• A muscle cramp is a sudden and involuntary contraction of one or more of your muscles. These contractions are often painful and can affect different muscle groups.
• Commonly affected muscles include those in the back of your lower leg, the back of your thigh, and the front of your thigh,abdominal wall,arms,hands&feet.
• The intense pain of a cramp can awaken you at night or make it difficult to walk.
•  A sudden, sharp pain, lasting from a few seconds to 15 minutes

CAUSES

• Inadequate blood supply. Narrowing of the arteries that deliver blood to your legs can produce cramp-like pain in your legs and feet while you’re exercising. These cramps usually go away soon after you stop exercising.
• Nerve compression. Compression of nerves in your spine (lumbar stenosis) also can produce cramp-like pain in your legs. The pain usually worsens the longer you walk. Walking in a slightly flexed position such as you would use when pushing a shopping cart ahead of you may improve or delay the onset of your symptoms.
• Aging: Over time, losing muscle mass can put more strain on your muscles. These changes can lead to more frequent muscle cramps as you age.
• Dehydration: Losing body fluids while exercising (especially in hot temperatures) can cause muscles to cramps
• Hypothyroidism: Having a thyroid gland that is less active than normal can lead to muscle cramps.
• Low electrolyte levels: Low levels of substances such as calcium or potassium in the blood can cause muscle cramps.
• Medication: Taking certain medicines, including pseudoephedrine (a drug used to treat nasal congestion) and statins (medications that treat high cholesterol), can cause involuntary muscle cramping.

TYPES OF MUSCLE CRAMPS

• Skeletal muscle cramps: Can be voluntarily controlled. Skeletal muscles that cramp the most often are the calves, thighs, and arches of the foot, Around 40% of people who experience skeletal cramps are likely to endure extreme muscle pain.
• Nocturnal leg cramps:These leg cramps are involuntary muscle contractions that occur in the calves, soles of the feet, or other muscles in the body during the night or (less commonly) while resting. The duration of nocturnal leg cramps is variable, with cramps lasting anywhere from a few seconds to several minutes.
• Smooth Muscle Cramps: Contractions may be symptomatic of endometriosis.Menstrual cramps may also occur during a menstrual cycle, as a result of uterine contractions as the uterus sheds its lining. Menstrual pain is common and most menstruating women experience it at some point, with more than 40% experiencing pain every period. Severe pain is less common, but still significant

CLINICAL PRESENTATION

• Weakness
• Swollen Joints
• Joint Pain
• Firmness,
• Tenderness,
• Bulging of the muscle,
• Swelling,
• Soreness, and
• Gait disturbances (if the cramp occurs in the leg or foot).

DIAGNOSTIC TESTS

• Blood test to check the levels of potassium and calcium in your blood, as well as your kidney and thyroid function.
• Electromyography :This is a test that measures muscle activity and checks for muscle abnormalities.
• MRI may also be a helpful test. It’s an imaging tool that creates a picture of your spinal cord.
• Urine tests to find the cause of muscle cramps. These tests can identify underlying conditions such as liver or kidney disease that may cause cramps.

RISK FACTORS

• Tight, inflexible muscles.
• Poor physical condition.
• Poor muscle tone.
• Inadequate diet.
• Physical overexertion.
• Physical exertion of cold muscles.
• Muscle injury.
• Muscle fatigue.

TREATMENT

• Stretch the affected area.
• Massage the affected area with your hands or a massage roller.
• Stand up and walk around.
• Apply heat or ice. Put an ice pack together or apply a heating pad, or take a nice warm bath.
• Take painkillers such as ibuprofen and acetaminophen,vitamin B12 complex.

PREVENTION

• Perform flexibility exercises on a regular basis.
• Work towards better overall fitness.
• Stretch your muscles regularly. Do this especially for those most prone to muscle spasms.
• Drink fluids frequently. Choose water and avoid alcohol and caffeine.
• Avoid exercising in hot weather.
• Wear shoes that fit you properly.
• Keep your weight at a healthy range. Experiment with mild exercise right before bed to prevent nocturnal leg cramps.
• Avoid medications that may cause muscle spasms as a side effect.
• To prevent leg cramps, use pillows to keep your toes pointed upwards if you sleep on your back. If you sleep on your chest, hang your feet over the end of the bed.
• Stretch your muscles before you go to sleep. When you sleep, keep the sheets and blankets loose around your legs.

