Eclampsia: preeclampsia and seizures.

34
 Oral pathology
• fibro-osseous diseases
1- Ossifying fibroma
- More common in female.
- Benign fibro-osseous neoplasm.
- Well circumscribed mixed density lesion.
- Rare chance of recurrence.
- Low malignant potential.

2- Fibrous dysplasia
- More common in female.
- Mora common in maxilla
- Poorly defined.
- Ground- glass appearance.
A. Monostotic: one bone.
B. Polystotic: two or more, ¾ of skeleton: Jaffe type.
C. Albright syndrome: multiple lesions, hyperpigmentation, endocrine disturbances;
precocious puberty or hyperparathyroidism.
D. Craniofacial.

3- Cemento-osseous dysplasia
- Most common type of fibro-osseous diseases.

A. Periapical: vital tooth.

B. Focal: edentulous area, less than 2mm.
C. Florid COD: two or more jaw quadrants; multiple confluent lobular radiopacity in tooth
bearing area.

• Vesiculo-bullous disease:
1- Apthous ulcer (canker sores)
- Recurrent.
- Idiopathic
- Haematological abnormalities
- hormonal influences
- infectious agent
- nutritional imbalance
- stress/ trauma
- allergy
à Types:
a. minor apthous ulcer à most common. 80-85% of the cases.
- non- keratinized mucosa.
- 2-3 mm
- leave no scar.

b. Major apthous ulcer à 10 % of all cases.

- More than 10 mm
- Deeper ulceration.

35
 - May leave a scar.
- Usually non-keratinized but less commonly keratinized. à dorsum of the tongue/ gingiva.

c. Herpetiform ulceration:
- Not caused by herpes simplex.
- Less than 1mm.
- Without scaring.
- Keratinized + non- keratinized.
*** RAS à recurrent apthous ulcer + systemic condition.

2- Pemphigus vulgaris (anti- desmosomes)

- Immune mediated (IgG, IgM); antibodies against desmosomes (desmogleins 1 and 3)
- Vesicles/ bullaeà blistersà rupture à painful ulcers.
- Nikolsky’s sign: rubbing of uninvolved mucosa à creates blisters.
- Intraepithelial cleft formation.
- Tzanck cells: acantholytic epithelial cell with enlarged dark nuclei.
- Fluorescent antibody test.
- Treatment: steroid and immunosuppressive drug; azathioprine.

3- Pemphigoid. (anti- hemi desmosomes)

- Sub epithelial cleavages from underlying CT.
- Autoantibodies target a component of basement membrane. (IgG+ C3)
- Cicatricial pemphigoid: benign mucous membrane pemphigoid:
A. symblepharon à eye involvement. May lead to blindness
B. vesicles + ulcers with scaring on skin.
C. Vesicles + ulcer without scaring on oral cavity.

4- Lichen planus:
- More in female.
- Cytotoxic cell- mediated hypersensitivity.
- Bilateral.
- May have an association with HCV.
- Histopathology:
ü Degeneration of the basal cell layer.
ü Hyperkeratosis.
ü “band-like” lymphocytic infiltration.
ü Saw tooth rete ridges.
ü Civatte bodies.

- Types
A. reticular (most common) (asymptomatic) (Wickham’s striae): white lesions à
epithelial thickening.
B. Erosive: painful ulceration, erythromtous gingiva

- Teatment: topical or systemic steroids for symptomatic lesions.

36
• Lichenoid reaction: drug induced LPà antihistamine + corticosteroids.

5- Erythema multiform:
- swelling + crusting + bleeding of the lip.
- Bullous (target lesion).
- Causative factors:
a. HSV
b. Drugs
c. Diseases such as Crhon’s and ulcerative colitis
Minor à HSV
Major à Steven- Johnson syndrome; skin/ oral mucosa/ conjunctiva/ genital.
TENà most severe form.

• Infectious Vesiculo-bullous disease:

1- Group A Coxsackie virus
- RNA virus
- Harpangia: soft palate, uvula, anterior tonsillar pillar.
- Sudden fever, sore throat, headache and neck pain.
- Common childhood disease.
- Hand- foot – mouth disease: resembles harpangia but larger.

2- Acute herpetic gingiva-stomatitis: HSV 1 (MORE COMMON), 2.

- HSV1 more common in children under 6 years old.
- Intraepithelial blisters.
- Symptoms: fever, oral ulcers and gingival bleeding.
- Treatment: acyclovir.

3- Varicella zoster HSV3: chickenpox, shingles

- Ramsay hunt syndrome (reactivation of herpes zoster)
- Avoid acetylsalicylic acid (aspirin) in children (Reye’s syndrome).

• Odontogenic tumors:
1. ameloblastoma:
- Most common odontogenic tumor from odontogenic epithelium.
- Originate from:
a. enamel organ
b. epithelial lining of odontogenic cyst.
c. basal cell layer of oral mucosa.
- locally aggressive benign neoplasm.
- Most commonly found in the molar ramus area of the mandible
- Types:
a. Conventional solid or multicystic type. (most common type)
b. Unicystic and plexiform unicystic.
c. Peripheral.

37
 2. Odontogenic myxoma
- Most common odontogenic tumor of mesenchymal origin.
- Precursor cells to dental follicle.
- 3rd most common benign tumor in the jaw.
- Tooth bearing area of maxilla and mandible, predilection for posterior mandible.
- Soap- bubble, honey comb, tennis request strings.

3. odontogenic fibroma
- Tooth loosening.
- Anterior maxilla, posterior mandible.

4. cementoblastoma
- Benign neoplasm of functioning cementoblast.
- Mixed radiolucency and radiopacity, Around vital tooth.

• Epstein pearls “gingival cyst”:

- Whitish –yellow cysts.
- Originate form dental lamina; cell rest of Serres.
- Filled with keratin.
- More common in babies 60-85%.

• Langerhans cell granulomatosis:

- disease of the bone; increased number of specialized WBCs.
- Langerhans cell histocytosis; abnormal increase level of histocytes.
1- Eosinophilic granuloma: chronic localized.
- Jaw (more common in mandible), resemble periodontitis.
- 10 -20 % of all cases.
- Cupped out radiolucency.

2- Letterer- swise disease: acute disseminated. à skin, internal organ; lung, bone and
liver.
- Frequently fatal.

3- Hand – schuller christen: chronic disseminated.

- More common in male.
- Punched out bone lesion in the skull and jaws.
A. Diabetes insipidus
B. Exophthalmos
C. Lytic bone lesion; radiolucency associated with apices of teeth: floating teeth.

** histocystes: monocyte, macrophages and dendritic cells.

38
• Syndrome with supernumerary teeth (More in female):
1- Gardner’s syndrome.
2- Clediocranial dystosis.
3- Cleft lip and palate.
4- Ehlers- danlos syndrome.
5- Sturge- weber (port- wine stain)

• Eagle syndrome:
- Elongation of styloid process.
- Sharp pain in jaw bone and joint, back of the throat and base of the tongue.

• Grinspan syndrome:
- Triad of hypertension, diabetes and oral lichen planus.

• Odontogenic Keratocyst originates from dental lamina; cell rests of serres.

• Periapical cyst originates from cell rests of malassez.
• Dentigerous cyst originates from reduced enamel epithelium. (cholesterol crystals)

39
 Notes
• Marble bone disease: osteopetrosis.
• Osteomalacia: sofetening of the bone; due to problem in Vitamin D.
• Long term trauma on TMJ leads to osteoarthritis.
• Most common complication of Rheumatoid arthritis involving TMJ; ankyloses.

• Mucous mucocele most common site; lower lip.

