Control In Clinical Environments

Introduction

Oral anatomy is referred to the field of anatomy in which the study of human tooth and other structures in the oral cavity are examined and studies for gaining knowledge. A detailed knowledge regarding oral anatomy is required for effective development of teeth and proper maintenance of good as well as hygienic oral health. In this assignment, the oral anatomical and morphological features are being explored to understand their relevance in the dental appliance design. Later, evidence for controlling the cross-infection in clinical and dental environment is discussed by considering the impact of disinfection, decontamination, antisepsis and scientific principles.

Anatomy of Oral Design

In Oral Design, the mouth which is also known as Oral Cavity or Buccal Cavity is the orifice through which the food, as well as air, enters the body. The oral cavity is designed into two sections that are vestibule which is area between the cheeks and teeth and the oral cavity proper. In the next section, the place is mainly filled by a muscular tongue which is firmly anchored to the mouth floor by the frenulum linguae (Shah and Garritano, 2015). The key structure of the oral design is teeth that grind and tear food into smaller pieces making them suitable for digestion. The tongue helps the food to get mixed with the saliva to later form into a bolus to be pushed down through the oesophagus for further digestion (Dias et al. 2016). (Refer to Appendix 1)

Tissues types present in oral cavity

The oral cavity is mainly lined by hard tissues which are the one that is mineralised with a firm intercellular matrix and soft tissues are tissues which are not calcified or hardened and connects, surrounds and supports the internal organs (Sardinha et al. 2016). The soft tissues in the oral cavity are oral mucosa which contains stratified squamous epithelium that may be keratinized or not along with an underlying layer of connective tissue layer known as lamina proper. The nonkeratinised squamous epithelium is seen to line the inner lips, soft palate, inner cheek as well as the floor of the mouth and the ventral surface of the tongue. The keratinised squamous epithelium is present on the hard palate and gingival along with the dorsal surface of the tongue (Cruchley and Bergmeier, 2018). The hard tissues of the oral cavity are the tooth enamel, cementum and dentin. The enamel is the outer lining of the tooth, dentin is the hard dense and bony tissues that form the bulk of the tooth and cementum is the calcified substance that covers the root of the tooth (Treuting et al. 2018).

Bones of head and musculature related with oral cavity

The skeletal framework related to the oral cavity includes paired palatine, maxillae and temporal bones along with unpaired mandible, hyoid and sphenoid bones. The palatine bone is present on the facial skeleton in paired form with an L-shaped structure which forms the part of the hard palate and the nasal cavity and is located between the sphenoid and maxilla (Angelopoulos and Scarfe, 2018). The maxilla is the upper part of the jaw which is a key structure of the viscerocranium and it is formed by the fusion of the two irregularly-shaped bones and the median palatine suture which is located at the roof of the mouth (Watanabe et al. 2018). (Refer to Appendix 2)

The muscles present in the oral cavity include that of the cheeks, lips, floor of mouth and tongue. The extrinsic and intrinsic muscle of the tongue helps in elevation, protrusion, elevation and depression of the tongue. The facial muscles present in the cheeks, lips and other parts of the oral cavity helps in expression (Sakamoto, 2018).

Development and malformation of oro-facial structures

The oro-facial structures are developed according to certain timeline with the pharyngeal arches developing in fourth week along with external face and primary palate by the sixth week. The secondary palate is developed by eighth week and the completion of soft palate of the face ends by twelfth week of the embryo (Sulik, 2017). The lack of proper physiological and genetic condition leads to malformation of the oro-facial structures as a result of delayed or early fusion of bone to form the head and face. The proper functioning of the FGFR2 gene along with other leads to proper signalling of the fusion of bone at the right time to develop proper oro-facial structures. However, in case of children suffering from Apert syndrome, it is seen that the mutation in a specific part of FGFR2 gene results in prolonged signalling that promotes premature fusion of the bones in forming the skull and oro-facial structures (Cha et al. 2018). The Pfeiffer Syndrome is also the result of the mutation in the FGFR2 gene which causes premature fusion of the skull bones preventing the embryo to normally form oro-facial structures thus affecting the shape of their face and head (Júnior et al. 2015).

Structure and Types of Teeth

The tooth is made up of enamel, cementum, dentin and in the interior, it contains pulp tissue. The outer covering of the crown of the tooth is enamel which is the hardest body tissue with dentin located just below it and above the cementum forming the root of the dental crown. This is softer than the enamel and a small tube is present in the dentin which contains the dentinal tubule. The cementum is present at the surface of the root of the tooth which forms connection of the alveolar bone with the tooth with the help of periodontal ligament. The pulp tissue is soft in nature and contains blood as well as lymph vessels along with nerve fibres offering nutrition to the dentin. The periodontal ligament is the fibrous tissue that connects the alveolar bone and the tooth root. The alveolar bone is the jaw bone in which the tooth is planted. The gingiva is the soft tissues covering the alveolar bone (Mills, 2014).