TRIMODAL PEAK OF DEATH:

1st Peak ( Immediate ) 50%

• Within first few minutes of injury
• Extensive trauma to Brain, Upper Spinal Cord, Heart or Major Blood Vessels, Rupture of Major Airway.
• Little can be done to salvage the Patient.

2nd Peak ( Early Deaths ) 30%

• Within first few hours of Injury
• Subdural/Epidural Hematoma
• Hemo/Pnemothorax
• Organ Rupture/Blood Loss
• Pelvic/long Bone Fracture

3rd Peak ( Late Deaths) 20%

• Weeks after Injury
• Multiorgan failure
• Sepsis

MANAGEMENT OF POLY-TRAUMATIZED PATIENT

There are many protocols for management of poly-trauma, the most universally accepted one is the protocol of ATLS (ADVANCED TRAUMA LIFE SUPPORT) which described by the American College of Surgeons, which consists of 3 steps:

• Primary survey.
• Secondary survey.
• Definitive treatment.

Another protocol is the 5 Rs, as follows

• R1: Rapid Evaluation = Triage.
• R2: Resuscitation.
• R3: Radiology and Other Investigations.
• R4: Re-Evaluation.
• R5: Repair and Rehabilitation.

 R1: RAPID EVALUATION = TRIAGE

Within few seconds you have to be able to put your patients in one of the following categories;

• Black (White) Zone: for those who are dead or dying(e.g. brain herniation).

• Red Zone: for those who needs urgent interference within 5-10 minutes (e.g. those with external hemorrhage and respiratory compromise).

• Yellow Zone: for those who needs also urgent intervention but could withstand for 1-2 hours with in which some resuscitation and investigations could be done (e.g. Internal hemorrhage patients).

• Green Zone: for those who needs intervention within 1-2 days (e.g. patients with fractures).

R2: RESUSCITATION

Including the urgent measures that should be done for the patient immediately after the accident (in the field of the accident) to save his life during the first minutes or hours(the golden hours), they should be done in the order of priority A B C D E as follows:

A-Airway:

B-Breathing:

C-Circulation:

D-Disability (Neurological Assessment):

E-Exposure:

A-AIRWAY:

• The patient’s airway should be evaluated and protected. In general, if the patient is capable of unstrained speech, his airway is patent. All patients should receive supplemental oxygen by mask till they reach the hospital.

Asses for: obstruction, facial fractures, tracheal injuries, tracheal deviation.

• Apply hard cervical collar.
• Open airway by doing jaw thrust maneuver (chin lift).
• Open the mouth, remove the obstruction or secretion. Do suction to remove any obstruction (e.g. secretions, blood, vomitus or any foreign body).

Insert oro-pharyngeal or naso-pharyngeal airway to maintain patency of airway and to prevent falling back of the tongue in an unconscious patient. This method is contra-indicated in conscious patients (stimulates gag reflex and vomiting)

Endo-tracheal Intubation (indicated in cases of apnea, head injuries, air way compromise like maxillofacial injuries, fracture cervical spine and if there is risk of aspiration).

Cricothyroidotomy : If there is upper airway obstruction and it is impossible to pass an endo-tracheal tube.

B-BREATHING:

Check for spontaneous breathing for 10 sec;

• If patient is breathing satisfactorily & PO2 above 90%» justobserve.
• If patient is breathing satisfactorily but PO2 below 90% »provide o2 therapy via mask 6 L/min, 60% O2 concentration.
• If patient is not breathing or PO2 still declining » manually ventilate patient with 15L/min, 100% oxygen concentration &Prepare for intubation and mechanical ventilation.