• Honey combed appearance:

- Ameloblastoma.
- Central haemangioma.
- Central giant cell granuloma.
- Aneurysmal bone cyst: soup bubble appearance.

• Moth- eaten appearance: suppurative osteomyelitis.

• Ground glass appearance: hyperparathyroidism; Brown tumor.
• Paget’s disease: cotton wool appearance.
• Chicken wire appearance of bone marrow: beta thalassemia major. (chipmunk face)
• Snow storm appearance: Sjögren’s syndrome.
• Onion- peel appearance: Ewing’s sarcoma.
• Sunburst appearance: osteosarcoma.

• Sulfur granules found in Actinomycosis; wooden tongue, bell neck.

• Petechia; pin point, round spots that appear on the skin as a result of bleeding less than 3mm
• Purpura 3-10mm
• Ecchymosis more than 10 mm

• ESR: erythrocyte sedimentation rate; progression of the disease.

- Male 0-22mm/hr
- Female 0-29 mm/hr
• Hb male 14-18/ female 12-16
• CSF Volume = 125-150 ml
• Pt = 11-15s
• PTT= 25-35s
• CPR 100-120/MINUTE
- 30:2 chest: breath
- BLS: basic life support; 1 breathe every 6 seconds.
- 6 cm in depth.
• Normal breathing rate 12-20/ minute
• Life span for macrophages= months – several years.
• Life span for neutrophils = 6-8 hours.
• Warthin duct; 5cm long, 0.5- 1.5 mm in diameter.

40
• Recommended sterilization:
- 121c /15ps/ 20 min
- 134c/ 32 ps/3 min
• radiotherapy after extraction 20-30days.
• Extraction after radiotherapy= 3-6months.

• Long term assessment for DM: glycated haemoglobin HbA1c test:

- Normal less than 5.7%
- Pre-diabetic 5.7-6.4%
- Diabetic more than 6.5%

• Creatinine test:
Increase of creatinine; kidney dysfunction.
Waste product from the normal wear and tear on muscles.
Male 0.6-1.2mg/dl
Female 0.5- 1.1mg/dl
- Alkaline phosphatase: liver test.

• The gold standard of measuring GFR (glomerular filtration rate) à urinary inulin clearanceà
ideal marker; free filtered, not secreted or reabsorbed.

41
 Reaction to tissue injury

• Major types of necrosis:

1- Coagulative necrosis (Most common form): MI, Gangrene.

à MI
- Ischemia
- protein denaturation
- tissue architecture preserved
- infract area is triangular

à Gangrene:
- ischemic coagulation
- putrefaction without infection ‫ﺗﻌﻔﻦ‬

2- Liquefactive necrosis: Brain abscess, Acute pancreatitis. à inflammation

à Brain abscess
- enzymatic degranulation
- suppuration
- loss of tissue architecture

à fat; Acute pancreatitis

- adipose liquefaction
- fatty acid released

3- Caseous necrosis: Tuberculosis

- Granulomatous inflammation
- Clumped cheesy material

• Cellular reaction to injury:

- Atrophy: decrease in cell size.

- Hypertrophy: increase in cell size.

- Aplasia: complete lack of cell (agenesis).

- Hypoplasia: decrease in cell number.
- Hyperplasia: increase in cell number.
- Metaplasia: reversible, morphological change from one cell type to another.
- Anaplasia: qualitative alteration of differentiation (loss of cellular architecture).
** uterine enlargement during pregnancy à hyperplasia + hypertrophy.
• Nuclear changes associated with cell death:

- Pyknosis: nuclear shrinkage, chromatin condensation.

- Karyolysis: nuclear dissolution and chromatin fading (basophilia).
- Karyorrhexis: nuclear fragmentation; completely disappear in 1-2 days.

42
• Apoptosis: programmed cell death (physiological + pathological).
- Doesn’t result in inflammatory response.
- Nuclear Pyknosis, Karyorrhexis.
- Normal cell volume is maintained.
- BCL-2 gene is either inhibit or induce apoptosis.

• Inflammation: vascular and cellular response to tissue injury.

1- Acute: leukocyte infiltration (PMNs).
2- Chronic: Lymphocyte, macrophages.

• Acute inflammation:
1- Vascular response:
- Vasoconstriction.
- Vasodilatation; increase vascular permeability à predominantly mediated by: Histamine
producing cell; mast cell(tissue), basophils (blood), platelets.
- Formation of an exudative edema (protein rich).
- Increase blood glow (hyperaemia).
- May lead to vascular congestion.

2- Cellular response:
- Margination, adhesion, diapedesis (movement of leukocytes out of the blood vessels to the
tissue.), chemotaxis of leukocytes (PMNs).
- Microbial lysis but also host tissue damage.

• Congestion (hyperaemia):
- Increase blood volume in local capillaries and small vessels.
A. active congestion (active hyperaemia): increase arteriolar dilation; inflammation, blushing
and in exercise.
B. passive congestion (passive hyperaemia): decrease venous return (obstruction and
increase back pressure).
1- Acute; Shock or right sided heart failure.
2- Chronic; In lung secondary to left sided heart failure.
In liver secondary to right sided heart failure.

• Five classic signs of acute inflammation:

1- Redness (rube): from vasodilatation and increase vascular permeability.

2- Heat (calor): from vasodilatation and increase vascular permeability.
3- Swelling (tumor): from edema.

4- Pain (dalor): from inflammatory mediators and pressure due to edema.

Examples: bradykinin and prostaglandins.
5- Loss of function (functio laesa): from swelling and edema.

43
• Outcome of acute inflammation:
1- Regeneration; complete resolution.
2- Repair; fibrosis.
3- Abscess; pus.
4- Chronic inflammation.

• Edema:

1- Exudate: from inflammatory response; increase vascular permeability.

- Cell – rich (WBCs, cellular debris).
- High plasma protein.
- High specific gravity.
- Flashes away foreign material.

2- Transudate: non- inflammatory; alteration of vascular hydrostatic or osmatic pressure.

- Few cells.
- Low plasma protein.
- Low specific gravity.

Acute inflammation generally precedes chronic inflammation but some type of injury can directly
induce chronic.
• Chronic inflammation
- Three stages:
1- Mononuclear cell infiltration: migration of macrophages, lymphocyte, plasma cell and
eosinophils.

2- Granulation tissue formation: heal tissue consisting largely of:

a. Fibrosis (fibroblast)
b. Angiogenesis; formation of new capillaries.
c. Inflammatory cells
** granuloma: containing epithelioid cells and multinucleated giant cell.

3- Host tissue destruction mediated by cytokines of host leukocytes.

44
 • Granulomatous inflammation
- Specific type of chronic inflammation
Transformed
Macrophages à epithelioid cells
surrounded by: lymphocytes
fibroblast
local parenchymal cells
- Associated with:
a. Tuberculosis.
b. Leprosy.
c. Sarcoidosis.
d. Syphilis.
e. Blastomycosis.
f. Crohn’s disease.
g. Foreign body containment (suture.)

Duration Predominate cells Response Maximum healing potential examples

Acute Days Neutrophils Exudative Regeneration Pulpal abscess
mast cells
Chronic Weeks- Lymphocytes Proliferative Repair; fibrosis Chronic
years Macrophages periodontitis
Plasma cell

• Systemic effect of inflammation:

Cell don’t have potential to regenerate:
1- Fever 1- CNS (neuron)
2- Leukocytosis: 2- Lung (alveolar)
- Neutrophilia: bacterial infection. 3- Heart (cardiac)
4- Muscle (smooth and skeletal)
- Eosinophilia: parasitic infection.
- Lymphocytosis: viral infection.

