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Studies in other animals, from insects to monkeys, have revealed the importance of olfaction for many basic aspects of behaviour, especially reproduction. The buccal gingiva around the posterior maxillary teeth is supplied by gingival and perforating branches from the posterior superior alveolar artery and by the buccal artery. Infants with cri-du-chat syndrome (trisomy 5) develop a high-pitched cat-like cry due to developmental abnormalities in the larynx. On the lingual surface, the cingulum and marginal ridges are less pronounced than the corresponding structures on the palatal surface of the maxillary deciduous canine. In multirooted teeth, ingrowth of the epithelial shelves from the root sheath takes place along paths of high vascularity. Women may also be referred for breast examination when a routine screening mammogram has shown an abnormality or because of a strong family history of breast cancer. While the woman is lying supine, finish your examination by palpating the liver for metastatic deposits. Spontaneous falling of the teeth indicates extension to the maxillary alveolus, while trismus indicates involvement of the pterygoid musculature. With subsequent movement and relocation of the teeth in the growing jaws, the developing permanent tooth comes to lie directly beneath the deciduous tooth and further resorption occurs from the apex. Patients with a large haemothorax causing haemodynamic instability do not have neck vein distension as they have hypovolaemia secondary to the haemorrhage. Attention should be given to any scars that suggest previous surgery or trauma to the chest. In secondary headaches, an underlying structural, vascular, metabolic or infective cause can be detected. All hip movements but specifically extension and internal rotation cause pain, and the range of movement is limited, although not as severely as in septic arthritis. The combination of its organic matrix and mineral composition gives it both strength and a degree of flexibility. In lateral approaches to the skull base, other lower cranial nerves can also be monitored. Meissner corpuscles are typical slowly adapting type I receptors found in the oral mucosa. Having a reduced height and a great reduction in the amount of organelles associated with protein synthesis, the distal end of the cell shows numerous infoldings, forming a striated border. The effect is to convert an isotonic or slightly hypertonic fluid (with concentrations similar to those in the plasma) into a hypotonic fluid. It is an indication of the level of filling and the level of competence of the right heart to receive and deliver blood. In the slender roots of deciduous molars, the root canals are narrower and more ribbon-shaped than those in permanent teeth. Greyish-white granular lesions with exudates and retinal opacification are visible. The risks of immunosuppressive therapy are reduced with various screening measures and with prophylaxis for opportunist infections. A number of endocrine and genetic disorders have surgical relevance in terms of both operative management and specialist requirements during the pre-, intra- and postoperative periods. The occlusal table can be divided into buccal and lingual parts by a mesiodistal fissure. Most features are suggestive of a connective tissue placed in compression during loading. A very sudden loss of weight is usually due to fluid loss from dehydration or the operative removal of fluid, the correction of fluid overload in renal, cardiac and liver disease, being post-partum and to a lesser extent being postmenstrual or having been catheterized. These aneurysms are classified as either true aneurysms involving all three layers of the arterial wall, or pseudoaneurysms secondary to trauma, anastomotic disruption or infection. Patients usually present with either pain or cosmetic deformity without neurological symptoms or signs. If an abdominal viscus is dilated with fluid and air, a splashing noise can be elicited by holding the trunk and shaking it from side to side. The highest and most constant fevers occur in infectious diseases but they are also associated with collagen disease and some neoplasms, thrombosis, ischaemia and drug reactions.