C-CIRCULATION:

Check peripheral pulsations: tachy- or brady- cardia.

Check Blood Pressure: be rapid and accurate in its measurement.

Check neck veins: is it

• Collapsed—– Hypovolemia.
• Distended—- Impaired Venous Return.
• Tension Pneumothorax; treat it immediately.
• Cardiac Tamponade; treat it immediately by Pericardiocentesis
• Myocardial Contusion & Infarction.

Fluids:

• 2 large bore IV Cannulas&starting with bolus IV fluids-10ml/kg(crystalloid)usual choice RL&NS
• If patient is stable maintenance fluids according to  patients weight will be continued &monitored with the help of blood pressure& urine output
• If immediate blood is not available patient can be started on crystalliods(HEMECEAL)after taking sample for blood group testing.
• O-ve can be transfused without waiting for grouping if available.

If the patient is in shock (neurogenic, oligaemic or cardiogenic), start

immediately anti-shock measures (arrest of bleeding, infusion of lactated

Ringer’s sol., and blood transfusion once available).

D-DISABILITY (Neurological Assessment):

Level of consciousness.

• AVPU scale;

• Awake.
• Verbal response.
• Pain response.
• Unresponsive.

For assessment, apply any scale e.g Glasgow Coma Scale.

GLASGOW COMA SCALE

• 3 – 15 point scale to assess mental status only
• Best observed response
• GCS ≤ 8 is a “coma” and requires intubation for airway protection

E-EXPOSURE:

• Remove clothing.
• Observe the chest for bruises, penetrations, and symmetry.
• Auscultate breath sounds.
• Auscultate heart sounds.
• For total assessment.

After exposure you may find:

Ecchymosis at site of trauma.

R3: RADIOLOGY & OTHER INVESTIGATIONS.

I- Basic X-Ray Films have to be done for every case of Polytrauma depends largely on the suspected site and the doctor who is going to request it. Every specialty has its own interest;

General Surgery: erect abdomen

Cardiothoracic Surgery: chest x-ray

Neurosurgery: skull and spines

Orthopedic Surgery: pelvis, spine and fractures

R4: RE-EVALUATION

(Secondary survey)

Now, this is the time of re-evaluation of the patient. It is done in two steps:

-History taking: this includes; SAMPLE;

• Symptoms.
• Allergies.
• Medications.
• Past history.
• q2Last meal.
• Events related to injury.

II-General Examination from Hair to Heal:

1.Head: search for sub-galeal hematoma, sub-conjunctival hemorrhage, facial fractures,…etc.

2.Neck: pain or tenderness, tracheal deviation, jugular vein, impaled objects and open wounds, Expanding neck hematoma.

3.Heart: rib fractures, pneumo- or hemo-thorax,…etc.

4. Abdomen & Pelvis: Cullen’s sign, Grey-Turner sign,Kher’s sign,…etc.

5.Extremities: Fractures, peripheral pulsations, soft tissue injuries,…etc.

6.Back: bruising, impaled objects, pain and tenderness.

Chest:

   Inspect the chest, observe the chest movements. Look in

particular for:  

• bruising (from seat-belts)
• asymmetric or paradoxical chest wall movement
• penetrating wounds are rare in children, but in cases

where there is a stabbing or other assault look for

“hidden” wounds – checking areas such as the axilla and

back

Palpate for clavicular and rib tenderness and auscultate the

lung fields and heart sounds.

Abdomen:

Inspect the abdomen, the perineum and external genitalia. Look

for in particular for:

   seat-belt bruising / handle-bar injuries

• distension

• blood at the urinary meatus / introitus

Palpate for areas of tenderness especially over the liver, spleen,kidneys and bladder, and auscultate bowel sounds.

Pelvis:

Inspect the pelvis for grazes over the iliac crest. Examine for bruising, deformity, pain or crepitus on movement.

R5: REPAIR & REHABILITATION.

(Definitive treatment of individual injuries )

Finally, the patient is admitted to the hospital in one of the following destination sites:

• General Surgery Department.
• Neurosurgery Department.
• Orthopedic Surgery Department.
• Cardiothoracic Surgery Department.
• ICU.