The humans are diphyodont meaning they develop two teeth set one of which is primary or deciduous teeth and the other is permanent teeth. The deciduous teeth are referred to initial set of teeth developed in humans during the embryonic stage and visible in infancy which is usually 20 in number. They are later replaced by permanent teeth developed in the adolescent stage which are 32 in number (incisors, canine, premolars and molars) (Herman et al. 2016). The defects in the oral cavity can be managed by the dentition such as in case of cleft palates the base plates are fixed by the dentitions to prevent the food and drinks to be ganged up in the nasal region (Lehtonen et al. 2015).

Relationship of Skeletal jaw

The relationship of the skeletal jaw can be explained through the process of occlusion which informs the manner in which upper and lower teeth come together in the situation when the mouth is closed. The occlusion is effectively achieved by proper placement of the mandible and maxilla brought down by the muscles and bones after the chewing process (Amini et al. 2017). The occlusion is of different types out of which centric relation is the position in which relationships between the maxilla and mandible is formed when the condyle is present in the posterior retruded position in relation with the glenoid fossa (Jiménez-Silva et al. 2017). The centric occlusion is defined as the situation when the mandible is in close centric relation with the maxilla making maximum contact between upper and lower jaw (Čimić et al. 2016). The malocclusion which is the hindered positioning of the teeth occurs as a result of genetic mutation, environmental factors, thumb sucking, pipe smoking, pencil chewing and others (Dimberg et al. 2014). The malocclusion is of different types such as the deep overbite in which the upper teeth remain in an over biting position over the lower teeth; deep underbite in which the upper teeth are present in the lower arch of the teeth resulting in the protrusive jaw, open bite and others (Koul et al. 2017).

Musculature related to facial expression and mastication

There are various muscles related to cause facial expressions such as depressor labii inferiors, risorius, triangularis and others. For instance, the depressor labii inferiors are present in the lower part of the mandible between the mental foramen and the anterior midline. The muscle controls the skin of the lower lip and results in pulling the lower lip down to let the lip to be shown inverted (Hur et al. 2014). The risorius is originated at the masseter muscles and the parotid salivary gland making the corners of the mouth to be drawn in to reveal dimple on the cheeks (Kim et al. 2015). The traingularis is originated from the mental foramen present on the lower part of the mandible which plays the action to pull the corner of the mouth (May et al. 2018).

The muscles related to the mastification are masseter which is assisted by temporalis, medial and lateral pterygoid to help in the process. The masseter is the muscle used for mastication of food and it has the key function to pull the mandible upwards while chewing. The temporalis is a fan-shaped muscle present on both sides of the head filling the temporal fossa which has the action to elevate and retract the mandible. The medial pterygoid is quadrilateral and thick muscle of mastication which performs the action to elevate the mandibule and close the jaw by helping the lateral pterygoid move the jaw from side to side (Grigoriadis and Trulsson, 2018; Dutt et al. 2015; Shimada et al. 2015). The lateral pterygoid originates at the infratemporal surface and infratemporal crest of the greater winged region of the sphenoid bone that performs the action to depress the mandible while mastication (Gonzalez-Perez et al. 2015). (Refer to Appendix 3)

Attachment and Impact on appliance design

The muscles responsible for mastication and facial expression act as an aid in application of retention and stability of the proper shape of the oral cavity. The facial tone of the muscle can be altered by teeth loss and clasping in this situation is attached to the teeth for avoiding displacement of the muscles of the oral cavity (Glaros et al. 2016). Thus, this affects the individuals to retain the proper shape of the oral cavity. The muscle tone of the face may be hindered by incorrect teeth placement where correct trimming of the teeth around the muscle effect to avoid alteration of the muscle tone. The attachment of artificial teeth in case is placed too far in the anterior position then it results the facial muscles to be stretched and the lips to appear shorter and unnatural (Fernandes et al. 2016). This result in extra pressure on the denture and therefore is required to be dislodged.