45
• Inflammatory mediators
- Cytokines (four major categories):
1- Interleukins IL: LARGEST group of cytokines, regulate leukocyte activity.
2- Interferon INF: interfere with viral replication.
Anti-proliferative effect.
Associated with non- specific immunity. (not virus specific)

3- Tumor necrosis factor TNF: regulate tumor suppression

P53 à tumor suppressor.
PC3 à initiate tumor.

4- Colony stimulating factor: regulate differentiation and growth of bone marrow elements.

HOT T-Bone stEAk

Il-1: fever
IL-2: T- cell activation
Il-3: bone marrow stimulation
Il-4: Ig E stimulation
Il-5: Ig A stimulation
Il-6: fever
Il- 8: chemotaxis PMNs migration
Il-10: inhibit T helper
Il-12: initiate T helper
INF-Y: stimulate macrophages, monocytes, PMNs, NK (interfere with viral replication)
TNF alpha, beta: stimulate osteoclasts, T-helper, cachexia (wasting syndrome; muscle +
weight loss.
TGF-B: anti-cytokine, stimulate collagen+ wound healing

46
• Another inflammatory mediator:

1- Histamine
- Produced by mast cell, basophils
- Vasodilation
- Constriction of bronchial
- Anaphylaxis

2- Prostaglandins
- Vasodilation
- Fever, pain

3- Leukotrienes
- Vasodilation
- Constriction of bronchial
- Primary mediator of asthma

4- Serotonin:
- Produced by platelets/ gastric mucosa
- Vasoconstriction

5- Bradykinin
- Dilatation of vessels and bronchi
- Hageman factor XII is necessary in the production of bradykinin

6- Complement proteins
- Vasodilation
- Bronchoconstriction
- Derived from hepatocytes
- C3a, C5a: vascular permeability
- C5a: chemotaxis
- C3b: opsonisation

• Stages of wound repair:

1- Inflammatory stage.
- immediately after tissue injury and lasts 3-5 days.

2- Fibroblastic stage.
- 3-4 days after tissue injury and lasts for 2-3 weeks.
- collagen formation.

3- Remodelling stage; maturation phase.

- 2 -3 weeks after.
- collage remodelling.
- wound contraction and scar formation.

47
• Wound healing:
- Primary intention: wound margins are closely re-approximated.
à faster healing with minimal scarring and risk of infection.
à example: replaced periodontal flap.
- Secondary intention: gap between margins, because re-approximation can’t occur.
àslower healing with granulation tissue formation and scarring. more prone to infection.
à examples: extraction socket, large burn or ulcers and external bevel gingivectomies.

• Dystrophic calcification: deposition of Ca+2 in degenerated tissues; previously damaged,

necrotic. à normal serum Ca+2.
• Metastatic calcification: deposition of Ca+2 in normal tissue. à increased serum Ca+2.

48
 Physiology

• O2- Hb dissociation curve: describe the equilibrium between PO2 and HB saturation.
- Right shift “Bohr effect”
- In an acidic environment to help unload O2 to the tissue.
- Favors O2 release to tissue.
- Hb has decreased affinity to O2 when Ph decreased.
- Hydrogen ion increased as ph decreased.
- As CO2 increases à ph decrease à curve shift to the right.
Ph

PCO2
2,3, DPG à product of glycolysis.
Temperature.

• Metabolic acidosis à increase level of Hydrogen ion à as a result of kidney disease.

• Metabolic alkalosis à increased serum bicarbonate HCO3-
à loss of H+, intracellular shift of H+, gastrointestinal loss of H+ or excessive loss in urine.

Muscle

• The sources of ATP for muscle contraction arise from:

1- Creatine phosphate. (unique to muscle metabolism.)
2- Glycogen stores (mainly in liver, skeletal muscles) à glycolysis.
3- TCA cycle (tri-carboxylic acid) à oxidative phosphorylation.

• Kinaesthetic sense: proprioceptors, awareness of the position and movement of the body
separate from visual input.
• Kinesiology: study of the movement of muscles.
• Electromyography: diagnostic procedure to assess the health of muscles and nerve cell that
control them.
• Heavy myosin à cross bridge of the sarcomere in skeletal muscle.

Bone marrow
- Yellow bone marrow: contains fat, found in maxilla and mandible.
- Red bone marrow: contains hematopoietic cells, found in mandibular ramus and condyles.

Heart
n Blood pressure controlled by:
1- Arterioles.
2- Kidney by renin- angiotensin- aldosterone.
3- Vasomotor center regulates blood vessels diameter.
4- Baroreceptors in carotid sinus.

49
n Blood pressure controlled by:
5- Arterioles.
6- Kidney by renin- angiotensin- aldosterone.
7- Vasomotor center regulates blood vessels diameter.
8- Baroreceptors in carotid sinus.

n Heart sounds:
- S1 (LUB): louder and longer, sound of AV closing; mitral and tricuspid.
à begins the systole; ventricular contraction.
- S2 (DUB): sound of semilunar valve closing; aortic and pulmonic.
à begins the ventricular filling.

S4à S1à S2à S3

• Right atrium pressure= 2-6mmHg
• Right ventricle pressure=
- Systolic= 25-25 mmHg
- Diastolic= 0-8 mmHg
• Central venous pressure= 1-6 or 0-8 mmHg

Blood
• Blood 8% of total body weight.
• Composed of plasma 55% and formed element 45% of blood.

• haematopoiesis: production of all the cellular components of blood and blood plasma.
- Fetus: in liver and spleen.
- Adults: in red bone marrow.
• Hemocytoblast; hematopoietic stem cell division

1- Myeloid
a. Megakeratocyte à thrombocyte à platelet
b. Erythrocyte à RBCs
c. Mast cell
d. Myeloblast
Granulocytes à basophils
à neutrophils (most abundant)
à eosinophils
Monocytes à macrophage.

2- Lymphoid
a. NK; large granular lymphocyte
b. Small lymphocytes:
à T-lymphocytes: 70 % of circulating lymphocytes. à produce interferons.

à B- lymphocyte: plasma cells à AB, Ig

50
Serum vs plasma
- Serum is blood plasma without fibrinogen and clotting factors.
- plasma have blood cells (fibrinogen) and clotting factors.

• RBCs= 4-5 million

• WBCs= 6,000-10,000 per microliter
• Platelet= 150,000- 400,000 per microliter
• HCT haematocrit is the percentage of erythrocytes in a blood sample 40-50%.
• The amount of bile pigment excreted by liver estimates the amount of erythrocytes destruction
per day.

• MCV = 82- 98 fL.

- Less than 79fL; microcytic
- More than 100Fl; macrocytic
- Ejection fraction= 55-70%

• Anti-thrombin III works on clotting factor 9, 10, 11, 12.

• Thrombin activates clotting factors 5, 8, 11.

neuro physiology
• Resting membrane potential
- Polarized membrane: more positive extracellular, more negative intracellular.
- RMP in all cells = -70 mv.
- RMP in cardiac and skeletal muscle = -90 mv.
- Threshold of depolarization: -50mv.

• Action potential
- Initiated by depolarizing stimulus.
- RMP à more positive= less negative
- Na channel opening à once threshold reach the AP will fire (threshold of AP= 20mv)

• Refractory period:
- Absolute à X
- Relative à larger than normal stimulus à hyperpolarization.

• Repolarization: (k out)
- Membrane potential returns to normal following an AP.
- Decrease Na permeability/ increase K permeability à k leak out of the cells.