• An increase in frequency of defecation urgency, or decrease in stool consistency (typically >3loose stools per day) for >4weeks.
• Abnormal stool form is the most important defining factor frequent defecation with normal consistency is termed pseudo diarrhoea.
• Etiologies include osmotic, secretory, malabsorptive, inflammatory, infectious, and hyper motility.
• Infectious causes of chronic diarrhea are uncommon in immunocompetent patients. Parasitic etiologies are more common than bacterial.

 STAGES OF DIARRHOEA

• Mild-2-5 times in a day, Sudden onset
• Moderate-10-12 times a day, Gradually  

·       Severe-More than 12 times in a day ,Sudden &gradually

 OSMOTIC DIARRHEOA

Absorption of water in the intestines is dependent on adequate absorption of solutes. If excessive amounts of solutes are retained in the intestinal lumen, water will not be absorbed and diarrhoea will result. Osmotic diarrhoea typically results from one of two situations:

• Ingestion of a poorly absorbed substrate: The offending molecule is usually a carbohydrate or divalent ion. Common examples include mannitol or sorbitol, Epson salt (MgSO₄) and some antacids (MgOH₂).
• Malabsorption: Inability to absorb certain carbohydrates is the most common deficit in this category of diarrhoea, but it can result virtually any type of malabsorption. A common example of malabsorption, afflicting many adults humans and pets is lactose intolerance resulting from a deficiency in the brush border enzyme lactase. In such cases, a moderate quantity of lactose is consumed (usually as milk), but the intestinal epithelium is deficient in lactase, and lactose cannot be effectively hydrolysed into glucose and galactose for absorption. The osmotically-active lactose is retained in the intestinal lumen, where it “holds” water. To add insult to injury, the unabsorbed lactose passes into the large intestine where it is fermented by colonic bacteria, resulting in production of excessive gas.

SECRETORY DIARRHEOA

Large volumes of water are normally secreted into the small intestinal lumen, but a large majority of this water is efficiently absorbed before reaching the large intestine. Diarrhoea occurs when secretion of water into the intestinal lumen exceeds absorption.

Many millions of people have died of the secretory diarrhoea associated with cholera. The responsible organism, Vibrio cholera, produces cholera toxin, which strongly activates adenylyl cyclase, causing a prolonged increase in intracellular concentration of cyclic AMP within crypt enterocytes. This change results in prolonged opening of the chloride channels that are instrumental in secretion of water from the crypts, allowing uncontrolled secretion of water. Additionally, cholera toxin affects the enteric nervous system, resulting in an independent stimulus of secretion.

Exposure to toxins from several other types of bacteria (e.g. E. coli heat-labile toxin) induce the same series of steps and massive secretory diarrhoea that is often lethal unless the person or animal is aggressively treated to maintain hydration.

 TYPES OF DIARRHOEA

ACUTE DIARRHOEA: The most common, acute diarrhoea is loose watery diarrhoea that lasts one to two days. This type doesn’t need treatment and it usually goes away after a few days.

 CAUSES:

• Viral infections. Many viruses cause diarrhoea, including norovirus. Viral gastroenteritis is a common cause of acute diarrhoea.
• Bacterial infections. Several types of bacteria can enter body through contaminated food or water and cause diarrhoea. Common bacteria that cause diarrhoea include Campylobacter, Escherichia coli.
• Parasitic infections. Parasites can enter your body through food or water and settle digestive tract. Parasites that cause diarrhoea include Cryptosporidium enteritis, Endamoeba histolytica, and Giardia lamblia, Cyclospora&Isosopra

TREATMENT:

Diet: Patient takes adequate oral fluids containing carbohydrates &electrolytes.

        Patients find it more comfortable to rest the bowel by avoiding high fibre foods ,fats, milk products ,caffeine and alcohol.