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The parotid duct bends sharply at the anterior border of the masseter muscle to pierce the underlying buccinator muscle. In road traffic accidents, the force transmitted along the femur or from the tightening of a lap seatbelt can cause significant injury to the bony pelvis. Pain may also be elicited from bony prominences, such as the tibial and femoral condyles, as well as entheses such as the pes anserinus (see p. Examination of the mouth may show ulceration and haemorrhagic gums in cases of neutropenia, leukaemia and thrombocytic purpura, while congenital haemorrhagic telangiectasia can produce numerous buccal lesions. It is estimated that 50 per cent of patients with peripheral arterial occlusive disease are asymptomatic, 40 per cent have intermittent claudication, and the remaining 10 per cent have critical leg ischaemia. Abnormalities of coagulation, platelets and the blood vessel wall comprise a large number of congenital and acquired defects. However, they are fewer in number and this is correlated with larger intercellular spaces that may comprise up to 5% of the volume of the tissue in the junctional epithelium. Cysts are excreted in the stool, the disease being contracted through poor hygiene or insect transfer. Granulomatous inflammation is a specific form of chronic inflammation that occurs particularly with Mycobacterium tuberculosis but also with fungi and parasites, and in a foreign body granuloma. In the late cap stage of tooth development, the central cells of the enamel organ have become separated (though maintaining contact by desmosomes), the intercellular spaces containing significant quantities of glycosaminoglycans. Sharpey fibres are the attachments of the principal bundles into alveolar bone and cementum. Changes in the articular cartilage of the patella and trochlea are the primary problems. The skin is subject to a large number and variety of focal and generalized diseases, many of which are cutaneous manifestations of systemic disorders. Condylar fractures are usually indirect, while direct impact produce fractures of the body. The Disc Herniation Disc herniation refers to herniation of the central disc material, the annulus pulposis, into the spinal canal. Partial relief may be obtained by the frequent administration of artificial salivas. In adults 80 per cent of tumours are supratentorial, whereas in children infratentorial lesions are the most common. Seizures and haemorrhage are the common presenting features of arteriovenous and cavernous malformations. The mechanism leading to clubbing is not completely understood, but it may be related to blood factors that are usually cleared by the lungs but remain elevated in the circulation if there is a right-to-left shunt. Through inspection, the examiner should identify old or new scars that indicate trauma or previous surgery. The neurological features are those of agitation, nervousness, restlessness, irritability and insomnia. In this manner, enamel reaches a higher degree of mineralization and its crystals are larger. Bowstring Test this is carried out in a similar manner to the straight leg raising test. The upper limbs should be examined for signs of decreased blood supply, and the pulses should be palpated. Of these, only the nasopharynx can be varied by the contractions of the pharyngeal muscles and movement of the soft palate. The second ectodermal cleft overgrows to fuse with the sixth and is usually obliterated. Seventeen Inflammatory cells Some inflammatory cells may also be found in the epithelium, having migrated through it from the underlying lamina propria.

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These proliferating epithelial cells may secrete enzymes which degrade the collagen. Although they have similar compositions, differences do exist, such as the presence of cementum attachment protein in cementum. The role of the tongue in mastication should highlight movements of the food bolus between the teeth and the complementary role played by the buccinator muscles. The calf muscles are then squeezed in the mediolateral Calf Muscle Strains these usually occur secondary to sports injuries or in individuals who are not accustomed to exercise. Outline essay answers Question 1 Surface enamel, being at the interface between the tooth and the environment, has considerable clinical significance. Jaw unloading reflex the jaw unloading reflex is not a true masticatory reflex in that it occurs during static biting on a hard object. Cellular cementum and bone have similar cell types, forming (cementoblasts and osteoblasts), maintaining (cementocytes and osteocytes) and resorbing (odontoclasts and osteoclasts) the tissues, as well as a stem cell population. Loads of 4 N are associated with a further decrease, followed by an increase during a 3-hour undisturbed recovery phase. Keloid is rare in infancy and in old age, and reduces in severity from about 30 years of age onwards. The true natural history of asymptomatic abdominal aortic aneurysms remains unknown. They are present particularly at the periphery of the dental pulp and around nerves and blood vessels. If the patient constantly deviates to one side when bending forwards, this is indicative of an irritative lesion such as a herniated disc, osteoid osteoma or spinal tumour, and should be investigated further. Statherin, a tyrosine-rich protein, has a negative amino terminal (phosphorylated) and hydrophobic carboxy terminal. All the extrinsic tongue muscles receive their motor innervation from the hypoglossal nerve. This will in turn assist in the generation of a greater force in order to crush the food. The configuration of the internal enamel epithelium broadly maps out the occlusal pattern of the crown of the tooth. They are common in masticatory epithelia such as gingiva, but less frequent in lining mucosa such as the buccal mucosa. Importantly, even if the complaint is unilateral, both lower extremities should be exposed when examining the leg and ankle for comparison. How does the condylar cartilage differ from a primary cartilage, such as the spheno-occipital synchondrosis Give some examples of the clinical relevance of a knowledge of the temporomandibular joint. That the periodontal ligament and its precursor, the dental follicle, is the source of the force(s) of eruption is well documented. The variability of the tubules gives rise to the primary (and secondary) curvatures. In inflammatory states, the volume of pleural fluid can increase dramatically, sometimes up to several litres of effusion. Mastication, bolus formation and swallowing depend on a moist, lubricated oral mucosa and fluid 80 Formation of saliva facilitate the protective role saliva plays in maintaining a balanced oral microflora, as these enzymes have antimicrobial properties. Sectioning of the temporalis muscle during early mandibular development may result in atrophy or complete absence of a coronoid process in the adult mandible. The measurement is made from the anterior superior iliac spine to the medial malleolus. This should be suspected in patients with venous ulcers who have non-palpable pulses or are not responding to compression therapy. The examiner should collect all the relevant details that are related to the complaint.