• Summation
1- Spatial summation: arrival of impulses from multiple presynaptic fibers at the same time;
two excitatory input arrives at a postsynaptic neuron simultaneously.
2- Temporal summation: two excitatory inputs arrive at postsynaptic neuron in rapid
succession. Increase the frequency of nerve impulses from a single presynaptic fiberà
increase pain experience.

51
• Nociceptors:
1- A delta mechanosensitive.
2- A delta mechano-thermal.
3- C Fibers Polymodal nociceptors; mechanical, thermal and chemical.

- C fibers: unmyelinated, 0.4-1.2 micrometre in diameter, slowest 0.5-2m/s, conduct pain

(mechanical, thermal and chemical.) Dull aching pain.
- A delta fiber: myelinated, 2-5 micrometre in diameter, fast 6-30m/s, conducts pain
(mechanical and thermal). Acute intense pain.

- Oligodendrocytes: myelinating cells of the CNS.

- Schwann cells: type of glial cell that surrounds neurons and sometimes covering them with a
myelin sheath. In PNS.

Immunity
• Immune system:
1- Innate: immediately, non-specific, no memory.
2- Acquired (adaptive): specific +memory.
a. Passive: antibodies; pregnancy IgG, Breast feeding IgA or vaccination with antibodies.
b. Active: either antibodies or T-cell; previous MOs infection or vaccination with life
attenuated or killed viruses.

• IgG: is the only Ig that crosses the placenta, responsible for secondary immune response.
• IgM is 1000 time stronger than IgG in complement fixation, the main Ig concerned in the ABO
blood grouping system (IgG + IgM) mainly + IgA small numbers.
• IgM à 5 antigen combing sites per molecule.

• Histocytes: CT
• Microglia: CNS
• Dust cells: lung
• Kupffer cells: liver

• Antigen presenting cells: express class II MHC proteins and present antigen to CD4-T cells:
1- Macrophages
2- B- cell
3- Dendritic cells

• Complement system:
- 20 plasma proteins.
- Mostly synthetized in the liver.
a. Classic pathway activated by An-Ab complex, IgG and IgM.
b. Alternative pathway activated by bacterial LPs (endotoxins).
c. Lectin pathway activated by microorganisms containing cell surface mannose.

52
• Reticuloendothelial system:
- Mononuclear phagocyte system.
- Population of phagocytic cells in systemically fixed tissue.
- Play important role in clearance of particles and soluble substance in circulation and tissue.
à part of immune system.
- Primary organs of RFS: liver, spleen and lung.
- Major component: monocyte and macrophages. à include all phagocytic cells except
PMNs.
- High level of Serum ferritin in megaloblastic anaemia; reflect reticuloendothelial iron level
à Hb (heme) à reticuloendothelial stores.
n Bacteria in the circulation is affected mainly by fixed macrophages lining the sinusoids (unique
blood vessels) of the liver and spleen.

Respiratory

• Lung volume:

TLV= IRV + TV + ERV + RV = 6 L

- IRV: inspiratory reserve volume; air inspired with maximal inspiratory effort (after inspiring
at TV).

- TV: tidal volume; air inspired or expired with a normal breath = 500 ml
Dead space = 150ml, used for alveolar ventilation= 350ml

- ERV: expiratory reserve volume; air expired after passive expiration

ERV= FRC –RV = 1000ML
- FRC: functional residual capacity; air left in lung after a normal passive expiration.
ERV+ RV= 1800-2200ml

- RV: residual volume; air remaining in lungs after maximal exhalation. 1200ml.
- RV increases:
1- COPD or asthma
2- Older individual

- Normal quiet respiratory movements by Hering- Breuer reflex (inhalation reflex).

- Normal concentration of CO2 in alveolar air= 5.6%
- Blood leave the lung with 95% O2.
- Intermediate size bronchi: major area of airway resistance.
- Narrowest upper airways in adult: glottis, children: cricoid.

- Atelectasia: collapse of alveoli.

- Dyspnea: difficulty breathing, unpleasant sensation.
- Apnea: cessation of breathing.
- Hyperapnea: abnormally deep and rapid breathing.

53
 - Hypercapnia: increase CO2 level in arterial blood secondary to decrease ventilation.
- Respiratory arrest: cessation of breathing.

- Hyperventilation: increase alveolar ventilation; greater than metabolic requirements à

decreased PCO2 (with decrease in cerebral perfusion à fainting /syncope.

- Hypoventilation: decrease ventilation; less than needed for metabolic requirements. à

increased PCO2.

Liver
• Liver function:
1- Store iron
2- Reservoir bile
3- Protein and amino acid synthesis.
4- Glycogen storage.
• Albumin: produced by liver, keeps fluid from leaking out of blood, carries hormone.
- Decreased albumin level à in chronic liver disease.

In severe liver disease, liver tissue B12 binding and storage is disrupted causes B12 leak out of liver
into the circulation. à increased level of B12.

54
Hormones
• Steroid hormone:
1- Sex hormones
2- Adrenalà cortisol, aldosterone.

• Amine hormones:
Tyrosine Tryptophan
Thyroid hormone: T3, T4 Melatonin
Catecholamine A. epinephrine Regulate the sleep
B. Norepinephrine
A,b à adrenal gland (medulla)
c. dopamine à hypothalamus
T3 à Triiodothyronine, less number, more potent *serotonin à melatonin
T4 à thyroxine, more number, less potent precursor.

Tyrosine à DOPA à dopamine à norepinephrine à epinephrine.

• Norepinephrine and epinephrine in response to:

1- Sympathetic stimulation
2- Exercise
3- Cold
4- Decreased BGL
• Norepinephrine and epinephrine FUNCTION à regulator for fat + carbohydrate metabolism and
cardiovascular effect.
1- Lipolysis
2- Increases BGL; increases glycogenosis, gluconeogenesis.
3- Increase cardiac output.
4- Increase blood pressureà vasoconstrictor.
5- Bronchodilator.

• Peptide hormones:
1- Anterior pituitary hormones:
- Growth hormone GH
- Thyroid stimulating hormone TSH
- Follicle stimulating hormone FSH
- Luteinizing hormone LH
- Prolactin

2- Posterior pituitary hormone:

- Antidiuretic hormone ADH à SUPRAOPTIC NUCLEUS
- Oxytocin à PARAVENTRICULAR NUCLEUS

3- Pancreatic hormone
- Insulin à beta
- Glucagon à alpha
4- Parathyroid hormone

55
• Hormones secreted by islet of Langerhans in pancreas:
1- Insulin
2- Glucagon
3- Somatostatin
4- Pancreatic poly peptides.

• Cortisol induced by stress and low blood sugar. à stimulate glucagon.

- Least amount at midnight.
n Albinism result from incomplete metabolism of tyrosineà melanin.
n Anterior hypothalamus: heat loss center. à damage: hyperthermia.
- Blood flow in the skin regulate the body temperature.
- Body heat lost by radiation 65%.

n Hormone stimulating erythropoiesis:

1- Specific à erythropoietin (kidney 85%)
2- Non- specific à A. androgen (sex hormone). B. thyroid hormone.

n Adenohypophysis= anterior pituitary gland.

n Neurohypophysis= posterior pituitary gland.
n Hypophysis cerebri develops pituitcytes from neuroglial cells.

Aldosterone ADH
- Secreted in response to decreased - Secreted in response to haemorrhage
plasma Na level and increased plasma or dehydration or shock.
K. - Act on distal and collecting tubules.
- Renin- angiotensin. - Supraoptic nucleus of posterior
- Act on collecting ducts. pituitary gland à ADH

• Renin secreted by juxtaglomerular cells.