Rehydration: Severe   diarrhoea ,dehydration can occur quickly, especially in children and older adults.Oral rehydration with fluids containing glucose,Na+,K+,CL-

 Antibiotic Therapy

Empiric Treatment-Ciprofloxacin 500mg OD for 3days

                                    Ofloxacin 400mg OD

CHRONIC DIARRHOEA:

Diarrhoea that lasts for more than four weeks or comes and goes regularly over a long period of time is called chronic diarrhoea.

CAUSES:

Viruses– Norwalk virus, enteric adenoviruses, Arbovirus, cytomegalovirus and viral hepatitis. Rotavirus is a common cause of childhood diarrhoea.

Bacteria and   parasites. E. coli or parasites through contaminated food or water, leads to diarrhoea. When traveling in developing countries, diarrhoea caused by bacteria and parasites is often called traveller’s diarrhoea.

• Medications. Antibiotics, can cause diarrhoea called Pseudomembranous colitis Antibiotics alleviate infections by killing bad bacteria, but they also kill good bacteria. This disturbs the natural balance of bacteria in intestines, leading to diarrhoea. Other drugs that cause diarrhoea are anti-cancer drugs and antacids with magnesium.
• Lactose intolerance. Lactose is a sugar found in milk. People who have difficulty digesting lactose have diarrhoea after eating dairy products.
• Fructose. Fructose is a sugar found naturally in fruits and honey. It’s sometimes added as a sweetener to certain beverages. Fructose can lead to diarrhoea in people who have trouble digesting it.
• Artificial sweeteners. Sorbitol, erythritol and mannitol artificial sweeteners are nonabsorbable sugars found in chewing gum and other sugar-free products  can cause diarrhoea in some otherwise healthy people.
• Surgery. Partial intestine or gallbladder removal surgeries can sometimes cause diarrhoea.

Digestive disorders. Irritable bowel syndrome, Crohn’s disease, ulcerative colitis, celiac disease, microscopic colitis and small intestinal bacterial overgrowth (SIBO).

SIGNS&SYMPTOMS

SIGNS                                                

• Sunken eye ball
• Dry tongue& mucosa
• Poor skin turgor
• Low blood pressure
• Lethargy
• Weight loss

SYMPTOMS

• Passage of loose stool
• Increased frequency of passage of stool
• Loose, watery consistency of stool
• Low urine output
• Increased volume of stool
• Vomiting

RISK FACTORS:

1.Osmotic

• Excess ingestion of non-absorbable carbohydrates, lactose intolerance & celiac disease

2.Secretory

• -Post surgical: extensive small bowel resection/ileal surgery, vagotomy, bile acid malabsorption.
• History of neuroendocrine disease
• History of stimulant laxative abuse
• Dysmotility syndromes.

3.Malabsorptive

• Chronic alcohol abuse
• Chronic pancreatitis
• Celiac disease

4.Inflammatory

• IBD, NSAID use
• Thoracoabdominal radiation, HIV/AIDS
• Antibiotic use

5.Hypermotility

• Psychosocial stress
• Preceding infection

COMPLICATIONS:

• Fluid and electrolyte abnormalities, Acute kidney injury
• Malnutrition, anaemia, unintentional weight loss
• Malignancy (colon cancer in IBD,small bowel cancer in celiac disease)
• Infection with immunomodular, biologic and corticosteroid therapies for IBD

PHYSICAL EXAMINATION

General: Volume depletion ,nutritional status ,recent weight loss

Skin: Flushing, erythema nodosum, pyodema gangrenosum, ecchymoses, dermatitis herpetiformis, hyperpigmentation.

Neck: Goiter, lymphadenopathy(whipple disease)

CVS: Tachycardia,heart murmur

Pulmonary:  Wheezing

Abdomen: Hyperactive bowel sounds,abdominal distension,diffuse tenderness.