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Whereas acellular cementum is the first-formed cementum and is found over the cervical two-thirds of the root, cellular cementum is formed later in the apical third (and in the inter-radicular region), especially in molar teeth. Pseudoachondroplasic Dysplasia this is an autosomal dominant disorder characterized by normal facies but with other features similar to those of achondroplasia. As secondary dentine is formed more slowly, the lines in it will be closer together. It may present as an indurated non-healing ulcer or a swelling that is painless in the initial phase. There is great regional variation in the amount of keratin, hair, pigment, vessels, nerves and glands among the different body sites. The mechanism of injury is usually a fall on an outstretched hand, and the fracture usually occurs in the midshaft. The pigment is passed to adjacent keratinocytes when the tips of the dendrites are actively phagocytosed. Posterior and middle superior alveolar nerves, buccal nerve, greater palatine nerve. Inflammatory cells will increase dramatically in inflammation, such as following gingivitis. In the case of chronic pulpal inflammation and where the stimulus persists for hours, there are obvious changes in the haemodynamics of the pulp and in nerve excitability that can be attributed to the release of algogenic chemicals in the pulp. There are three types of pathological tremor: resting, postural (which can also remain during movement) and kinetic (which occurs during the voluntary active movement of an upper body part). These are derived from the epithelial root sheath, which plays an important role in root formation. The patient presents with pain and tenderness of the tendon above the line of pressure from the shoe, and occasionally with a red, tender nodule at its insertion on the calcaneus. The hallmark histological feature of acute inflammation is the presence of neutrophil polymorphs within the extracellular space. Note the large, multinucleated cells (odontoclasts) (arrows) lying within resorption lacunae. If the aortic root is involved, the coronary arteries are re-implanted and the aortic valve may be replaced. Due to the profound catabolic state that ensues, patients with lung abscesses are cachectic and severely ill. Examine all the node groups, particularly nodes that are not usually palpable such as the occipital and external and anterior jugular nodes. This is evidence of specialization of neurones as they get higher in the central nervous system. The joint cavity is subdivided into upper and lower compartments by an intra-articular disc. The root is the largest, and stoutest, in the dentition and is triangular in cross-section. Thus, the maxillary first (central) incisor occludes with the mandibular first (central) and second (lateral) incisors. The range of presentation to the oral pathologist is also considerable due to the diversity of the number of cells present. Nerve fibres innervating the head region arise from cell bodies in the trigeminal ganglion. The root morphology of the permanent premolars and molars (maxillary and mandibular) should be described, with appropriate diagrams. The nidus grows into larger masses consisting of basaloid cells that display little atypia with only few mitoses, form characteristic palisades at the periphery and surround themselves with a concentric thin stroma from which the tumour frequently detaches or clefts.