56
Nutrition

• Amount of K in blood= 3.5 -5 g/dl

• Amount of Ca in blood= 9-11 g/dl
• 1 g of protein à 4 kcal
• 1 g of fat à 9 kcal

• Calcium 1- Muscle contraction 2- Nerve impulses 3- Aid in coagulation 4- stimulate insulin

release in the blood.
• Cholineà fat metabolism.

• HDL: high density lipoproteinà rid the body of excess cholesterol to the liver.
• LDL: low density lipoprotein à rid the body of excess cholesterol to the arteries.

• Thiamine B1 deficiency: Beriberi PNS, Wernicke CNS

• Riboflavin B2 deficiency: angular stomatitis.
• Niacin B3 deficiency: Pellagra: Dementia, Diarrhea and Dermatitis.
• Pyridoxine B6 deficiency: anaemia.

n Vitamin D:
1- Bone à increase Ca metabolism.
2- Intestineà increase Ca reabsorption.
• Active form of vitamin D: 1,25 dihydroxycholecalciferols.
• 7- dehydrocholesterol (skin/ sunlight)à cholecalciferol D3 à (liver) 25, hydroxycholecalciferol
à (kidney) 1,25 dihydroxycholecalciferols.

• B12 Affect blood cell reproduction; DNA formation.

• Pernicious anaemia: glossitis.
• Avidin: biotin binding protein.

57
 Microbiology

n Red complex:
1- Porphyromonas gingivalis.
2- Tannerella forsythia.
3- Treponema denticola.

n Sepsis by:
1- Staph. Aureus.
2- Klebsilla sp.
3- E. coli.

n Streptococci pneumonia:
1- Sinusitis.
2- Otitis media (children)
3- Meningitis.
4- Pneumonia.

n Viridians group: streptococci mutans + streptococci sanguis:

1- Caries.
2- Endocarditis.

n Streptococci pyogenes:
1- Pharyngitis.
2- Scarlet fever (strawberry tongue).
3- Rheumatic fever.
4- Cellulitis.
5- Impetigo.
6- Glomerulonephritis.
7- Pyogenic infection.

n Staphylococcus aureus:
1- Abscess.
2- Osteomyelitis.
3- Endocarditis.
4- Toxic shock syndrome.
5- Scalded skin syndrome.
6- Food poisoning.
7- MRSA.
8- Pneumonia.

58
 n Alpha haemolytic streptococcus à endocarditis.
n Streptokinase: dissolve a performed blood clot.
n MRSA: hospital acquired infection, treated by vancomycin or floxacillin.
n Maxillary sinus infection à anaerobic bacteria (most common).

n Candida albicans
- Gram + fungus
1- Yeast: unicellular.
2- Hyphae: multicellular.
3- Pseudo-hyphae

n Clostridium tetani
- Gram + ve, obligate anaerobic rod. (form spores)
- Motile.

n Actinomyces species
- Gram +ve anaerobic bacteria.

Major Hepatitis viruses

HAV HBV HCV HDV HEV
RNA DNA RNA RNA RNA
Fecal-oral Blood- borne Blood borne Blood borne Fecal-oral
Self-limiting Increase incidence of: Require presence of Epidemics in
Recovery within - Chronic liver disease. HBsAg for underdeveloped
4 months. - Cirrhosis replication. countries.
- Hepatocellular carcinoma

Incubation period of HBV: 30-180

days.

No vaccine No vaccine

- HBV destroyed by boiling for 2 minutes, 40% spread between patients, needle stick injury
10-30%. à hepadnaviridae.
- HCV shorter course and less severe than HBV.
- HCV: needle stick injury 1-3%
- HIV: needle stick injury 0.1-0.3%
- EBV: DNA virus.

59
 Pharmacology

Antibiotics

Inhibition of cell wall synthesis:

1- Beta lactam antibiotics:

a. Penicillin.
b. Cephalosporin.
c. Carbapenem.
- Very wide spectrum antibiotic.
- Bactericidal.
- High specificity for PBP- 2 of gram +ve and gram –ve bacteria.
- Resist most beta lactamases.
- Side effect: cross allergenicity with beta lactamase, CNS toxicity and seizures.

d. Monobactam.
- Limited to aerobic gram –ve species.

e. Carbacephem.
- Potent wide spectrum.

2- Vancomycinà bactericidal, treatment of choice for MRSA.

3- Bacitracin à against gram +ve, topical.

Resistance:
• Penicillin: Bacteria à beta lactamase; hydrolyse
- Bactericidal. the beta lactam ringà incapable of
- Gram +ve. binding to PBP.
- Increase PT/ INR in patient taking oral
anticoagulant. To overcome resistanceà beta
- Types: lactamase inhibitor; clavulanic acid +
1- Penicillin G, V (narrow spectrum) amoxicillin, sulbactam + ampicillin,
tazobactam+ piperacillin.

Penicillin G Penicillin V
- Natural - Semi synthetic
- Gram +ve mainly. - Gram +ve mainly.
- Poor gastric absorption; Acid laible. - Acid resistance; acid stable.
- IM/ IV - Oral only.
2- Anti-staphylococcal penicillin (narrow spectrum)
à penicillinase resistance; resistance to degradation by penicillinase.
à example: nafcillin à metabolized in liver.

3- Aminopenicillin (extended spectrum)

à gram +ve and increased effect against gram –ve.
à bactericidal.

60
 à acid stable; orally, IV and IM.

Ampicillin Amoxicillin
- Incompletely absorbed orally; - Completely absorbed orally.
food interfere with absorption. - Excreted completely in urine.
- Excreted in urine, high
amount in bile.
4- Extended spectrum penicillin; anti- pseudomonal.
à mainly gram –ve.
à adverse reaction: platelet dysfunction, hypokalaemia and hypersensitivity reaction.

• Cephalosporin:
- Cross hypersensitivity 2-10% with penicillin.
- Bactericidal
- Adverse effect:
a. Allergy.
b. Transient increase in liver enzyme.
c. Nephrotoxicity.
d. Neutropenia, eosinophilia and thrombocytopenia.

1st generation:à gram +ve more than gram –ve.

Examples: cefazolin, cephalexin.

2nd generation: à greater effect on gram –ve.

Examples: cefoxitin, cefprozil.

3rd generation:à indicated for penicillin resistance.

4th generation:
à not active against MRSA, greater stability against breakdown by many beta lactamases.
Example: cefepime.
th
5 generation:
à more extended spectrum against beta lactamases, effective agent against MRSA.

• Vancomycin:
- inhibit aerobic and anaerobic gram-positive bacteria.
- I.V
- adverse effect:
a. Nephrotoxicity.
b. Auditory toxicity.
c. Ototoxicity.
d. Neurotoxicity.
e. Hypotension.
f. Red man syndrome: flushing of skin with rapid infusion of IV.

61
Alteration of cell membrane integrity (holes in the wall/ membrane)
1- Polymyxin B: for gram- negative bacteria.
Adverse reactions:
a. Paraesthesia.
b. Slurred speech.
c. Ataxia.

2- Daptomycin: for gram- positive bacteria, given IV.

Adverse reactions:
a. Skeletal muscle damage.
b. Peripheral neuropathy.

Suppression of DNA synthesis: (Metronidazole/ Fluoroquinolones/ Rifampicin)

• Metronidazole:

- Bactericidal.
- Suppression of DNA synthesis (interfere with DNA function)
- Active only against anaerobes.
- Antibacterial + antifungal
- Has excellent CNS penetration.
- Orally or IV.
- Metabolized in liver.
- Drug of choice for à protozoal infection.
- Metronidazole + amoxicillin à acute orofacial infection. Example: aggressive periodontitis.