Anorectal: anorectal fistulas,fissures,fecal impaction

Extremitis: arthritis

Neurologic: tremor

DIAGNOSTIC TESTS:

• Initial tests (lab, imaging)
• Test patients with alarm symptoms or persistent symptoms and no identifiable cause.
• Blood :CBC,electrolytes,total protein,albumin,TSH,T4,erythrocyte sedimentation rate,C-reactive protein,IgA anti-tissue transglutamine,iron studies
• Stool:  WBCs or fecal calprotein,culture,ova and parasites,Giardia stool antigen,,  electrolytes,occult blood,osmolality,quanlitative fecal fat .
• CT or MRI to evaluate the structure of the GI tract

MANAGEMENT:

• Plenty of fluids to prevent dehydration
• Oral rehydration drinks to replace lost salts and minerals. An alternative is one part unsweetened pure fruit juice diluted with four parts of water.
•  Nutrition rich foods-the vicious circle of malnutrition &diaarhoea can be broken by continuing to give nutrient rich foods
• ORT: They contain 2-3 g/dL of glucose, 45-90 mEq/L of sodium, 30 mEq/L of base, and 20-25 Me q/L of potassium. Osmolality is 200-310 mOsm/L.-1liter 1day.
• In children with severe acute malnutrition and diarrhea, low osmolarity oral rehydration solution (ORS) ( osmolarity:  245, sodium: 75 mEq/L) with added potassium (20 m mol/L) 
• Diarrhoea 30 episodes give IV fluids-Ringer lactate TID
• Ofloxacin+ornidazole 200+500mg BD for 5days
• Racecodotril 100mg BD 3days
• Sporlac sachets-TID for 3-5days
• Entero germinal respules-BD for 3-5days
• If abdominal pain-adults-Buscopan&,Peadiatrics-Cyclopam syrup

DIET:

• Elimination diet: avoid gluten-containing foods,non absorbable carbohydrates,lactose containing products&food allergens depending on etiology of diarrhoea.
• Low FODMAP (Fermentable oligosaccharides, disaccharides,monosaccharides&polyols)diet helps symptoms in upto 75% of IBS patients.
• High carbohydrate intake and obesity have been linked to chronic diarrhoea.

PATIENT EDUCATION:

Wide variation in normal bowel habits

Diarrhoea is generally defined as 3 or more loose bowel movements per day for over 4 weeks.

• Drink plenty of liquids, including water, broths and juices. Avoid caffeine and alcohol.
• Add semisolid and low fiber foods gradually as your bowel movements return to normal. Try soda crackers, toast, eggs, rice or chicken.
• Avoid certain foods such as dairy products, fatty foods, high-fiber foods or highly seasoned foods for a few days.

RED FLAGS Hypotension,sunken eyes

PEARL: ORS therapy

REFERENCE:

5 minutes consultant.com

• Periodontitis is a disease which categorized under periodontal diseases.
• The word periodontitis comes from periodontium means surrounding(peri) the tooth (odont)
• A serious gum infection that damages gums & can destroy the jawbone.Around 40%of people suffer from periodontitis, among adults, it is estimated that around 70%of tooth loss is caused by periodontitis.
• It is a disease which affects more than one or all the constituents of the periodontum.The constituents of the periodontum are gingiva,periodontal ligaments,cementum and alveolar bone.

CAUSES:

Periodontitis is typically caused by poor dental hygiene.Our mouths are full of bacteria,along with mucus and other particles,constantly form a sticky,colorless plaque on teeth.

• If you don’t remove the plaque by brushing, the bacteria deposit minerals within the plaque over time.
• This mineral deposit is known as tartar, which will encourage more bacterial growth toward the root of the tooth

• Your body’s immune response to this bacterial growth leads to inflammation in your gums.
• The attachment of the gum to the root of a tooth is disrupted over time, and a periodontal pocket (gap) may form between the gum and root.

STAGES OF PERIODONTAL DISEASE:

1. GINGIVITIS:1^st stage of periodontal disease.Inflammation of the gums.This is the body’s response to bacteria that has been accumulated on the teeth.usually involve red,swollen gums&bleeding especially while brushing.