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After describing the muscles and their attachments, the clinical significance of these in relation to understanding the effects of fractures of the mandible should be discussed. The accessory nerve may innervate the very back part of the tongue, indicating some contribution from the 4th pharyngeal arch. Oesophageal Rupture Oesophageal rupture typically follows an episode of retching, resulting in an oesophageal tear. The lingual surface is flatter than the corresponding palatal surface of the maxillary permanent canine, and the cingulum, marginal ridges and fossae are indistinct. The patient has trismus, and a complete oral examination is not possible due to his restricted mouth opening. When warts grow over the palms and soles, there is characteristically a loss of the skin lines (dermoglyphics), and black dots are seen within the papules, corresponding to thrombosed blood vessels. However, it is not necessary for the full absorption of fish, eggs, rice, bread or cheese. The rate of fracture repair appears to slow down with age, the precise reason for which remains to be clarified. Initial collagen deposition does not begin immediately against the basal lamina of the epithelial cells of the root sheath. Duplex ultrasonography is the first-line imaging modality for suspected peripheral aneurysms as it can provide information on the size of the aneurysm, its patency and the presence of a mural thrombus. Later on, after the femoral head bone has collapsed, the signs are similar to those of an arthritic hip. Cutaneous Lesions of Melanocytic Origins 305 malignant change in the basal layer of the epidermis. It can be associated with systemic diseases such as diabetes mellitus, thyroid disease and chronic kidney disease. This is because the systems available tell the surgeon what he has just done, often many seconds after, rather than what is just going to happen if he persists with what he is doing. In the past, all the events that occur from the ingestion of the food to the beginning of the swallow have been termed mastication, but this term is now confined to the process of mechanical reduction of food. The heart failure is accompanied by low blood pressure and a tachycardia with a lowvolume pulse. Osteoblasts are derived from stromal/mesenchymal (neural crest) cells, while osteoclasts are derived by fusion of mononuclear haemopoietic cells of the macrophage/monocyte lineage. A weak, thready pulse and hypotension, secondary to the massive blood loss into the thorax, will be noted. Neurones that respond to mechanical stimulation of the oral and perioral tissues have been located in the trigeminal nuclei, the thalamus and the somatosensory cortex. Similarly, a history of drug or supplement exposure is of essence when a drug eruption is suspected. Incremental lines Cementum is deposited rhythmically, resulting in unevenly spaced incremental lines (of Salter). They are, however, contraindicated in bilateral renal artery stenosis as they result in a worsening of renal function. The clinical features of an abnormally low body water content usually relate to the underlying disease. A ranula is a cystic swelling that arises from the sublingual salivary gland, and its usual position is in the anterior floor of mouth. This epithelial contribution is reflected in the structure of the internal enamel epithelial cells, which possess some of the intracellular organelles associated with protein synthesis and secretion. The evidence for a conditioned reflex salivation in human beings, similar to that seen by Pavlov in dogs, is very weak; if such a reflex exists, it is extremely small and extinguished very rapidly. The central canal (about 50 m in diameter), together with the concentric lamellae, is known as an osteon or Haversian system. Vowel sounds are modified by resonance and are all voiced; they are produced without interruption of the air flow, the air being channelled or restricted by the position of the tongue and lips.

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At birth, there is no distinct chin and the two halves of the mandible are separated by the mandibular symphysis. The maxillary arch is slightly larger and broader than the mandibular arch and therefore usually overlaps the mandibular arch by a couple of millimetres. Dermatomyositis and polymyositis cause progressive, symmetrical and proximal muscle weakness. When this sign is present, however, it carries up to a 99 per cent specificity for renal artery stenosis. Consolidation of the underlying lung parenchyma, hydrothorax, haemothorax, chylothorax and lung- or pleural-based masses lead to decreased resonance or dullness to percussion. From the stroma of the capsule surrounding and protecting the gland pass septa that subdivide the gland into major lobes; lobes are further subdivided into lobules. Aortic regurgitation is best heard over the left edge of the sternum and the apex (in the direction of the regurgitant flow). Mucosal Lesions 371 Erythroplakia Erythroplakia is defined as a fiery red patch that cannot be characterized either clinically or pathologically as any other definable lesion. The periodontal ligament fibroblasts appear as flattened, disc-shaped cells with many fine cytoplasmic processes. Severe osteogenesis imperfecta can also present with a disproportionate loss of stature. Sensory fibres to the connective tissue within the parotid gland are derived directly from the auriculotemporal nerve. The physical examination of the arterial system includes auscultation of the abdomen for the presence of a bruit, an evaluation of the presence of abdominal aortic aneurysms or other femoral or popliteal aneurysms, and palpation of the femoral, popliteal, posterior tibial and dorsalis pedis pulses. The pelvis and acetabulum form a solid unit that usually fails in significant traumatic stress. Verbal performance is graded as orientated conversation, confused