à Contraindicated with:

1- Warfarin à (bleed more easily)

2- Alcoholic patient à Disulfiram like reaction.
3- Phenytoin à speed up elimination of metronidazole.
4- Cimetidine (histamine H2 receptor) (inhibit stomach acid production, mainly used for
treatment of heart burn and peptic ulcers. à increase metronidazole level then increase its
side effect.

• Fluoroquinolones: Ciprofloxacin, oxacin suffix.

- Bactericidal
- Inhibit DNA gyrase.
- Well absorbed orally.
- Adverse effect:
1- Mild neuropathy
2- Dermatological toxicity
3- Chondrotoxicity
4- Photo toxicity à skin exposed to the sun light.
- Ciprofloxacin used with caution in pregnancy and children, other Fluoroquinolones are
contraindicated in children younger than 18 years.

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• Rifampicin:
- for gram- positive and negative bacteria.
- decrease the effectiveness of oral anticoagulant and oral contraceptive.

Inhibition of Ribosomal protein synthesis

• Macrolides

- Inhibition of ribosomal protein synthesis.

- 50s bacterial ribosomes.
- Bacteriostatic at low concentrations
- Bactericidal at high concentrations

Erythromycin Clarithromycin Azithromycin

Source Natural Semisynthetic Semisynthetic
Antibacterial Narrow spectrum Broad spectrum Broad spectrum
spectrum
Duration of Short acting Long Long
action
Effectiveness Positive Positive anaerobic Negative anaerobic
against
Stability in Least stable Most stable Stable
stomach
Excreted Bile Urine Bile
Least drug –drug interaction

Adverse effect:
1- Steven- Johnson syndrome
2- Erythromycin induce digoxin toxicity

Least safe in pregnancy

Adverse effect of macrolides:

a. Acute pancreatitis.
b. Cholestatic hepatitis.
c. Ototoxicity.
d. Steven- Johnson syndrome (erythromycin).

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Drug interactions with macrolides:
a) Bacteriostatic macrolides interfere with bactericidal effect.
b) Reduce digoxin metabolism in GIT.
c) Increase anticoagulant effect of oral anticoagulant.

• Aminoglycoside:

1- Gentamycin: most commonly used.

2- Streptomycin = first line drug for TB.
3- Mikacin
4- Neomycin: topical, nephrotoxic
- Bactericidal.
- Irreversible binds to 30s ribosomes.
- Gram negative bacilli and mycobacteria.
- Poorly absorbed orally à IV / eye drop.
- Not safe during pregnancy.
- Excreted by kidney.

Adverse reaction:
1- Renal toxicity.
2- 8th CN toxicity; auditory and vestibular ototoxicity.

• Tetracycline: bacteriostatic, inhibit protein synthesis.

- Contraindicated in pregnancy; staining the teeth and hepatotoxicity.
- Should not be used in children younger than 8 years.

• Doxycycline:
- Broad spectrum.
- Orally or IV.
- Bacteriostatic.
- Excreted in bile or feces.
- Used to treat bacterial pneumonia, acne, Lyme disease, cholera and syphilis.
- Elimination half-life 18 hours.

• Chloramphenicol
- Bacteriostatic.
- Broad spectrum antibiotic.
- 50s ribosomal subunits.
- Adverse reactions:
1) Reversible and irreversible bone marrow depression.
2) Grey baby syndrome: inability of the immature liver of neonate to detoxify the drug.

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 • Clindamycin
- Inhibition of ribosomal protein synthesis.
- 23s subunits of 50s bacterial ribosomes.
- Bacteriostatic.
- Gram positive + negative/ anaerobic, facultative/ aerobic MOs.
- Well absorbed orally, IV, IM, ORALLY.
- Metabolized in liver.
- Treatment of: Acute infection/ bone infection /female genital tract infection/ abdominal
penetrating wound/ pelvic infection.
- Penetrate bone well but not CNS.
- ADVERSE EFFECTS:

1- Pseudomembranous colitis. à treatment metronidazole or vancomycin.

2- Metallic taste.
3- Reversible myelosuppression; bone marrow suppression.
4- Reversible increase in liver enzyme. (serum transaminase)
5- Allergy and maculopapular rash.
6- Sweet syndrome.

Inhibit folic acid synthesis

• Sulfonamides
- Bacteriostatic.
- Broad spectrum +ve, -ve.
- Orally or topical.
- Penetrate CNS.
- Adverse effect:
1) Steven- Johnson syndrome.
2) Induce vitamin K deficiency.

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• Anti-fungal agents:
1) Amphotericin B
- Fungi static or cidal depending on the dose, PH and the fungus involoved.
- Peak activity at PH between 6-7.5.
- Broad spectrum.
- Topical, oral or IV (most toxic)
- Adverse effect:
a) Hypochromic, normochromic anemia.
b) Nephrotoxicity.
c) Hypokalemia.

2) Nystatin
- Narrow spectrum than amphotericin B.
- Not absorbed well from skin, mucous membrane on GIT.
- Topical nystatin is a drug of choice for the treatment of candida infection of oral cavity.
- Bitter foul taste.

3) Fluconazole (IV systemic)

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 • Corticosteroid: class of steroid hormone produced by adrenal cortex, (anti- inflammatory +
immunosuppressive.)

- Long term corticosteroid therapy causes:

1- Avascular bone necrosis; osteonecrosis. à increase lip in blood à decrease blood flow.
2- thinning bones (osteoporosis).
3- Hypertension
4- Hyperglycemia; increasing the production of glucose.

• Aspirin “acetylsalicylic acid”:

- NSAID and supresses the normal functions of platelets; anti-inflammatory, analgesic,
antipyretic and anti- platelet drug.
- MOA: Inactivation of COX enzymeà decrease/ inhibit the production of prostaglandin and
thromboxane A2.
- Thromboxane A2 à produced by activated platelets, it stimulates activation of new
platelets as well as increase platelet aggregation.
- Aspirin + child + VZV= Ray’s syndrome à brain + liver.
- Aspirin irreversible inhibit COX-1 and modifies COX-2.
à MOA for other NSAIDs: reversible inhibition.

à Arachidonic acid cascade

Phospholipids (hydrolysed by phospholipase A2 (PLA2)) à A.A (COX1 and COX-2)à prostaglandin
G2 à
1- Prostacyclin
2- Prostaglandin
3- Thromboxane A2 à platelets.

à COX -1:
1- Produce prostaglandin
2- Activated platelet (thromboxane)
3- Protect the lining of GI tract

à COX-2:
1- Inflammation
2- Pain

à COX-2 inhibitor:
- Anti-inflammatory, analgesic and antipyretic.
- Side effects: increases cardiovascular side effect; hypertension and thrombotic effect.
Examples: celecoxib, valdecoxib, rofecoxib…

à vitamin E used for periodontal disease; it has an effect on decreasing PG.

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• Salicylism; aspirin overdose:
1) Tinnitus.
2) Nausea.
3) Vomiting.
4) Headache.
5) Hyperventilation; acidosis.
6) Mental confusion.

• Paracetamol:
- Category A drug
- Weak inhibitor of the synthesis of prostaglandins in CNS.
- Antipyretic.
- Relief pain.
- Metabolized in liver à contraindicated in liver diseases (acute liver failure.)
- Excreted in urine.
- Toxic metabolite: N- acetyl- P-benzoquinone imine.
- Maximum dose must not exceed 3g per day.

** maximum dose of ibuprofen must not exceed: 3.2g/ day.

• Acute paracetamol poisoning: nausea, vomiting, hypotension, hypoglycaemia, coma and death.
Treatment: N- acetylcysteine.