• SLIGHT PERIODONTAL DISEASE: At this stage, the infection has spread to the bone and begins to attack bone tissues with stronger, highly aggressive bacteria. Symptoms of

slight periodontal disease include increased swelling or redness of the gums and bleeding during brushing or flossing

• MODERATE PERIODONTAL DISEASE: The symptoms of moderate periodontal disease are the same as slight periodontal disease, although probing depths will be deeper, between six and seven millimeters.

With those deeper pockets between your teeth and gums, even more bacteria attacks your teeth and jawbone. At this stage, the bacteria can make its way into your bloodstream and immune system as well.

• ADVANCED PERIODONTAL DISEASE: If you ignore the symptoms of earlier stages of periodontal disease, you will shift into stage 4, which threatens a 50-90% chance of irreversible bone loss. Symptoms of this final stage include red, swollen gums that ooze pus, painful chewing, extreme cold sensitivity, severe bad breath, and loosened teeth. The only remedy at this point is periodontal surgery or periodontal laser therapy, which will clean out the deep pockets of bacteria beneath the gums and allow the infected tissue to heal.

CLINICAL PRESENTATION:

• Bleeding gums caused due to brushing.
  • Bad breath(Halitosis), Changes in the positioning of teeth in the jaws
  • Receding gums-Where teeth appear longer
  • Constant unbearable pain
  • Teeth sensitivity

RISK FACTORS:

• Smoking:Smokers are much more likely to develop periodontitis than non -smokers. In smokers ,gum bleeding may be less noticeable because of the effect of nicotine on blood vessels, which means that the progress of the disease may be hidden.
  • Genetics, Age
  • Diabetes, Poor diet, Stress

COMPLICATIONS:

Painful abscesses

Loose teeth or loss of teeth

DIAGNOSIS:

• Review medical history–To identify any factors that could be contributing to your symptoms
  • Take dental Xrays, Measure the pocket depth.

TREATMENT:

1.Deep cleaning 2.Medications 3.Surgical Treatment

1. DEEP CLEANING:

• The dentist,periodontist, or dental hygienist removes the plaque through a deep cleaning method called scaling&root planning.
  • Scaling means scraping off the tartar from above&below the gum line.
  • Root planing gets rid of rough spots on the tooth root where the germs gather,and helps remove bacteria that contribute to the disease.
  • In some cases a laser may be used to remove plaque and tartar.This procedure can result in less bleeding,swelling,and discomfort compared to traditional deep cleaning methods.

2. MEDICATIONS:

PRESCRIPTION ANTIMICROBIAL MOUTHRINSE:

• A prescription mouth rinse containing an antimicrobial called chlorhexidine.
  • To control bacteria when treating gingivitis and after gum surgery
  • Its used like a regular mouthwash.

ANTIBIOTIC GEL:

• A gel that contains the antibiotic doxycycline
  • To control bacteria and reduce the size of periodontal pockets.
  • The periodontist puts it in the pockets after scaling and root planing. The antibiotic is released slowly over a period of about 7days.

ANTIBIOTIC MICROSPHERES:

• Tiny,round particles that contain the antibiotic minocycline.
  • To control bacteria and reduce the size of periodontal pockets.
  • The periodontist puts the microspheres into the pockets after scaling and root planing. The particles release minocycline slowly over time.

ENZYME SUPPRESSANT:

• A low dose of the medication doxycycline that keeps destructive enzymes in check.
  • To hold back the body enzyme response if not controlled certain enzymes can break down gum tissue.
  • This medication is in tablet form.it is used in combination with scaling &root planing.

ORAL ANTIBIOTICS:

• Metronidazole-500mg tid for 7 days,Doxycycline 200mg qid for 21 days.

3. SURGICAL TREATMENT:

FLAP SURGERY:To remove tartar deposits in deep pockets or to reduce the periodontal pocket and make it easier for the patient,dentist ,hygienist to keep the area clean.

BONE AND TISSUE GRAFT:In this dentist regenerate any bone or gum tissue lost to periodontitis.