conversation, inappropriate words, sounds. Much of the work on mechanoreceptors has been carried out on hairy and non-hairy skin and the adjacent subcutaneous connective tissues, and comparatively little has been carried out on the oral tissues. Cardiovascular symptoms may dominate the clinical features and patients may present with the dyspnoea of cardiac failure. This is mainly due to the dilated air-filled bowel loops that are seen in the latter, and the significant abdominal pain that prevents the examination being Treatment Acute Mesenteric Ischaemia the management of acute mesenteric ischaemia is aimed at promptly restoring the blood flow to the affected mesenteric vessel and its branches, and resecting non-viable bowel segments. Both the masseter and the temporalis muscles are innervated by branches of the anterior division of the mandibular nerve. The maxillary and mandibular processes are derived from the 1st pharyngeal (branchial) arches. The cells responsible for the resorption and shedding of deciduous teeth are distinct in origin and form from osteoclasts responsible for bone resorption. Plain radiographs of the spine reveal resorption of the horizontal trabeculae with biconcavity of the vertebral bodies. The diameter and fluid content are variable depending on the duration, the extent of the stimulus producing it and any associated infection. Note that the anterior retromandibular vein has left the parotid gland to approach the facial vein as it runs in the neck. The patient is likely to suffer from other life-threatening injuries that are of more immediate relevance. Dentine formation begins when the tooth germ has reached the bell stage of development. Accordingly, the tooth type is prespecified and is not dependent on the environment within the jaws. Pemphigus and Pemphigoid Pemphigus is the term given to a group of potentially lethal disorders that are all characterized by autoantibodies directed against intercellular substances or stratified squamous cell epithelium. Instead, they show all the characteristics of a cell actively synthesizing and secreting protein rather than those of a motile/ contractile cell. Swelling of the hand can result from trauma, infections, compression and less often lymphatic or venous obstruction, for example after breast surgery.

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It usually produces mild chronic haemolysis but acute haemolysis may be precipitated by intercurrent illnesses and exposure to oxidant drugs, including antimalarials. There is no field defect, and the lesion is incidentally discovered on fundoscopy. In cases of bulimia, the erosion characteristically affects the palatal surfaces of the upper anterior teeth. C = posterior belly of digastric (innervated by the digastric branch of the facial nerve). The mesial surface is straight and approximately at right angles to the incisal margin. It is performed with the patient lying prone and their feet hanging off the edge of the examination table. Most surgeons tend to use 80 per cent stenosis as the level of stenosis for intervention. This location can vary with right and left ventricular hypertrophy or lung disease affecting the location of the heart in the chest. The tourniquet test, when the cuff is pumped to systolic pressure for 60 seconds, has a similar effect. This accounts for some of the changing occlusal relationships between the teeth during childhood. As with the crown, the internal enamel epithelial cells of the root sheath enlarge during their inductive stage. In children, metastatic adenopathy is commonly seen from a primary in the nasopharynx or thyroid. Receptor cells in the taste buds on the tongue are innervated by the trigeminal nerve. Unilateral cleft lip, bilateral cleft lip, median cleft lip (with nasal defect), oblique facial cleft (with cleft lip), median mandibular cleft, macrostomia. The cytoplasm contains large numbers of vesicles of different sizes and types; some contain acid phosphatase. The life-threatening injuries that need to be identified during the primary survey are shown in Table 6. Hydrocephalus in the infant is manifest as an enlargement of the head, a wide, bulging anterior fontanelle and dilatation of the scalp veins. It may be that there is a reduction in the number of viable stem cells in bone with age. They result from an inclusion of ectodermal elements during closure of the neural tube adjacent to the fetal suture lines. If the patient survives the initial reaction, they are subject to adult respiratory distress syndrome. Carditis may also develop, manifesting as an apical systolic murmur due to mitral regurgitation, or an early diastolic murmur due to aortic regurgitation following valvulitis. Physical Examination Head and Face the whole head and face should be carefully inspected and palpated, looking for tenderness, deformity and bleeding. Infections commonly arise from regular skin commensals becoming pathogens by breaching the body surface and multiplying. If no lump is palpable in the ipsilateral breast, additional imaging studies (see below) should be carried out. However, macromolecules can diffuse intercellularly towards the basement membrane, which is a limiting barrier. Grasping the lower tibia or ankle with the other hand, the examiner then moves the leg away from the midline to test for abduction, and towards the midline to test for adduction. This contrasts with earlier views that degradation was essentially an extracellular event involving the activity of proteolytic enzymes such as collagenases. Neuropathic ulcers are by definition associated with far less pain than one would expect, while venous ulcers are not usually very painful. In general, mineralization of root dentine proceeds as a continuation of that in the crown, although in multirooted teeth separate areas of mineralization may occur. Collagen fibrils with small diameters are associated with connective tissues under compression.