• Morphine
- Anti-cough.
- Morphines
- M: meiosis.
- O: orthostatic hypotension.
- R: respiratory depression.
- P: physical dependency.
- H: histamine release.
- I: increase intracranial pressure.
- N: nausea.
- E: euphoria.
- S: sedation.

• Carbamazepine (Tegretol)
- Anticonvulsant medication: treatment of epilepsy and neuropathic pain.
- May cause life threatening allergic reaction: Stevens- Johnson syndrome, TEN à
hypersensitivity type IV.
- Treatment of facial, trigeminal neuralgia: carbamazepine (Tegretol).

Note: sulfa drugs and erythromycin may cause Stevens- Johnson syndrome as well.

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 • Diazepam (Valium):
- Inhibitory neurotransmitter in brain.
- Benzodiazepam family.
- Treatment of:
1- Anxiety
2- Seizurs
3- Alcohol withdrawal syndrome
4- Muscle spasms
5- Insomnia
6- Restless leg syndrome (willis- Ekbom disease)
à iron deficiency and neurological disorder.
à body needs iron for dopamine à movement.
7- Used to cause memory loss.
- Dosage increase gradually.
- Onset of action orally: begins after 15-60 minutes. à rapid.
- Terminal elimination half-life: 20-8- hours.
- Metabolized in liver.

• Tranquilizers; anti-anxiety, decrease fear, tension.

- Major tranquilizer: antipsychotics à schizophrenia.
- Antipsychoticsà the most common drug that induce xerostomia.

• Isoniazid:
- Inhibit cell wall synthesis
- Used to treat TB.
- Bactericidal: mycobacterium grow rapidly.
- Bacteriostatic: mycobacterium grow slowly.

• Clopidogrel: anti-platelet medication, increase bleeding time.

•Heparin unfractionated: acts by potentiating anti-thrombin III, which inhibit clotting

factors II, IX, X, XI.
à LMWH: low molecular weight heparin (fractionated) acts on factor X.
à the incidence of heparin induced thrombocytopenia (HIT) is greater for unfractionated heparin
than LMWH.

• Proton pump inhibitor: causes prolonged and profound reduction of stomach acid
production.
- By irreversible inhibiting the stomach H+/K+ ATPase proton pump.
- Used for peptic ulcers, Barrett’s esophagus.

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 • Clonidine small dose will stop the onset of migraine.
à more preferable than ergotamine.

• Nystatin: only topicalà not metabolized in liver.

• Antihistamine induce xerostomia à anticholinergic action.

- Cimetidine: decreases stomach acid secretion. (heart burn + peptic ulcer)

• Acyclovir: treatment of HSV 1, 2. Resistant from à Foscarnet.

• Bisphosphonate: inhibit osteoclast, to treat osteoporosis and similar diseases.

• Drugs contraindicated with NSAIDs:

1- Diuretics: reduce diuresis.
2- Beta blocker, ACE inhibitor: decrease antihypertensive effect.
3- Anticoagulant: increases bleeding
4- Alcohol
5- Cyclosporine: increases the nephrotoxicity.
6- Sulfonylurea: increase hypoglycaemic risk.

• NSAIDs contraindication:
- N: nursing and pregnancy.
- S: serious bleeding.
- A: allergy or asthma.
- I: impaired renal function.
- D: drugs.

• Gingival overgrowth is often drug related:

1- Cyclosporine; immunosuppressant for transplanted organ.
2- Calcium channel blocker (nifedipine, verapamil, diltiazem); used to lower blood
pressure.
3- Phenytoin; anti-seizure medication.
4- Valopric acid = sodium valproate; anti-epileptic.

• Drugs cause light sensitivity:

1) Ibuprofen.
2) Naproxen.
3) Methotrexate.
4) Antihistamine.
5) Sulphonamides.
6) Tetracycline.
7) Oral contraceptive.

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 • Examples of category X medications:

1- Thalidomide
2- Oral contraceptive
3- Statins; most common cholesterol lowering drug.

• Thalidomide àimmuno-modulatory medication, to treat number of cancer; including

Multiple Myeloma.

• Paracetamol à category A
• Erythromycin/ Clindamycin à category B
• Ibuprofen/ ciprofloxacin à category C

• DEXTROSE 50% for:

1- Acute alcoholic intoxication.

2- Sulfonylurea overdose.
3- Insulin overdose.
4- Hyper kalemia à potassium.

• Adrenaline IM; 0.5mg per dose, may require two doses.

• Paracetamol 500mg
• Amoxicillin 500mg
• Clindamycin 150-300mg or 300-450mg.
• Maximum dose of ibuprofen 3.2g / day à 800mg/ dose.

• Hepatic disease à don’t give him erythromycin

- Safe antibiotics for hepatic patients:
1- Amoxicillin
2- Fluoroquinolones; ciprofloxacin
3- 3rd generation of cephalosporin: ceftriaxone, cefotaxime.

• Treatment of tuberculosis:
1- Streptomycin.
2- Isoniazid.
3- Rifampicin. à Discoloration of saliva.
4- Pyrazinamide.

• Treatment of Rheumatic arthritis: indomethacin (NSIAD) + methotrexate.

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 • Lupoid reaction: drug induced lupus erythematous.
1- Phenytoin.
2- Quinidine; to treat irregular heartbeats.
3- Isoniazid.
4- Minocycline
à symptoms similar to SLE.

• Anti-dote (antagonist)
- Naloxone à Opioids
- Atropine (anticholinergic; decrease heart rate, decrease salivation) à physostigmine.
- Benzodiazepineà flumazenil.
- Ethanol à fomepizole.
- Paracetamol (acetaminophen) à intravenous acetylcysteine.
- Aspirin à sodium bicarbonate.
- Heparin à protamine sulfate.
- Warfarinà vitamin K.
- Sodium cromoglycate (antihistamine) à block hypersensitivity type I.

• Contraindication of renal failure à Itraconazole (IV)

• Ketoconazole à increase the level of blood warfarin.
• Prednisolone à not contraindicated with warfarin.
• Streptomycin à actively secreted in saliva.
• Sulfonamides à induce vitamin K deficiency.

n Substantivity: property of continuing therapeutic action despite the removal of vehicle.

à chlorhexidine (4-12 hr.)

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Local anaesthesia

- Procaine and lidocaine potent vasodilators; increase absorption to limit this action
vasoconstrictor is added.
- Prilocaine and mepivacaine not a strong vasodilator; don’t require much vasoconstrictor to
limit their action.
- Short acting: procaine.
- Moderate acting: lidocaine, mepivacaine and prilocaine.
- Long acting: tetracaine and bupivacaine.

- Most effective topical anaesthesia: tetracaine.

- ELMA= 2.5% lidocaine and 2.5% prilocaine; to increase solubility of both drugs when
formulated together.
- Phentolamine mesylate (OraVerse): reversal of soft tissue anaesthesia.

- pKa and onset of action are inversely related; increased pKa = slow onset of action and so
on.
- Increased lipid solubility increases the potency of local anaesthesia.
- Increased protein binding increases the duration of action.
- Acidic environment, hypokalaemia and hypercalcemia antagonize the block of local
anaesthesia.

- Most cardio toxic LA: Bupivacaine.

- Mepivacaine is used with cardiac patients.
- During pregnancy lidocaine and prilocaine are safe.

- Drug interaction with LA:

1) Tricyclic anti-depressant: increase the effect of vasoconstriction and increase the risk
of hypertension and cardiac arrhythmia.
à use prilocaine with flypressin.
2) Sulphonamide
Procaine and other esters (PABA) antagonize antibacterial action of sulphonamide.