 PREVENTION:

• Consistent good dental hygiene
  • Brush twice daily with a fluoride toothpaste(be sure to replace toothbrushes every 1-3 months)
  • Clean between the teeth with floss or an interdental cleaner.
  • Eat a well balanced diet and limit between meal snacks.
  • Have regular visits with a dentist for teeth cleaning and oral examinations
  • If you smoke,you should quit smoking is a major risk factor for gum disease.

RED FLAGS:

           Bleeding gums&tooth sensitivity

PEARLS:

           Early diagnosis&treatment

REFERENCES:

• J.D Da Saliva et al Oxford American Hand book of clinical Dentistry.
  • PubMed

https://youtu.be/G93lPrHGZdo

https://youtu.be/G93lPrHGZdo

• It is a wave generated at the base of Aorta& spreading along the arterial wall to the

peripheral arteries.

• Wave is generated due to pumping of blood by heart.
• Pulse is not due to blood flow in the vessel.

Sites of pulse examination

• Superficial Temporal Artery
• Facial Artery (Anterior border of Masseter muscle)
• Carotid (Medial to Sternocleidomastoid muscle)
• Apical
• Brachial artery
• Radial artery
• Femoral artery(Inguinal region)
• Popliteal artery(Behind knees)
• Posterior Tibial artery
• Dorsalis pedis artery(1st Intertarsal space)

Temporal: The site is above and lateral to the eye where the temporal artery passes over the temporal bone of the head. It is one of two terminal branches of the external carotid artery. It supplies the temporalis muscle and the scalp and, as a donor artery, it supplies vascularity to the temporoparietal fascia.

Facial artery: It supplies the muscles and skin of the face. It has a crucial function in maintaining these areas, and provides them with oxygen and nutrients. The facial artery is one of the eight branches of the external carotid artery.It is also known as the external maxillary artery.

• Carotid: At the side of the neck where the carotid artery runs between the trachea and the sternocleidomastoid muscle. an artery on each side of the neck which divides into the external carotid artery and internal carotid artery
• External carotid artery, an artery on each side of the head and neck supplying blood to the face, scalp, skull, neck and meninges
• Internal carotid artery, an artery on each side of the head and neck supplying blood to the brain

Apical: At the apex of the heart. It can be found in the left center of your chest, just below the nipple. This position roughly corresponds to the lower (pointed) end of your heart.& is located at the fourth intercostal space at the left midclavicular line.

Brachial: The brachial pulse can be located by feeling the bicep tendon in the area of the antecubital fossa.palpated on the anterior aspect of the elbow by gently pressing the artery against the underlying bone with the middle and index fingers.

Radial:Use the tip of the index and third fingers of your other hand to feel the pulse in radial artery between your wrist bone and the tendon on the thumb side of  wrist. Apply just enough pressure so you can feel each beat.

Femoral: Is felt at the groin just below the inguinal ligament midway between the anterior superior iliac spine and the symphysis pubis. located along the crease midway between the pubic bone and the anterior iliac crest. Use the tips of your 2nd, 3rd and 4th fingers. If there is a lot of subcutaneous fat, you will need to push firmly.

Popliteal: Is rather difficult to feel as it lies deep behind the knee. The knee is flexed to 40degrees with the heel resting on the bed, so that the muscles around the popliteal fossa are relaxed .The clinician places his fingers over the lower part of popliteal fossa &the fingers are moved sideways to feel the pulsation of the popliteal artery against the posterior aspect of the tibial condyles.This artery can also be palpated by turning the patient into prone position and by feeling the artery with the finger tips after flexing the knee passively with another hand.

Posterior tibial: Is felt just brhind the medial malleolus midway between it and the tendo achillis.

Anterior tibial artery:Is felt in the midway anteriorly between the two malleoli against the lower end of tibia just above the ankle joint and just lateral to the tendon of the extensor halluces longus which is made prominent by asking the patient to extend his great toe.

Dorsalis pedis:Is felt just lateral to the tendon of the extensor halluces longus.It is absent in 10% of cases. Where the dorsalis pedis artery passes over the bones of the foot, on an imaginary line drawn from the middle of the ankle to the space between the big and second toes.