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Internally, the capsule is attached to the intra-articular disc and is lined by synovial membrane. These measurements allow surgeons to decide on the best approach and treatment modality for the aneurysm. This property is related to structural components within the dentine, such as dentinal fluid, nerves and the odontoblast processes, although the dental pulp must also participate. However, there is some degree of evidence for central processing in that the neurones within the central nervous system appear to have a wider range of activity than the individual primary, firstorder receptor neurones. The dentinal tubules have become completely occluded by mineral deposition (arrows). Calcospherites fuse together to give rise to a globular pattern of mineralization. Most operating rooms are equipped with hybrid rooms where an intraoperative angiogram can be obtained to determine suitability for endovascular repair. Important components of the synovial fluid are the proteoglycans, which aid lubrication of the joint. It is worth re-emphasizing the importance of multiple pathological sampling, including to check for mycobacteria and fungi. This represents the junction of the pulp and periodontal tissue (although there is no visible demarcation in the soft tissue). The artery also gives off branches to the adjacent buccal gingiva, maxillary sinus and cheek. Salivary secretion is dependent on reflex activity, not by conditioned reflexes but by innate reflexes. When malignant, they may spread to other parts and may also involve the facial nerve that is located within the parotid gland itself. Biochemical aspects of dentine mineralization Concerning biochemical aspects of dentine mineralization, collagen fibril formation proceeds, with alignment of tropocollagen molecules being guided by non-collagenous proteins such as decorin. In contrast, neoplastic vertebral destruction is more likely to be centered in the vertebral body and spare the disc space. These are usually associated with abnormalities of the pupil such as afferent pupillary defects (a non-reactive direct reflex but a reactive consensual reflex in the affected eye). As the tooth erupts, resorption is the predominant pattern of bone activity at the base of the socket. During the early phase of the chewing cycle, the lips remain closed together, thus providing an anterior w. Deformation of bone following loading is thought to deform the cell processes/cell membranes either directly, or indirectly through movement of tissue fluid residing in the lacunocanalicular system. Although physical pain can be associated with gynaecomastia, most men present for evaluation due to the psychological stress the condition can cause. The predominant cell type mediating chronic inflammation is macrophages, to phagocytose, or ingest, pathogens and cellular debris. The rapid increase usually signifies an aggressive histology (poorly differentiated or anaplastic), lymphoma or haemorrhage into a nodule in a multinodular gland. Hybrid approaches of open and endovascular therapy have paved the way to treating all segments of the aorta, including the ascending aorta and the aortic arch. The sensory supply to the soft palate is via the greater and lesser palatine nerves. The individual sockets are separated by plates of bone termed the interdental septa, while the roots of multirooted teeth are divided by inter-radicular septa. In Ramsay Hunt syndrome, facial nerve paralysis is associated with herpes zoster infection.

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The description of a penetrating injury with a rapid progression to systemic features and the hand signs given is typical of a tendon sheath infection. When evaluating a stricture, it is important to identify whether a concurrent malignancy is present. The degree of parental involvement is not a good predictor of the degree of expression in the next generation. Several typical patterns are seen in the hip, with shortening and external rotation of the leg or the distal radius with dorsal and radial displacement. The ameloblasts seem to mature at the surface at the same time, so that perikymata are rarely evident. Platelet Abnormalities Platelets contribute to haemostasis in that they adhere to damaged endothelium. Convergence of primary afferent neurones can also explain the phenomenon of referred pain, where pain appears to come from structures other than the injured or inflamed tissue. The characteristics of these endings were that they were branched, unencapsulated and incompletely surrounded by terminal Schwann cells with extensions projecting towards the collagen bundles. Descending pathways from the motor cortex may influence the central pattern generator by switching the process on or off or by altering the duration of the chewing cycles themselves. The characteristic small, pearly, firm, umbilicated papules are found on epithelial surfaces. It covers a spectrum of diseases ranging from dysplasia to subluxation and instability to complete dislocation. For each of the following patients with malignancy of the nose and throat select the most likely diagnosis from the list below. Despite the fact that atherosclerosis is a systemic disease, the plaques tend to occur more in specific areas, mainly those with high turbulence, low shear stress and flow stagnation. Organic matrix the organic matrix in mature enamel mainly comprises two unique groups of proteins. Shoulder dislocations can be complicated by a supraspinatus tear or a fracture of the surgical neck or greater tuberosity