Musculature on throat and neck and its impact

The muscles present on the throat that is involved in functioning with the oral cavity are suprahyoid muscles and infrahyoid muscles. The suprahyoid muscles are four in number which are present on the position above the hyoid bone in the neck. They play their role to manage the movement of the larynx so that the food coming down from the oral cavity is proper passed down the oesophagus and do not enter the airways (Matsubara et al. 2018). The infrahyoid muscles are also four in number placed in the anterior part of the neck which depresses the larynx during swallowing of food and proper speech (Deganello and Leemans, 2014). The pharynx is divided into three sections which are nasopharynx (upper part of pharynx making connection between the soft palate and nasal cavity), orthophraynx (middle part of the throat) and layrxophraynx (end part of the throat). They function altogether in production of speech or vocalisation (Cuaron et al. 2016).

Temporo-mandibular joint

The temporo-mandibular joint is referred to the two joints that connect the jawbone to the skull. It is a bilateral synovial articulation present between the temporal skull bones (above) and mandible (below). The key function of the bone is to connect the jaw to move them up and down well as move them down and sideways to chew, talk and yawn. The disorder in the Temporo-mandibular joints results to cause pain in the joints as well as the muscles which are involved in controlling the jaw movement. This is going to result to create hindrance in chewing, mastication and talking (Attanasio et al. 2015).

Nerves related to dental treatment

The seventh cranial nerve is the facial nerve which is responsible for controlling the facial muscles for making facial expression and has the action in conveying sensations of taste to the anterior two-thirds region of the tongue. Moreover, it is originated from the pons region of the brainstem (Shidhaye and Giri, 2014). The fifth cranial nerve is the trochlear nerve which is divided into ophthalmic, mandibular and maxillary nerve and performs to control facial expression and chewing (Tripathy et al. 2017).

Systemic considerations of Cardiovascular and Lymphatic system

The oral cavity is related to the cardiovascular system in the way such as if disease-causing bacteria are developed in the mouth they can reach the cardiovascular system to create issues in health. The people who are infected by chronic gum condition like gingivitis and others are able to get their heart damaged through transmission of bacteria in the cardiovascular area through the bloodstream resulting in heart diseases like endocarditis and others (El Kholy et al. 2015). The lymphatic system plays an important role in the controlling immunity and detoxification of the body. Thus, their failure may result to raise changes of diseases in the oral cavity as well as all over the mouth (Bruch and Treister, 2017).

Saliva, microorganisms and plaque in dental technology restoration and appliances

The salivary glands are of three types which are parotid, sublingual and submandibular glands. The parotid is present beneath and front of the ear and the duct known as Stensen’s duct drains the saliva into the mouth from the parotid gland. The submandibular gland is located under the tongue and the sublingual gland is present under the tongue as well as in the front and bottom of the mouth (Dodds et al. 2015). The salivary gland produces saliva which has the key function to maintain tooth integrity, protection of the oral cavity from bacteria, tissues repair, help in taste and assistance of development of food bolus for assisting digestion process (Yandrapu et al. 2015). The saliva also functions in formation of pellicle to prevent tooth wearing which supports the attachment of free-floating bacteria on the teeth. In this condition, the bacteria begin to form pattern by attaching with other bacteria and uses saliva in forming new biofilm to infect new areas of the tooth resulting in healthy plaque formation (Kullaa et al. 2014). Moreover, the saliva also contains calcium, bicarbonate and phosphate which neutralise plaque acids as well as repair tooth damage and prevent early tooth decay (www.adha.org, 2009).

Scientific principle related to cross-infection control in dental technology

The scientific principle of cross-infection control in dental technology is that proper hand hygiene is to be maintained by the dentitions, personal protective equipment are to be used, dental laboratory areas required to be cleaned and others. As mentioned by Pandit (2015), the lack of using personal protective equipment (PPE) by the dentitions results them to face potential injury leading to exposure to pathogens which can be borne through the bloodstream. This is because injury causes break in the skin which results in release of blood. Thus, in this case, the pathogens present in the mouth of the patients attended by the dentition transfer them through the cut area via bloodstream when in contact to infect the individual in the process. As commented by Grayson et al. (2018), maintaining hand hygiene is scientific principle in controlling cross-infection in dental technology as it avoids healthcare personals to prevent the transmission of infectious disease through contact in the clinical setting. This is because the dentitions mainly use their hands in operating and checking the dental disorder of the patients. Thus, maintaining proper hand hygiene is going to prevent cross-infection as the pathogens cannot be carried from one place to another through contact. The dental laboratory areas are required to be cleaned and all the dental equipment are to be disinfected after each use to avoid cross-infection (Gupta et al. 2017). This is because using the same equipment in the laboratory results in contaminating the patients as well as samples taken for diagnosis as the equipment may be previously infected by pathogens from the patients on whom they are used for health check-up.