3) Opioids increase systemic toxicity of local anaesthesia.

• LA à PABA:
1- Benzocaine.
2- Tetracaine.
3- Procaine.

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• Adrenaline absolute contraindication à thyrotoxicosis à prilocaine.
• Lidocaine and procaine are potent vasodilator.
• Methemoglobinemia à benzocaine, lidocaine, prilocanie and tetracaine.
IV Methylene blue à antidote.

74
 Oral histology

• Hertwig’s epithelial root sheath:

- Bilayer epithelial sheath originated from the apical region of the enamel organ.
- Guiding root development; formation and determining the size and number of roots.

• Sharpey’s fibers: portion of principle fibers that insert into cementum (fully mineralized) or
alveolar bone proper (partially mineralized) (thicker on the alveolar side). àtype I collagen.

• Lamina dura = alveolar bone proper = bundle bone= cribriform plate:

- Thin layer of cortical bone that immediately surround the teeth and into which PDL fibers
(Sharpey’s fibers) are embedded.
- Its coronal margin becomes alveolar crest.

• Principle PDL fibers: mostly type I collagen but also type III collagen.
** fibroblast is the most common cell of the PDL.

A. Trans-septal: extend inter-proximally over the alveolar crest from the cementum of one
tooth to that of an adjacent.
Resist medial- distal forces

B. Alveolar crest: extend obliquely from the cementum (just apical to the junctional
epithelium) to the alveolar crest.
Resist vertical (intrusive and extrusive) forces

C. Horizontal: extend at right angle from cementum to alveolar bone.

Resist lateral (tipping) and rotational forces

D. Oblique (most abundant principle fibers): extend from cementum to the alveolar bone.
Main resistance to masticatory forces (intrusive, rotational) forces

E. Apical: cementum to the alveolar bone at root apices.

Resist extrusive forces (vertical)

F. Inter-radicular: radicular cementum àinter-radicular alveolar bone.

Only in multi-rooted teeth.
Resist vertical (intrusive+ extrusive) and lateral tipping forces

** oxytalan fibers: run parallel to the tooth surface and bend to attach to cementum. (largely
associated with blood vessels)

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 • Pulp collagen: I + III.
• Dento-gingival connective tissue: collage type I (bulk)

• Gingival fibers groups:

1- Dentogingival: fan laterally, from cementum to the adjacent CT.

2- Alveolgingival: fan coronally, from alveolar crest to the adjacent CT.
3- Dentoperiosteal: from the cementum over the alveolar crest turn apically to insert into
the periosteum of the buccal side of alveolar bone.
4- Circumferential: surround the tooth in a circular fashion.
• Prevent rotational forces.
• Located in lamina propria pf marginal gingiva.

• Specialized epithelial cells: most of them in basal cell layer.

1- Melanocytes
2- Keratinocytes
3- Langerhans cell: antigen presenting cell, may extend to stratum spinosium.
4- Markel cell; touch- sensory cells.

• DEJ (hypo mineralized) more protein

1- Enamel tufts: hypo calcified, fan shaped enamel protein projecting a short distance into
enamel.
2- Enamel lamellae: hypo calcified, enamel defect that extend all the way to the enamel
surface; enamel protein of oral debris.
3- Enamel spindles: trapped odontoblastic processes in the enamel. (linear defect)

• Epithelial cuff = REE + oral mucosa.

• Modulation of enamel (PH cycling): involves the cyclic transformation of ruffle- ended
ameloblasts facing slightly acidic enamel into smooth- ended ameloblasts near PH – neutral
enamel.
• Unique phenomena during maturation stage.
• When modulation is delayed or disrupted àenamel mineralization reduced.

• Lines of salter of cementum: annual

• Rest period in cementum formation.
• More mineralized than adjacent.
• Dark lines parallel to rod surface.
• In both cellular and acellular.
• Increased ground substance and less collagen.

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 • Aging on dentine:
A. Increase sclerotic dentin; less dentinal tubules diameter à continued deposition of
peritubular dentin.
B. Increase reparative dentin formation.
C. Increase dead tracts.

• Aging on enamel:
1. Increase attrition.
2. Discoloration.
3. Less permeability; especially to fluoride.

• Aging on pulp:
A. Increase collage fibers and calcification.
B. Decrease pulp chamber volume.
C. Decrease apical foramen size.
D. Less cellularity, vascularity and sensitivity.

** Denticles (pulp stones): calcification in concentric pattern.

• Aging on cementum: increase cementum deposition.

- Cementum (avascular).

• Aging on PDL: less PDL width, cellularity, fibers and fibroblastic contents, with increase in
elastic fibers.

• Aprismatic enamel:
- 30 micrometres in thickness.
- 70 % of permanent teeth and all primary teeth.
- Adjacent to DEJ and outer surface of the teeth.
- Highly mineralized.

• Howship’s lacunae: groove or cavity containing osteoclasts.

• Dentine dysplasia type II: defect of dentin and pulp. àThistle- tube shaped coronal pulp
chambers that contains pulp stones.

• Stratum intermedium:
- Derived from ectoderm.
- Connected to each other via desmosomes.
- Contain alkaline phosphatase.
- Lies adjacent to the ameloblasts.

77
 Saliva
• Parotid gland pierces Buccinator muscle.
• Minor salivary glands absent from:
1- Gingiva.
2- Dorsum of anterior two third of tongue.
3- Anterior hard palate.

• Unstimulated saliva= 0.2 -0.5 ml/min

• Stimulated saliva= 1-2ml/min

• Serious acini à spherical.

• Mucous acinià tubular.

• Minor salivary gland most numerous at posterior soft palate and laterally.
à Fovea palatinae: two small pits of mucous salivary gland, one on either side of the
midline on the anterior part of soft palate.

• Salivary gland: compound tubule-acinar.

• Submandibular gland mixed mainly serous.
• Sublingual gland: not capable of producing hypotonic saliva; lack striated duct.
• Pleomorphic adenoma à chondroid cell.

• Most common unilateral benign tumor: pleomorphic adenoma.

• Most common bilateral benign tumor: warthin’s tumor.
- Second most common benign tumor in salivary glands.
- 3.4% lymphoid neoplasia.
• Most common viral infection sialdenitis à MUMPs à paramyxovirus.
- Bilateral mostly.

• From ectoderm: parotid and minor salivary gland.

• From the junction between ectoderm and endoderm: submandibular and sublingual.

• Natal teeth à at birth.

• Neonatal à during first 30 days.
• Oligodontia: congenital absence of more than six teeth.
• Third week à gastrulation: an embryo transforms from 1 D to 3D; multi-layered structure:
gastrula.
• 2nd to third week: primary germ layer:
1- ectoderm
2- endoderm
3- mesoderm

78
• palatine tonsils:
- from the 2nd pharyngeal pouch.
- Superior constrictor muscle of pharynx immediately latera to it.
- If inflamed à ear ache.
- Often has large palatine vein in its bed.

• Lower arch increases in length at 8 years.

• Upper arch increases in length at 13 years.
• Maximum mandibular canine distance: female 9 years, male 10 years.
• Cleft lip and palate operations time:
- Lip closure: 2-3 months.
- Palate closure: 12-18 months.
- Interceptive orthodontics treatment: 5-7 years.
- Bone grafting: 9-11 years.
- Comprehensive orthodontics treatment: 12 years.

• Paranasal sinusà frontal sinus aid in skeletal age à 7 years.

• Ossification of cranial bone à 7-8th week.

79