of the humerus. The action of the palatoglossus is to raise the tongue in order to narrow the transverse diameter of the oropharyngeal isthmus. There is a total preoccupation with weight, obsession with a thin figure, fear of weight gain and altered body perception. It would appear that intradental nerves are more easily excited by fluid flow outwards from the pulp than inwards towards the pulp. It may be associated with gastro-oesophageal reflux, increased upper oesophageal sphincter pressure or an inferior constrictor strain swallow because of irritation from the lingual tonsil/epiglottis area and increased muscle tension. Those particularly at risk include manual workers, patients with diabetes and those who are immunosuppressed. The single root of the first incisor tapers towards the apex and is conical in cross-section. The sensory supply of the temporomandibular joint is derived primarily from the auriculotemporal (and masseteric) nerve. It may be seen in congenitally acquired pulmonary diseases, such as cystic fibrosis, or it may follow an acquired infectious process. Stimuli of different types and extent may be applied to teeth at different stages of development or ageing, resulting in a response tissue that may vary considerably in appearance and composition. The body responds to all injuries with an inflammatory response, this being capillary dilatation and the production of an inflammatory exudate incorporating both cellular and humoral responses to the damaged tissue. These patients must be taught how to regularly examine their feet with a mirror, by palpation or with the help of a carer to identify early lesions and initiate therapeutic and preventive measures. It is usually precipitated by a preceding upper respiratory tract infection, generally of viral origin. In a third of patients, it is associated with constitutional symptoms of fever, weight loss and night sweats.

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The presence of the oral fluids (saliva/gingival crevicular fluid) is essential, as the calcium and phosphate required for mineralization of the plaque are present to some extent in these fluids. A subgaleal haemorrhage secondary to rupture of the veins running between the scalp and the dural sinuses may extend from the orbital ridges to the nape of the neck and ears depending upon the severity. Pinprick and light touch are used to test the sensory function of a peripheral nerve. A useful marker for osteoclasts is the enzyme tartrate-resistant acid phosphatase. Buccinator is a muscle of facial expression (therefore innervated by the facial nerve) that lies in the cheek and helps position the bolus of food between the teeth during chewing. Sublingual keratosis is a white patch seen on the floor of the mouth and has a higher incidence of malignant transformation. This is the key to understanding how the amelogenin nanospheres regulate hydroxyapatite crystal growth. Clinical examination should identify any pain, tenderness, bruising, oedema or deformity. They appear perpendicular to the long axis of the dentinal tubule and are about 3 m apart. An additional origin for the tensor veli palatini muscle is the cartilage of the auditory (Eustachian) tube. Showering of emboli from the aneurysm is a feared complication as it can involve the coronary, cerebral, mesenteric and extremity vasculature. There is also convergence here between gustatory and thermoreceptor inputs, with many neurones responding to cooling of the tongue, as well as to chemical stimuli. The sympathetic root of the ganglion is derived from postganglionic fibres from the superior cervical ganglion and reaches the submandibular ganglion via the plexus around the facial artery. For each of the following conditions, select the most likely finding from the list below. Chondrocytes in the deep part of the condylar cartilage hypertrophy and synthesize type X collagen, following which the matrix undergoes endochondral ossification. Minor salivary glands in the soft palate derive their secretomotor supply from the greater petrosal nerve via the pterygopalatine ganglion. Involvement of the medial condyle is a more serious injury and calls for a prompt vascular evaluation of the lower extremity. While some mammals have a separate region in the upper lip called the premaxilla, which is separate from the remaining maxilla and associated with the developing incisor region, this is not present in humans. The largest is the auriculotemporal nerve, supplying the medial, lateral and posterior parts of the joint. This is probably associated with the presence in the dental pulp of a population of stem cells that can be stimulated to give rise to odontoblast-like cells capable of forming tertiary dentine. Numerous functions have been ascribed to the mast cell, including the production of histamine, heparin and factors associated with anaphylaxis. Additional local infiltration of anaesthetic solution around the tooth may solve the problem. Supragingival plaque is less mineralized than subgingival plaque (approximately 40% v. It must be remembered that meningitis is such a devastating disease that a degree of risk has to be considered when undertaking the investigations. Meniscal tears in the young are usually of traumatic origin, while in the elderly they usually have a degenerative aetiology. A number of the capillaries are fenestrated and blood flow rates can be considerable. The taste bud complex is a dynamic system in which the lifespan of the receptor cells within the taste bud is 28 days.

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