Disinfectant method and techniques

In disinfection method and techniques, various disinfecting agents are being used for maintaining clean environment to control cross-infection in dental laboratory areas. In clinical condition in dental technology, the gentle scrubbing and later rinsing to decrease bioburden as well as subsequently disinfecting the areas with application of an antimicrobial agent helps to control cross-infection (Gounder and Vikas, 2016). Moreover, the dental impressions are able to be disinfected by spraying or dipping or immersing them in disinfectants. The benefit of using spraying method to use disinfectant for avoiding cross-infection through dental equipment in clinical condition is that less disinfectant can be used and the same product may also be used for disinfecting environmental surfaces in the dental technology (Mojarad et al. 2017). However, the spraying method may not be better than dipping method of dental equipment in clinical surroundings as some areas may be left in the equipment where disinfectants are not used to clean them to prevent cross-infection. Moreover, spraying disinfectant to control cross-infection in dental laboratory surroundings can cause pollution to the environment (Gounder and Vikas, 2016). Thus, dipping or immersion process for disinfecting equipment used in clinical dental technology is to be applied to prevent cross-infection. The contaminated prostheses used in the dental technology are to be properly disinfected by using disinfectants and scrubbed with an antimicrobial soap for preventing cross-infection. Moreover, the dental prostheses are to be dipped in disinfectants before they are been used in dental technology for treatment and diagnosis of patients (Demajo et al. 2016). Currently, in the dental environment, the ASEPTOFLUX is being used as a part of infection control system. The ASEPTOFLUX is a turbine that is specially designed for sucking most of the air in the clinical laboratory or areas used in dental technology and are then automatised in spraying non-wetting disinfectants for purifying the areas (Sebastiani et al. 2017). This technique is effective as leaves no moisture and is able to clean even the inaccessible areas in the dental laboratory where the infecting agents can be remained resulting in cross-infection.

Decontamination processes

The decontamination is needed for minimising the risk related to cross-infection between patients as well as between patients and dentitions. The key stages of decontamination process include pre-sterilisation cleaning, disinfection, inspection, sterilisation and storage (Gray, 2018). In the pre-sterilisation cleaning stage, the instruments being used in dental technology are cleaned with hands followed by ultrasonic bath or using washer or disinfector previous to sterilisation (Gray, 2018). The only hand cleaning of instruments is avoided as it is the least effective option to control cross-infection. During hand cleaning, cleaner requires wearing rubber gloves so that they are not contaminated by pathogens while washing the instruments. The ultrasonic cleaners are to have detergents that are disposed at each end of clinical session in the dental laboratory. The disinfectants are the best way to clean and avoid cross-infection as they make the instruments safe for handling while inspection (Alotaibi et al. 2018).

In the inspection stage, the instruments are to be thoroughly checked to ensure they are properly cleaned and not contaminants are present on them. The instruments which are still found to be contaminated are to be rejected and cleaned again and (Gray, 2018). In the sterilisation stage, the instruments are to be put into autoclave machine under the temperature of 134-137ºC for 3-4 minutes. The instruments are to be positioned in such a way so that the steam is able to freely circulate to properly sterilise them (Gray, 2018). After the sterilisation, the equipment is to be stored in a dry and clean environment where they would be covered so that they are not infected by any pathogen or microorganism while storage (Gray, 2018).

Principle of antisepsis and use in dental environment

The principle of antisepsis is the used of technique for sterilisation or disinfecting pathogen in the wounds so that they cannot be cross-infected. The alcohol involving can be used in killing pathogens to avoid cross-infection through wounds (Boyce, 2018). The chlorhexidine gluconate is a nature of skin antiseptic used for treatment of gingivitis or inflammation of gums (Arruda et al. 2018). The Balsam of Peru can be used as an antiseptic in treatment of surgical wounds around mouth (Mittermüller et al. 2018). The isopropanol can be used as an antiseptic agent for cleaning dental equipment before using them on patients to avoid cross-infection as alcohol is seen to kill pathogens and microorganisms (Boyce, 2018).

Transmissible

The transmissible diseases encountered in dentistry include respiratory virus infection, herpes virus, Hepatitis virus, HIV and others. In study by Cleveland et al. (2016), it is informed that the dentitions have higher prevalence to get infected by influenza A and B viruses, adenovirus, respiratory syncytial virus and others. Therefore, annual immunizations of the dentist are to be done to reduce the potential for the diseases to infect them. The Hepatitis virus is seen to execute persistent infection in many populations and is easily transmitted through bloodstream (Halboub et al. 2015). Since dentists are often in direct contact with the patients while checking for dental infection in oral cavity they have increased chances of getting affected by the virus through contact with the patient. This is because the virus may be transmitted to the dentist while checking the wound of the patients in unprotected way through contact.

Role of the individuals and risk assessment on dental environment

The role of the dentist to avoid cross-infection in dental environment is to wear personal protective equipment while attending patients and diagnosing the sample of the patient’s samples. For instance, the dentist is to wear gloves and use face masks while checking the oral cavity for detecting defects in teeth of the patients (Urban and Rowe, 2015). This is because it would lead to reduce their direct contact with the patients to prevent cross-infection between them and patients as not pathogens can pass through sneezing, saliva, droplets and others. The dentists are to ensure that they use sterilised and disinfected equipment like curettes, excavators, elevators, mirror, forceps, probes and others that are generally required in analysis of patient’s condition in dental environment (Kakudate et al. 2015). This is because without using disinfected equipment raises changes of cross-infection between patients by transmission of pathogens through saliva. The risk assessment in the dental environment is to be executed to identify the potential agents, infected equipment and infected areas that may be able to cause the transmission of pathogen to execute cross-infection. The risk assessment is also required to ensure that the one-time use equipment and syringes in the dental environment are properly disposed of so that they do not spread infection (Fontana, 2015). Further, risk assessment is required at the dental environment to control cross-infection through transmission of pathogens by saliva, droplets and others of the patients.

Conclusion

The above discussion informs that oral cavity consists of the teeth, tongue, lips, cheeks, and others which are lined on the inner side by the mucosal squamous epithelium as the key tissue. Various muscles such as masseter which is assisted by temporalis, medial and lateral pterygoid are used for making the jaws up and down for mastication of food. The inner layer of the teeth contains pulp cavity that is linked with nerves and blood vessels. The teeth developed in the infant stage are temporary or deciduous teeth which fall with ageing and permanent teeth are developed accordingly which is of 14 pairs. The saliva helps in building healthy plaque to protect the teeth from destroying or damaging. In order to avoid cross-infection in dental environment, the PPE, hand hygiene and other scientific principles are to be maintained. The decontamination process includes pre-sterilisation cleaning, disinfection, inspection, sterilisation and storage stage which is to be maintained for dental equipment used in the environment. The antiseptic is to be used for disinfecting the wounds of the patients in dentistry to avoid spread of pathogens. The risk assessment process is to be abided by for control risk-free and infection free environment in dentistry.

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Anatomy of Oral Design

The palate present in the oral design separates the nasal cavity from the mouth to help proper passage of air. The oral cavity is mainly lined by mucous membrane and contains stratified squamous epithelium also known as oral epithelium. Moreover, the mouth is lined by connective tissues named as lamina proper. There mucous membrane contains many small glands along with three pairs of salivary glands for keeping the oral cavity moist and free from debris (McHanwell et al. 2018).

Bones of head and musculature related with oral cavity

The temporal bone is the bilaterally symmetrical bone which is the base of the cranial vault leading the articulation of the mandible that is lower part of the jaw through mandibular fossa. The hyoid bone is horseshoe-shaped bone located at the anterior midline of the neck and it supports the anchoring of the tongue in the front of the neck. The Sphenoid bone is the unpaired bone located at the middle of the skull in the front region and it forms the base of the cranium (Angelopoulos and Scarfe, 2018). The zygomatic bone is paired irregular bone which helps to articulate the upper part of the jaw that is maxilla as well as the sphenoid, temporal and frontal bone (Marani and Heida, 2018).

Musculature related to facial expression and mastication

The muscle of the tongue is divided into two which are extrinsic muscles like genioglossus muscle, hyoglossus muscle, etc and the intrinsic muscle like superior and inferior longitudinal, transverse and vertical muscles (Kouskoura et al. 2016). The genioglossus originates from the mental spine of mandible and it is inserted in the hyoid bone and the tongue bottom to allow the tongue to protrude (and stick) out. The hyoglossus muscles are responsible to retract, protract, elevate and depress the tongue and it is thin and quadrilateral in shape which originates from the side of the body, greater cornu of hyoid bone (Cobourne et al. 2018). The vertical muscle flattens and broadens the tongue and it originates from the submucosal fibrous layer of dorsal region of the tongue. The transverse muscle of the tongue originates from the median fibrous septum which performs the action to narrow and elongate the tongue. The pair of longitudinal muscle of the tongue originates from the epiglottis and the median fibrous septum. The superior longitudinal muscle performs the action to retract the tongue along with the action of the inferior longitudinal to make it thick and short (Aoyagi et al. 2015).